Treatment-Refractory Depression in the Elderly: An Audit of Primary Care Referrals to Psychiatric Services in Swindon, U.K

BACKGROUND: Our objective was to audit primary care referrals for depression to assess prereferral quality of antidepressant treatment. METHOD: We performed a retrospective audit of referrals from primary care to the Department of Old Age Psychiatry in Swindon, Wiltshire, U.K., for a new episode of depression, excluding life-threatening cases, between January 1, 1997, and December 31, 1998. To determine if treatment before referral met criteria for an adequate trial, for audit purposes we defined an adequate trial as 8 weeks at maximal dose as specified by the British National Formulary. RESULTS: A computer search identified 58 referrals: 33 cases were excluded-3 notes were unavailable for audit, 7 were wrongly coded, 8 were life-threatening, and 15 were non-primary care referrals. Of the 25 evaluable patients, 2 had had an adequate duration of treatment and 6 were taking maximal doses of antidepressants, but none was taking a dose for an adequate duration. CONCLUSION: Patients referred to secondary care for depression are often undertreated prior to referral, which may explain why the patients in this retrospective audit had failed to respond. Primary care physicians should be encouraged to use medication in elderly patients that requires little or no dose titration at high doses and for at least 8 weeks before considering the patient to be treatment refractory.