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22 MEDResearch 23 Identifying depression in the elderly The results of the National Institutes of Health-fund Epidemiology of Late-Life Depression and Ethnicity Research Study conducted by Hector Gonzalez, Ph.D., will provide insights into the opportunities for late-life depression prevention in an aging and increasingly diverse population. Elderly Americans are more likely to take their own lives. While they make up about 13 percent of the population, Americans 65 and older accounted for 16 percent of suicides in 2004, according to the National Institute for Mental Health. For every 100,000 Americans 65 and older, 14.3 died by suicide that year, a rate higher than the 11 suicides per 100,000 in the general population. White males 85 and older have the highest suicide rate in the United States. Of the 35 million Americans 65 and older, nearly 2 million suffer from depression. An additional 5 million of that age segment cope with less severe forms of depression. The NIMH says that depression in older adults is a “widely under-recognized and under- treated illness.” The condition is commonly associated with suicide in the elderly. Studies indicate that as many as 75 percent of older adults who took their lives visited a physician within a month of committing suicide. “These findings point to the urgency of improving detection and treatment of depression among older adults,” the NIMH says. The incidence of late-life depression becomes all the more significant with the continued aging of America’s population. The baby boomer generation alone — those born between 1946 and 1964 — make up 13 percent of the population. The boomers begin hitting age 65 in 2011, so recognizing and treating depression in older Americans is rapidly becoming a critical issue. A Wayne State University School of Medicine assistant professor has secured a National Institute of Mental Health grant to investigate the prevalence, risks and burdens associated with late-life depression among the national population and among major ethnic groups in the United States. Hector Gonzalez, Ph.D., will use the $1.2 million, three-year grant to fund the Epidemiology of Late-Life Depression and Ethnicity Research Study, or ELLDERS, to provide updated estimates on the distribution of major depression and the functional status of affected older adults in the U.S. The results, Dr. Gonzalez predicted, will offer insights about the opportunities for late- life depression prevention in an aging and increasingly diverse population. “Depression is a leading cause of disability in the United States and will continue to ascend in importance as the population continues to grow older over the coming decades,” said Dr. Gonzalez, a clinical neuropsychologist and assistant professor in the Department of Family Medicine and Public Health Sciences. He has a joint appointment with the Wayne State University Institute of Gerontology. “For older adults, national prevalence estimates of ‘true’ depressive disorders meeting established diagnostic criteria date back to the pioneering psychiatric epidemiologic work in the 1980s.” Demographically, Dr. Gonzalez pointed out, much has changed over the past 20 years in public health. Middle-aged baby boomers are entering retirement age, and Latinos, “largely ignored until the turn of the millennium,” are now the largest ethnic minority in the country. New technologies have advanced the understanding and treatment of depression over the last 20 to 30 years, yet most Americans suffering depression continue to go untreated or under-treated, especially disadvantaged ethnic and racial minorities, he said. Medicine needs updated national estimates of depressive disorders in older adults to shape current and projected evidence-based allocations of appropriate mental health resources for an aging population. The National Mental Health Association in 2003 reported that 15 percent of seniors living independently displayed signs of depression. Identifying depression in the elderly Hector Gonzalez, Ph.D., leads study to reshape depression treatment for millions of elderly in America by Philip Van Hulle Photos by David Dalton
Transcript

22MEDResearch 23Identifying depression in the elderly

The results of the

National Institutes

of Health-fund

Epidemiology of

Late-Life Depression

and Ethnicity Research

Study conducted by

Hector Gonzalez,

Ph.D., will provide

insights into the

opportunities for

late-life depression

prevention in an

aging and increasingly

diverse population.

Elderly Americans are more likely to take their own lives.

While they make up about 13 percent of the population, Americans 65 and older accounted for 16 percent of suicides in 2004, according to the National Institute for Mental Health. For every 100,000 Americans 65 and older, 14.3 died by suicide that year, a rate higher than the 11 suicides per 100,000 in the general population. White males 85 and older have the highest suicide rate in the United States.

Of the 35 million Americans 65 and older, nearly 2 million suffer from depression. An additional 5 million of that age segment cope with less severe forms of depression. The NIMH says that depression in older adults is a “widely under-recognized and under-treated illness.” The condition is commonly associated with suicide in the elderly. Studies indicate that as many as 75 percent of older adults who took their lives visited a physician within a month of committing suicide. “These findings point to the urgency of improving detection and treatment of depression among older adults,” the NIMH says.

The incidence of late-life depression becomes all the more significant with the continued aging of America’s population. The baby boomer generation alone — those born between 1946 and 1964 — make up 13 percent of the population. The boomers begin hitting age 65 in 2011, so recognizing and treating depression in older Americans is rapidly becoming a critical issue.

A Wayne State University School of Medicine assistant professor has secured a National Institute of Mental Health grant to investigate the prevalence, risks and burdens associated with late-life depression among the national population and among major ethnic groups in the United States.

Hector Gonzalez, Ph.D., will use the $1.2

million, three-year grant to fund the Epidemiology of Late-Life Depression and Ethnicity Research Study, or ELLDERS, to provide updated estimates on the distribution of major depression and the functional status of affected older adults in the U.S. The results, Dr. Gonzalez predicted, will offer insights about the opportunities for late-life depression prevention in an aging and increasingly diverse population.

“Depression is a leading cause of disability in the United States and will continue to ascend in importance as the population continues to grow older over the coming decades,” said Dr. Gonzalez, a clinical neuropsychologist and assistant professor in the Department of Family Medicine and Public Health Sciences. He has a joint appointment with the Wayne State University Institute of Gerontology. “For older adults, national prevalence estimates of ‘true’ depressive disorders meeting established diagnostic criteria date back to the pioneering psychiatric epidemiologic work in the 1980s.”

Demographically, Dr. Gonzalez pointed out, much has changed over the past 20 years in public health. Middle-aged baby boomers are entering retirement age, and Latinos, “largely ignored until the turn of the millennium,” are now the largest ethnic minority in the country. New technologies have advanced the understanding and treatment of depression over the last 20 to 30 years, yet most Americans suffering depression continue to go untreated or under-treated, especially disadvantaged ethnic and racial minorities, he said.

Medicine needs updated national estimates of depressive disorders in older adults to shape current and projected evidence-based allocations of appropriate mental health resources for an aging population. The National Mental Health Association in 2003 reported that 15 percent of seniors living independently displayed signs of depression.

Identifying depression in the elderly Hector Gonzalez, Ph.D., leads study to reshape depression treatment for millions of elderly in America

by Philip Van Hulle Photos by David Dalton

24MEDResearch 25Identifying depression in the elderly

“Treatments are

only good if you

can get them to the

right people,” says

Dr. Gonzalez. “Thus

far, we are seeing

very low rates of

treatments for ethnic

minorities, lower

than what has been

previously reported.”

That number jumped to 25 percent for those seniors residing in nursing homes.

Many elderly depressives aren’t treated properly — some estimates place that treatment rate at only 10 percent — because they may display the symptoms differently, or family members and physicians may misinterpret those symptoms as signs of multiple illnesses and the drugs prescribed to treat them, or simply as signs of growing older. Other serious illnesses, such as Parkinson’s disease, the onset of Alzheimer’s or dementia and heart disease can exacerbate depression in the elderly. The risk of depression in the elderly escalates when they incur other illnesses and when their functionality becomes limited. In addition, as many as 5 million senior Americans are estimated to suffer from “subsyndromal” depression, displaying symptoms that don’t meet the complete diagnostic definition of depression. Missing or misreading the symptoms of depression delays effective treatment.

While ELLDERS will study the nation’s whole population because of the dated psychiatric epidemiological information, ethnic and racial minority groups will be targeted because they were largely ignored 30 years ago, with a consequent dearth of longitudinal information available today.

“While those early studies were pioneering, they lacked the large samples needed to understand depression in ethnically diverse populations. We expect to revise our current understanding of the epidemiology of depression and what will appear in textbooks,” Dr. Gonzalez explained. “Considering depression is a leading cause of disability worldwide, we believe our work has very important public health implications for the nation and for large and growing segments of the population.”

The research will compare the epidemiology of depression between ethnic groups. An earlier study conducted by Dr. Gonzalez and colleagues at the University of Michigan, the University of California, Los Angeles, and Harvard University identified a number of disparities in mental health treatment between ethnic groups in the United States. That study found that only 51 percent of the study subjects who fit the criteria for major depression during the past 12 months had received any kind of treatment for the condition, and only 21 percent received treatment that was consistent with American Psychiatric Association guidelines. Among the groups surveyed, African-Americans and Mexican-Americans had the lowest rates of depression care.

Published in the January 2010 edition of the Archives of General Psychiatry, the study provides a detailed picture of the care received for major depression among different ethnic and racial groups, and factors that contribute to disparities. The paper reports that too few Americans with recent major depressive disorders receive adequate depression care, and most receive no care at all.

African-Americans and Mexican-Americans, according to the study, may face greater barriers to mental health care. “Contrary to our expectations that most Americans with depression would be using antidepressant drugs, we actually found higher psychotherapy use, especially among ethnic and racial minorities,” Dr. Gonzalez said.

Mexican-Americans make up more than two-thirds of Latinos in the U.S. The study found distinctive differences in mental health care use between Mexican-Americans and other Latino subgroups that had not been previously reported. The authors noted that Latinos will make up one-third of the U.S. population by mid-century, and suggested that Mexican-Americans should be a focus of

efforts to reduce health disparities to ensure the nation’s health quality in coming decades.

All groups were more likely to have received psychotherapy than pharmacotherapy. Caribbean blacks and African-Americans were particularly unlikely to receive pharmacotherapy consistent with APA guidelines. Enabling factors such as education, health insurance and income did not explain the lower rates of medication use. The authors noted possible reasons for this, including research indicating that perceived discrimination can shape health care seeking. They speculate that the non-immigrant status of Puerto Ricans — and with that, greater predominance of English language use within

this group — may be factors in their relatively high rates of health care use.

“Treatments are only good if you can get them to the right people. Thus far, we are seeing very low rates of treatments for ethnic minorities, lower than what has been previously reported,” Dr. Gonzalez said. “While that may be largely explained by differences in access to health care, we are seeing some interesting differences in which types of treatment different ethnic groups are willing to stick with. Because there are many different and effective depression treatments available, knowing who prefers what type of treatment can be helpful in reducing the stark inequalities in care we are seeing.”


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