2007, Number 6
Salud Mental 2007; 30 (6)
Guía de práctica clínica para el diagnóstico y tratamiento de depresión en los adultos mayores
Espinosa-Aguilar A, Caraveo-Anduaga J, Zamora-Olvera M, Arronte-Rosales A, Krug-Llamas E, Olivares-Santos R, Reyes-Morales H, Tapia-García M, García-González J, Doubova s, Peña-Valdovinos A
PDF size: 92.53 Kb.
Depression is growing in importance every day. It is estimated that by the year 2020 it will be worldwide the second cause for the loss of healthy life years and the first in developed countries. Considering this, an adequate and opportune diagnosis will allow for a complete handling of the disorder. This should include adequate psychotherapy and medical treatment which will in turn improve significantly the prognosis and life quality of depressed individuals.
In the primary care area, sub-diagnosis and delays to identify depression are common. These have a negative effect on the individuals’ well-being, in public health and in the direct and indirect costs of health services. It is not uncommon for primary care practitioners to consider everyday complaints, the inability to cope with family stress, social isolation, role change and money problems as «causes» for depression. Thus, they deem depression «justified» and fail to offer treatment when actually this very inability is often caused by depression.
Depression is among the most frequent psycho-geriatric ailments. In Mexico, its overall prevalence is 9.5% in women and 5% in men age 60 or more. In most instances, it goes undiagnosed given its atypical expression or the false belief which considers it part of the normal aging process. In the elderly, depression may conceal somatic symptoms, be it as expressions of the depressive syndrome or because these same symptoms aggravate symptoms from other concomitant diseases. Secondary cognitive symptoms are more frequent among this age group.
To provide physicians at primary care a guideline with enough technical-medical elements to facilitate the timely diagnosis and integral treatment of elderly with depression.
This study comprised two phases: design and validation of the guideline.
1. Key words for search: depression, elderly, clinical guidelines, prevalence, primary care, assessment, treatment, suicide risk.
2. Data bases used: Cochrane, Pub-Med and Medline for the 1990-2006 period.
3. Twenty-six references for major depression in the elderly were found: eight random meta-analysis, two random clinical, one cohort, twelve descriptive non-experimental, and three book articles (DSM-IV[HRM1] TR; CIE 10, Psycho-geriatrics Manual).
4. Evidence category and strength of recommendation. This indicates the user about the origin of recommendations issued.
In the algorithm from the clinical guide, the concepts or support for each recommendation are identified. In this guide, the diagnosis of depression is based on the CIE-10 and its ranking may be comparable to that for major depression in the DSM-IV TR. Differential diagnosis; criteria for referring a patient to the psychiatrist; guidelines for pharmacological, psychotherapeutic and psychosocial treatment; onset phase and maintenance phase are included.
Thus, the clinical practice guide proposed is based on a strict methodology. It offers enough elements for the general practitioner to assess an opportune and complete treatment for elderly people with depression. In addition, it incorporates criteria based on scientific evidence, which will allow updating it, and evaluating its solidity in the face of new evidence, which will in turn maintain its validity.
AMERICAN PSYCHIATRIC ASSOCIATION: Diagnostic and Statistical Manual of Mental Disorders TR (DSM-IV-TR). 4th ed. Washington, 2000.
BANDEIRA CA, LIMA MS, GEDDES J, GUEDES VP y cols.: Carbamazepine for bipolar affective disorders [protocol]. Cochrane Depression Anxiety & Neurosis Group. The Cochrane Database of Systematic Reviews. Issue 1, 2006.
BEEKMAN A, COPELAND J, PRINCE M: Review of community prevalence of depression in later life. Br J Psychiatry,174:307–11, 1999.
BELLO M, PUENTES-ROSAS E, MEDINA-MORA M, LOZANO R: Prevalencia y diagnóstico de depresión en población adulta en México. Mex Public Health, S1:S4-S11, 2005.
CHURCHILL R, DEWEY M, GRETTON V, DUGGAN C y cols.: Should general practitioners refer patients with major depression to counselors? A review of current published evidence. Br J Gen Pract, 49:737–743, 1999.
COHEN S, WILLS T. Stress, social support and the buffering hypothesis. Psych Bull 1985; 98(2):310-357.
Drug Information Branch, Center for Drug Evaluation and Research: Guidance for Industry: Pharmacokinetics in patients with impaired renal function—Study design, data analysis, and impact on dosing and labeling, 1998. http://www.fda.gov/cder/guidance/index.htm
ELKIN I, SHEA MT, WATKINS JT, IMBER SD y cols.: National Institute of Mental Health treatment of depression collaborative research program: general effectiveness of treatments. Arch Gen Psychiatry, 46:971–982, 1989.
GILL D, HATCHER S: Antidepressants for depression in medical illness. [Systematic Review] Cochrane Depression Anxiety & Neurosis Group Cochrane Database of Systematic Reviews. Issue 1, 2006.
HOTOPF M, HARDY R, LEWIS G. Discontinuation rates of SSRIs and tricyclic antidepressants: a meta-analysis and investigation of heterogeneity. Br J Psychiatry, 170:120–129, 1997.
DE LA SERNA DE PEDRO I: Manual de Psicogeriatría Clínica, Psiquiatría Médica, Ed. Masson, cap. 6, pp. 220, 2001.
JICK S, DEAN A, JICK H: Antidepressants and suicide. BMJ, 310:215–218, 1995.
KATON W, SCHULBERG H: Epidemiology of depression in primary care. Gen Hosp Psychiatry,14:237–247, 1992.
KATON W, VON KORFF M, LIN E: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA, 273:1026–1031, 1995.
KUPFER D. Long-term treatment of depression. J Clin Psychiatry, 52(S5):28-34, 1991.
LIMA MS, MONCRIEFF, J, SOARES B. Drugs versus placebo for dysthymia. [Systematic Review] Cochrane Depression Anxiety & Neurosis Group. The Cochrane Database of Systematic Reviews. Issue 1, 2006.
LOONEN AJ, PEER PG, ZWANIKKEN GJ. Continuation and maintenance therapy with antidepressive agents: metaanalysis of research. Pharm Week Sci, 13:167–175, 1991.
McCUSKER J, COLE M, KELLER E, BELLAVANCE F, BERARD A: Effectiveness of treatments of depression in older ambulatory patients. Arch Intern Med, 158(7):705–712, 1998.
MONCRIEFF J, WESSELY S, HARDY R: Meta-analysis of trials comparing antidepressants with active placebos. [dagger] (papers). Br J Psychiatry, 172(3):227-231, 1998.
PEREZ-FRANCO B, TURABIAN-FERNANDEZ J: ¿Es válido el abordaje ortodoxo de la depresión en atención primaria? Aten primaria,37(1):37-39 2006.
SAIZ J, IBAÑEZ A: Diagnóstico de equivalentes depresivos. Rev Clin Esp, 2:88-90, 2002.
SECRETARIA DE SALUD. Proyecto de Modificación a la Norma Oficial Mexicana NOM-015-SSA2-1994 para la Prevención, Tratamiento y Control de la Diabetes. Rev Med IMSS, 38(6):477-495, 2000.
SONG F, FREEMANTLE N, SHELDON T, HOUSE A y cols.: Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability. BMJ, 306(6879):683–687, 1993.
THASE M, GREENHOUSE J, FRANK E, REYNOLDS Ch y cols.: Treatment of major depression with psychotherapy or psychotherapy–pharmacotherapy combinations. Arch Gen Psychiatry, 54(11):1009–1015, 1997.
WORLD HEALTH ORGANIZATION. The ICD-10 Classification of Mental and Behavioral Disorders. Ginebra, 1992.