|
Depression study
Isolation is leading to unhappiness
The UK population aged 65 and over has increased dramatically and the proportion of very old people
continues to grow1. In community studies2 depression is present in 12 to 15 per
cent of these, and almost twice that number in those attending their GPs, those who are physically ill
and those in institutional care3.
Such depression carries burdens in terms of associated mortality, carer burden, and increased use of
health and social service facilities4 as well as loss of functional ability comparable to
that found in chronic physical illness5. It also tends to persist, with about 50 per cent of
people remaining depressed over a period of years6. Though depression in old age can respond well to the
same range of physical or psychological treatments as depression earlier in life7, 8, there is evidence
of failure by GPs to diagnose, record or treat it9.
Our own study10 revealed that only 10 per cent were given antidepressants, despite significantly higher
rates of GP and secondary-care consultation. Newer antidepressants may make such treatment more feasible
in practice because of their reduced number of contraindications, drug interactions and side-effects.
Several screening scales exist to detect depression in old age. Improving detection rates does not
appear to be the whole answer however: While it might seem self-evident that a screening programme
would increase recognition and treatment of the condition, this is not always the case. Screening for
depression in older people in general practice, with feedback of results to the GP, has been found to
have no impact on subsequent treatment11. Similarly, publication of guidelines alone has little effect
on outcome12. A recent Cochrane review found that even 'owned' guidelines, created through a local
consensus process, was not effective in improving the delivery of services to manage common conditions
in primary care13.
In contrast, most studies suggest that a concerted, educational intervention, aimed at ensuring good
practice through guideline implementation, leads to constructive changes in primary care practice and
sometimes to measurable patient benefits14.
Encouraged by this, we evaluated the feasibility and efficacy of a nurse-led, interactive, intervention
package (including an information pack) designed in consultation with a GP and practice nurse panel,
focusing on primary care professionals' attitudes, knowledge and practice relating to depression in old
age10. Disappointingly, most practices approached (105/121; 87 per cent) did not, despite our intensive
efforts, agree to participate. Our strong impression was that most GPs perceived themselves as being under
extreme work pressure and were understandably reluctant to give up their time. A further factor may have
been that the direct contact was from a nurse, rather than a doctor.
Even among those practices agreeing to participate (where the GPs might be expected to be particularly
interested in the subject matter), attendance at the session was poor. Among individual GPs, questionnaires
were also completed only erratically.
Similarly, a recent overview emphasised consistently disappointing results in attempts to change
and standardise management of younger patients with depression in primary care context15. In
particular it showed failure to change detection or outcome even when a programme conforms to
good educational principles and is well received by practitioners who have self-selected to participate
and have high interest16. Education alone does not appear to be enough in this complex area.
Some positive findings did emerge from our study. There were clear differences in attitude between
doctors and nurses, suggesting that nurses were less confident and more reluctant to recognise the
biological component to depression in old age and its potential responsiveness to treatment. This
emphasises the possibility of educational intervention specifically targeted to nurses. Similar conclusions
have been reached in a report of a nurse-run clinic for depressed people in primary care17.
In a Cochrane review of randomised, controlled trials of interventions in healthcare practice in different
settings and conditions, audit and feedback have been identified as having the potential to change the
practice of healthcare professionals; feedback being defined in this context, as a summary of clinical
performance over a specified period of time.
The detection and management of depression in older people in primary care may be improved by education,
audit and feedback. This is a very productive area for primary care-led health improvement programme
initiatives within health authorities and Primary Care Trusts.
Dr Gill Livingston and Professor Cornelius Katona, Department of Psychiatry and Behavioural Sciences,
Royal Free and University College Medical School, London
References
1 OPCS 1991. National Population Projections: Mid-1989 based. OPCS Monitor p. 291. London, HMSO.
2 Beekman ATF, Copeland JRM, Prince MJ. Review of community prevalence of depression in late life. Br J Psychiatry 1999; 174: 307-311.
3 Katona C and Livingston G (1997) Comorbid depression in older people. London, Martin Dunitz.
4 Livingston G, Manela M and Katona C. Cost of community care for elderly people. Br J Psychiat 1997; 171: 56-59.
5 Wells KB, Stewart A, Hays RD et al. The functioning and well-being of depression of depressed patients. Results from the Medical Outcome Study. JAMA 1989; 262: 914-919.
6 Livingston G, Watkin V, Milne B, Manela M and Katona C. The natural history of depression and the anxiety disorders in older people J Aff Dis 1997; 46: 255-262.
7 Mittman N, Hermann N, Einarson TR et al. The efficacy, safety and tolerability of antidepressants in late-life depression: a meta-analysis. J Aff Dis 1997.
8 Koder DA, Brodaty H and Anstey KJ. Cognitive therapy for depression in the elderly. Int J Geriat Psychiatry 1996; 11 57-61.
9 Mullan E, Katona P, D'Ath P, Katona C. Screening, detection and management of depression in elderly primary care attenders. 2. Detection and fitness for treatment: a case record study. Family Practice 1994; 12: 267-270.
10. Katona CLE, Manela M, Livingston G. Comorbidity with depression in older people: the Islington study. Ageing and Mental Health 1997: 1; 57-61.
11 Iliffe S, Mitchley S, Gould M and Haines A (1994) Evaluation of the use of brief screening instruments for dementia, depression and problem drinking among elderly people in general practice. British Journal of General Practice 44: 503-507.
12 Haines A and Feder G (1992) Guidance on guidelines. British Medical Journal 305: 785-786.
13 O'Brien T, Oxman AD, Davis AD, Haynes RB, Freemantle N and Harvey EL Audit and feedback strategies: effects on professional practice and health care outcomes The Cochrane library 2000 Issue 1: 1-11.
14 Grimshaw J and Russell I (1993) Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 342: 1317-1322.
15 Livingston G, Yard P, Beard A and Katona C (2000) A nurse co-ordinated educational initiative addressing primary care professionals? attitude to and problem-solving in depression in older people- a pilot study. International Journal of Geriatric Psychiatry 15: 401-405.
16 Kendrick T (2000) Why can't GPs follow guidelines in depression? BMJ 320: 200-1.
17 Thompson C, Kinmouth AL, Stevens L et al (2000) Effects of a clinical-practice guideline and practice -based education on detection and outcome of depression in primary care: the Hampshire depression project randomised controlled trial Lancet 355: 185-91.
18 McCullagh M and Gardner S (2000) Can primary care improve care for depressed patients Letters BMJ 320: 1603.
|