In Australia, between 10 and 15 percent of older people are living with depression. For those who are living with dementia, it’s believed that around one in five people will also have depression. But depression can be hard to spot, and even harder to treat in older people.
The task is made all the more difficult in cases of Treatment-Resistant Depression (TRD), which is believed to be prevalent in up to 40% of older people living with depression.
“The problem of treatment-resistant depression in later life [TRD-LL] is increasingly recognised but remains poorly characterised,” Randall Espinoza, Clinical Professor in the Division of Geriatric Psychiatry, University of California, Los Angeles, told the audience at the American Association of Geriatric Psychiatry Annual Meeting.
TRD, which is often associated with higher morbidity and mortality, and increased pain and suicide rates, can increase health care costs and, understandably, starkly decrease quality of life. Research has also found that it is often chronic and recurring. Between 20% and 35% of people will have TRD depression for more than a year, between 25% and 40% of people will experience a recurrence in two years, and 60% a recurrence after five years.
Mr Espinoza broke down TRD into three categories, attributing these different categories to the difficulty in identifying cases. Those three categories are “non-response to treatment and a high degree of functional impairment; treatment resistant depression, which shows minimal to partial response to treatment; and treatment refractory depression, which shows no response to treatment and symptoms unchanged or worsening.”
It was also explained that TRD commonly arises in older people due to trauma, social adversity and losses. Treatment is also complicated due to the ageing brain and most clinical trials of drugs and medications do not include older adults, making medical treatment difficult to ensure success.
So, how can we treat TRD and other forms of depression in older adults? Once someone has been identified and diagnosed, what options are available and what is the best way forward?
Mr Espinoza recommended a thought shift from “treatment-resistant” to “difficult to treat depression” (DTD), suggesting that the method of treatment would best start with the school of thought of the clinicians. Instead of considering their progress on a cure or remission-based model, an emphasis on capability, recovery and symptom management should be prioritised.
“DTD captures not only acute phase treatment but also encourages a shift of focus to long-term treatment with the goals of improving overall function, quality of life, and optimisation of treatment when full remission is no longer viable,” he said.
Other treatment options discussed included the use of psychedelic drugs such as ketamine, which has shown promising antidepressant properties, particularly in TRD.
In the argument for the use of psychedelics for the treatment of mental illness, the Australian government has just approved a $15 million competitive grant round to investigate the therapeutic properties of psychedelics and other innovative therapies in the treatment of debilitating mental illnesses.
In a press release from the office of the Minister for Health and Aged Care, Greg Hunt, the grant will further investigate findings from around the world regarding the effectiveness of illicit drugs in the treatment of mental illness in a controlled environment.
According to the Minister for health, an estimated 4 million Australians experience at least one mental illness per year, and almost half the population will experience mental health disorders in their lifetime.
Current treatments for mental illnesses can vary in efficacy and recovery, and very few advancements have been made in the mental health pharmaceutical industry in recent years.
“There is now a strong and emerging body of international evidence that shows that substances such as ketamine, psilocybin, and 3,4-methylenedioxymethamphetamine (MDMA), when used in a controlled environment and supported by psychological/psychiatric care, offer a promising new approach to effectively treating pernicious mental illnesses that are resistant to first-line treatments,” said the press release.
“The Government’s $15 million Innovative Therapies for Mental Illness Grant Opportunity under the Medical Research Future Fund (MRFF) will accelerate global efforts by supporting Australian-led research into the use of these approaches to combat resistant illnesses such as PTSD, major depressive disorder, addiction disorders and eating disorders that are impacting the lives of so many Australians.”
According to Mr Hunt, research into the efficacy of these alternative therapies both nationally and internationally have offered “extremely encouraging” results. This grant would ensure that testing continued, so further evidence could be provided before psychiatrists began administering the drugs outside of clinical trials.
“This grant opportunity will boost local research into potentially life-saving therapies and offers hope to all those suffering from mental illness, including our Veterans and emergency service personnel dealing with the devastating effects of PTSD,” Minister Hunt said.
“It is vital that we continue to support the search for new and better treatments for mental illness.”
In early 2019, St Vincent’s Hospital Melbourne conducted a clinical trial of a synthetic version of psilocybin, the psychoactive ingredient in psychedelic mushrooms, administering it to terminally ill patients in an effort to ease feelings of anxiety and depression about their death.
The trial saw 40 terminal patients receive one to two doses of psilocybin, along with a program of psychotherapy and clinical support.
In a media release by St Vincent’s Melbourne, lead therapist and Chief Principal Investigator of the trial, Dr Margaret Ross, said, “We see a lot of fear and despair in our terminally ill patients, so to be able to offer a novel trial treatment that has already shown such promise is excellent. It’s really a privilege to be able to conduct this research. This is one of the most exciting developments in psychiatric research in decades.”
According to St Vincent’s Melbourne’s 2019-20 Annual Report, “This treatment has been shown to dramatically reduce symptoms of anxiety and depression in cancer patients and in many cases produces a substantial positive shift in their perspectives on life and death.”
With the new grant into research into the positive effects of controlled doses of psychedelics on people living with severe mental illness, the future treatments of mental health disorders, particularly in older people, could be changed forever.