Family Practice Vol. 18, No. 3, 321-327
© Oxford University Press 2001
Treatments for late life depression in primary care—a systematic review
Regional Office, NHS Executive South West, 22 Chesterfield Road, Bristol BS6 5DL,
a Department of Epidemiology and Public Health, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK and
b Department of Primary Care, Rehabilitation and Preventive Medicine, University of Marburg, Blitzweg 16, D-35033 Marburg, Germany.
Freudenstein U, Jagger C, Arthur A and Donner-Banzhoff N. Treatments for late life depression in primary care—a systematic review. Family Practice 2001; 18: 321–327.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
Background. Depression is common among older people. It is associated with increased mortality and use of health services. We could identify no prior systematic review of treatment for depression in either primary care attenders or population samples of older people.
Objectives. The aim of this study was to carry out a systematic review of trials of treatments for depression of patients over 60 years of age in primary care or population samples.
Methods. We searched Medline, Embase, Cinahl, the Cochrane Library, Psyclit, BIDS—Social Science and BIDS—Science Citation Indices for trials of drug treatment, interpersonal psychotherapy, cognitive behavioural psychotherapy, counselling and social interventions for late life depression in English, French or German published between 1980 and June 1999.
Results. Of the studies identified, only two were of patients over 60 years of age and met all inclusion criteria for content and quality. Three further studies that were not restricted to but included patients over the age of 60 years also fulfilled our criteria. We found no studies of psychological therapies for depression in older people. With few exceptions, studies were limited to older people who reached a diagnostic threshold and excluded those with ‘subcase level depression’.
Conclusion. There is little evidence of effectiveness for a variety of treatment approaches for depression in older people in primary care, particularly in those with less severe depression. As older people take more medication, making contra-indications to the use of antidepressant drugs more likely, there is a pressing need for studies of the efficacy of non-pharmacological interventions in primary care settings.
Keywords. Aged, depression, drug therapy, primary health care, psychotherapy.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
Major depression is associated with subjective well-being, increased mortality1,2 and, more importantly for health care providers, increased health service utilization.3–5 The weighted average prevalence of major depression in older people was 1.8% in an international systematic review, although estimates as high as 35% have been reported.6
Little is known about the effectiveness of treatments for depressed older people in primary care.7 More evidence exists concerning the management of depression in other settings,8 yet a review of international studies (mostly conducted in Britain and the USA) suggests that only ~10% of depressed older people are referred to psychiatric services.9 This latter group are likely to differ substantially from depressed primary care attenders by being more severely depressed.10,11
We have sought, therefore, to identify studies of treatments for depression in older people in primary care in order to summarize the current state of knowledge and to provide guidance for future studies in this area.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
Sources and type of studies and treatments included
We searched the electronic databases Medline, Embase, Cinahl, the Cochrane Library, Psyclit, BIDS—Social Science Citation Index and BIDS—Science Citation Index, and the references of studies we identified as well as those of other reviews of antidepressant treatment. Controlled clinical trials, randomized controlled trials, ‘controlled before and after studies’ and ‘interrupted time series’ studies were included if they were published between 1980 and June 1999 and the language of publication was English, French or German. We sought trials of cognitive and/or behavioural therapy,12 interpersonal psychotherapy,13,14 ‘counselling’, social support and drug treatment.
In addition, subjects had to be recruited from a sample of the general population or from primary care attenders. Studies were included if all subjects were over the age of 60 years. However, studies that were not elderly specific but included some subjects over the age of 60 were sought and analysed separately. Initial selection on all the above criteria was made by one of the authors.
Methodological quality criteria for inclusion
All included studies had to comply with the quality criteria for intervention studies published by the Cochrane Effective Practice and Organisation of Care Group.15 The criteria pertinent to the retrieved studies were: relevant and interpretable data, concealed allocation of subjects, follow-up of at least 80–100% of randomized patients, a baseline measurement, a reliable primary outcome measure, protection against contamination, and blinded assessment of primary outcomes or use of an objective outcome measure. This review was, however, not carried out by members of the Cochrane Effective Practice and Organisation of Care Review Group but employed some of its methods.
Two reviewers, trained in the use of the quality criteria, read each study independently (and blind to the other's appraisal). They summarized the presented data and categorized the compliance of studies with the quality criteria (done, not clear, not done or do not know). They then compared their findings and discussed differences. Agreement on the accuracy of the factual information, the quality and the decision to include or exclude a study were made by consensus between the two reviewers. In general, studies were excluded if one of the quality criteria was classified as ‘not done’. However, the actual method of randomization often was not stated. We therefore included studies that stated randomization without providing further detail.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
Seven studies of patients over the age of 60 years met all selection criteria. All were randomized controlled trials. Only two of them also met all methodological quality criteria and were therefore included in the review. Both investigated the effectiveness of psychiatric team care for patients with depressive symptoms or depression found among a population sample screened for depressive symptoms. Information about included and excluded studies is presented in Tables 1
and 2, respectively.
|
|
We found no studies of psychological treatment, nor did we find any high quality studies of drug treatment in the studies restricted to older people. Studies of drug treatment that we did find were short (4–8 weeks) and excluded many patients with other illnesses, thus making any assessment of how treatment would perform under health service conditions (effectiveness) rather than ideal circumstances (efficacy) virtually impossible.
Exclusions commonly used in studies of antidepressants in older people are summarized in Table 3 to show the limited generalizability of drug trial results.
|
Given the extent of the evidence, only limited conclusions are possible. A flexible approach to the treatment of depression in older people led by a community psychiatric team can lead to the considerable improvement of 40–50% of those treated. Routine treatment in primary care only achieved ~25–30% improvement. The difference was probably largely due to the greater number of patients on antidepressant drug treatment in the intervention groups.
A total of eight studies that were not primarily of older people, but did include patients over the age of 60 years, met all selection criteria. All were randomized controlled trials of antidepressant drugs. Three of them also met all methodological quality criteria and were therefore included in the review. None of the eight studies investigated the effectiveness of psychotherapy.
The studies are also shown not because they allow specific conclusions to be drawn for the overall effectiveness of antidepressant treatment in older people but because they provide a fuller impression of the treatments used with older people even when they were not the focus of the study. Only one excluded study analysed results for subjects over 65 years separately. A meta-analysis of results was therefore impossible.
We did not analyse effect sizes in more detail because of this lack of separate analysis and the lack of comparability of patient groups between the two trials of older people alone.
In contrast to trials of psychiatric team care, the drug trials of antidepressant drugs with less representative participants and of younger patients achieved higher rates of improvement (54–81%). The most likely explanation would be the exclusion of patients with significant co-morbidity. It is also worth noting that 47% of patients treated with placebo improved over 6 months in the study of Malt et al.,16 probably reflecting the spontaneous improvement of some patients over the relatively long observation period as well as the placebo effect.
We cannot say on the basis of our review whether serotonin re-uptake inhibitors (SSRIs) should be used in preference to older antidepressants in the elderly. The high quality studies of community mental health team care did not provide a breakdown of specific treatments used. Of the studies including some patients over the age of 60, only that of Malt16 compared a tetracyclic antidepressant (mianserin) with an SSRI (sertraline) and placebo. Total drop-out from active treatment was 29% for the tetracyclic, 26% for the SSRI and 5% for placebo. In contrast, Ekselius et al.17 compared two SSRIs in a slightly younger population with only about half the drop-out rates (10 and 15%). Subject selection rather than the nature of the drug may be the cause of the differences between studies of similar size and the same duration.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
The aim of this review was to evaluate critically the current evidence for treatment of depression in older people. We found a lack of good quality studies in this area as well as a concentration on treatment of severe depression with no allowance made for prior duration, previous episodes or additional morbidity.
The focus on severe depression is understandable as researchers have reliable methods to identify severe depression. However, depressive symptoms below that level are much harder to classify meaningfully. They could represent the early or late stages of severe depression, reactions to upsetting life events or the response to adverse social circumstances. They could also be the effect of physical disease such as stroke. Older primary care patients with depressive symptoms also have more physical illness than their non-depressed peers.18 As in major depression, the treating physician has to decide whether to consider depressive symptoms as a disorder in their own right or as the symptom of another illness.19
A previous history of depression particularly before the age of 65 increases the likelihood of recurrence.20 Age alone after adjustment for other known risk factors does not appear to make depression more likely.21 In contrast, it has been debated whether older people are less depressed than younger age groups.22,23 However, it is clear that the inability to fulfil social roles resulting from physical disabilities is a major risk factor for depression in older people.24–26 Ironically, this risk factor may be the reason why older people often are excluded from trials of potentially effective interventions for depression.
Older people take more medication on a regular basis,27 thus increasing the likelihood of drug interactions and making contra-indications to the use of antidepressant drugs more likely. The need for other forms of treatment therefore becomes more pressing in this age group.
Improvements on placebo that were apparent in Malt's generally younger study population16 may be less common in older people. A systematic review found that after 1 year, only 33% of patients were well compared with 21% who had died and another 33% who were still depressed.28 Because of the protracted nature of late life depression, studies need to treat or at least follow-up participants for at least 6 months.
Studies to date that have compared SSRIs and older antidepressants have been efficacy studies. We still need studies showing us how newer antidepressant drugs would perform specifically for older patients with minimal exclusions. Such studies might take the same flexible approach as Waterreus' and Banerjee's studies29,30 but use exclusively SSRIs in one group and older antidepressants in the other group.
Cognitive and behavioural psychotherapy can improve severe depression in depressed psychiatric in- and out-patients. Interpersonal psychotherapy has been tested successfully in maintenance treatment of recurrent severe depression.31–34 Cognitive behavioural therapy has also been shown to be effective when delivered to psychiatric out-patients as an outreach service.35 Consequently, if psychotherapy was given to primary care patients, it should only be offered to those with major depression. This will require some formal psychiatric assessment.
Counselling was included in our review because it is widely available in UK primary care. It does not describe any specific psychotherapeutic approach but individual approaches to helping clients by counsellors with different backgrounds and with or without formal qualifications.36 A recent review of the effectiveness of counselling for major depression in adults under the age of 65 concluded that counselling was not effective in the treatment of major depression on current evidence37 and did not recommend its use for that purpose. However, it is also tremendously popular with the general public in Britain, with 90% of a representative sample considering it as effective for depression and only 60% thinking the same about antidepressants.38
The benefits of all forms of treatment are much less clear for patients with milder forms of depression whose weighted average prevalence in the community is ~9.8%.6 It is also found more commonly in primary care. Only a third of adults under 65 years treated by primary care physicians in London reached Hamilton Depression Scale scores commonly used to select depressed individuals for inclusion into drug trials.11 It has been suggested that by limiting research to uncomplicated major depressive disorder, tested treatments may only apply to <15% of depressed primary care patients.7 Consequently, it is likely that primary care physicians currently are treating many depressed patients for whom there is no evidence that antidepressants are more effective than placebo.
We do not deny the obstacles confronting researchers who wish to study treatment strategies for depression in primary care. Only 11% of older people living in the community and screened as depressed would agree to take antidepressant medication as part of a trial.3 GPs too need to be convinced of the importance of evaluating interventions for adequate sample sizes to be achieved. In one study in the UK, only 10% of randomly selected practices were willing to take part.40 Losses to follow-up may be ~10% over 1 year especially if those over 80 years are included. Although the prevalence of dementia in 60- to 64-year-olds is only ~1%, in 95- to 99-year-olds ~35% suffer from the condition. Test thresholds of case finding instruments change in the presence of mild dementia,41 and an assessment may become very difficult when it is severe. The design of future trials needs to address these problems to ensure that health care professionals can base their treatment on better evidence of effectiveness.
The alternative, chosen by some studies, of undertaking a population survey increases the numbers of eligible individuals but goes beyond the self-referral or case finding practised in primary care. Consequently, those studies tell us more about the burden of disease than the effectiveness of interventions in a primary care setting.
The natural history of depression is very variable. The positive predictive value of a variety of screening tools in primary care attenders was ~30% in one study of emergency primary care attenders.42 Only three out of 10 individuals identified by those screening tools as probably depressed, were actually depressed. For those reasons, if none other, screening is unlikely to be adopted as a routine measure.
On the basis of this systematic review, we would recommend that more research needs to be undertaken into the effectiveness of all forms of treatment of depression, both major and less severe, in older people by GPs. More evidence is needed about the effectiveness of psychological treatment for depressed older patients in primary care settings.
|
Key points |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
- There have been no trials of specific psychotherapies or counselling for depression of older people in primary care.
- Two studies of patients over 60 years of age studied the effectiveness of community psychiatric team care.
- Three further studies, that only included some patients over the age of 60 years, tested the effectiveness of antidepressant drugs.
- Older people are more likely to require non-pharmacological interventions. These need to be tested in primary care.
- Follow-up of patients in trials of antidepressant therapy should be of at least 6 months duration.
- Patients with depression of lesser severity need to be included in trials in primary care as they are far more common than those with severe depression.
|
Acknowledgments |
|---|
This work was funded by research and development grant RBH 97XX3 from the Regional Office of the NHS Executive Trent.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionKey pointsReferences |
|---|
1 Pulska T, Pahkala K, Laippalla P, Kivela S-L. Major depression as a predictor of premature deaths in elderly people in Finland: a community study. Acta Psychiatr Scand 1998; 97: 408–411.[Web of Science][Medline]
2
Dinan TG. The physical consequences of depressive illness. Br Med J 1999; 318: 826.
3 Conwell Y. Outcomes of depression. Am J Geriatr Psychiatry 1996; 4 (Suppl 1): S34–S44.
4 Fredman L, Schoenbach VJ, Kaplan BH et al. The association between depressive symptoms and mortality among older participants in the epidemiologic catchment area—Piedmont Health Survey. J Gerontol 1989; 44: S149–S156.
5
Bruce ML, Leaf PJ. Psychiatric disorders and 15-month mortality in a community sample of older adults. Am J Public Health 1989; 79: 727–730.
6
Beekman ATF, Copeland JRM, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry 1999; 174: 307–311.
7 Callahan CM, Hendrie HC, Tierney WM. The recognition and treatment of late-life depression: a view from primary care. Int J Psychiatry Med 1996; 26: 155–175.[Web of Science][Medline]
8
McCusker J, Cole M, Keller E, Bellavance F, Berard A. Effectiveness of treatments of depression in older ambulatory patients. Arch Intern Med 1998; 158: 705–712.
9 Cole MG, Yaffe MJ. Pathway to psychiatric care of the elderly with depression. Int J Geriatr Psychiatry 1996; 11: 157–161.[Web of Science]
10 Klinkman MS, Schwenk TL, Coyne JC. Depression in primary care—more like asthma than appendicitis. Can J Psychiatry 1997; 42: 966–973.[Web of Science][Medline]
11
Sireling LI, Freeling P, Paykel ES, Rao BM. Depression in general practice: clinical features and comparison with outpatients. Br J Psychiatry 1985; 147: 119–126.
12 Woods RT. Psychological therapies and their efficacy. Rev Clin Gerontol 1992; 2: 171–183.
13 Hinrichsen GA. Interpersonal psychotherapy for depressed older adults. J Geriatr Psychiatry 1997; 30: 239–257.
14
Reynolds CF, Frank E, Perel JM et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression—a randomized controlled trial in patients older than 59 years. J Am Med Assoc 1999; 281: 39–45.
15 Cochrane Effective Practice and Organisation of Care Review Group. The Data Collection Checklist. http://www.abdn.ac.uk/ publichealth/hsru/epoc/checklist98.doc [3/6/99].
16
Malt UF, Robak OH, Madsbu H-P, Bakke O, Loeb M. The Norwegian naturalistic treatment study of depression in general practice (NORDEP)—I: randomised double blind study. Br Med J 1999; 318: 1180–1184.
17 Ekselius L, von Knorring L, Eberhard G. A double-blind multicenter trial comparing sertraline and citalopram in patients with major depression treated in general practice. Int Clin Psychopharmacol 1997; 12: 323–331.[Web of Science][Medline]
18 Williamson-Russo P. Barriers to diagnosis and treatment of depression in primary care settings. Am J Geriatr Psychiatry 1996; 4 (Suppl 1): S84–S90.
19 Reifler BV. Depression: diagnosis and comorbidity. In: Reynolds CF, Schneider LS, Lebowitz BD, Kupfer DJ (eds), Diagnosis and Treatment of Depression in Late Life: Results of the NIH Consensus Development Conference. Washington, DC: American Psychiatric Press, 1994: 55–80.
20 van Ojen R, Hooijer C, Jonker C, Lindeboom J, van Tilburg W. Late-life depressive disorder in the community, early onset and the decrease of vulnerability with increasing age. J Affect Disord 1995; 33: 159–166.[Web of Science][Medline]
21 Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Does growing old increase the risk for depression? Am J Psychiatry 1997; 154: 1384–1390.[Abstract]
22 Fombonne E. Increased rates of depression: update of epidemiological findings and analytical problems. Acta Psychiatr Scand 1994; 90: 145–156.[Web of Science][Medline]
23 Wittchen H-U, Knäuper B, Kessler RC. Lifetime risk of depression. Br J Psychiatry 1994; 165 (Suppl 26): 16–22.[Web of Science]
24 Rozzini R, Frisoni GB, Ferrucci L, Trabucchi M. Co-occurrence of disadvantage conditions in elderly subjects with depressive symptoms. J Affect Disord 1997; 46: 247–254.[Web of Science][Medline]
25 Zeiss AM, Lewinsohn PM, Rohde P, Seeley JR. Relationship of physical disease and functional impairment to depression in the elderly. Psychol Aging 1996; 11: 572–581.[Web of Science][Medline]
26 Prince MJ, Harwood RH, Thomas A, Mann AH. A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII. Psychol Med 1998; 28: 337–350.[Web of Science][Medline]
27 Swift CG. Iatrogenesis. In: Ebrahim S, Kalache A (eds), Epidemiology in Old Age. London: BMJ Publishing Group, 1996: 398–407.
28
Cole MG, Bellavance F, Mansour A. Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis. Am J Psychiatry 1999; 156: 1182– 1189.
29 Waterreus A, Blanchard M, Mann A. Community psychiatric nurses for the elderly: well tolerated, few side-effects and effective in the treatment of depression. J Clin Nurs 1994; 3: 299–306.[Medline]
30
Banerjee S, Shamash K, Macdonald JD, Mann AH. Randomized controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home. Br Med J 1996; 313: 1058–1061.
31 Koder DA, Brodaty H, Anstey KJ. Cognitive therapy for depression in the elderly. Int J Geriatr Psychiatry 1996; 11: 97–107.
32 Niederehe G. Psychosocial treatments with depressed older adults: a research update. Am J Geriatr Psychiatry 1996; 4 (Suppl 1): S66–S78.
33 Scogin F, McElreath L. Efficacy of psychosocial treatments for geriatric depression: a quantitative review. J Consult Clin Psychol 1994; 62: 69–74.[Web of Science][Medline]
34 Weissman MM. Psychotherapy in the maintenance treatment of depression. Br J Psychiatry 1994; 165 (Suppl 26): 42–50.[Web of Science]
35 Cuijpers P. Psychological outreach programmes for the depressed elderly: a meta-analysis of effects and dropout. Int J Geriatr Psychiatry 1998; 13: 41–48.[Web of Science][Medline]
36 British Association for Counselling. Counselling: Definition of Terms in Use with Expansion and Rationale. Information Sheet 1, 1991.
37 Churchill R, Dewey M, Gretton V, Duggan C, Chilvers C, Lee A. Should general practitioners refer patients with major depression to counsellors? A review of current published evidence. Br J Gen Pract 1999; 49: 737–743.
38
Paykel ES, Hart D, Priest RG. Changes in public attitudes to depression during the Defeat Depression Campaign. Br J Psychiatry 1998; 173: 519–522.
39 Stevens T, Katona C, Manela M, Watkin V, Livingston G. Drug treatment of older people with affective disorders in the community: lessons from an attempted clinical trial. Int J Geriatr Psychiatry 1999; 14: 467–472.[Web of Science][Medline]
40 The Counselling versus Antidepressants in Primary Care Study Group. How disabling is depression? Evidence from a primary care sample. Br J Gen Pract 1999; 49: 95–98.[Web of Science][Medline]
41
O'Riordan TG, Hayes JP, Oneill D, Shelley R, Walsh JB, Coakley D. The effect of mild to moderate dementia on the geriatric depression scale and on the general health questionnaire. Age Ageing 1990; 19: 57–61.
42 Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med 1997; 12: 439–445.[Web of Science][Medline]
43 Patris M, Bouchard J-M, Bougerol T, Charbonnier J-F. Citalopram versus fluoxetine: a double-blind, controlled, multicentre, phase III trial in patients with unipolar major depression treated in general practice. Int Clin Psychopharmacol 1996; 11: 129–136.[Web of Science][Medline]
44 Hutchinson DR, Tong S, Moon CAL, Vince M, Clarke A. Paroxetine in the treatment of elderly depressed-patients in general practice: a double-blind comparison with amitriptyline. Int Clin Psychopharmacol 1992; 6 (Suppl 4): 43–51.
45 Schweizer E, Rickels K, Hassman H, GarciaEspana F. Buspirone and imipramine for the treatment of major depression in the elderly. J Clin Psychiatry 1998; 59: 175–183.[Web of Science][Medline]
46 Vallé-Jones JC, Swarbrick DJ. A comparative-study of once-daily flupenthixol and amitriptyline in the treatment of elderly depressed patients: a multicenter trial in general-practice. J Int Biom Inform Data 1983; 4 (Suppl 1): 29–35.
47 Brodie NH, McGhie RL, O'Hara H, Vallé-Jones JC, Schiff AA. Anxiety/depression in elderly patients: a double-blind comparative study of fluphenazine/nortriptyline and promazine. Practitioner 1975; 215: 660–664.[Web of Science][Medline]
48 Høstmaelingen NJ, Asskilt O, Austad SG et al. Primary care treatment of depression in the elderly: a double-blind, multi-centre study of flupenthixol and sustained release amitriptyline. Curr Med Res Opin 1989; 11: 593–599.[Web of Science][Medline]
49 Laakmann G, Faltermaier-Temizel M, Bossert-Zaudig S, Baghai T, Lorkowski G. Treatment of mild to moderate depressive syndrome. A placebo-controlled double-blind trial on therapy with benzodiazepines or antidepressants. Münch Med Wochenschr 1996; 138: 39–44.
50 Laws D, Ashford JJ, Anstee JA. A multicentre double-blind comparative trial of fluvoxamine versus lorazepam in mixed anxiety and depression treated in general practice. Acta Psychiatr Scand 1990; 81: 185–189.[Web of Science][Medline]
51 Dorn M. Psychopharmaka in der Praxis. Doppelblindprüfung Lofepramin gegen Amitryptilin. Z Allgemeinmed 1980; 56: 133–139.
52 Sussex Clinical Trials Group. Separate and combined anxiolytic and anti-depressant treatment of mixed anxiety/depression. A double-blind, placebo controlled comparison. Sussex Clinical Trials Group. Acta Psychiatr Scand 1985; 72: 81–88.[Medline]
53 Moon CA, Laws D, Stott PC, Hayes G. Efficacy and tolerability of controlled-release trazodone in depression: a large multicentre study in general practice. Curr Med Res Opin 1990; 12: 160–168.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  H. Burroughs, K. Lovell, M. Morley, R. Baldwin, A. Burns, and C. Chew-Graham 'Justifiable depression': how primary care professionals and patients view late-life depression? a qualitative study Fam. Pract., June 1, 2006; 23(3): 369 - 377. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||