Depression predicts a wide range of negative health outcomes for older adults, including reduced life expectancy. Research has shown that antidepressant medication is often an effective treatment for major depressive disorder (MDD), but its efficacy is less clear for other depressive disorders. Evidence suggests that a combination of psychotherapy and antidepressant medication is generally most effective for the treatment of depression. A trend analysis showed that, from 1992 to 2005, the rate of depression diagnosis and the use of antidepressants increased among community-dwelling older adults, while participation in psychotherapy sharply declined (Akincigil et al., 2011).
The analysis was based on data from the Medicare Current Beneficiary Survey, an ongoing and representative sample of Medicare users. The Survey gauged rates of diagnosis and treatment of depression within the sample. The data available were the coded medical claims reported to Medicare, which provided the clinical assessments and prescribed treatments of almost 40,000 Medicare recipients from 1992 to 2005. Diagnoses included MDD, depressive psychosis, dysthymic disorder (chronic depressive mood with less clinical severity than MDD), depressive adjustment disorder (a clinically relevant depressive response to a life stressor), and depressive disorders NOS (not otherwise specified).
During this period of time (1992 to 2005), the rate of depression diagnosis nearly doubled within the sample, with about one quarter of diagnosed individuals receiving a diagnosis of MDD throughout. When controlling for demographic, socioeconomic, and health status (all of which changed over time), the odds of a diagnosis of depression actually more than doubled. While different subpopulations showed different rates of diagnosis, this increase was found across groups. For instance, 3.3 percent of whites within the sample were diagnosed with depression (from 1992 to1995) and 6.6 percent received a diagnosis of depression (from 2002 to 2005). African-Americans, however, were less likely to be diagnosed with depression at each measured time interval (from1992 to1995 and from 2002 to 2005) but saw a similar increase of diagnosis overall—from 2.7 percent to 4.8 percent. The analysis shows disparities across subpopulations—men and women, rural and urban, and different ethnic groups—that require further study (including information on the diagnosis process).
The rates of antidepressant use showed a similar trend, as 7.3 percent of all older adults, regardless of diagnosis, used antidepressants from 1992 to 1995, while 15.3 percent did so from 2002 to 2005. This was not wholly explained by the increase in depression diagnosis: the proportion of diagnosed individuals who were given antidepressants rose from 53.7 percent to 67.1 percent. At the same time, the proportion of diagnosed individuals who were given psychotherapy declined from 26.1 percent to 14.8 percent. Thus, there was a slight increase in the proportion of diagnosed individuals receiving some form of treatment (64.6 percent to 71.4 percent), however, this was overwhelmingly due to increased use of antidepressants. Combined psychotherapy and antidepressant treatment actually declined over this period, particularly among males: 18.9 percent of males with a depressive diagnosis from 1992 to 1995 received both antidepressants and psychotherapy, while only 8.1 percent did so from 2002 to 2005.
While these statistics were insufficient to determine which persons within the sample would have been best cared for with combined treatment, research suggests that this balanced approach is particularly effective with older adult depression. Thus, these findings suggest that there are missed opportunities for the most effective treatment of depression.
In addition, there were many changes made in the treatment of depression within the Survey time period. For instance, new antidepressant medications with lower rates of side effects were more widely available; Medicare reimbursement practices changed; pharmaceutical companies marketed their products to consumers more vigorously; and cultural attitudes about depression and its treatment changed. The article notes that trends in the diagnosis and treatment of depression have been similar in younger populations, for whom changes in health care led to reduced access to psychotherapy. This study is a useful documentation of changes in the treatment and diagnosis of depression among older adults and raises important questions for researchers.
