Risk of depression, anxiety in elderly can be cut
■ A new study finds that prevention is possible in the primary care setting.
By Victoria Stagg Elliott — Posted April 6, 2009
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The chance that someone older than 75 will develop anxiety or depression can be halved if those with the early signs of these disorders are monitored and receive escalating levels of intervention, says a study in the March Archives of General Psychiatry.
"Depressive and anxiety disorders ... are associated with reduced quality of life, can be difficult to diagnose, can be difficult to treat and are costly," wrote Petronella J. van't Veer-Tazelaar, in an e-mail. She is the lead author and a scientist at VU University Medical Center's Institute for Research in Extramural Medicine in Amsterdam, the Netherlands. "Prevention is better than cure. We have proven to be successful in the prevention of depression and anxiety using a simple and relatively cheap program that can be applied [in] primary care."
Researchers randomized 170 elderly people presenting to primary care clinics with the first signs of anxiety or depression into two study groups -- one receiving usual services and a second for which intervention was stepped up as needed. This intervention group initially received watchful waiting. If symptoms did not resolve, they were visited at home by a nurse who provided coping skills training and written information about mental health.
If patients were still symptomatic, they received seven sessions of cognitive behavioral therapy. Finally, if still necessary, they were advised to discuss pharmaceutical options with their primary care physicians.
Experts praised this paper for increasing awareness that these mental health issues are not an inherent part of aging and suggesting a strategy to determine who needs additional help.
"It's not ... just part of getting older. In healthy, community living elderly, the rate is lower than in other population groups," said Jürgen Unützer, MD, MPH, professor of psychiatry at the University of Washington. He has extensively studied mental health issues in this age group.
Some physicians working in this area, however, wanted more assessment of the levels of anxiety tracked by this study, since the screening tools used to detect subclinical symptoms of mental health problems were focused on depression. A desire also was expressed to see data on the cost of this intervention and their effect on downstream health outcomes.
"I think it's great that the paper raises awareness, and I think it's interesting that it talks about prevention," said Bruce L. Rollman, MD, MPH, associate professor of medicine and psychiatry in the division of general internal medicine at the University of Pittsburgh School of Medicine. "But it would be helpful to see if the prevention of anxiety and depression affects emergency department utilization or other health care costs."
The study also gives rise to questions surrounding how to incorporate this kind of screening and intervention into geriatric care. Although validated screening tools exist to detect early signs of depression or anxiety, experts say mental health care can get lost in treatment for the other chronic conditions that so many elderly patients have. In addition, the symptoms for these other illnesses often mimic those for psychological ills.
"Early recognition and early intervention are essential," said Seren Cohen, PhD, a geriatric psychologist in Santa Fe, N.M. She also is a spokeswoman for the American Geriatrics Society. "But it's sometimes difficult with the geriatric population. We may not get an adequate mental health history because of stigma or a reluctance to disclose. Many in this generation don't perceive depression as necessarily being that important."
Meanwhile, reducing the risk of these mental illnesses as people age is increasingly the focus of research. "Path to prevention" is the theme of the 14th International Congress of the International Psychogeriatric Assn. in Montreal in September.
In addition, interest in the link between physical and mental health has grown significantly. Dr. Rollman is researching the impact of treating depression on outcomes for patients undergoing coronary artery bypass.
Preliminary data from this study were presented at the American Psychosomatic Society meeting in Chicago in March.