Mohammed T. Abou-Saleh

428 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY30 of the 100 recover (only nine in the ‘‘treated’’ group and 21spontaneously recovering in the ‘‘not treated’’ group).Where, then, should effort be focused to address this situation?The spontaneous recovery rate will be fairly resistant to changeand the gain from trying to improve the efficacy of treatmentwould appear to be relatively limited. For example, an increase inthe efficacy from 60% to 80% (an increase unlikely to be possibleat present) would only increase the numbers recovering by 3 to 12in the ‘‘treated’’ group. What is clear from Figure 1 is that themain determinant of the poor population outcome is the low rateof recognition/active management. This would suggest thatresources should be focused on increasing the proportion thatenter the ‘‘treated’’ group, since there is the greatest scope forimprovement at this point and any benefit at this stage willcascade down the system. So, if the proportion ‘‘treated’’ were tobe raised by 20% to 35%, the numbers recovering in the ‘‘treated’’arm would rise to 21 (with 37% recovering overall). If only half ofthe population of people with depression were identified andtreated, then this would rise further to 30 (with 43% recoveringoverall) and a 75% treatment rate would yield 45 recoveries (51%overall).CONCLUSIONSThese data demonstrate that, on a population level, there is likelyto be far greater health gain from attending to the processes ofrecognition of depression in the elderly, and of linking thisrecognition to action, than there is by simply focusing resourceson attempting to develop interventions with greater efficacy. Thisis supported by the emerging evidence base, which endorses thefeasibility, acceptability and effectiveness of screening for andtreating depression in older adults in the community 18–21 .REFERENCES1. Copeland JRM, Dewey ME, Wood N et al. Range of mental illnessamong the elderly in the community prevalence in Liverpool using theGMS–AGECAT package. Br J Psychiat 1987; 150: 815–23.2. Livingston G, Hawkins A, Graham N et al. The Gospel Oak Study:prevalence rates of dementia, depression and activity limitation amongelderly residents in inner London. Psychol Med 1990; 20: 137–46.3. Gurland B. The impact of depression on quality of life of the elderly.Clin Geriat Med 1992; 8: 377–86.4. Conwell Y, Rotenberg M, Caine ED. Completed suicide at age 50 andover. J Am Geriat Soc 1990; 38: 640–44.5. Murphy E, Smith R, Lindesay J, Slattery J. Increased mortality ratesin late life depression. Br J Psychiat 1988; 152: 347–53.6. Blanchard MR, Wattereus A, Mann AH. The nature of depressionamong older people in Inner London, and their contact with primarycare. Br J Psychiat 1994; 164: 396–402.7. Banerjee S, Macdonald A. Mental disorder in an elderly home carepopulation: associations with health and social service use. Br JPsychiat 1996; 168: 750–56.8. Livingston G, Manela M, Katona C. Cost of community care forolder people. Br J Psychiat 1997; 171: 56–69.9. Copeland JRM, Gurland BJ, Dewey ME et al. Is there moredementia, depression and neurosis in New York? A comparativestudy of the elderly in New York and London using the computerdiagnosis AGECAT. Br J Psychiat 1987; 151: 466–73.10. Skoog I, Nilsson L, Landahl S, Steen B. Mental disorders and the useof psychotropic drugs in an 85-year-old urban population. IntPsychogeriat 1993; 5: 33–47.11. Crawford MJ, Prince M, Menezes P, Mann AH. The recognition andtreatment of depression in older people in primary care. Int J GeriatPsychiat 1998; 13: 172–6.12. Macdonald AJD. Do general practitioners ‘miss’ depression in elderlypatients? Br Med J 1986; 292: 13650–8.13. Banerjee S. The needs of special groups: the elderly. Int Rev Psychiat1998; 10: 130–33.14. Prince M, Harwood R, Thomas A, Mann AH. A prospectivepopulation-based cohort study of the effects of disablement and socialmilieu on the onset and maintenance of late-life depression. PsycholMed 1998; 28: 337–50.15. Banerjee S. Prevalence and recognition rates of psychiatric disorder inthe elderly clients of a community care service. Int J Geriat Psychiat1993; 8: 125–31.16. Gill D, Hatcher S. Antidepressants for depression in people withphysical illness (Cochrane Review). In The Cochrane Library, Issue 4.Oxford: Update Software, 2000.17. Banerjee S, Dickinson E. Evidence-based old age psychiatry. Int JPsychiat Med 1997; 27: 2803–92.18. Banerjee S, Shamash K, Macdonald A, Mann A. Randomisedcontrolled trial of effect of intervention by psychogeriatric team ondepression in frail elderly people at home. Br Med J 1996; 313:1058–61.19. Waterreus A, Blanchard M, Mann A. Community psychiatric nursesfor the elderly: well tolerated, few side-effects and effective in thetreatment of depression. J Clin Nurs 1994; 3: 299–306.20. Blanchard MR, Waterraus A, Mann A. The effect of primary carenurse intervention upon older people screened as depressed. Int JGeriat Psychiat 1995; 10: 289–98.21. Rabins PV, Black BS, Roca R et al. Effectiveness of a nurse-basedoutreach program for identifying and treating psychiatric illness inthe elderly. J Am Med Assoc 2000; 283: 2802–9.