Approaches to the management of depression in old age.

Depression in old age is common, underdiagnosed and undertreated. It has a high rate of recurrence and is associated with significantly increased mortality. Its mismanagement stems in large part from the misconceptions that it is an inevitable condition, that old people are too inflexible to change, and that treatment is unacceptably hazardous. There is considerable potential for prevention, improved detection and appropriate treatment. In addition, it is increasingly clear that treatment can improve prognosis. Prevention requires education, and a political agenda to address aetiological factors such as poverty, loneliness, institutionalisation and poor physical health. Treatment with antidepressant drugs and/or psychological techniques is effective. Newer drugs may well be superior in safety and real-life tolerability but require better evaluation in representative samples, against placebo and incorporating cost-benefit and quality-of-life measures. Prophylaxis with antidepressants, electroconvulsive therapy and psychotherapy groups has been shown to be effective. The prophylactic efficacy of newer antidepressants has yet to be properly evaluated.