• Therapy? 25 February 2019 | View comments

  • 25th February 2019 | By David Jolley

    It is refreshing to find an article in the national news which is about older people but does not rehearse the statistics of what a burden we are, and addresses depression, which is something which can affect the lives of people with dementia or without dementia.

    Denis Campbell’s article from February 12th www.theguardian.com/society/2019/feb/12/too-many-older-people-given-antidepressants-instead-of-therapy highlights a systematic review from Rachel Frost and colleagues based in University College London and Bristol University. This considered 1471 papers published since 1806 looking at the issue of how older people who are recognised as being depressed, are managed by primary health care staff. Depression is common in old age and older people are present in ever increasing numbers – So this is a Big Issue. Depression is associated with reduced quality of life and with increased mortality, cognitive decline, functional decline and use of health services (ah – burden finds its way in!).

    The systematic review was limited to qualitative studies and relies on detailed analyses of only 27 papers which were deemed to meet inclusion criteria.

    It is accepted that many people with depression or other mental health problems do not have their condition recognised. Amongst those where primary care recognises their depression almost 90 percent receive a prescription of an antidepressant. This is not deemed good by the authors of the 27 papers, nor the authors of the systematic review. They see depression in older people as ‘understandable’ in terms of the social, physical health and psychological experiences of being old. Therapy should avoid medicalisation of such an understandable condition. Their preferred answer is referral to Improving Access to Psychological Therapies (IAPT) https://www.england.nhs.uk/mental-health/adults/iapt/. The rage is that people age 85 and over are five times less likely to be referred to IAPT than are younger people.

    The healthcare professionals who have contributed views to the 27 papers feel this is wrong. But they are the very people who determine when referrals might be made. Odd isn’t it?

    But there is something strange about the whole paper and the newspaper take on it: No-one can be against supporting practice which encourages clinical staff to listen to patients, gather a proper history and understand who the person is that they have the privilege to be serving, and the factors which are contributing to their difficulties. We do this for people with any symptoms – including those who have dementia. And we use this knowledge in formulating with them and their families, a strategy to try to help them become well.

    The number of older people with depressive symptoms is such that this will always be done in primary care, with referral to specialist reserved for people where symptoms are most severe, dangerous or puzzling. The proposition that the only best practice is referral to a super-specialist, nonmedical service like IAPT is hard to support.

    Toward the end of the systematic review we read:

    ‘When nothing else could be offered, GPs and community nurses tended to provide support themselves to the older person in various ways, or prescribe antidepressants.’

    The only thing wrong with that observation is that ‘or prescribe’ would be better said: ‘and prescribed’. In the management of people with dementia, we should never give up on understanding and working with our knowledge of the patient and their family – but it would be wonderful to have a medication which could be as effective as antidepressants are, to add to our basic therapies.

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