PERS PE C T IV E
Disclosure forms provided by the authors 1. Gould E, Wething H, Sabadish N, Finio N.
are available with the full text of this article
at NEJM.org.
From the Robert Wood Johnson Founda-
tion Health and Society Scholars Program,
University of Pennsylvania, Philadelphia
(B.S.); the Department of Healthcare Policy
and Research, Virginia Commonwealth Uni-
versity, Richmond (L.S.); and the Depart-
ment of Health Policy and Management,
Harvard School of Public Health, Boston
(B.D.S.).
Diagnosing Depression in Older Adults in Primary Care
Ramin Mojtabai, M.D., Ph.D., M.P.H.
T he prevalence of diagnosed
depression in U.S. adults 65
years of age or older doubled
from 3% to 6% between 1992
and 2005.1 A majority of pa-
tients with diagnosed depres-
sion were treated with antide-
pressant medications by primary
care and other general medical
clinicians.1 Several factors prob-
ably contributed to this trend,
including publicity regarding
the extent of underdiagnosis
and undertreatment of depres-
sion in older adults, aggressive
pharmaceutical marketing ef-
forts targeting providers and
consumers, and the introduction
of new antidepressants. A ma-
jority of the people diagnosed
with depression in primary care
settings, however, do not meet
the diagnostic criteria for major
depressive disorder.2
This conclusion is supported
by data from two sets of national
surveys conducted between 2005
and 2010 examining the preva-
lence of major depressive epi-
sodes (as defined by the Diagnos-
tic and Statistical Manual of Mental
Disorders, fourth edition [DSM-
IV]) at any time in the previous
year, clinicians’ diagnoses of de-
pression in the previous year,
1180
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Copyright © 2014 Massachusetts Medical Society. All rights reserved.
4. Goldman DP, Joyce GF, Zheng Y. Prescrip-
What families need to get by: the 2013 up-
date of EPI’s budget calculator. Issue brief
no. 368. Washington, DC: Economic Policy
Institute, July 3, 2013.
2. Manning WG, Newhouse JP, Duan N,
Keeler EB, Leibowitz A, Marquis MS. Health
insurance and the demand for medical care:
evidence from a randomized experiment.
Am Econ Rev 1987;77:251-77.
3. Remler DK, Greene J. Cost-sharing: a blunt
instrument. Annu Rev Public Health 2009;
30:293-311.
and current use of antidepres-
sants (see graphs). Like other
epidemiologic studies, these data
indicate that depression is sig-
nificantly less prevalent among
older adults than in other age
groups. The number of antide-
pressant prescriptions, however,
does not match this trend. Al-
though antidepressants are pre-
scribed for various diagnoses,
research indicates that almost
two thirds of prescriptions are
for a clinician-diagnosed mood
disorder. The correspondence be-
tween clinicians’ diagnoses and
diagnoses based on structured
interviews is significantly poorer
in older adults than in younger
adults (see graph, Panel B). Only
18% of older adults with a clini-
cian’s diagnosis of depression
meet the diagnostic criteria for a
major depressive episode on the
basis of a structured interview.
Clinical studies have similarly
shown that less than one third of
older adults with major depres-
sion diagnosed by primary care
clinicians also meet the diagno-
sis of major depression according
to structured interviews or rating
scales.3
It’s difficult to diagnose de-
pression in primary care set-
n engl j med 370;13 nejm.org march 27, 2014
Pinching the Poor?
tion drug cost sharing: associations with
medication and medical utilization and
spending and health. JAMA 2007;298:61-9.
5. Wright BJ, Carlson MJ, Allen H, Holmgren
AL, Rustvold DL. Raising premiums and
other costs for Oregon health plan enrollees
drove many to drop out. Health Aff (Mill-
wood) 2010;29:2311-6.
DOI: 10.1056/NEJMp1316370
Copyright © 2014 Massachusetts Medical Society.
tings, especially in older adults.
Sleep problems, fatigue, and low
energy levels associated with
medical conditions often mimic
depressive symptoms. Further-
more, losses of friends and loved
ones and a shrinking social net-
work in old age result in dimin-
ished social involvement, which
is a common feature of depres-
sion. These problems of old age
are sometimes difficult to distin-
guish from depressive symp-
toms.
The challenge of correctly
identifying depression in primary
care is compounded by the fact
that depressed patients seen in
these settings have less-clear-cut
symptom profiles than those
seen in specialty mental health
settings, mainly because their
symptoms are less severe or dis-
abling. Some patients diagnosed
with depression in primary care
may meet the criteria for dysthy-
mia or adjustment disorder with
mood symptoms. Others may
have mild depressive symptoms
that don’t reach the threshold for
diagnosis of major depressive
disorder. Many such patients
would benefit from supportive
counseling or lifestyle modifica-
tion. In some cases, watchful
PE R S PE C T IV E Diagnosing Depression in Older Adults

physical health. To maximize

A
20
benefit from treatments, howev-
18 Met criteria for Currently taking
er, the accuracy of depression di-
major depressive antidepressant agnosis in these settings must be
16 episode medication
improved, especially as applied
14
to older adults. Over the years,
Prevalence (%)
12
various approaches to improving
10
primary care diagnosis and treat-
8
ment of depression have been pro-
6
posed, including use of screening
4
measures, implementation of inte-
2
grated care models, and stepped-
0
18–25 26–34 35–49 50–64 ≥65 care approaches.4,5
Age (yr) Routine use of screening in-
struments is controversial. In
B 2009, the U.S. Preventive Services
7
Told by a clinician they had Told by a clinician they had Task Force recommended screen-
6 depression; met criteria for depression; did not meet criteria ing for depression when “staff-
major depressive episode for major depressive episode
assisted depression care supports”
5 — staff who can provide care co-
ordination, follow-up planning,
4
Prevalence (%)

mental health referrals, psycho-

3 education, and sometimes psy-
chotherapy — are in place. More
2 recently, the Canadian Task Force
on Preventive Health Care ad-
1
vised against routine screening
0
because of the lack of high-qual-
18–25 26–34 35–49 50–64 ≥65 ity data supporting its benefits
Age (yr) and concerns about increased
Prevalence of Major Depressive Episodes in Relation to Antidepressant-Medication Use
rates of false positive diagnoses
and Clinician-Diagnosed Depression, 2005–2010. and unnecessary treatment. Staff-
The prevalence of major depressive episodes at any time in the previous year is shown assisted depression care supports
in relation to the use of antidepressant medications (Panel A) and to the prevalence of are also essential to integrated
depression diagnosed by a clinician in the previous year (Panel B). Major depressive models of depression care, which
episodes are as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth require greater access to mental
edition. I bars indicate 95% confidence intervals. Data on major depressive episodes and
clinician-diagnosed depression are from the U.S. National Survey on Drug Use and
health specialists than is available
Health (https://nsduhweb.rti.org/); data on antidepressant use are from the U.S. in many primary care settings.
National Health and Nutrition Examination Survey (www.cdc.gov/nchs/nhanes.htm). Stepped-care models represent
a nuanced approach to diagno-
waiting with regular follow-up less robust. Exposing older adults sis and treatment of depression
may be appropriate. Yet the ma- to antidepressants in the absence in which symptoms of varying
jority of primary care patients di- of evidence for benefit raises severity and duration are matched
agnosed with depression are sim- safety and ethical concerns. with appropriate intervention
ply prescribed antidepressants.2 Nonetheless, many patients options. The 2009 guidelines is-
Although there is good evidence with depression and other com- sued by the U.K. National Insti-
for antidepressants’ efficacy in mon mental disorders are treated tute for Health and Clinical Ex-
major depressive disorder — in general medical settings, and cellence (NICE) (www.nice.org.uk/
­especially when it’s severe — the there’s some evidence that treat- nicemedia/live/12329/45888/45888
evidence for efficacy in less-­ ing depression in patients with .pdf) represent one such approach.
severe cases and for “subthresh- physical health conditions might As a first step, these guidelines
old” depressive symptoms is much positively affect both mental and recommend assessment, support,

n engl j med 370;13 nejm.org march 27, 2014 1181

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Copyright © 2014 Massachusetts Medical Society. All rights reserved.
PERS PE C T IV E
and psychoeducation for patients
with all “known and suspected
presentations of depression.” Cli-
nicians are advised to be alert to
possible depression in patients
with a history of the illness or
chronic physical health problems
associated with functional im-
pairment. Clinicians are to con-
sider asking patients with possi-
ble depression whether they’ve
had depressed mood or loss of
interest in daily activities in the
past month. A positive response
on either count should be fol-
lowed by a fuller assessment of
the severity and duration of symp-
toms and functioning, if the cli-
nician is competent in conduct-
ing such an assessment (see the
Supplementary Appendix, avail-
able with the full text of this ar-
ticle at NEJM.org). The guide-
lines also advise clinicians to
consider using validated mea-
sures of symptoms and function-
ing; the Patient Health Question-
naire 9 is one such validated and
widely used measure that cap-
tures the DSM-IV criteria for a
major depressive episode (http://
phqscreeners.com/pdfs/02_PHQ-9/
English.pdf). If the clinician is
not competent to conduct such
an assessment, the patient may
be referred to a mental health
professional for assessment.
Step 2 involves management
of persistent subthreshold depres-
sive symptoms and mild-to-mod-
erate depression (see the Supple-
mentary Appendix for definitions
of levels of depression). NICE
recommends active monitoring,
including psychoeducation and
follow-up in 2 weeks for sub-
threshold depressive symptoms
that may remit without formal
treatment. Active monitoring may
also be appropriate for patients
1182
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Copyright © 2014 Massachusetts Medical Society. All rights reserved.
Diagnosing Depression in Older Adults
with mild depression who aren’t
interested in more intensive treat-
ment. For these patients, NICE
also recommends “low-intensity
psychosocial interventions,” which
include individual guided self-
help based on the principles of
cognitive behavioral therapy, com-
puterized cognitive behavioral
therapy, and structured group
physical activity (see the Supple-
mentary Appendix).
The guidelines discourage rou-
tine use of antidepressants for
persistent subthreshold depres-
sive symptoms or mild depres-
sion. However, clinicians may
consider these medications for
patients with a history of mod-
erate or severe depression, sub-
threshold symptoms lasting
2 years or longer, and subthresh-
old symptoms or mild depression
that persists after low-intensity
psychosocial interventions. Medi-
cations (typically selective sero-
tonin-reuptake inhibitors) or
high-intensity psychosocial inter-
ventions, such as individual cog-
nitive behavioral therapy or in-
terpersonal therapy, alone or
combined with medications, may
be considered as a third step for
patients with no response to low-
intensity psychosocial interven-
tions and those with moderate-
to-severe depression. When
medication has been started, the
guidelines recommend continu-
ing it at a therapeutic dose for at
least 6 months after remission of
an episode.
The fourth step involves men-
tal health referral for patients with
high risk of suicide, psychotic
symptoms, or complex, severe de-
pression whose management re-
quires expert knowledge. There is
some evidence that when it’s cou-
pled with organizational changes
n engl j med 370;13 nejm.org march 27, 2014
The New England Journal of Medicine
such as the addition of support
staff, training of clinicians in us-
ing practice guidelines such as
NICE’s can improve outcomes of
depression care in general. Imple-
menting these guidelines, how-
ever, may require extended and
more frequent visits, which may
be difficult to accommodate in
many primary care settings.
With the looming shortage of
geriatric mental health care pro-
viders, general medical clinicians’
role in managing older adults’
mental health problems will
probably increase. A nuanced ap-
proach to depression diagnosis
and treatment may improve the
management and outcome of
geriatric depression in primary
care settings. Incorporating the
stepped-care approaches into gen-
eralists’ training and making low-
intensity psychosocial interven-
tions more widely available may
help prepare clinicians to more
effectively meet future needs.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
From the Department of Mental Health,
Bloomberg School of Public Health, and the
Department of Psychiatry and Behavioral
Sciences, School of Medicine, Johns Hop-
kins University, Baltimore.
1. Akincigil A, Olfson M, Walkup JT, et al.
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older community-dwelling adults: 1992-2005.
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2. Mojtabai R. Clinician-identified depres-
sion in community settings: concordance
with structured-interview diagnoses. Psy-
chother Psychosom 2013;82:161-9.
3. Mitchell AJ, Rao S, Vaze A. Do primary
care physicians have particular difficulty
identifying late-life depression? A meta-anal-
ysis stratified by age. Psychother Psychosom
2010;79:285-94.
4. Williams JW Jr, Noël PH, Cordes JA,
Ramirez G, Pignone M. Is this patient clini-
cally depressed? JAMA 2002;287:1160-70.
5. Batstra L, Frances A. Holding the line
against diagnostic inflation in psychiatry.
Psychother Psychosom 2012;81:5-10.
DOI: 10.1056/NEJMp1311047
Copyright © 2014 Massachusetts Medical Society.