Prevalence of depression is high among older people, but is difficult to identify and often poorly managed. Screening tools can help to ensure early referral
Maria Jones, BSc, RN, is nursing sister, DAART (diagnostics, assessment and access to rehabilitation and treatment), Shropshire County PCT.
Jones M (2009) Using screening tools to identify the risk or presence of depression in older people. Nursing Times; 105: 49-50, early online publication.
Depression is a common mood disorder affecting at least 20% of older people and has been predicted to become one of the world’s most disabling illnesses.
Perhaps due to its wide range of signs and symptoms, the condition remains notoriously complex to diagnose, management is typically inadequate and its prognosis is bleak.
This article examines the use of screening tools for mild depression in those over 65 in primary care, to help determine whether screening would aid recognition and improve patient outcomes.
Keywords: Depression, Screening, Older people
- This article has been double-blind peer reviewed
- Risk factors for depression (Box 1) should be considered during assessment to help recognise patients who are at risk.
- Awareness of and observation for symptoms of the condition in older people is vital.
- When deciding which tools to use in practice, nurses should review the available screening tools and consider how user friendly they are.
It is well acknowledged that depression is widespread (Osborn et al 2003; Sharp and Lipsky, 2002) and is the most prevalent mental health problem for older people (Age Concern, 2007). The condition affects one in five people over 65 and rises to two in five in those over 85 (Mental Health Foundation, 2008).
A broad literature review focusing on depression screening in older people, which included both electronic and manual searches, highlighted four key issues:
- The problem - the prevalence of depression, its causes, difficulties in diagnosis, prognosis and the impact of the condition;
- Screening for depression – which tools are available? Arguments for and against the use of screening tools;
- Treatment - pharmacological and alternative approaches;
- The future - how can we improve the management of mild depression in primary care settings?
Murray and Lopez (1997) warned that by 2020, depression will be the world’s most disabling condition, secondary to cardiovascular disease. This suggests that by 2021, an astounding 3.5 million older people will be suffering with symptoms of depression, rising to five million by 2051 (Age Concern, 2007).
The causes of depression are so wide ranging that the surge in incidence predicted by Murray and Lopez (1997) seems understandable. Reasons for the onset of depression are broad and extensive and some are listed in Box 1.
The condition has far-reaching effects, which include individual suffering and economic costs to health and social services (Table 1).
Depression can also have a detrimental impact on family life, as relatives may need time off work to care for family members, which can put great strain on carers (Louch, 2008). The cost of the condition to society is another area of concern, partly due to informal care and growing medical costs (Louch, 2008). NICE (2009) estimates the economic cost of lost working days associated with depression to be £8bn in the UK.
Box 1. Possible causes of depression
- Previous history of depression
- A fall
- A fracture sustained from a fall
- Parkinson’s disease
- A familial history of depression
- Medications: beta-blockers, anti-hypertensives and sedatives
- Being widowed
- Marital separation
- Persistent relationship trouble
- Becoming victim of a criminal act
- Alcohol misuse
- A significant change in personal circumstances, such as retirement, moving house or empty nest syndrome
- Social isolation
- Nutritional deficiencies
- Low physical fitness levels
Table 1. Effects of depression
|Fatigue (key symptom)||Lack of enjoyment in life (key symptom)||General sadness (key symptom)|
|Insomnia||Social isolation||Lack of concentration|
|Poor appetite||Decreased self esteem|
|Weight fluctuations||Self harm|
|Feelings of despair and worthlessness|
Source: Mental Health Foundation (2007); Baldwin et al (2003)
Despite the significant problems caused by depression, it is well documented that the illness is poorly diagnosed and insufficiently treated (Louch, 2008). It is frequently encountered in primary care (Gilbody et al, 2003) and should be suspected if any two of the key symptoms or any of the other signs (Table 1) continue for at least two weeks (Mental Health Foundation, 2007).
So why does depression appear to be such a complex condition to diagnose? First, the main rationale for poor diagnosis in those over 65 appears to be due to the fact that emotions are rarely discussed during GP consultations (Sharp and Lipsky, 2002). Second, the typical GP consultation time is too brief for doctors to be able to identify mood problems (Sharp and Lipsky, 2002). Lastly, many GPs receive no extra training in the recognition and management of depressive disorders (Clinical Standards Advisory Group, 2000). These factors may explain why GPs may not detect depression, which suggests that screening aids may be a useful addition to support clinical judgement.
The literature review identified the prognosis of depression as extremely unfavourable. One longitudinal study on older patients with depression highlighted that almost 75% had died or had a long term, severe illness within the subsequent three years of onset of the mental illness (Denihan et al, 2000). This is a substantial figure, which highlights the poor outlook for undiagnosed people and again supports the use of a screening tool.
In addition, depression is known to increase disability, whether it is mild or major (NICE, 2009). This is a key point, as an increase in disability can affect people in numerous ways, for example, it could increase the length of time taken to rehabilitate following a fall purely as a result of depression. Furthermore, the suicide rate is one of the highest in older people, of which depression is the leading cause (Mental Health Foundation, 2007). Depression is therefore considered to be a significant, disabling illness that has an extremely detrimental impact on individuals, affecting multiple aspects of life, and carries the risk of incomplete recovery.
The five screening tools that were cited most frequently for patients with normal cognitive function are shown in Box 2.
A disadvantage of these tools is that they are self completed; a National Statistics report (2003) suggested that patients from lower socioeconomic groups underestimate symptoms associated with depression when completing self assessment questionnaires.
Other factors to consider when using self completion tools are that patients’ visual acuity and reading and writing skills need to be adequate to achieve accurate results. If patients are unable to complete the tools satisfactorily, healthcare professionals could be denied a true picture of their mental status. This would therefore support the use of assessment tools carried out by practitioners. However, it is common knowledge that extra paperwork for nursing staff is unpopular, and the only tools identified that were developed for staff to complete were those which assess the severity of depression, rather than aid diagnosis.
Box 2. Depression screening tools
- Beck Depression Inventory (BDI) (Beck et al, 1961)
- Patient Health Questionnaire (PHQ) (Kroenke et al, 2001)
- Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983)
- The Geriatric Depression Scale (GDS) (Yesavage et al, 1982)
- Zung Self Rating Depression Scale (ZSDS) (Zung, 1965)
Using screening tools
The HADS is recommended for use in patients who are medically unwell rather than the general population (National Institute for Mental Health in England et al, 2009). The ZSDS is aimed only at patients deemed to be at high risk of depression (Sharp and Lipsky, 2002), while the PHQ and BDI are unsuitable for those under 65 (Louch, 2008). In addition, cross cultural assessment is an area which warrants further attention if using an assessment tool, as the BDI, for example, has reduced value when used in certain cultures (Kerr and Kerr, 2001). Although these findings may decrease the popularity of screening tools, the literature review highlighted the GDS as the best universal assessment tool, which can be used with healthy patients and those who are medically unwell (National Institute for Mental Health in England et al, 2009).
The review of screening tools begs one key question: would improved recognition of depression lead to its enhanced management and improve patient outcomes? Despite recommendations for the GDS, there are arguments against using such a tool, including that the act of screening alone will not influence patient outcomes (Gilbody et al, 2005).
Gilbody et al’s (2008) review of randomised controlled trials, incorporating over 7,500 patients, revealed that routinely administered depression screens had little influence on identification of the condition.
NICE (2009) advocates being alert to possible depression, particularly in people with a past history of the condition and long term physical health problems with associated functional impairment. Determining which older people fall into these categories may prove time consuming for staff, so rather than apply a lengthy assessment tool, NICE (2009) recommends asking people who might have depression the following two questions:
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
However, such simple means of screening may not be the answer, as one large scale study demonstrated. Almost 14,000 people aged over 75 were assessed for depression using the GDS-15; the findings were compared with results from the same people assessed for depressive disorder using a single screening question, yet this question failed to detect depression in almost half of all cases (Osborn et al, 2003). This implies there may be problems detecting low mood using brief screening methods. However, a systematic review by Pignone et al (2002), which studied trials on recognising depression in primary care, highlighted that two-question screens are as valuable as lengthier assessment tools.
There are other reasons to use depression assessment tools. The complexity involved in merely diagnosing the condition supports their use (Sharp and Lipsky, 2002), while patients generally improve with earlier recognition of depression (Pignone et al, 2002). In addition, early recognition is driven by standard seven in the national service framework for older people (Department of Health, 2001), which prioritises the identification and management of depression. However, standard two of the NSF introduced the single assessment process (SAP), devised to enable assessors to perform a person centred, holistic assessment of older people (Osborn et al, 2003). It is therefore open to question whether an additional screening tool is necessary when the SAP already checks for low mood. However, the literature review found recommendations verifying that GDS or the HADS can be used in addition to the SAP to help assess mood status (DH, 2004).
To help decide which tool, if any, to use, nurses should consider helpful comments by Sharp and Lipsky (2002). They suggested that the patient/client group, the user friendliness of the tool and the time needed to complete it should all be taken into account when deciding to use either a two-question screen or a longer screening aid.
Antidepressants: While depression is a treatable problem and the most widespread reversible mental illness (Anderson, 2001), the literature review revealed it is poorly managed.
It is important to remember that antidepressants are not the only treatment option. In fact, NICE (2009) says these drugs should not be used routinely to treat persistent subthreshold symptoms or mild depression because the risk–benefit ratio is poor, although they should be considered for certain patients in these groups (see guidance for full details).
For those prescribed antidepressants, the literature suggests the dosage is frequently inadequate (Clinical Standards Advisory Group, 2000). This may be a contributing factor in treatment failure (Denihan et al, 2000) especially if patients experience medication side effects. In addition, older people who are believed to be depressed are less likely to be offered treatment as depression is frequently associated with the ageing process (Mental Health Foundation, 2007). However, this is incorrect; old age does not cause depression (Age Concern, 2007).
Alternative treatment: in the UK, many patients are treated with antidepressant medication, but a greater number are in need of an alternative form of intervention (Singleton and Lewis, 2003). Alternative forms of treatment for persistent subthreshold symptoms and mild to moderate depression include (NICE, 2009):
- Advice on sleep hygiene;
- Active monitoring (which includes arranging a further assessment, normally within two weeks);
- Low intensity psychosocial interventions (one or more of individual guided self help, computerised cognitive behavioural therapy and/or a structured group physical activity programme).
In addition to these strategies, the use of exercise to combat depression is well supported due to its effects on enhancing mood, improving cognitive function and reducing anxiety; it is also less expensive than medication (Louch, 2008). However, a Cochrane review on the use of exercise to treat depression established that although it helped to improve symptoms, it was not clear which form of exercise is beneficial or how useful it is at alleviating depressive (Mead et al, 2008). The evidence therefore indicates that exercise on prescription is an area which warrants further exploration as its effectiveness remains unclear.
Despite NICE (2009) guidance recommending giving sleep hygiene advice, literature on this subject was extremely limited.
While alternatives to pharmacological management of depression exist, the literature showed that not all GPs are aware of specific therapies for mental health problems, and indistinct referral pathways can prevent patients being referred for psychological therapy (Clinical Standards Advisory Group, 2000). Gilbody et al (2005) argued that alternative interventions are not effective in enhancing patient outcomes by themselves, and recommended a form of collaborative care.
Improving the management of mild depression
Having analysed the impact of depression, the problems surrounding its diagnosis and treatment options, the ideal form of management for mild depression in primary care settings was reviewed. The literature review concluded with many recommendations for collaborative care (Gilbody et al, 2005; Unutzer et al, 2002), which appears to be the way forward in terms of treating depressive disorders.
Collaborative care is a model for managing depression: the programmes vary but the concept remains the same (Baldwin et al, 2003). It may involve enhanced patient supervision by a primary care mental health lead plus problem solving treatment and antidepressant management (Unutzer et al, 2002). The key component is that depression is managed via multiple interventions rather than with one single method.
Unutzer et al’s (2002) study of 1,800 people highlighted almost half of patients on such a programme experienced improved outcomes with more satisfaction in the care they received and a reduction in symptoms of low mood. Katon et al’s (1999) smaller scale study on 228 moderately depressed patients on the collaborative care scheme, indicated a greater recovery rate from depression, compared with those who were receiving anti-depressant therapy only.
NICE (2009) guidance recommends combining drug treatment and psychological therapy for people with moderate and severe depression, however, additional to this, this review reveals evidence of benefit also in cases of mild depression.
Depression is a great cause for concern for both individual patients and for society. Nurses therefore play a vital role in helping to recognise the condition and refer older people who show signs of the condition for further intervention. Screening may be in the form of an appropriate depression assessment tool or with the simpler two-question screen approach.
The evidence presented in this review has highlighted, after depression has been diagnosed, it is crucial for patients to be referred to a collaborative care scheme if we are to enhance our quality of care and see effective intervention with improved patient outcomes.
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