Older Australians are less likely to be depressed, yet are more likely to be prescribed antidepressants – why?
One in four older adults in Australia is prescribed antidepressants1 and often stay on them longer than recommended. Why is this happening and what can be done to break the cycle?
I have been a GP for 25 years and have tended to accept the common wisdom that older people are more prone to depression, and that long-term antidepressant usage is somewhat inevitable and relatively low risk.
So, it was useful to see in recent data that in fact older Australians are less likely to be depressed or anxious than those under 65 years of age2 yet are almost twice as likely to be treated with antidepressants. And not only are 1:4 prescribed antidepressants but the average duration of use in Australia is about four years.3 This is despite the current guideline recommendation of antidepressant use of 6-12 months for a single episode of depression.4 In aged care facilities, a staggering 60% of residents are prescribed antidepressants.5
I had also underestimated the morbidity from the extended use of antidepressants in older people. We are all aware that these medications are not without risk, however it was salutary to see this quantified, particularly the significant increase in all-cause mortality. The data shows that exposure to antidepressants over a one year period has been associated with significant increased risks of harm: up to 52% increase for hyponatremia, 64% for falls, 62% for fractures, 36% for stroke and 62% increase in all-cause mortality.6
Realising that potential harm is higher than I had expected, I was interested to know why rates are so high. Here again the data is fairly reproducible, and in line with my clinical experience.
1. Diagnosing mental health problems in older adults is challenging
Mental health conditions like depression, anxiety, grief, and loneliness often overlap in older adults, making diagnoses complex. The low mood and fatigue of grief are also typical of depression, and the loneliness that too often accompanies ageing can amplify depressive feelings. Differentiating these conditions is challenging, but crucial, as antidepressants may not always be the best treatment.
2. The ‘chemical imbalance’ legacy
For years, depression was widely seen as a result of a chemical imbalance in the brain, which could be addressed with antidepressants. The theory influenced both patients and healthcare providers but is not supported by the evidence. Depression has multifactorial causes, including life stressors, social isolation, medical conditions, or even medications mimicking depressive symptoms such as corticosteroid and anticholinergics. This complexity of the aetiology of depression underscores the need for a nuanced approach to treatment, moving beyond a one-size-fits-all reliance on antidepressants.
3. Antidepressant expediency
Antidepressants are familiar to both patients and GPs and there can be pressure to provide a quick fix. Patients may also have significant wait times to see a psychologist or psychiatrist, or be resistant to these options and antidepressants can be seen as a stop gap and once started, it can be hard to find the right time to stop them and they just continue. However, the evidence to support antidepressant use in older adults is variable and modest at best and this modest benefit must be carefully weighed against the potential for harms.7
4. Risk aversion in aged care
By the time our patients make it into aged care, they usually have multiple significant health issues that occupy our time. So, if they go into care on antidepressants, there may be limited bandwidth to discuss deprescribing. A common scenario is that on admission into aged care, the patient becomes depressed as they face their loss of independence, and antidepressants are provided to try and lift them out of their malaise. Then, once the patient and their carers have seen an improvement in mood, there is often a reluctance to cease the medication and a lack of understanding about the downsides of staying on treatment.
5. The challenges of safely withdrawing from antidepressants
There is resistance from older patients and their families to withdraw something that is seen to be working. And when symptoms occur, it can be difficult to differentiate between relapse symptoms and withdrawal symptoms. Common withdrawal symptoms (i.e. anxiety, irritability, worsened mood, panic) mimic symptoms of depression or anxiety.
So how do we reverse the spiral of long-term usage?
Reversing long-term antidepressant use requires the collaboration of patients, carers, GPs, nurses, pharmacists, and mental health professionals. The federal government has prioritised this issue and funded the Quality Use of Medicines (QUM) Alliance, led by Medcast (of which I am a Director), the Healthcare Consumers’ Association, RACGP, Pharmaceutical Society of Australia and others, to address it.
This initiative focuses on providing GPs with alternate approaches to the management of depression and safe and effective ways to deprescribe. Shared decision-making between healthcare providers and patients is crucial and is supported by the provision of resources for you and your patients and carers.
Available at Medcast QHUB, resources include a quick reference clinical guide, conversation starters, a decision aid on treatment choices for use with patients, antidepressant comparison table, deprescribing guide and planning tool for patients. They are supported by a range of accredited CPD activities including webinars and educational visits.
Moving in the right direction
Being involved in the development of this program has helped my clinical knowledge and the way I approach my older patients when managing their depression. This is a complex but urgent challenge and I hope that this program from the QUM Alliance helps all GPs in this complex clinical area. By fostering open conversations and exploring non-pharmacological options, we can begin to reverse the cycle of long-term antidepressant use while prioritising the well-being of older Australians.
For more information visit QHUB.
The Quality Use of Medicines Alliance is funded by the Australian Government Department of Health and Aged Care. It comprises Medcast, Health Care Consumers’ Association, QUM Connect, Wiser Healthcare, Arthritis Australia, Eczema Support Australia, Pharmaceutical Society of Australia, Royal Australian College of General Practitioners.
Clinical A/Prof Stephen Barnett is the Managing Director of Medcast, a GP in the Southern Highlands of NSW and an experienced GP supervisor and Medical Educator.
He is a Clinical Associate Professor with the University of Wollongong Graduate School of Medicine and holds a PhD in e-learning and GP Training.
References:
- Australian Institute of Health and Welfare. [cited 2024 Jun 11] https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions
- Australian Institute of Health and Welfare. [cited 2024 Jun 11] https://www.aihw.gov.au/mental-health/overview/prevalence-and-impact-of-mental-illness
- Kjosavik SR, Gillam MH, Roughead EE. Average duration of treatment with antidepressants among concession card holders in Australia Aust N Z J Psychiatry. 2016 Dec 1;50(12):1180-5.
- Therapeutic Guidelines. Depressive disorders. 2021 [cited 2024 Jun 6] https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=overview-depressive-disorders
- Hughes GA, Inacio MC, Rowett D, Lang C, Jorissen RN, Corlis M, et al. National Trends in Antidepressant Use in Australian Residential Aged Care Facilities (2006–2019). J Am Med Dir Assoc. 2024 Feb 29;104957.
- Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ. 2011 Aug 2;343:d4551.
- Hvidberg MF. Are antidepressants effective in the treatment of depression in the elderly? A critical umbrella review on reviews, methods, and future perspectives. Ment Health. 2023;10(7):e14. doi: 10.1002/mhs2.14.
