Depression Care May Extend Lives of Elderly Patients

At age 91 “Earl” was in remarkably good health and excited about attending his 70th college class reunion. He was particularly looking forward to seeing his old college friend “Frank” there. During the reunion, however, Frank died, and Earl became extremely depressed. Eight months later Earl died as well. Would Earl have lived closer to the century mark or even beyond if he had not been depressed?

Depression in older individuals has been strongly linked with an increased risk of dying from various medical illnesses (Psychiatric News, October 18, 2002). Also, several studies have suggested that treating older persons' depression can extend their lives.

One was the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHED) trial. It found that use of a selective serotonin reuptake inhibitor was associated with a reduction in death over a 40-month period. The other was the Sertraline Anti-Depressant Heart Attack Randomized Trial (SAD-HART). It included subjects who had had a heart attack and were depressed. It found that there was a consistent trend, over a 24-week period, for subjects taking an antidepressant to have a lower death rate than subjects taking a placebo. However, the difference did not reach statistical significance (Psychiatric News, August 2, 2002).

Now a new study headed by Joseph Gallo, M.D., an associate professor of family medicine and community health at the University of Pennsylvania, reported in the May 15 Annals of Internal Medicine, further suggests that depression treatment can extend the lives of seniors.

The study included 396 people aged 60 or older with major depression and 203 with clinically significant minor depression. Half of those with major depression received care as usual in a primary care practice, and half received an experimental intervention. It was the same for those with less-severe depression. The intervention consisted of a depression-care manager working with a primary care physician to provide algorithm-based care.

The researchers then followed the subjects for about four years to determine which ones died and why. Finally they assessed whether there was any significant difference in the rates of death between the major-depression subjects who had received usual care and those who had received the intervention. They also evaluated whether there was any significant difference in the rates of death between the minor-depression subjects who had received usual care and those who had received the intervention. In each of these analyses, they took possibly confounding factors such as age, gender, education, smoking status, cardiovascular disease, stroke, diabetes, cancer, cognition, comorbid medical conditions, and suicidal ideation into consideration.

No significant differences in death rates were found for the minor-depression subjects, but significant differences were found for subjects with major depression. Specifically, major-depression subjects in the intervention arm of the study were significantly less likely to die over the follow-up period than were major-depression subjects in the usual-care arm. The risk of death was cut by 45 percent.

Moreover, the benefit seemed to be limited to a reduction in deaths due to cancer. The reason for this finding, Gallo told Psychiatric News, might be because the “cause of death from death certificates isn't as reliable as vital status (whether someone died or not). So we can't make too much of this particular observation. However, there could be biological reasons why depression and cancer are related, or depression could interfere with a person's cancer being adequately detected and treated.”

Gallo also hypothesized as to why his study seemed to produce more positive results than the two cardiovascular studies cited above. “The persons in our study were, for the most part, community-dwelling older adults, while the persons in the other studies were identified after a cardiac event,” he explained. “How depression affects medical illness and whether treatment affects mortality might differ depending on. .how far along a person is in the course of their medical disease.”

The take-home message from the two cardiovascular studies and their own, Gallo said, is that early treatment of depression in older individuals can not only relieve psychological distress, but may extend lives as well.

The study was financed by the National Institute of Mental Health.

“The Effect of a Primary Care Practice-Based Depression Intervention on Mortality in Older Adults” is posted at<www.annals.org/cgi/reprint/146/10/689.pdf>.▪