Access to mental health care in depressed older patients

Late-life depression presents clinical challenges, including more comorbidities, longer time to treatment response, longer treatment duration, and older age stigmatization. Such characteristics may increase the perception that depressed older adults are difficult to treat, but evidence suggests that benefits from treatment are similar to these observed in younger adult patients. Antidepressant treatment may confer even greater protection against suicide in older than younger adults. However, a retrospective matched cohort study carried on in American managed care population showed that depression goes commonly untreated in older people compared with younger adults. Despite a high rate of comorbidity that was associated with more frequent antidepressant dispensing, this age group was at higher risk of untreated illness either by antidepressant (25.6% vs. 33.8%) or by psychotherapy (13.0% vs. 34.4%) and of later treatment after depression diagnosis (51 vs. 14 days), showing a lower access to treatment. In this study, before 2006, older adults treated for depression received more frequently antidepressants at lower prescribed doses, had poorer adherence and higher non-persistence to treatment than younger adults. However, these differences disappeared or reversed after Medicare Part D implementation, which improved the refunding of drugs in the elderly population. Similarly, a historical cohort study showed, in the French universal health care system, that antidepressant treatment duration and adherence were better in the treated older patients than in the younger ones. This favourable finding may be partly attributed to the universal healthcare system in which all subjects are treated in the same way, regardless of age. However, the reasons for the more appropriate use of antidepressants in the older subjects remain to be elucidated.