Guideline for the management of late-life depression in primary care

Pharmacologic response to a diagnosis of late-life depression: A population study in Quebec

OBJECTIVE

To identify predictors of receiving psychoactive medication and receiving recommended first-line pharmacotherapy in individuals with newly diagnosed late-life depression.

METHODS

We undertook a retrospective database cohort study of 5258 beneficiaries of the Quebec provincial health insurance plan between 1999 and 2002. Subjects were aged 65 to 84 years and diagnosed with depression by primary care physicians or psychiatrists between October 2000 and March 2001; they had no depression diagnosis in the previous year. We defined receipt of psychoactive medication as having a pharmacy claim in the year following the depression diagnosis. We determined receipt of recommended first-line pharmacotherapy from the first psychoactive medication dispensed following diagnosis and defined it accordingly; we defined first-line pharmacotherapy according to the 2001 Canadian Psychiatric Association guidelines. We used multivariate generalized estimating equations models to identify the determinants of the 2 outcomes.

RESULTS

A total of 4421 (84.1%) patients received psychoactive medication following diagnosis; 2623 (59.3%) patients had not received antidepressants in the previous year. Of these, 1310 (49.9%) received recommended first-line pharmacotherapy. Independent predictors of receiving psychoactive medication were female sex, depression not otherwise specified (NOS), increasing comorbidity, and living in rural areas. Independent predictors of receiving recommended first-line pharmacotherapy were male sex, depression NOS, receiving medication in the month following diagnosis, and having the same physician diagnosing and treating the patient.

CONCLUSION

Male sex and continuity of care predicted that patients had the recommended medication dispensed.

Treatment options for post-stroke depression in the elderly

Depression is an important complication of stroke – although common and associated with poor outcomes it is often undetected, undiagnosed, untreated or undertreated. There are several explanations for this unsatisfactory situation: it undoubtedly reflects complexities in the assessment of mood disorders in patients with disability and medical comorbidities; there are various barriers to implementation of effective antidepressant therapy in clinical practice; and there is a lack of high-quality, randomized evidence of effective management strategies in this aspect of stroke care. As well as education of healthcare providers and the general public on the importance of depression in the context of physical illness, new models of multidisciplinary healthcare delivery on stroke outcomes and cost-effectiveness need to be explored in different settings. There is a need for research to investigate etiologic factors and produce randomized evaluations of interventions for the prevention and treatment of post-stroke depression.

Disparities in antidepressant treatment in Medicaid elderly diagnosed with depression

OBJECTIVES

To determine whether there were racial or ethnic disparities in the use of antidepressants in low-income elderly patients insured by Medicaid.

DESIGN

Examination of 1998 Medicaid claims data.

SETTING

Centers for Medicare and Medicaid Services Medicaid claims data for five U.S. states.

PARTICIPANTS

All Medicaid recipients aged 65 to 84 with a diagnosis of depression.

MEASUREMENTS

Treatment versus no treatment; in those treated, treatment with drugs was classified as old- or new-generation antidepressants.

RESULTS

In 1998, 7,339 unique individuals aged 65 to 84 had at least one outpatient encounter with depression as the primary diagnosis. Nearly one in four (24.2%) received no antidepressant drug therapy, and 22% received neither psychotherapy nor an antidepressant. African-American individuals were substantially more likely to be untreated (37.1%) than Hispanic (23.6%), white (22.4%), or Asian (13.8%) individuals. In logistic regression models adjusting for sex, state, long-term care status, and age group, African Americans with a primary diagnosis of depression were almost twice as likely as whites not to receive an antidepressant within the study period (odds ratio=1.91, 95% confidence interval=1.62-2.24). Patients in long-term care facilities and those aged 65 to 74 were less likely to receive treatment.

CONCLUSION

Substantial numbers of elderly Medicaid enrollees with a primary diagnosis of depression did not receive antidepressants or behavioral therapy. This gap in care disproportionately affected African-American patients.

A cross-sectional analysis of factors that influence the detection of depression in older primary care patients

OBJECTIVE

To determine the characteristics of depressed older patients whose mental health status is detected by their general practitioner (GP).

METHOD

Cross-sectional analytical design of 218 patients scoring above the cut-off (> or = 16) of the Center for Epidemiological Studies-Depression Scale (CES-D), from a sample of 916 consecutive patients aged 60 years or over attending one of 54 randomly selected GPs in Western Australia. Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about depressive symptomatology (CES-D). Following the consultation, general practitioners recorded the patient's presenting complaint(s), medication information, and mental health details on a patient summary sheet.

RESULTS

Among these 218 patients, 39.9% (87/218) were correctly classified as depressed by their GP. Detection of depressive symptomatology was associated with patients who acknowledged taking sleeping tablets (OR = 2.6, 95% CI = 1.3-5.4), had CES-D scores indicative of major depression (> or = 22) (OR = 2.8, 95% CI = 1.4-5.6) and were thought to be at risk for suicide (OR = 35.1, 95% CI = 4.5-274.2).

CONCLUSIONS

While GPs are most apt to detect depression among older patients with prominent mental health symptoms, many patients in this age group silently experience significant depressive symptomatology and miss the opportunity for effective treatment. The routine use of screening tools in primary care is recommended to enhance the detection rate of depression in older adults.

The Authority/Pharmacotherapy Care model: an explanatory model of the drug use process in primary care

BACKGROUND

Drug utilization studies have proliferated and many variants exist. Few models have been presented that account for all of the different types of studies and approaches.

PURPOSE

This article presents the Authority/Pharmacotherapy Care model, a structural-functional model of the drug use process that illustrates the factors involved in drug utilization and the relationships between factors. The concepts of authority and transfer of authority underlie the relationships.

METHODS

The drug use process is presented at the microlevel from the viewpoint of an individual who requires treatment with prescription drugs. The various categories of activity/authority (ie, level of patient care) are those of the individual, physician, pharmacist, patient, and drug. Influencing factors, both internal and external, impact upon each level of care. Three aspects must be considered at each level, which are structures, processes, and outcomes, according to Donabedian's model.

RESULTS

The result is a structural-functional model that depicts all of the major points in the drug use process, which might be used as a framework to categorize drug utilization studies.

CONCLUSIONS

This model may be used to represent the drug use process, identify the types of drug use studies, determine pertinent factors involved in the process, understand the relationships between factors, and help in evaluating drug use.

Effets indésirables des antidépresseurs chez le sujet âgé : analyse des notifications en France

The prescription of antidepressants in the elderly has changed since the marketing of new antidepressants such as selective serotonin reuptake inhibitors (SSRIs). We analysed the adverse effects associated with antidepressants in subjects aged > or =75 years reported to the pharmacovigilance centres in France. Among the 2381 cases recorded between 1985 and 2001, the distribution of adverse effects may reflect sales figures: 1040 for SSRIs (44%), 586 for tricyclic and related antidepressants (25%), 46 for monoamine oxidase inhibitors (2%) and 654 for other antidepressants (27%). Adverse effect patterns differed according to antidepressant class. For SSRIs, hyponatraemia was predominant (30%), followed by psychiatric (13%) and nervous system (10%) effects. For tricyclic antidepressants, psychiatric effects (confusion, agitation) [21%] were the most frequent followed by cardiovascular effects (15%). However, the consequences of adverse effects such as hyponatraemia are far from negligible in the elderly.