Primary care issues related to the treatment of depression in elderly patients.

Late-life depression is a serious public health problem and a concern for the primary care physician. Illnesses that often occur with aging may present in association with depression, which can interfere with patient compliance and recovery and worsen disease outcomes. Late-life depression is also associated with disproportionately high rates of completed suicide and high mortality rates independent of suicide. A shared therapeutic nihilism exists between many patients and physicians, who inappropriately accept major depression as normal and inevitable during advanced age and with related chronic disease states. Thus, the older depressed patient is too often not diagnosed and not treated. Furthermore, symptom overlap between depression, anxiety, and many chronic medical illnesses may confuse proper diagnosis. Therefore, screening for and diagnosing depression using an inclusive approach is highly recommended in the primary care setting and long-term care facility. Because of their improved safety, tolerability, and ease of dosing, newer generation antidepressants, such as the selective serotonin reuptake inhibitors, should be the first choice of treatment. Collaboration between primary and specialty providers is recommended, and referral to psychiatry is advised for patients with complex medical illnesses, comorbid psychiatric illness, suicidal ideation or intent, complicated medication regimens, and poor or no response to antidepressant therapy.