Preventing major depression in older medical inpatients: innovation or flight of fancy?

Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007). To date, few healthcare policies or practices address the enormous burden of major depression in older medical inpatients and none does so systematically. Psychiatric consultation may be requested by attending physicians but the majority of older medical inpatients with major depression remain undetected and untreated (Koenig, 2006; Cepoiu et al., 2007). Even if detected and treated, available treatments appear to have limited benefits. Antidepressant treatment is modestly efficacious in older ambulatory patients (McCusker et al., 1998; Williams et al., 2000) but two trials of disease-management models for depression in older medical inpatients have reported high rates of drop-out and non-compliance and limited value in reducing depressive symptoms or improving outcomes (Cole et al., 2002; Oslin et al., 2004). These findings challenge healthcare professionals to find innovative, feasible, effective, inexpensive, and easily implemented approaches to reducing the burden of major depression in this population. The success of a program to prevent delirium in older medical inpatients (Inouye et al., 1999) offers hope that major depression may be prevented in this population. The delirium program identified older medical inpatients with at least one of six risk factors for delirium and implemented standardized intervention protocols for each of the risk factors present. The program attenuated the risk factors and reduced the incidence of delirium by 40%.