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Depression in older people is common, underdiagnosed, undertreated and attracts therapeutic nihilism.
One in five older people have clinical depression and, contrary to some popular and professional opinion, it is eminently treatable.
Depression is associated with personal suffering, more physical health problems, social isolation, suicide and increased health and social care costs. It is a heterogeneous condition, can sometimes be the portent for dementia and treatment resistant depression can be associated with cerebrovascular disease.
Older people with depression can have similar and recurrent symptoms to younger people, less related to work stress but more commonly associated with a caring role or physical illness and frailty. It is often expressed through physical complaints (somatisation) causing fruitless physical investigations.
The presence of depression strongly predicts the outcomes in physical conditions such as hip fracture, stroke and myocardial infarction. There is also compelling evidence that depression is a risk factor for heart attacks and strokes.
Treatments for depression in older people are largely the same as in younger people and there is high quality and convincing evidence that older people respond very well to interventions.
Exercise is a very effective treatment for depression. The Health Survey for England showed that only 18 percent of men and 19 percent of women aged 55-64 undertake the recommended amount of regular exercise, a figure falling to 10 percent and 2 percent for people aged 75-85.
Anxiety is less common than depression but often associated with it and dementia. Older people have the same types of general and specific anxiety disorders as anyone else but are amenable to treatment.
Improving Access to Psychological Therapies (IAPT) is a key part of the treatment armamentarium for depression and anxiety in older people. However, the proportion of older adults – those aged 65 and over- accessing IAPT services is low, rising from 5.5 percent in 2012-13 to 7 percent in 2015-16. This is despite the fact that recovery rates of 60.4 percent are higher than the rest of the population (46.3 percent), a rate that increased by over 2 percent in the last year.
Older people complete treatment with lower levels of drop outs – 74 percent complete treatment compared to 68 percent in the general population. The most recent information on access for older adults to IAPT services in proportion to age are, overall, 33 percent for England with some regional variation. So although some progress has been made, services are seeing two-thirds less older people than you might expect.
It’s an easy win – a group of people needing treatment, they respond well and their participation will help CCGs reach their desired goal for numbers of people in, and recovering from, treatment.
So, what’s the problem? A combination of things – older people come from a generation where talking about your problems is not the norm, professionals may not think of referring older people and some therapists may feel they do not have the skills to help patients who may be of their own parents’ age.
So, what can be done?
There are areas where access for older adults is particularly high, for example in Aylesbury Vale, Castle Point and Rochford, North Norfolk and North Somerset. The “Right Care” data pack for Mental Health which went to CCG’s includes a case study on how North Somerset increased access for carers of dementia which helped older people access treatment.
Expanding psychological therapies into integrated services in physical health pathways is an opportunity for additional older people to access treatment. People are more likely to have a long term physical health problem as they get older – so integrated services should make therapies more accessible.
IAPT is one part of the Mental Health Quality Premium – a financial incentive for CCGs – active in both 2017-18 and 2018-19. This highlights both the need and the requirements on CCG’s to consider local demography in commissioning services and incentivises the improvement of access and outcomes for under-represented groups, in particular older people.
Developing and sharing case studies supports learning where there are providers who innovate or areas of good practice. Clinical networks are leading this process, providing inspiration for areas to improve. Work continues with Age UK on campaigns to highlight how IAPT services can deliver effective support for older adults and meet regularly to review progress.
Next steps to take:
- If you are involved in commissioning IAPT services, look at the rates of uptake for older people in your area and check if there is room to improve on that number
- If you a clinician, when you see an older person think of making a referral to IAPT
- If you are an IAPT practitioner, do what you can locally to encourage more referrals of older people to your service.
If you need any advice, have any comments or wish any help with this please write to me at Alistair.firstname.lastname@example.org.