Depression in older adults needs adequate follow-up to prevent relapse.
According to estimates from Statistics Norway (SSB), the number of older adults will increase by 36 % until 2030 (1). If we assume that the prevalence of mental disorders will remain unchanged, this will entail an increase in the number of older adults with depression. In recent years, mental disorders have become less of a taboo subject. It is thus likely that older adults of the future will seek help for mental disorders, including depression, to a greater extent than now.
In the future, most patients with depression will be treated by their GP, as they are today. For mild and moderate depression, drugs constitute a limited component of this treatment (2). We may nevertheless assume that drugs will be the main element in the treatment provided to a considerable proportion of older adults with less severe forms of depression, perhaps because this represents a quick solution in a busy daily schedule. For many, counselling by the GP with a focus on solving problems and providing support may bring improvement, provided that sufficient time is allocated. In more pronounced forms of depression the GP may also draw on other local service providers. The psychiatric services will primarily follow up only very severe disorders. Most local councils also employ municipal mental health officers. These are usually intended for young people, but some local councils have also started to employ psychologists who will primarily work with older people. When the reform of care for the elderly, Lev hele livet [Live life to the full], was adopted in the autumn of 2018, the majority in the Storting requested the government to encourage the establishment of low-threshold mental health services in more municipalities (3).
Older adults with severe depression will normally be referred to the specialist health service. In Norway, there are currently 22 geriatric psychiatry departments that provide both outpatient treatment and hospitalisation (4). The expected increase in the number of older adults with a need for treatment in the years to come cannot be fully handled by these departments. Furthermore, many people live too far from a geriatric psychiatry ward to make outpatient treatment a practical option. In the future, the District Psychiatric Centres (DPS) will need to play a greater role in the treatment of older adults, including those with depression. A study published in 2012 showed very large variation in the kinds of services that these centres provided to older adults (4), and our experience indicates that this situation has not improved significantly in recent years. In the same study staff members were interviewed who felt that they had little competence in treating older adults with mental disorders. Older patients may benefit from psychotherapy (5), but there is reason to assume that they are not offered such treatment to the extent that would be desirable.
Depression in older adults may also accelerate or exacerbate an existing pre-clinical dementia condition
The study by Borza and colleagues which is now presented in the Journal of the Norwegian Medical Association shows that only a minority of the patients who had been hospitalised with depression avoided a relapse during the three subsequent years (5). This finding illustrates that depression in older patients may often take the form of a constantly recurring or more chronic disorder. The study also shows that the treatment of depression should not be considered as completed when the acute stage has passed. For patients with severe depression, drug prophylaxis will normally be used over a period of time to reduce the risk of relapse (2). In addition, other interventions such as counselling or psychotherapy, strengthening of networks, physical activity and correct diet are all important. However, there is still a need for more knowledge about the effect of different interventions for preventing relapse into depression among older adults.
After three years of follow-up, more than one-half of the participants from Norwegian geriatric psychiatry departments were diagnosed with dementia or mild cognitive impairment (6). This result is supported by findings in previous studies, which have pointed to an increased risk of developing dementia after a depressive episode (7). There is reason to believe that for some of these patients depression was a prodromal symptom of nascent dementia, but as pointed out by Borza and colleagues, it has also been shown that depression in older adults may accelerate or exacerbate an existing pre-clinical dementia condition (8). Primary prevention of depression in older people is therefore extremely important.