Ageing well: preventing the onset of depression in older people
Professor Simon Gilbody, Director of Mental Health and Addictions Research Group (MHARG), University of York
Depression is a serious disorder which can affect people of any age. However treating and preventing the condition in older age is especially challenging.
Some aspects of older age increase the chances of developing depression. The condition is often triggered by life transitions such as retirement and bereavement. Loneliness is common in elderly people and those without social support are at the greatest risk.
Physical health problems are also a factor, with around 60% of older people reporting one or more long term health conditions such as diabetes, heart disease or arthritis. When depression occurs alongside these health conditions levels of disability and pain are often greater and research shows a person’s life expectancy can be reduced.
A silent killer
Despite this, depression among older people often goes un-recognised. Many older people do not report their symptoms or they communicate low mood through worsening physical symptoms or increased reports of pain, meaning carers and healthcare professionals do not always pick up mood symptoms. What is most troubling is that depression is often seen as an inevitable consequence of growing old. This is unfortunate since good treatments exist.
An ounce of prevention is worth a pound of cure
We launched the CASPER study – the largest ever trial of a psychological approach to prevent the onset of clinical depression amongst older people. Our study, funded by the NIHR Health Technology Assessment Programme (HTA), identified older people with early or lower severity symptoms of a risk of depression. These people showed signs of subthreshold depression, when two or three depressive symptoms are present such as sleep disturbance, loss of appetite, or loss of pleasure, but fall short of clinical depression. We offered eight sessions of structured psychological support. Research told us this was a good place to start since the risk of depression developing in the next 12 months is up to four times more likely for people with subthreshold depression.
What we found in the CASPER trial
We recruited 705 pensioners aged 65-99 from 32 GP practices for our randomised trial. Participants received eight sessions of structured psychological support. They were allocated to receive either behavioural activation – a treatment which explores how physical health problems and low mood are linked – while the other half received GP care according to the play of chance.
At start of the trial we found that lower severity symptoms were associated with higher than expected levels of anxiety and reduced quality of life. Participants received on average six telephone sessions. Many accepted the offer of the first session face to face. When we followed patients up after four months there were significant reductions in levels of depression and anxiety and improvements in quality of life and function. After twelve months, we found that all these benefits were maintained. Our most interesting finding was that the risk of onset of clinical depression at 12 months had halved. To our knowledge this was the first time this had been demonstrated in elderly people.
Reflections on CASPER – where do we go from here?
NHS services currently do not generally offer psychological treatments for older people with depression in primary care. The expansion of psychological therapy services in the NHS (the IAPT programme) has largely focussed on working age adults. The results of the CASPER trial support the value of psychological approaches and provide an alternative to drug based treatments for older people with subthreshold symptoms. Our companion trial, CASPER-PLUS, uses a similar psychological approach in people with already established depressive illness. Both studies will be helpful in informing the provision of care for older people.
NHS services currently place greater emphasis on the treatment of depression rather than prevention. The results of the CASPER trial represent compelling evidence of the value of preventative approaches. This will be challenging and requires investment and re-orientation of services.
Further research is needed to look at the longer term impact of approaches such as those we were funded to investigate by NIHR. Our concurrent economic evaluation showed positive evidence that preventative approaches represent value for money for the NHS. In the short term the treatment of lower severity depressive symptoms was good value for money (comparable with many things the NHS chooses to fund) costing less than £10,000 per Quality-Adjusted Life Year (QALY).
*CASPER was published in the Journal of the American Medical Association (JAMA).
Read more about the trial in the NIHR Journals Library.
**The NIHR has launched new mental health funding opportunities into the promotion of good mental health and the prevention or treatment of mental ill health. More information and details of how to apply are available on our website.