Can Skype Help With Depression in Older Adults?

Depression among Americans over 65 doesn't get the attention it deserves. The National Institute of Mental Health estimates that close to 6 million older adults live with depressive symptoms, and only about one in ten of them ever gets proper treatment. Part of the problem is that the illness hides well in this age group. Older patients tend to carry more chronic conditions, live with more disabilities, and take more prescriptions, and all of that can mask what a depressive disorder actually looks like.

When it goes unrecognized, the consequences stack up. Depression in later life raises the odds of other medical trouble and makes recovery from illness slower and less complete. The suicide rate climbs sharply for white men between 80 and 84, roughly double that of the general population. Older people who are depressed face about twice the likelihood of developing heart disease, which brings its own risk of heart attack and death. And when depression sits alongside another illness, the chance of dying from that illness goes up.

Several things push someone toward major depressive disorder. Damage the body takes from other conditions is one: a stroke, cancer, an amputation. A personal or family history of depression is another. Chronic high blood pressure matters too, partly because it restricts blood flow to the brain.

Treatment is where the picture gets complicated. Exercise helps many people with depression, but a frail patient who can barely move won't get much from it. Antidepressants show real promise, though they tend to work more slowly in older bodies, and sensitivities often force doctors to keep doses low. There's also a higher chance that these drugs collide with whatever else the person is taking. Amitriptyline and imipramine, for example, can ease insomnia, which is itself both a symptom and a trigger of depression in the elderly, but they can also cause heavy sedation or a sudden drop in blood pressure. A fall follows, then a fracture, and for someone already depressed, that may be a decline they never climb back from.

For seniors who can't leave the house, in-home care and telemedicine have started to look like a workable answer. Telemedicine simply means moving information and services from a provider to a patient somewhere else, using whatever tools fit: two-way radios, email, smartphones, other wireless devices. A report in JAMA Internal Medicine pointed to the value of folding depression treatment into routine Medicare home health visits. Researchers at the Weill Cornell Medical College Department of Psychiatry ran a trial called Depression Care for Patients at Home, or Depression CAREPATH, built around patients' regular in-home appointments. They trained 178 nurses drawn from six home health agencies, who then cared for 306 Medicare home health patients with depression. Patients were checked again at 3, 6, and 12 months.

The whole group didn't show a drop in depressive symptoms. But among the 208 participants who started with severe scores, there was clear improvement. The study's authors put the difficulty plainly: Medicare advises screening and intervention for depression, yet the clinical needs of these patients, the shortage of mental health specialists, and the way home health care is actually structured all get in the way. Their answer is more training and in-home programs capable of delivering fuller treatment.

There still isn't much research aimed squarely at depression in homebound older people. Rhode Island Hospital, working with other groups, launched a pilot built on a telemedicine-based depression care protocol for home health settings. The data is early, but patients and caregivers already seem to like it. Most reported being satisfied or very satisfied and said they would use the program again. The equipment turned out to be easy to handle, with few technical hiccups, and the telehealth nurses felt their patients' care improved and that the Depression TeleCare Protocol was straightforward to follow.

At the follow-up point, 19 patients who had entered the study with scores in the markedly severe range came out scoring in the mild range. The researchers read this as a meaningful sign for how home health care for depressed older adults might be run going forward. If these services keep getting better, this population could gain a better quality of life, and treating their depression may turn out to help with their other illnesses too.

- Melissa Lavery, M.S.