Depression

Depression is the most frequent psychiatric problem in the older population. Approximately one-quarter of older patients seen in primary care settings are clinically depressed. The prevalence of depression in patients with macular degeneration is even higher, at 30%–40%. The suicide rate in white American men older than 65 years is 5 times greater than that of the general population; loneliness is the main reason cited, along with financial problems and poor health. Successful suicide is much less common in older American women, but older women attempt suicide more often than do men.

The criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), make a clear separation between depressive symptoms that result from a general medical condition and the medication used to treat it from late-life depression. An alternative diagnosis of mood disorder is preferred for the former.

Major depressive disorder is characterized by episodes of at least 2 weeks of depressed mood or loss of interest or pleasure in activities with 4 or more of the following symptoms:

• changes in appetite with associated weight loss or gain

• significant weight loss or gain

• sleep disturbance

• agitation

• diminished libido

• retardation (slowing down)

• loss of energy

• feelings of worthlessness or guilt

• difficulties in concentration and decision-making

• recurrent thoughts of suicide or death

Although the signs and symptoms of depression in older individuals are similar to those seen in younger age groups, older depressed patients are more likely than younger patients to have somatic or hypochondriacal complaints, minimize depression symptoms (masked depression), and have psychotic delusional disease. However, they are less likely to report symptoms of guilt. The most frequent presentations of subclinical depression include new medical complaints, fatigue, poor concentration, exacerbation of existing symptoms and medical problems, preoccupation with health, and diminished interest in pleasurable activities.

The ophthalmologist’s role is to recognize and refer the patient with depression or to be aware of precipitating factors. For instance, loss of function, such as moderate or severe vision loss, can precipitate depression, as can recent death of a spouse. Ophthalmic medications such as β-blockers and α-agonists can cause fatigue, depression, and diminished cognition. Red flags may include frequent visits to the ophthalmology office and unexplained vision loss. Though not prevalent in the ophthalmology setting, testing patients for depression might be enormously helpful in attaining care for those patients who have this disorder; an appropriate referral for such testing may be necessary.

Many targeted screening tests, also called case-finding instruments, ask about depressed mood and anhedonia, a psychological condition characterized by inability to experience pleasure in acts that normally produce it. Most of these instruments require more time than is available during a typical office visit. A briefer case-finding instrument, the Patient Health Questionnaire-2 (PHQ-2), is a suggested screening device. It is sensitive, but not specific; it does not suggest or establish a final diagnosis or monitor depression severity, but screens for depression in a “first step” approach. The self-report questionnaire consists of the following 2 questions:

1. During the past month, have you been bothered by feeling down, depressed, or hopeless?

2. During the past month, have you often been bothered by little interest or pleasure in doing things?

If the first question is answered in the affirmative, it is highly likely that the patient has depression. The added sensitivity and greater specificity provided by the second question, if answered in the affirmative, makes it worthwhile to ask the questions. A score of 2 or 3 on either question is considered a positive response to this 2-question test and is in line with DSM criteria for depression. Further information on the PHQ-2 is available on the website of the Center for Quality Assessment and Improvement in Mental Health (www.cqaimh.org; see STABLE Resource Toolkit). After using the PHQ-2 to evaluate a patient, the ophthalmologist may conclude that further evaluation by the patient’s primary care physician is necessary.

• Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–1292.

• Miguel A, Henriques F, Azevedo LF, Pereira AC. Ophthalmic adverse drug reactions to systemic drugs: a systematic review. Pharmacoepidemiol Drug Saf. 2014;23(3):221–233.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.