Mood disorders in the elderly

Depression remains a common illness in older people, with major depression affecting approximately 3%, and 10–15% having significant depressive symptoms which fall short of this diagnosis. Some groups of people, such as the bereaved and people with dementia, are at high risk and need careful assessment for depression. The clinical features of late-life depression are broadly similar to those in younger adults. Accumulating neuroimaging evidence shows atrophy of the hippocampii and key frontal and subcortical structures occurs in older people with depression and hyperintense lesions on MRI occur with increased frequency in late-life depression. Neuropathological studies have demonstrated these lesions are ischaemic and indicate that more widespread inflammatory changes may be present in the prefrontal cortex. This and the strong bidirectional relationship of depression with vascular disease support the view that some older people have a ‘vascular depression’. Management of late-life depression involves similar approaches to younger adults, although older people may take longer to respond. SSRIs should be used as first-line treatment and lithium augmentation and electroconvulsive therapy are efficacious in those who don not respond after switching to an alternative antidepressant. Continuation and maintenance treatment should be given with full-dose antidepressants and combination with manualized psychotherapy is effective. Late-life depression is associated with an increased mortality, much of which is due to cardiovascular and cerebrovascular disease. Chronicity of the depression syndrome and of troubling symptoms occurs in about a third of patients, with a similar proportion having further depressive episodes.