Screening for Depression in Older Adults: Recommended Instruments and Considerations for Community-Based Practice
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Introduction
Depression is a treatable medical condition and one of the most frequent causes of emotional distress in older adults. Depressive symptoms are not a normal part of aging, and a recent population-based survey documents the prevalence of current depressive symptoms (defined as an 8-item Patient Health Questionnaire [PHQ-8] score of 10 or higher) as 4.9% among community-dwelling older adults 65 years of age and older.1 Depression in older adults complicates chronic conditions (eg, cardiac disease, diabetes) and reduces quality of life and functional abilities.2 Older adults with depression are less capable of performing self-care behaviors necessary for managing chronic conditions and participating in disease-prevention activities.3,4 Depression negatively affects overall healthcare by affecting patient-provider relationships, decreasing access to care, and increasing costs of care.5 Older adults are also at the greatest risk for suicide as compared with other age cohorts,6 making the detection and treatment of depression even more vital.7 Despite its importance, depression continues to be underrecognized in this population.8 In this article, we review depression screening instruments determined to be appropriate for older adults, and that are reliable and feasible for use by community-based clinicians.
Clinical and Community Recommendations for Depression Screening
Several national organizations have recognized depression as a significant public health issue for the growing number of older adults.9,10 The U.S. Preventive Services Task Force (USPSTF) currently recommends depression screening for adults (including older adults) in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.10 The Guide to Community Preventive Services recommends both home- and clinic-based depression care management for older adults.9 These evidence-based interventions emanate from the depression care management model11 and require use of a validated depression measure to both screen for depression and to monitor the outcomes of the treatment. As noted by the USPSTF, because there is little evidence that screening by itself will lead to effective treatment, screening needs to be done in a setting capable of providing the necessary diagnostic evaluation and treatment.10 Establishing a screening program includes selecting a depression screening instrument that is appropriate for the target older adult population. Screening instruments signify the risk or likelihood of having depression and by themselves do not constitute a diagnosis. The diagnosis and care of older patients with depression requires clinical evaluation by someone trained in evaluating both the criteria symptoms and other medical problems associated with depressive symptoms. It is critical for clinicians who care for older adults to be familiar with appropriate depression screening measures and practical considerations for establishing a depression screening program.
Depression Screening Instruments for Older Adults: Review and Recommendations
Recommendations throughout this article were generated regarding the effectiveness and feasibility of several depression screening instruments that could be used by community-based providers. These recommendations were based on findings from a systematic literature review and evaluation of the review by a 14-member expert panel of researchers and community-based practitioners.12 Detailed study methods are described elsewhere.12,13 The expert panel considered several criteria when making recommendations for appropriate screening instruments for community-based settings. From the systematic literature review, the panel considered the effectiveness of the instruments as reflected in screening performance statistics (eg, sensitivity, specificity, predictive values).
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