Management of depression in the elderly by general practitioners: I. Use of antidepressants

Abstract

Depression is a common problem in the elderly but studies have suggested that it is often inadequately treated by general practitioners (GPs). This study aims to investigate how GPs manage depression in the elderly. A national questionnaire study on the management of depression in the elderly was carried out. Case vignettes were used to investigate how GPs manage depression and what influenced their decision making process. Each case vignette had a factor complicating the use of the older tricyclics. The questionnaire was completed by 407 out of 667 GPs (61%). Many GPs chose the newer antidepressants but a substantial proportion preferred the older tricyclics. Many GPs selected subtherapeutic doses, particularly of the older tricyclics. Few GPs said they maintained patients on antidepressants for more than 3 months after recovery and only 1 in 12 continued antidepressants for over 6 months. If these results reflect GPs practice there is a danger that many patients will be inadequately treated and also at risk of relapse because of their antidepressants being stopped too soon after recovery.

A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression

“…TAU was as close to standard care as possible and required that the actual management of depression was carried out by General Practitioners (GPs) in the community using standard service delivery models. TAU could include involvement of GPs, Community Psychiatric Nurses and other mental health services as individual circumstances dictated, consistent with reports in the literature (Orrell et al, 1995;Rothera et al, 2002). TAU could include any combination of physical treatment for depression, such as prescription of antidepressant medication, physical review, and referral for non-counselling interventions by Community Psychiatric Nurse teams or other services (e.g.…”

“…Treatment is usually antidepressant medication, however fears about side-effects of medication on older people often result in the prescription of medications at sub-therapeutic levels (Orrell et al, 1995;Nelson, 2001;Birrer and Vermuri, 2004).…”

The impact of the Defeat Depression campaign

“…GPs who were unaware of the campaign also appeared to be less knowledgeable about the management of depression. To some extent, at least in its first year, the campaign may have been preaching to the converted rather than reaching the majority of doctors in primary care or geriatric medicine, many of whom also have a clear and expressed need for more training In the treatment of depression in the elderly (Collins et al 1995;Orrell et al 1995b). However, it is also possible to argue that 40% awareness among GPs is not a bad start and that awareness should be increasing as the campaign continues.…”

“…A large opinion poll in December 1991 found that only 16% of the public felt that people with depression should be offered antldepressants (Vize & Priest, 1993). Many GPs fail to treat depression in the elderly {Macdonald, 1986) and are reluctant to keep patients on antidepressants for more than 3 months even though maintenance treatment with antidepressants considerably reduces the risk of relapse (Orrell et al 1995o). This suggests a need for a better awareness of treatment for depression among GPs.…”

An examination of the attitudes and practice of general practitioners in the diagnosis and treatment of depression in older people

“…Attitudes to ageing, previous experience and training may influence the type of treatment the older person receives. Earlier studies Orrell et al, 1995), using case vignettes and examining attitudes to ageing have shown that, not only do older GPs tend to perceive late-life depression as being difficult to treat but that medication is often stopped soon after recovery. GPs also identified a need for further training in the management of late-life depression.…”