Depression in Late Life, 3rd ed.

This book serves many purposes but is, above all, about clinical values and intellectual principles. Its explicit intention is to provide a broad biopsychosocial account of late-life depression that explicates the development of late-life depression; most importantly, however, it provides a meaningful guide to treatment.

Central to the book is Blazer’s own clinical thinking and his way of integrating new findings in the care of the individual patient. Late-life depression is a disease that tries the clinician’s skills to their limit. Psychiatry now believes that late-life depression is a disease with rather specific brain abnormalities, but seemingly less specific factors often play a devastating role in late life. Many depressed patients are medically ill, have lost cognitive abilities necessary for negotiating their environment, are unable to care for themselves, experience unanticipated indignities, and lose the sense of meaning in their lives. In some cases, the biological mechanisms of what was originally thought to be a nonspecific factor are clarified. For example, subcortical white matter abnormalities and executive dysfunction, one of its clinical expressions (1), may lead to depression by inducing disability (2), but a concomitant path to both depression and disability may be dysfunction of frontostriatal systems (3) resulting from white matter abnormalities. Blazer’s book serves as a guide to the role of each path in the depression of the individual patient by placing biological and psychosocial findings in the clinical and personal context of the individual patient.

The book uses skillfully presented case reports to initiate discussion of scientific findings. Building the exposition of new findings on the foundation of clinical issues and questions arising from treatment of the individual patient lets the reader know how Blazer thinks when he works with depressed old people. One may agree or disagree with the author’s views, but it is impossible not to think critically.

Blazer takes the position that adherence to the biopsychosocial model is necessary for planning the treatment of depressed elderly patients. “If we deviate from that model we will defeat our intentions to provide the best possible care to depressed older adults.” Whether he summarizes biological and psychosocial findings or presents steps of differential diagnosis and treatment, Blazer remains faithful to this goal throughout the book.

The biopsychosocial model has been inadequately tested in late-life depression and in most other psychiatric disorders. In fact, a complex model such as the biopsychosocial model cannot be adequately tested with the available, rather reductionistic experimental methodology. Although it defies some of the epistemological requirements for experimental support, the biopsychosocial model still has merit. Most theoretical generalizations about observable phenomena are rejected before they are subjected to experimental testing (4). The criteria for selecting a theoretical model are pragmatic and include its aesthetic value (simple meaningful concepts) and its usefulness (5). The biopsychosocial model passes this formal test with flying colors. Every thoughtful clinician knows that the biopsychosocial model is the best way to understand and integrate new findings in late-life depression. Blazer’s book simply explains, in the most elegant way, how to do so and better the care of depressed older people.