PERS PE C T IV E

Pinching the Poor?

Disclosure forms provided by the authors

are available with the full text of this article
at NEJM.org.
From the Robert Wood Johnson Foundation Health and Society Scholars Program,
University of Pennsylvania, Philadelphia
(B.S.); the Department of Healthcare Policy
and Research, Virginia Commonwealth University, Richmond (L.S.); and the Department of Health Policy and Management,
Harvard School of Public Health, Boston
(B.D.S.).

1. Gould E, Wething H, Sabadish N, Finio N.

What families need to get by: the 2013 update of EPIs budget calculator. Issue brief
no. 368. Washington, DC: Economic Policy
Institute, July 3, 2013.
2. Manning WG, Newhouse JP, Duan N,
Keeler EB, Leibowitz A, Marquis MS. Health
insurance and the demand for medical care:
evidence from a randomized experiment.
Am Econ Rev 1987;77:251-77.
3. Remler DK, Greene J. Cost-sharing: a blunt
instrument. Annu Rev Public Health 2009;
30:293-311.

4. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with
medication and medical utilization and
spending and health. JAMA 2007;298:61-9.
5. Wright BJ, Carlson MJ, Allen H, Holmgren
AL, Rustvold DL. Raising premiums and
other costs for Oregon health plan enrollees
drove many to drop out. Health Aff (Millwood) 2010;29:2311-6.
DOI: 10.1056/NEJMp1316370
Copyright 2014 Massachusetts Medical Society.

Diagnosing Depression in Older Adults in Primary Care

Ramin Mojtabai, M.D., Ph.D., M.P.H.

he prevalence of diagnosed
depression in U.S. adults 65
years of age or older doubled
from 3% to 6% between 1992
and 2005.1 A majority of patients with diagnosed depression were treated with antidepressant medications by primary
care and other general medical
clinicians.1 Several factors probably contributed to this trend,
including publicity regarding
the extent of underdiagnosis
and undertreatment of depression in older adults, aggressive
pharmaceutical marketing efforts targeting providers and
consumers, and the introduction
of new antidepressants. A majority of the people diagnosed
with depression in primary care
settings, however, do not meet
the diagnostic criteria for major
depressive disorder.2
This conclusion is supported
by data from two sets of national
surveys conducted between 2005
and 2010 examining the prevalence of major depressive episodes (as defined by the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition [DSMIV]) at any time in the previous
year, clinicians diagnoses of depression in the previous year,
1180

and current use of antidepressants (see graphs). Like other

epidemiologic studies, these data
indicate that depression is significantly less prevalent among
older adults than in other age
groups. The number of antidepressant prescriptions, however,
does not match this trend. Although antidepressants are prescribed for various diagnoses,
research indicates that almost
two thirds of prescriptions are
for a clinician-diagnosed mood
disorder. The correspondence between clinicians diagnoses and
diagnoses based on structured
interviews is significantly poorer
in older adults than in younger
adults (see graph, Panel B). Only
18% of older adults with a clinicians diagnosis of depression
meet the diagnostic criteria for a
major depressive episode on the
basis of a structured interview.
Clinical studies have similarly
shown that less than one third of
older adults with major depression diagnosed by primary care
clinicians also meet the diagnosis of major depression according
to structured interviews or rating
scales.3
Its difficult to diagnose depression in primary care set-

tings, especially in older adults.

Sleep problems, fatigue, and low
energy levels associated with
medical conditions often mimic
depressive symptoms. Furthermore, losses of friends and loved
ones and a shrinking social network in old age result in diminished social involvement, which
is a common feature of depression. These problems of old age
are sometimes difficult to distinguish from depressive symptoms.
The challenge of correctly
identifying depression in primary
care is compounded by the fact
that depressed patients seen in
these settings have less-clear-cut
symptom profiles than those
seen in specialty mental health
settings, mainly because their
symptoms are less severe or disabling. Some patients diagnosed
with depression in primary care
may meet the criteria for dysthymia or adjustment disorder with
mood symptoms. Others may
have mild depressive symptoms
that dont reach the threshold for
diagnosis of major depressive
disorder. Many such patients
would benefit from supportive
counseling or lifestyle modification. In some cases, watchful

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PE R S PE C T IV E

Diagnosing Depression in Older Adults

A
20
18

Prevalence (%)

16

Met criteria for

major depressive
episode

Currently taking
antidepressant
medication

14
12
10
8
6
4
2
0

1825

2634

3549

5064

65

Age (yr)

7
6

Told by a clinician they had

depression; met criteria for
major depressive episode

Told by a clinician they had

depression; did not meet criteria
for major depressive episode

Prevalence (%)

5
4
3
2
1
0

1825

2634

3549

5064

65

Age (yr)

Prevalence of Major Depressive Episodes in Relation to Antidepressant-Medication Use

and Clinician-Diagnosed Depression, 20052010.
The prevalence of major depressive episodes at any time in the previous year is shown
in relation to the use of antidepressant medications (Panel A) and to the prevalence of
depression diagnosed by a clinician in the previous year (Panel B). Major depressive
episodes are as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition. I bars indicate 95% confidence intervals. Data on major depressive episodes and
clinician-diagnosed depression are from the U.S. National Survey on Drug Use and
Health (https://nsduhweb.rti.org/); data on antidepressant use are from the U.S.
National Health and Nutrition Examination Survey (www.cdc.gov/nchs/nhanes.htm).

waiting with regular follow-up

may be appropriate. Yet the majority of primary care patients diagnosed with depression are simply prescribed antidepressants.2
Although there is good evidence
for antidepressants efficacy in
major depressive disorder
especially when its severe the
evidence for efficacy in less-
severe cases and for subthreshold depressive symptoms is much

less robust. Exposing older adults

to antidepressants in the absence
of evidence for benefit raises
safety and ethical concerns.
Nonetheless, many patients
with depression and other common mental disorders are treated
in general medical settings, and
theres some evidence that treating depression in patients with
physical health conditions might
positively affect both mental and

physical health. To maximize

benefit from treatments, however, the accuracy of depression diagnosis in these settings must be
improved, especially as applied
to older adults. Over the years,
various approaches to improving
primary care diagnosis and treatment of depression have been proposed, including use of screening
measures, implementation of integrated care models, and steppedcare approaches.4,5
Routine use of screening instruments is controversial. In
2009, the U.S. Preventive Services
Task Force recommended screening for depression when staffassisted depression care supports
staff who can provide care coordination, follow-up planning,
mental health referrals, psychoeducation, and sometimes psychotherapy are in place. More
recently, the Canadian Task Force
on Preventive Health Care advised against routine screening
because of the lack of high-quality data supporting its benefits
and concerns about increased
rates of false positive diagnoses
and unnecessary treatment. Staffassisted depression care supports
are also essential to integrated
models of depression care, which
require greater access to mental
health specialists than is available
in many primary care settings.
Stepped-care models represent
a nuanced approach to diagnosis and treatment of depression
in which symptoms of varying
severity and duration are matched
with appropriate intervention
options. The 2009 guidelines issued by the U.K. National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk/
nicemedia/live/12329/45888/45888
.pdf) represent one such approach.
As a first step, these guidelines
recommend assessment, support,

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PERS PE C T IV E

Diagnosing Depression in Older Adults

and psychoeducation for patients

with all known and suspected
presentations of depression. Clinicians are advised to be alert to
possible depression in patients
with a history of the illness or
chronic physical health problems
associated with functional impairment. Clinicians are to consider asking patients with possible depression whether theyve
had depressed mood or loss of
interest in daily activities in the
past month. A positive response
on either count should be followed by a fuller assessment of
the severity and duration of symptoms and functioning, if the clinician is competent in conducting such an assessment (see the
Supplementary Appendix, available with the full text of this article at NEJM.org). The guidelines also advise clinicians to
consider using validated measures of symptoms and functioning; the Patient Health Questionnaire 9 is one such validated and
widely used measure that captures the DSM-IV criteria for a
major depressive episode (http://
phqscreeners.com/pdfs/02_PHQ-9/
English.pdf). If the clinician is
not competent to conduct such
an assessment, the patient may
be referred to a mental health
professional for assessment.
Step 2 involves management
of persistent subthreshold depressive symptoms and mild-to-moderate depression (see the Supplementary Appendix for definitions
of levels of depression). NICE
recommends active monitoring,
including psychoeducation and
follow-up in 2 weeks for subthreshold depressive symptoms
that may remit without formal
treatment. Active monitoring may
also be appropriate for patients

1182

with mild depression who arent

interested in more intensive treatment. For these patients, NICE
also recommends low-intensity
psychosocial interventions, which
include individual guided selfhelp based on the principles of
cognitive behavioral therapy, computerized cognitive behavioral
therapy, and structured group
physical activity (see the Supplementary Appendix).
The guidelines discourage routine use of antidepressants for
persistent subthreshold depressive symptoms or mild depression. However, clinicians may
consider these medications for
patients with a history of moderate or severe depression, subthreshold symptoms lasting
2 years or longer, and subthreshold symptoms or mild depression
that persists after low-intensity
psychosocial interventions. Medications (typically selective serotonin-reuptake inhibitors) or
high-intensity psychosocial interventions, such as individual cognitive behavioral therapy or interpersonal therapy, alone or
combined with medications, may
be considered as a third step for
patients with no response to lowintensity psychosocial interventions and those with moderateto-severe depression. When
medication has been started, the
guidelines recommend continuing it at a therapeutic dose for at
least 6 months after remission of
an episode.
The fourth step involves mental health referral for patients with
high risk of suicide, psychotic
symptoms, or complex, severe depression whose management requires expert knowledge. There is
some evidence that when its coupled with organizational changes

such as the addition of support

staff, training of clinicians in using practice guidelines such as
NICEs can improve outcomes of
depression care in general. Implementing these guidelines, however, may require extended and
more frequent visits, which may
be difficult to accommodate in
many primary care settings.
With the looming shortage of
geriatric mental health care providers, general medical clinicians
role in managing older adults
mental health problems will
probably increase. A nuanced approach to depression diagnosis
and treatment may improve the
management and outcome of
geriatric depression in primary
care settings. Incorporating the
stepped-care approaches into generalists training and making lowintensity psychosocial interventions more widely available may
help prepare clinicians to more
effectively meet future needs.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
From the Department of Mental Health,
Bloomberg School of Public Health, and the
Department of Psychiatry and Behavioral
Sciences, School of Medicine, Johns Hopkins University, Baltimore.
1. Akincigil A, Olfson M, Walkup JT, et al.
Diagnosis and treatment of depression in
older community-dwelling adults: 1992-2005.
J Am Geriatr Soc 2011;59:1042-51.
2. Mojtabai R. Clinician-identified depression in community settings: concordance
with structured-interview diagnoses. Psychother Psychosom 2013;82:161-9.
3. Mitchell AJ, Rao S, Vaze A. Do primary
care physicians have particular difficulty
identifying late-life depression? A meta-analysis stratified by age. Psychother Psychosom
2010;79:285-94.
4. Williams JW Jr, Nol PH, Cordes JA,
Ramirez G, Pignone M. Is this patient clinically depressed? JAMA 2002;287:1160-70.
5. Batstra L, Frances A. Holding the line
against diagnostic inflation in psychiatry.
Psychother Psychosom 2012;81:5-10.
DOI: 10.1056/NEJMp1311047
Copyright 2014 Massachusetts Medical Society.

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The New England Journal of Medicine

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Copyright 2014 Massachusetts Medical Society. All rights reserved.