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The recent paper by Cameron et al1 raises some underlying issues regarding antidepressant prescribing for older adults.
The study indicated that ‘all adult patients’ were eligible to participate. However, the mean age was 48 years (SD = 18 years). This suggests that almost no participants were over the age of 65 years. The study also stated ‘detected participants tended to be younger’.
Our concerns are twofold. Firstly, the paper is misleading if there was an upper-age cut off in this study, or older people were excluded without that being stated. Secondly, if older people were included, then why was their depression not detected? Was there an assumption that depressive symptoms are an inevitable part of old age and, therefore, depression was not considered an appropriate clinical diagnosis, which would ultimately lead to undertreatment?2
The study debunks the view that GPs are to blame for an increase in antidepressant prescribing, but does not answer the question of the real cause for this increase. A timely paper by Moore et al3 illuminates this issue. This primary care study confirms an increase in the number of overall prescriptions (2.8% in 1993 to 5.6% in 2004), but suggest this is due to patients being prescribed antidepressants for a longer duration with an increase in repeat prescriptions. Older people, with a higher tendency to experience relapses of depression, would be likely to benefit from longer-term prescribing.4
The paper also did not mention rates of benzodiazepine prescribing. One hopes that benzodiazepine prescriptions are inversely related to antidepressant prescribing for depression. Higher rates of antidepressant prescribing are likely to be preferable to alternative drug regimes. Again, this has specific relevance to older people who may be particularly sensitive to side effects of benzodiazepines.
All in all, we think these issues should be addressed, especially the lack of identification of depression in older people in this study. This is of concern because depression in old age is as common as in younger people, and is associated with equal if not higher rates of suicide.