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Depression in older adults: why medication review should not be just a tick in the box

Carolyn Chew-Graham is a GP in Manchester and professor of general practice research at Keele University. She is on Twitter: @CizCG

Catherine Ruane is a person with expertise in supporting older adults with depression.

Philip Wilkinson is a consultant psychiatrist and honorary senior clinical lecturer at Oxford Health NHS Foundation Trust and the University of Oxford.

Up to 16% of community-dwelling older people experience clinically significant depressive symptoms,1 with depression closely linked to comorbid medical disorders and social factors.2 As depression in older people can present with somatic and cognitive symptoms, however, it is often attributed to normal ageing and may be overlooked by the clinician and the older adult.

The updated National Institute for Health and Care Excellence (NICE) guideline Depression in adults: treatment and management3 addresses the management of depression in older people. We believe this is an opportune time for GPs to reflect on this and related guidelines to develop an active approach to addressing depression in their older patients.

Asking about mood should be routine in consultations with older people

Time pressure in consultations with older patients may result in GPs prioritising physical illness while normalising low mood with failure to address management of depression.4 To help with case recognition, the NICE guideline Depression in adults with a chronic physical health problem: recognition and management5 recommends asking patients two straightforward questions (see Box 1).

Box 1. Screening questions for depression from Depression in adults with a chronic physical health problem: recognition and management5
During the last month, have you often been bothered by:

  • feeling down, depressed, or hopeless? Or,
  • having little interest or pleasure in doing things?

The answer ‘yes’ to one of these prompts should lead the clinician to ask more questions about mood and consider inviting the patient to complete a PHQ-9.6

Asking about mood, and being asked, may be easier if the older adult and GP have an established relationship (see Box 2).

Box 2. Example of consultation benefitting from an established patient–GP relationship
Catherine Ruane describes an encounter with an older relative and a trusted GP:

‘My aunt didn’t have any symptoms of depression until she reached her eighties and her own physical health started to deteriorate which was an added pressure on top of the stress of her being a carer for her husband. I took her to a GP appointment for a physical health problem and the GP (who knew her well) spotted that she was quieter than usual and asked about her mood as part of her appointment. The GP picked up her depression and addressed it, offering a number of treatment options and, importantly, arranged a follow-up appointment which my aunt was really grateful for. I think this experience highlights the importance, for older adults and carers, of the GP knowing the patient who is consulting.’

As depression is often a chronic or relapsing condition that is comorbid with physical illness, we believe that GPs can, and should, play an important public education role by keeping depression on the agenda when reviewing patients with long-term physical conditions.

The NICE depression guideline update advises an open, non-judgmental approach to discussing mood. This is important in consultations with older adults as they may not disclose symptoms of depression. It is also vital to assess risk of self-harm or suicide. After this discussion, it can be helpful to direct patients and their caregivers to information resources on depression in older people, such as the MindEd website (https://www.mindedforfamilies.org.uk/older-people).

Psychological treatments are an important option

The NICE depression guideline recommends that clinicians explore patients’ treatment preferences. Older people appear vulnerable to the adverse effects of antidepressants, particularly cognitive and cardiac side-effects, and falls.7 They often express a wish for psychological treatments but are underrepresented in referrals to Improving Access to Psychological Therapies (IAPT) services.8

A straightforward treatment model for depression is behavioural activation (BA), which explores the links between physical inactivity, low mood, and reduced reward. Within BA, the clinician and patient develop a treatment plan to reinstate or replace former activities to increase positive reinforcement.9 Principles of BA can be used by GPs in their consultations and BA may be offered by local IAPT services.

The NICE depression guideline recommends a service model called ‘collaborative care’ to improve coordination of treatment provision for older people with depression so that it might prevent them falling through a gap in provision. Collaborative care, which straddles primary and secondary care, combines an intervention such as BA with active symptom monitoring by a care coordinator.

Regular review of people on antidepressants is important

The NICE guideline Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults10 recommends when antidepressants are initiated that people be given information about how long treatment may be needed, potential side-effects, and possible withdrawal effects.

The guidance emphasises the need for support for people who choose to reduce antidepressants. Many people are keen to stop their antidepressants as soon as possible. However, there is good evidence from studies involving younger people that continuing antidepressants for at least 6 months after recovery can help to reduce the risk of depressed mood returning.11

We suggest a number of questions to include in an antidepressant review (see Box 3). Antidepressant withdrawal is an increasing concern, and the NICE depression guideline provides advice on managing this. Regular monitoring of older adults taking antidepressants and support with withdrawal are vital, and this is best done by a doctor who knows the patient.

Box 3. Questions to consider in reviewing a patient taking an antidepressant
  • Which antidepressant is being prescribed?
  • At what dose?
  • Are they taking it? How long have they been taking it?
  • Do they feel they have any side-effects? Remember to ask about libido and weight gain.
  • Has the antidepressant helped their mood?
  • Do they still have depressive symptoms? Any symptoms of anxiety?
  • What are their thoughts on this antidepressant?
    –  If they say their mood is good, do they wish to continue this antidepressant or have they thought about reducing? What strategies do they have to keep well? Negotiate and agree plan and arrange review — be proactive.
    –  If their mood is low or they have anxiety symptoms, are they on the correct antidepressant? Do you need to consider an increase in dose or change the antidepressant? Would augmentation treatments be helpful? This should only be considered in liaison with specialist care.
  • Negotiate and agree plan and arrange review — be proactive.
  • Consider potential harms (such as drug interactions and hyponatraemia risk).
  • Consider risks of stopping treatment (such as recurrent depression, risk history, and age).
  • Have they previously received talking treatments (such as cognitive behavioural therapy, interpersonal psychotherapy, or counselling)? Are they still using strategies learned?
  • Are there (now or in the past) any thoughts of self-harm?
  • What other illnesses do they have? What other medications are they taking?
  • Do they use alcohol or other drugs?
  • Do they do any meaningful activity or exercise? Have they tried yoga or mindfulness?
  • Would social prescribing be something they might be interested in?
  • Who is at home with them?
  • Is social isolation or loneliness a problem?

In conclusion, we believe that GPs are in a unique position to promote awareness of depression among their older patients and to adopt an active approach to monitoring and treatment.

References

  1. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 2003; 58(3): 249–265.
  2. Herrman H, Patel V, Kieling C, et al. Time for united action on depression: a Lancet-World Psychiatric Association Commission. Lancet 2022; 399(10328): 957–1022.
  3. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NG222. 2022. https://www.nice.org.uk/guidance/ng222 (accessed 27 Sep 2022).
  4. Frost R, Beattie A, Bhanu C, et al. Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies. Br J Gen Pract 2019; DOI: https://doi.org/10.3399/bjgp19X701297.
  5. National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. CG91. 2009. https://www.nice.org.uk/guidance/cg91 (accessed 27 Sep 2022).
  6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9): 606–613.
  7. Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011; 343: d4551.
  8. Pettit S, Qureshi A, Lee W, et al. Variation in referral and access to new psychological therapy services by age: an empirical quantitative study. Br J Gen Pract 2017; DOI: https://doi.org/10.3399/bjgp17X691361.
  9. Psychology Tools. How to use behavioral activation (BA) to overcome depression. https://www.psychologytools.com/self-help/behavioral-activation (accessed 27 Sep 2022).
  10. National Institute for Health and Care Excellence. Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. NG215. 2022. https://www.nice.org.uk/guidance/ng215 (accessed 27 Sep 2022).
  11. Lewis G, Marston L, Duffy L, et al. Maintenance or discontinuation of antidepressants in primary care. N Engl J Med 2021; 385(14): 1257–1267.

Competing interests

Carolyn Chew-Graham, Philip Wilkinson, and Catherine Ruane were members of the NICE Depression in Adults (update) Guideline Committee. Philip Wilkinson was a contributing author to the MindEd website resources. Carolyn Chew-Graham is in receipt of external funding to support her research into mental health of older adults. The guideline referred to in this article was produced by the NICE. The views expressed in this article are those of the authors and not necessarily those of the NICE.

Featured photo by Alex Boyd on Unsplash.

The British Journal of General Practice and BJGP Open are bringing research to clinical practice. BJGP Life is where we add the debate and opinion to help ensure everyone benefits from that research.

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