Poor prognosis of depression in elderly people: causes and actions

Depression is the most common mental health problem of older people. It is a serious disorder which can lead to persistent suffering, increased mortality, from both suicide and general medical causes, and poorer overall health. Although presenting symptoms are similar in all age groups there are different aetiological pathways. In older people the waning effect of genetic predisposition to affective disorder may be replaced by subcortical brain abnormalities of presumed vascular aetiology. These may influence prognosis. Depression in later life is often under-diagnosed and under-treated; these two factors are the main hurdles to an improved prognosis. Antidepressant treatment should be tailored to the patient and works best when combined with psychological therapy, but the latter treatment modality is woefully neglected in later life psychiatry. Improvements in prognosis are unlikely to come from new revolutionary treatments but from vigorous treatment in the acute phase, continuation after recovery for at least 12-18 months and long-term maintenance treatment for those at high risk of recurrence.