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The recent report by Age Concern (2008a) - Undiagnosed, untreated, at risk: the experiences of older people with depression - highlights the ‘scandalous treatment’ of older people suffering from depression.

The report is scathing, saying that depression as an illness which can be easily managed if older people seek help, are diagnosed and receive appropriate treatment. It comments that many do not seek help, and for those who do, ageist attitudes among health professionals can be a barrier to diagnosis. It further opines that for the ‘lucky ones’ who are diagnosed, access to the full range of treatments may be denied because of ageist attitudes. The opening part of the report is unequivocal – ‘older people with depression deserve better’; that ‘ignoring the problem is not an option’ and that ‘immediate action’ needs to be taken to address this ‘scandal’.

Ageism in the treatment of older people with depression
The report suggests that ageism is a core problem for the treatment of depression in older people as identified in the Independent UK Inquiry into Mental Health and Well-Being in Later Life (Age Concern, 2006). This Inquiry looked at improving services and support for older people with mental health problems and their carers. The Inquiry identified age discrimination as a significant obstacle to older people receiving treatment for depression, and echoed previous research by Age Concern and other organisations in recent years.

The report also noted the Government has repeatedly stated its commitment to promoting age equality in mental health, but at the same time it had set up pilots of psychological therapies for people with depression which were restricted to ‘so-called “adults of working age”’. This ignored NICE guidance (2004) that a full range of treatments is effective and should be available to older people with depression. Age Concern however, did comment that it felt a ‘massive step forward’ to end age discrimination has been made by the Government this year when it released details of its planned Equality Bill and its intention to outlaw age discrimination in health and social care and to introduce a duty on the public sector to promote age equality.

Late-life depression
The report provides a helpful overview of the extent of the problem of depression in later life. It is a serious and disabling illness. One in four older people – two million over the age of 65 – living in the community have symptoms of depression severe enough to warrant intervention, and half of this group have symptoms of clinical depression. In the older population depression tends to last for longer periods and have shorter intervals without symptoms. The occurrence of depression increases with age from around 1 in 5 among the 65-69 age population to 2 in 5 among those aged 85 and above. 40 per cent of people in care homes have depression. One in seven people aged over 65 has ‘major’ depression which is severe, persistent and disrupts day-to-day functioning. The proportion rises to one in four if all depressions which are severe enough to impair quality of life are included. Currently this translates into 1.4 million older people with major depression and 2.4 million older people with all types of depression in the UK. As the population ages, these numbers will increase to 1.8 million and 3.1 million over the next 15 years if rates of depression remain at current levels (Age Concern, 2006).

Depression increases the risk of physical illness (especially heart disease, diabetes and CVA), abuse (by three times) and is of course the leading risk factor for suicide among older people (older men and women have some of the highest suicide rates of all ages in the UK). Needless to say people with depression take longer to recover from illness and are more likely to be readmitted to hospital after a previous stay.

Depression rates are increased in those with physical disability or illness; a past history of depression; other mental health problems such as dementia; alcohol misuse and those who act as carers. Social isolation and consequent loneliness is also an important factor for the development of depression. 45 per cent of men and 34 per cent of women over 80 living alone describe feeling lonely, compared to 4 per cent of men and 10 per cent of women living with a partner (Age Concern, 2008b).

Obstacles to recovery: lack of awareness and negative attitudes
Whilst depression is the most common mental health problem in later life, awareness of what it is appears low among older people themselves and their relatives and carers. Often there is physical illness contributing to, but clouding the presentation of the depressive symptoms. The report suggests that many older people consider depressive symptoms to be part of the natural ageing process and little or nothing can be done to help them; furthermore, they receive little information to persuade them otherwise. There are negative entrenched attitudes and stigma for many older people and the wider public, that depression is a “sign of weakness”. The report also makes the observation that older people from black and minority ethnic (BME) groups also have to contend with other negative cultural perceptions of mental health problems – beliefs about the origin of the illness and the high value placed on family reputation results in many BME elders, and their families, hiding depression and keeping it a secret (Glasgow Anti Stigma Partnership, 2007).

Many older people do not know they have depression and hence do not mention it to their GP, or find it difficult or inappropriate to mention non-physical problems to their GP (only a third of older people with depression discuss it with their GP – Godfrey et al., 2005). It appears that practice or district nurses are more able and attuned to talk to older people about ‘non-medical’ problems. Nearly half of older people who take their own lives visit their GP in the month prior to committing suicide (Tadros & Salib, 2006).

Obstacles to recovery: ageist attitudes among health professionals
The report suggests that lack of awareness and ageism go hand in hand to hinder and prevent the diagnosis of depression. It concludes that the vast majority - 90 per cent (Godfrey et al., 2005) – of GPs understand the importance of recognising early signs of and diagnosing depression but that this contrasts with the low number of older people with depression who are actually diagnosed and receive treatment. It explains that this is partly because of the difficulty of distinguishing between physical and mental problems – and indeed older people may become preoccupied with their physical symptoms, thus hindering GPs’ diagnosis. The report suggests however, that there is ‘no avoiding the fact that some older people encounter health professionals with ageist attitudes’ and therapeutic ‘defeatism’ which prevents proper diagnosis and access to treatments.

Overall, of the third of older people with depression who discuss it with their GP, only half are diagnosed and receive treatment. This translates to about 15% of all older people with clinical depression receiving treatment – 850,000 out of 1 million therefore don’t. Even more worryingly only 6% of older people with depression receive specialist mental health care. Another area of concern is in care homes where only half of older people who are diagnosed with depression receive any kind of treatment.

Obstacles to recovery: a system that discriminates against older people
The report observes that arbitrary divisions in mental health services, based solely on age, has created an unfair system for older people. In particular, this means that older people have less access to psychological therapies than younger people. Fewer than 10% of older people with clinical depression are referred to specialist mental health services compared with about 50% of younger adults with mental and emotional problems.

In its 2004 guidance NICE has emphasised that older people should be offered the full range of services including psychological services – “because they may have the same response to psychological interventions as younger people”. The report suggests that despite this guidance, older people continue to be neglected by an unfair system but that the Government has repeatedly stated its commitment to promoting age equality in mental health. The Department of Health’s (2005) document Securing Better Mental Health for Older Adults specifically states that services should be based on need and not solely on age, but conversely observed that, “older adults with mental illness had not benefited from some of the developments seen for younger adults, and some of the developments seen in older people’s services were not fully meeting the mental health needs of older people”.

Further evidence of continuing unfair treatment came in the report Living Well in Later Life (Commission for Healthcare Audit and Inspection, 2006) that reviewed the implementation of the National Service Framework for Older Adults. This concluded that “the organisational division between mental health services for adults of working age and older people has resulted in the development of an unfair system, as the range of services available differs for each of these groups”. This was followed by another Department of Health (2006) document – A New Ambition for Old Age – reiterating the Government’s declaration and commitment to age equality in mental health.

The Age Concern report points out an anomaly demonstrated in the Government White Paper “Our health, our care, our say: a new direction for community services” (HM Government, 2006) which on one hand declares a commitment to “a health and social care system that promotes fairness, inclusion and respect for people from all sections of society, regardless of their age, disability, gender, sexual orientation, race, culture or religion, and in which discrimination will not be tolerated”, but on the other hand the same paper announced pilots of psychological therapies which actually excluded older people in favour of so-called “adults of working age” (aged 18-65). In summarising this dichotomy of intent for older people’s services, the report was again fiercely scathing when it stated, “This arbitrary, ageist division has created an unfair system where older people with depression have access to fewer and lower standard services than those under the age of 65”.

Age Concern’s three-point plan to improve the lives of older people with depression

1. Encourage older people with depression to seek help.

• Public education programmes aimed at older people and their families/carers – how to recognise depression symptoms, know it can be treated and where to seek help.
• Offer support at times when older people are at increased risk of depression e.g. bereavement.

2. Ensure older people with depression are correctly diagnosed.

• Eradicate ageist attitudes held by some GPs that prevent older people with depression from receiving appropriate help.
• Improve the training of GPs to recognise and treat depression in later life
• Develop the GP contract to incentivise the identification and treatment of depression in later life.

3. Ensure older people with depression get the treatment they need.

• Plan and commission mental health services that take into account the prevalence of depression among older people and the evidence of effective treatments i.e. ensure access to treatments for depression are planned and implemented to provide fair access.
• Remove the insulting, arbitrary and ageist rules that deny older people access to effective treatments.

Summary
Depression is a serious illness which is being under diagnosed in older people. In the clinical setting, whether that be primary care or in the acute or rehabilitation services of secondary care, awareness by clinicians of the possibility of depression as part of the clinical presentation should always be considered. The use of screening and rating tools e.g. Hospital Anxiety and Depression Scale (HADS), Geriatric Depression Scale (GDS), Brief Assessment Scale (BASDEC) as part of an assessment can be a way of picking up cases of depression but also, by regular use, heightens awareness and attunes clinicians and healthcare professionals to the possibility of depression being present. These scales can similarly be used by healthcare professionals in the care home setting, where depression rates are high but potential cases go undetected.

An area not really covered by the report is that of depression presenting in older people with dementia. This again, is an area where depression can be missed, particularly if the patient has communication difficulties. In clinical practice I tend to put a lot of emphasis on non-verbal behavioural signs e.g. persistent tearfulness, subdued behaviour, marked sleep and appetite disturbances (not accounted for by concomitant physical illness, sedating medication or pain), poor facial responsiveness and interaction. Often the relatives or carers will be very familiar with regular behavioural patterns of patients with a significant dementia, and will often spot non-verbal depressive changes, but not appreciate they could be depressive symptomatology. Often these symptoms are wrongly considered to be part of the primary dementia process. In patients admitted to my dementia ward with significant and often severe behavioural problems, I have a very low threshold for suspecting a depressive element to their presentation and starting antidepressants very early in their assessment based upon non-verbal signs. I have seen some quite astounding changes in severely behaviourally disturbed dementia patients, who respond to antidepressant medication (as opposed to routinely starting with antipsychotics and all their associated side-effects and deleterious effects on cognition). This important area is currently being addressed by the national HTA Study of Antidepressants for Depression in Dementia (HTA-SADD trial). This randomised controlled trial will determine the clinical and cost-effectiveness of two types of antidepressants (SSRI – sertraline; NASSA – mirtazapine) for people who have dementia and depression.

The report, in advocating increased access for older people to psychological therapies, gives examples of two Age Concern sponsored projects which provide such services and in particular concentrate on making the services as accessible as possible – Camden’s Talking Therapies project for black and minority ethnic and refugee older people and Peer Support Volunteers who are working in partnership with the Coventry and Warwickshire Partnership Mental Health Trust (having been set up in response to the relatively low number of older people engaged in local psychological therapy services).

Martin Curtice
Consultant Physician in Old Age Psychiatry
Birmingham and Solihull
Mental Health Foundation Trust

BGS Newsletter, Oct 2008
Issue 18 ISSN 1748-6343 18