Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association

Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association Luis Agüera-Ortiz 1,2 *, Marı ´a Dolores Claver-Martı ´n 3 , Marı ´a Dolores Franco-Ferna ´ndez 4 , Jorge Lo ´pez-A ´ lvarez 1 , Manuel Martı ´n-Carrasco 5 , Marı ´a Isabel Ramos-Garcı ´a 6 and Manuel Sa ´nchez-Pe ´rez 7 1 Servicio de Psiquiatría, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain, 2 Centro de Investigacio n Biome dica en Red de Salud Mental (CIBERSAM), Madrid, Spain, 3 Madrid Salud, Ayuntamiento de Madrid, Madrid, Spain, 4 Psychiatry Department, University of Sevilla, Seville, Spain, 5 FIDMAG Research Foundation (CIBERSAM), Barcelona, Spain, 6 Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain, 7 Unidad de Psiquiatría Geriátrica, Hospital Sagrat Cor. Martorell, Barcelona, Spain Introduction: Present knowledge about depression in the elderly is still scarce and often controversial, despite its high frequency and impact. This article reports the results and most relevant conclusions of a Delphi-based consensus on geriatric depression promoted by the Spanish Psychogeriatric Association. Methods: A 78-item questionnaire was developed by 7 highly specialized geriatric psychiatrists and was evaluated using the Modified Delphi technique in two rounds answered by 35 psychiatrists with an extensive expertise in geriatric depression. The topics and number of questions (in brackets) covered were: concepts, clinical aspects, and risk factors (12); screening and diagnosis (7); psychotic depression (17); depression and dementia (5); antidepressant drug treatment (18); non-pharmacological biological treatments (5); psychotherapeutic treatments (4); comorbidity and preventive aspects (6); professional training needed (4). In addition, the expert panel’sopiniononthe antidepressants of choice in 21 common comorbid conditions and on different strategies to approach treatment-resistant cases in terms of both efficacy and safety was assessed. Results: After the two rounds of the Delphi process, consensus was reached for 59 (75.6%) of the 78 items. Detailed recommendations are included in the text. Considering pharmacological treatments, agomelatine was the most widely mentioned drug to be recommended in terms of safety in comorbid conditions. Desvenlafaxine, sertraline, and vortioxetine, were the most frequently recommended antidepressants in comorbid conditions in general. Combining parameters of efficacy and safety, experts recommended the following steps to address cases of treatment resistance: 1. Escalation to the maximum tolerated dose; 2. Change of antidepressant; 3. Combination with another antidepressant; 4. Potentiation with an antipsychotic or with lamotrigine; 5. Potentiation with lithium; 6. Potentiation with dopamine agonists or methylphenidate Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3801 Edited by: Francesca Assogna, Santa Lucia Foundation (IRCCS), Italy Reviewed by: Nerisa Banaj, Santa Lucia Foundation (IRCCS), Italy Luca Cravello, ASST Rhodense, Italy *Correspondence: Luis Agüera-Ortiz [email protected] Specialty section: This article was submitted to Aging Psychiatry, a section of the journal Frontiers in Psychiatry Received: 26 January 2020 Accepted: 16 April 2020 Published: 20 May 2020 Citation: Agüera-Ortiz L, Claver-Martı ´n MD, Franco-Ferna ´ndez MD, Lo ´pez-A ´ lvarez J, Martı ´n-Carrasco M, Ramos-Garcı ´a MI and Sa ´nchez-Pe ´rez M (2020) Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association. Front. Psychiatry 11:380. doi: 10.3389/fpsyt.2020.00380 ORIGINAL RESEARCH published: 20 May 2020 doi: 10.3389/fpsyt.2020.00380 Discussion and Conclusions: Consensus was reached for a high number of items as well as for the management of depression in the context of comorbid conditions and in resistant cases. In the current absence of sufficient evidence-based information, our results can be used to inform medical doctors about clinical recommendations that might reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders. Keywords: depression, elderly, consensus statement, clinical recommendations, antidepressant drugs, treatmentresistance, comorbidity INTRODUCTION Depression in the elderly can be considered a real public health problem, because of its frequency, its clinical implications, and the great suffering that it causes (1,2). To date, unfortunately, the degree of knowledge by the health professionals involved in its diagnosis and treatment is far from what would be desirable. The irrefutable epidemiological data pertaining to the increase in the proportion of elderly population and the high prevalence of depression in such age group have led to a growing demand for care that requires efficient, evidence-based responses (3–5). However, until recent decades, neither primary care physicians nor specialists have given this disease due consideration, and this is reflected in the scarce literature on the topic. While professionals demand information, what can be found in the specialized literature, be it articles, books or clinical practice guidelines, does not frequently meet their expectations. Significant advances have been made regarding the neurobiology of depression in older people, from many points of view, from basic science (6) to the influence of psychological issues (7). The link with neurodegenerative diseases has also been extensively explored (8,9). Nevertheless, research performed in the area is clearly insufficient. Furthermore, older adults are often excluded from pharmacotherapeutic clinical trials. Because of all this, physicians’decision making is permanently affected by the lack of sound scientific bases and by the use of information drawn from non-geriatric population groups. This results in frequent disagreement regarding the divergent findings of the available research, which partly explains the variability of professional judgment and clinical habits among specialists in the area. One way to remedy this situation is to draw up clinical practice guides and build expert consensuses. In recent years, the number of guides addressing geriatric depression therapy has slightly increased. However, the scarcity of documents that approach depression in the elderly from a broader perspective that goes beyond treatment is still remarkable (10–16). The Spanish Psychogeriatric Association drew up a first consensus document on geriatric depression that was presented in 2011 (17). However, it is now deemed necessary to update its proposals and contents. This second edition is not a revised version of the first one, but constitutes a new work practically from scratch. The common goal of both projects was and is to reach consensus on a proposal for professional criteria and clinical recommendations to reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders. As with the first edition of the Consensus, the latest version of the Delphi method, an agreement of expert’s technique that is reliable and has a long tradition of use in biomedicine has been used. The main purpose of this project was to explore the opinion of a panel of experts in psychogeriatrics and reach sufficient professional consensus based on a battery of criteria and recommendations regarding depression management in elderly patients in the light of the available scientific knowledge and the panel’s clinical expertise. The study consists of three parts: an actual consensus on different issues regarding the management of depression in the elderly, using the Delphi method; and two specific analyses that follow two different approaches, one addressing the choice of the most adequate antidepressant drug according to existing comorbidities and another on strategies for cases of inadequate response to antidepressant therapy. This article reports the results and most relevant conclusions of the study, hoping that they might be of practical interest not only for specialists in psychiatry, but also for other professionals that care for the elderly, such as geriatricians, primary care physicians, physicians working at nursing homes, neurologists or psychologists, beyond the territorial context where it was carried out. MATERIALS AND METHODS Delphi Study The first part of the consensus document is a study using the Delphi method. Such technique is based on the answers to a questionnaire previously drawn up by a scientific committee of experts or “core”provided to a group of experts in the same area, known as panellists, that is assessed more than once. The purpose of the series of questionnaires is to reduce variability in answers as far as possible. The expert committee for this consensus consisted of seven leading members of the Spanish Psychogeriatric Association, and the panel of experts was made up of 35 psychiatrists with clinical expertise and specific professional recognition in the approach of depression in elderly patients, selected in accordance with the Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3802 criteria of the expert committee following a snowball sampling procedure (18). The various geographical areas of Spain were represented thus assuring a lack of regional bias. Some of the experts, but not all, had taken part in the first edition. The scientific committee drew up a series of items for the survey, designed in the form of statements (positive and negative). A first list of these statements was built using in part those of the first edition of the consensus and many other new ones. In some instances, questions that achieved a good degree of agreement in the first edition were not repeated in the second in order to keep a manageable total number that could be adequately answered by the experts. The items included in the final questionnaire were the product of a process of consensus achieved through email exchanges among the members and a face-to-face meeting. The final version of the survey contains 78 items structured into nine topic areas. The items by topic area were: Topic area Number of items 1.- Concepts, clinical aspects, and risk factors 12 2.- Screening and diagnosis 7 3.- Psychotic depression 17 4.- Depression and dementia 5 5.- Antidepressant drug treatment 18 6.- Non-pharmacological biological treatments (fundamentally ECT) 5 7.- Psychotherapeutic treatments 4 8.- Comorbidity and preventive aspects 6 9.- Professional training to address depression in the elderly 4 TOTAL 78 The two rounds of the Delphi process were performed in the first trimester of 2018. Once the Delphi method had been applied, results were organized and discussed by the core of experts, checking them against the existing scientific literature. All the results and conclusions have been published in an extensive monograph that is available on the website of the Spanish Psychogeriatric Association (www.sepg.es). This article presents the most relevant aspects of such study. The Delphi method is a structured technique for a process of group communication by members who are generally geographically scattered, and is effective in allowing a group of individuals, as a whole, to address a complex problem. The forecasting capacity of the Delphi method is based on the systematic use of an intuitive opinion expressed by a group of experts (19,20). The modified Delphi method (21) that has been used in this study was applied in two successive rounds of a closed-ended questionnaire constructed by the core of experts. In between rounds, each participant was informed of the processing of the intermediate results achieved and the comments made by the panel, which offers individuals the opportunity to contrast their opinions with those of the other panelists and reconsider their position. The main characteristics of a Delphi study are anonymity, possible panelist heterogeneity, iteration, and controlled feedback of group answers indicating the level of agreement or disagreement reached, as well as the statistical validation of the final result. For interaction between panelists and the scientific committee, this study used a specifically designed website where participants entered their answers and received the corresponding feedback on them. Statements (items) were assessed using a single ordinal ninepoint Likert type scale, according to the UCLA-Rand Corporation format that is currently used for healthcare technology assessment (19,21,22). Response categories are defined by linguistic descriptors of agreement/disagreement with the statements presented, as follows: •1-3: I disagree with the statement (the lower the score, the greater the level of disagreement). •4-6: I neither agree nor disagree with the statement; I do not have a well-defined criterion on the issue (choose 4 or 6 if closer to disagreement or to agreement, respectively). •7-9: I agree with the statement (the higher the score, the greater the level of agreement). The phases of the Delphi study are shown in Figure 1. Statistical Analysis of the Delphi Study Results For each item of the questionnaire, the mean of the panelists’ scores and the confidence interval for the average at a 95% confidence level were calculated. Interpretation according to statistical estimators was performed using the following explicit criteria for achieved or failed consensus: •The higher the average (closer to 9) for each item, the stronger the group’s agreement with the statement expressed by the item. •The lower the average (closer to 1) for each item, the stronger the group’s disagreement with the statement expressed by the item. •The lower the confidence interval, the greater the unanimity in the group’s agreement or disagreement opinions. •If the confidence interval encompasses the value 5 (“neither agree nor disagree”), the group does not reach unanimous consensus in either direction. In such case, a description of the causes for such lack of consensus in any direction of the side values will be described (there are either markedly different opinions among panelists, or most of the group claims to have no definitive criterion on the item). The analysis of group opinion and the type of consensus reached on each of the questions posed was conducted using the position of the median of group scores (score zone: [1-3] [4-6] [7-9]) and the “level of agreement”reached by the respondents, according to the following criteria: Item consensus was established when the panel showed “concordance”of opinion, that is, when experts scoring outside the three-point zone ([1-3], [4-6], [7-9]) that includes the median accounted for less than one third of the respondents. In such case, the median value defined the type of group consensus reached: majority “disagreement”with the item, if the median was ≤3, or majority “agreement”with the item if the Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3803 median was ≥7. When the median was within the 4-6 zone, items were considered “unclear”for a representative majority of the group. Conversely, when the scores of one third or more of the panelists fell within the [1-3] zone and those of another third within the [7-9] zone, “discrepancy”in criterion was established. The remaining items that obtained neither consistency nor discrepancy were considered of “indeterminate”level of consensus. All the items on which the group did not reach clear consensus in favor or against the issue (unclear items, those where disagreement can be observed and those where consensus was indeterminate) were proposed for reconsideration by the panelists in the second round of the Delphi. Items on which there was high dispersion of opinions among the respondents, with interquartile ratings ≥4 points (from p25 to p75) were also subjected to reassessment. In between both rounds, panelists were informed of the detailed distribution of the group’s answers to the first survey (using bar graphs), and they were provided with the comments and explanations contributed by each participant. After reviewing such information, they were asked for a new personal assessment of the items on which no consensus had been reached in the first round. The findings are presented using a color code that accounts for the final positioning of group opinion on each of the assessed items (a clinical criterion or recommendation): Representation of findings is done as follows: CONSENSUS AGREEMENT WITH ITEMS (The group ACCEPTS the item by consensus). Marked in green color NO CONSENSUS ON ITEMS AFTER THE TWO INTERACTION ROUNDS (The group does not have a sufficiently homogeneous opinion). Marked in orange color CONSENSUS DISAGREEMENT WITH ITEMS (The group REJECTS the item by consensus). Marked in red color Choice of Antidepressant Drug According to Existing Medical Comorbidities Preferences regarding the use of different antidepressants in patients with various medical comorbidities that are frequent in older adults were subjected to the consensus process and collected during the first round of the Delphi study. All the modern antidepressants available in Spain at the time of the fieldwork were included. Regarding the oldest drugs, monoamine oxidase inhibitors were not included, and of the tricyclics, only nortriptyline -which is possibly the most widely supported tricyclic choice for use in the elderly populationwas assessed. The observations in this section mostly refer to the safety of antidepressants in the presence of each of the listed situations and not to the efficacy of the drug under such circumstances, except in the generic case of chronic pain patients. The comorbidity situations proposed were as follows: 1. Ischemic cardiomyopathy/infarction 2. Arrhythmias 3. Hypertension 4. Anticoagulated patient 5. Diabetes 6. Dyslipidemia 7. Obesity FIGURE 1 | Phases of the Delphi study. Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3804 8. Appetite and weight loss 9. Significant constipation 10. Risk of gastrointestinal bleeding 11. Risk of hyponatremia 12. Drowsiness 13. Falls 14. Alcohol abuse 15. Sexual dysfunction 16. Glaucoma 17. Risk of epileptic seizures 18. Stroke 19. Parkinson’s disease and extrapyramidal disorders 20. Cognitive impairment, dementia, Alzheimer’s disease 21. Pain disorders For each of these situations, the expert was asked to choose among the following options: a. Drug contraindicated in such clinical situation b. Drug to be avoided as far as possible:ithassome disadvantages compared to other options c. Drug that could be used: it has no particular advantages or disadvantages d. Drug that is a good alternative: it has certain advantages over the rest of options e. Drug of choice in this clinical situation f. No opinion about it To facilitate interpretation, answers have been arranged according to the following criteria for each of the given comorbidity situations: Specifically recommended antidepressants •Selected as drug of choice by ≥6 panelists •Selected as contraindicated drug by < 6 panelists Antidepressants that are a reasonable option •Selected by ≥6 panelists •Selected as contraindicated drug by < 6 panelists Antidepressants to be avoided •Selected as contraindicated drug by ≥6 panelists Strategies for Treatment-Resistant Depression or Inadequate Response to Antidepressant Therapy The last part of the consensus involved assessing the different strategies to approach cases where depression was resistant or whereadequateresponsetothe originally prescribed antidepressant treatment was not achieved, in terms of efficacy and of safety separately. This information was collected during the first round of the Delphi study. Experts were provided with a list of 9 possible strategies to rank in order of preference. We opted for a fairly open definition of inadequate response or resistance to treatment. Experts were asked to order the 9 options in the form of progressive steps in case the previous one failed, in an attempt to reflect routine clinical practice. Such 9 strategies were as follows: Escalation to maximum dosage Change to an antidepressant from a different group Change to an antidepressant of the same group Combination with another antidepressant Potentiation with lithium Potentiation with an antipsychotic drug Potentiation with lamotrigine Potentiation with a dopamine agonist Potentiation with methylphenidate Each of these options was to be assessed on a 1 to 9 scale, where 1 =first to use; and 9 = last to use. Besides, they were asked to rank the different options in order of safety on another 1 to 9 scale, where 1 = safest; and 9 = least safe. Results were analyzed by summarizing the number of votes. RESULTS Delphi Consensus After the two rounds of the Delphi process, consensus was reached for 59 (75.6%) of the 78 items that made up the survey. Such percentage comprises the 47 (60.2%) items where there was consensus in accepting the statement proposed and the 12 (15.4%) items where there was consensus in rejecting it. No consensus was reached on 19 items (24.4%). The number and percentage of items (in brackets) for which a consensus was reached in each section were as follows: Concepts, clinical aspects, and risk factors: Consensus in 11 (92%) out of 12 items. Screening and diagnosis: Consensus in 6 (85,7%) out of 7 items. Psychotic depression: Consensus in 10 (59%) out of 17 items. Depression and dementia: Consensus in all 5 (100%) items. Antidepressant drug treatment: Consensus in 11 (61%) out of 18 items. Non-pharmacological biological treatments (fundamentally ECT): Consensus in 4 (80%) out of 5 items. Psychotherapeutic therapies: Consensus in 2 (50%) out of 4 items. Comorbidity and preventive aspects Consensus in all 6 (100%) items. Professional training to address depression in the elderly: Consensus in all 4 (100%) items. Table 1 provides a summary of the results of the different question groups, distinguishing between items for which consensus was reached and those for which it was not. Among the former, there is also a distinction in the central columns between items with agreement consensus and items where there is consensus in rejecting the statement. Figure 2 shows a summary of the overall level of consensus achieved. The degree of consensus on the different items grouped into nine topic areas is shown in Tables 2–10. Arithmetical means Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3805 and confidence intervals for each item appear in the Supplementary Material. Antidepressant Selection According to Medical Comorbidities Table 11 gathers all the recommendations regarding individual drugs for each of the clinical situations proposed. Strategies for Managing Inadequate Response and Treatment-Resistant Depression Figure 3 gathers the answers expressing priority actions when there is inadequate response to the initial antidepressant treatment, targeting efficacy. Figure 4 gathers the answers for priority actions when there is inadequate response to the initial antidepressant treatment, in terms of safety. DISCUSSION The discussion of results is approached using a question-answer format, since this makes understanding and grouping into homogeneous areas easier. Concepts, Clinical Aspects, and Diagnosis Process A basic question is to consider whether geriatric depression as an entity is sufficiently defined in itself and in relation to that of the FIGURE 2 | Global results: Degree of consensus. TABLE 1 | Degree of consensus for the items grouped into sections. Section Total items Items that reached consensus (%) Items that did not reach consensus (%) Items with agreement consensus (%) Items with disagreement` consensus (%) Concepts, clinical aspects and risk factors 12 11 (92%)1(8%) 11 (92%) 0 (0%) Screening and diagnosis 7 6(85.7%)1(14,3%) 5 (71,4%) 1 (14,3%) Psychotic depression 17 10 (59%)7(41%) 6 (35%) 4 (24%) Depression and dementia 5 5(100%)0(0%) 4 (80%) 1 (20%) Antidepressant drug treatment 18 11 (61%)7(39%) 9 (50%) 2 (11%) Non-pharmacological biological treatment (fundamentally ECT) 54(80%)1(20%) 2 (40%) 2 (40%) Psychotherapeutic therapies 4 2(50%)2(50%) 2 (50%) 0 (0%) Comorbidity and preventive aspects 6 6(100%)0(0%) 5 (83%) 1 (17%) Professional training to address depression in the elderly 44(100%)0(0%) 3 (75%) 1 (25%) Total 78 59 (75.6%) 19 (24.4%) 47 (60.2%) 12 (15.4%) Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3806 adult. Furthermore, it is important to discern which are the relevant aspects for the diagnostic process. Are There any Differences Between the Clinical Symptoms of Depression in Adults and in the Elderly? The panel of experts defended the importance of the clinical differences between depression in old age and depression in younger adults, specifically stressing a possible increase in anxiety, hypochondriac symptoms, suicidal ideation, and functional impact in the elderly, alongside with less likeliness to express sadness. It should be noted that whether there are differences or not in symptomatology—somatic, cognitive, emotional—between depression in the elderly and in young individuals has been discussed at length (23), with authors and studies advocating one or the other position, although, in general, clinicians are inclined to acknowledge the existence of differences, which would allow greater diagnostic precision. Despite this, such differences are not contemplated in classification systems such as ICD-11 and DSM-5 (24). Does Current Nosology Adequately Reflect Depression in the Elderly? There is major consensus on considering that the criteria of current nosology to diagnose and classify depression in the latest stages of life are insufficient. According to our experts, the particularities of the clinical expression of depression in older adults, its evolution (which is associated with a greater risk for becoming chronic and with higher relapse rates) and its high comorbidity with other somatic and brain pathologies (25), are not adequately reflected in standard criteria. The practically unanimous recommendation of our experts, which is consistent with that found in the scientificliterature (26,27), is the appropriateness of establishing certain specific criteria for depression in the elderly that may reflect its clinical and evolutionary particularities, thus enabling better understanding and easier identification of such clinical patterns and selection of the appropriate treatment. It is not possible to infer from the previous statements that experts regard depression in the elderly as a different clinical entity from that in adults, but rather that they recommend greater alertness when gathering the clinical singularities in the diagnostic algorithm. Are the Concepts of Late-Onset Depression, Vascular Depression and Depressive Pseudodementia Useful? A favorable agreement on the clinical usefulness of the concepts of “late-onset depression”and “vascular depression”was TABLE 2 | Topic area 1—Concepts, clinical aspects, and risk factors. Consensus Disagreement No consensus Consensus Agreement 1.1. Late-onset depression (first episode in old age rather than in adulthood) is a clinically useful concept in psychiatry. 1.2. Vascular depression is a clinically useful concept in psychiatry. 1.3. Depressive pseudodementia is a clinically useful concept in psychiatry. 1.4. Depression in the elderly, as compared to adults, is more specifically associated with higher levels of anxiety. 1.5. Depression in the elderly, as compared to adults, is more specifically associated with higher levels of hypochondriac symptomatology. 1.6. Depression in the elderly, as compared to adults, is more specifically associated with less likelihood to express sadness. 1.7. Depression in the elderly, as compared to adults, is more specifically associated with higher levels of suicidal ideation. 1.8. Depression in the elderly, as compared to adults, is more specifically associated with greater impact on daily life. 1.9. Frailty states in the transition from autonomy to dependence entail a significant risk factor for depression in old age. 1.10. Disclosure of a dementia diagnosis is a significant risk factor for depression in old age. 1.11. Severe physical diseases in older adults are a higher risk factor for suicide in men than in women. 1.12. Non-depressed older adults with thoughts of death require clinical care. TABLE 3 | Topic area 2—Screening and diagnosis. Consensus disagreement No consensus Consensus agreement 2.1. The diagnostic criteria of standard nosologies (ICD 11, DSM5) are adequate to diagnose and classify depressive disorders in the elderly. 2.2. Specific diagnostic criteria for depressive disorders in the elderly population are necessary. 2.3. Teleassistance services should include some type of screening system for depression. 2.4. ALL elderly patients living in nursing homes should be systematically screened for depression. 2.5. ALL elderly patients should be systematically screened for depression in Primary Care. 2.6. Any diagnostic process in lateonset depression should include laboratory tests. 2.7. Any diagnostic process in lateonset depression should include neuroimaging testing. Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3807 reached, although there is not enough empirical evidence of them yet. In the first case, interest is associated with a tendency to the onset of more prominent cognitive symptoms, brain lesions – for example, of a vascular nature –and a higher risk for developing dementia in cases of late onset (28). As regards vascular depression, the presence of characteristic lesions detected through magnetic resonance imaging can help to shed TABLE 4 | Topic area 3—Psychotic depression. Consensus disagreement No consensus Consensus agreement 3.1. Negativistic/oppositional behaviors in depressed older adults point towards the presence of psychotic depression. 3.2. The onset of psychotic symptoms in depressed older adults involves a higher risk for evolving into dementia. 3.3. The onset of psychotic symptoms in depressed older adults involves a greater risk for suicide. 3.4. ECT is the first therapeutic option to treat psychotic depression in the elderly. 3.5. Combined treatment with antidepressants and antipsychotics is the first therapeutic option to treat psychotic depression in the elderly. 3.6. ECT should ONLY be used to treat psychotic depression in older adults when there is lack of response to pharmacological treatment. 3.7. In psychotic depression in the elderly, dual-action antidepressants are preferable to SSRIs. 3.8. When pharmacological treatment fails, ECT is the best option to treat psychotic depression in the elderly. 3.9. In non-life-threatening psychotic depression in the elderly that does not respond to pharmacological treatment, ECT should be prescribed no later than 6 weeks. 3.10. In non-life-threatening psychotic depression in the elderly that does not respond to pharmacological treatment, ECT should be prescribed no later than 12 weeks. 3.11. In non-life-threatening psychotic depression in the elderly that does not respond to pharmacological treatment, ECT should be prescribed no later than 24 weeks. 3.12. After good response to ECT in the acute phase, pharmacological treatment combined with continuation/ maintenance ECT is the treatment of choice to prevent early relapse and recurrence. 3.13. After good response to ECT in the acute phase, pharmacological-only continuation/ maintenance treatment is the (Continued) TABLE 4 | Continued Consensus disagreement No consensus Consensus agreement treatment of choice to prevent early relapse and recurrence. 3.14. After good response to ECT in the acute phase, continuation/ maintenance ECT therapy-only is the treatment of choice to prevent early relapse and recurrence. 3.15. After good response to ECT in the acute phase, the addition of lithium to the combined antidepressant-antipsychotic drug therapy is the treatment of choice to prevent early relapse and recurrence. 3.16. During continuation/ maintenance treatment of psychotic depression, the antipsychotic should be maintained as long as the antidepressant. 3.17. In psychotic depression in the elderly, pharmacological treatment should be maintained indefinitely even if there has only been one episode. TABLE 5 | Topic area 4—Depression and dementia. Consensus disagreement No consensus Consensus agreement 4.1. The criteria to diagnose depression in dementia/major neurocognitive disorder are well defined and clinically useful. 4.2. It is necessary to establish differentiated depression criteria for the different diseases or clinical conditions that may involve dementia/major neurocognitive disorder (for example, Alzheimer’s disease, Parkinson’s disease, frontotemporal dementia, etc.). 4.3. It is necessary to establish differentiated depression criteria for the different phases of dementia/ major neurocognitive disorder. 4.4. Antidepressant drugs are effective in the treatment of depression in dementia. 4.5. Psychological therapies are effective in the treatment of depression in dementia. Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3808 light on certain cases of poor therapeutic response and higher risk for evolving into dementia (29). On the other hand, there is no consensus on the clinical usefulness of the concept of “depressive pseudodementia”,a traditional term that refers to the onset of symptoms involving such prominent cognitive and functional impairment that they imitate the presence of a dementia disorder, but that are really caused by a case of depression and are therefore approachable using the appropriate antidepressant treatment. The classical controversies around the usefulness of the concept are reflected in the dispersion of answers obtained in this consensus. In any case, it must be noted that the term has plainly fallen into disuse in scientific literature. Should the Process of Diagnosing Depression in the Elderly Include Routine Laboratory Tests and Neuroimaging? The request for laboratory testing throughout the process of diagnosing geriatric depression has been a subject of discussion. According to our experts, the high comorbidity that is often present in these patients, many of them sufferers of multiple pathologies and also polymedicated, makes it necessary to carry out laboratory tests. Their opinion, however, is less unanimous as to the routine use of neuroimaging tests, despite their importance in the differential diagnosis of dementia cases (30). Nevertheless, TABLE 6 | Topic area 5—Antidepressant drug treatment. Consensus disagreement No consensus Consensus agreement 5.1. Subclinical depression requires pharmacological treatment. 5.2. When prescribing antidepressants for elderly patients, laboratory tests should be carried out at the beginning of treatment. 5.3. When prescribing an antidepressant for an elderly patient, an EKG should be performed at the beginning of treatment. 5.4. In general, SSRIs antidepressants are first choice treatment drugs for depression in the elderly. 5.5. In general, dual-action antidepressants are first choice drugs for depression in the elderly. 5.6. Dual-action antidepressants achieve higher levels of effectiveness in the treatment of depression in the elderly as compared to SSRIs. 5.7. Dietary supplements (Omega 3, DHA…) are effective in improving depression in the elderly. 5.8. Antidepressants have a slower onset of action in the elderly than in younger adults. 5.9. The introduction of antidepressants increases the risk for suicide in depressed elderly patients at the beginning of treatment. 5.10. The elderly tolerate dualaction antidepressants better than SSRIs. 5.11. Sexual dysfunction caused by antidepressants is a problem for elderly patients. 5.12. After a depressive episode in an elderly patient, treatment at effective doses should be maintained for 6 months. 5.13. After a depressive episode in an older adult, treatment at effective doses should be maintained for 1 year. 5.14. After a depressive episode in an older adult, treatment at effective doses should be maintained for 2 years. 5.15. After a depressive episode in an older adult, treatment at effective doses should be maintained for 3 to 4 years. 5.16. In depression in elderly patients, indefinite pharmacological therapy should be stablished after the first episode. (Continued) TABLE 6 | Continued Consensus disagreement No consensus Consensus agreement 5.17. In depression in elderly patients, indefinite pharmacological therapy should be stablished after the second episode. 5.18. In depression in elderly patients, indefinite pharmacological therapy should be stablished after the third episode. TABLE 7 | Topic area 6—Non-pharmacological biological treatments (fundamentally ECT). Consensus disagreement No consensus Consensus agreement 6.1. ECT is indicated for vascular depression. 6.2. ECT is indicated for depression in elderly patients with dementia. 6.3. Bilateral ECT should only be used when unilateral ECT yields unsatisfactory results. 6.4. Cognitive effects associated with ECT significantly limit its indication for depression in elderly patients. 6.5. Transcranial magnetic stimulation should be regarded as a therapeutic option for resistant depression in elderly patients. Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 3809 depression (76). Reluctance to initially using bilateral ECT in depressed older adults is based on the purpose of avoiding cognitive effects in elderly patients, although, as with psychiatric drugs, the decision should always aim towards a more effective therapeutic response, balanced with a reasonable assessment of its side effects (77). Do Cognitive Effects Associated With ECT Significantly Limit its Prescription in Geriatric Depression? Group consensus is again reached against this assertion. ECT- related cognitive effects are frequent within all age ranges and are one of the common reasons for complaint among patients. Moreover, there are a series of concurrent factors in the elderly that are associated with greater cognitive side-effects: older age (78) pre-existing cognitive impairment, neurological diseases, such as basal ganglia lesions and hyperintensities on magnetic resonance imaging (79). In such situations, successful resolution of the severe depressive episode should prevail, even in old age, since there is no evidence of ECT per se causing brain damage (69) and this is what the consulted experts express. Should Transcranial Magnetic Stimulation Be Taken Into Consideration as a Therapeutic Option In Resistant Depression in old age? Transcranial magnetic stimulation (rTMS) consists in magnetic stimuli applied in a rhythmic and repeated way, with different frequency ranges. It has proven effective to treat depression and, also, chronic pain, stroke, Parkinson’s disease, schizophrenia, and obsessive-compulsive disorder among others (80). The experts took no position for or against the statement, probably for a lack of direct experience or the absence of conclusive data on its effectiveness. Psychotherapeutic Treatments There is not yet much consensus among experts on the issue of psychotherapy in older adults, perhaps due in part to the heterogeneity of the studies available and the difficulty to compare them. Is Psychotherapy as Effective in the Elderly as in Adults? The efficacy of psychological treatments for depression in older adults is already sufficiently supported in the literature. Metaanalytic studies involving randomized controlled trials (81), systematic reviews (82) and studies comparing pharmacotherapy and psychotherapy (83,84) conclude that psychotherapeutic treatment is useful in addressing depression in older adults, with moderate to high effects and low heterogeneity. More recent studies (23,85,86) support the existing research, stressing that psychotherapies are an effective treatment for depression in old age, although the magnitude of the effect varies according to the type of control group. All of the above endorses the fact that the elderly can benefit from psychotherapeutic treatments, when available. But, despite their acknowledged efficacy, their use on this segment of the population is still rare. This seems due to the scarce availability in healthcare services of these treatments for the elderly and to the prejudices of professionals who are generally reluctant to carry out these interventions (87,88). While old age in itself is not an obstacle to psychotherapy (89), in our consensus there is no homogeneous view on the matter, and a relatively high percentage of panelists (45.7%) believe that it is less effective in older adults. Psychological treatments might be more relevant in the elderly, since aged patients with depression are more vulnerable to the side effects and pharmacological interactions of drugs. (11). Our study shows general consensus in favor of psychotherapy’s efficacy in treating subclinical geriatric depression. The studies reviewed that included patients suffering from minor depression or dysthymia provided evidence of psychotherapy’s greater effect. Research in the area suggests that psychotherapies are effective even in the presence of cognitive impairment (90)or executive dysfunction (91). The experts participating in this consensus agree with the idea that the presence of mild cognitive impairment/mild dementia does not limit the application of psychotherapy. Is Psychotherapy as Effective as Pharmacological Treatments in Geriatric Depression? Even though 45.7% of the experts consulted believe that psychotherapy is not as effective as pharmacological treatment in the elderly, the opinion is not homogeneous enough to achieve consensus. Among the studies that exclusively compare psychotherapeutic treatment with treatment combining psychotherapy and pharmacotherapy (92), the combined choice is believed to be more effective than psychological treatment alone, placebo, pharmacotherapy alone or the combination of psychotherapy and placebo, although the relevance of this difference from a clinical perspective is unclear. Results suggest that the inclusion of psychotherapy reduces lack of response and helps toward patients’ adherence to treatment. Comorbidity and Preventive Aspects Is Late-Onset Depression a Risk Factor for Medical Conditions? Research confirms the vulnerability of depressed individuals to physical diseases in general. In 2004, the World Health Organization included comorbidity between depression and chronic physical illness among its ten world public health concerns. The association between depression and medical conditions is bidirectional, being especially relevant in old age. While such relationship has been extensively studied, and although there is an increase in the number of studies where depression is regarded as a result of chronic conditions (93,94), there is also evidence of the inverse relationship. According to longitudinal population-based studies, patients diagnosed with depression are at higher risk for certain medical conditions and for higher degrees of disability as compared to the general population (95). Related to functional condition and chronic clinical burden, Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38016 older adults with a prior history of depression show faster rates of physical health decline than those who have never suffered from such disorder. This means that depression can be a risk marker for physical health deterioration (96). In prospective analyses, the probability of depressed patients to be affected by physical conditions during the follow-up period was almost two-thirds higher than in community controls (97). In our study, there is outstanding consensus with regard to the comorbidity of geriatric depression. More than 90% of the experts agreed that the presence of late-onset depression makes it necessary to consider the eventual onset of a neurodegenerative disorder (e.g. dementia or Parkinson’s disease) or of serious medical conditions such as cancer or heart disease (77% of the group of experts). What Weight Does Loneliness and Social Isolation Carry in the Prevention of Depression in Old Age? There are robust data supporting that the presence of depression in the elderly population is associated with greater social isolation. Loneliness and social isolation are linked with higher rates of morbimortality, especially from mental disorders or cardiovascular disease (98). Older adults living with relatives or those who have higher levels of social contact score significantly higher in physical, mental, and emotional health, which means that these two factors have a protection effect against the onset of depressive symptoms (93). In our study, the experts surveyed show maximum consensus on the assertion that interventions aimed at reducing social isolation are a significant strategy that is effective in the prevention of depression in older adults. What Role Does Physical Exercise Play? Sustained physical activity is associated with increased longevity and better maintenance of physical and mental functions (99). Physical exercise has a positive impact on mood and improves quality of life. Besides, there is evidence of it being effective in the treatment of depressed elderly patients, also improving their quality of life (100–102). In our study, there is broad and consistent consensus among the experts on the significance of physical exercise as a protecting factor against depression in old age. What Role Can Teleassistance Services Play? According to the reviews on interventions to reduce suicide in the elderly population, the most effective were multifaceted depression detection and management programs in primary care, therapeutic approaches (pharmacotherapy and psychotherapy), community programs, and telephone counseling for vulnerable older adults (103,104). Our experts agree that teleassistance services are useful in reducing the risk for suicide in older adults. Do Patients Living in Geriatric Institutions Receive the Same Type of Care as Those Living in the Community? There was also consensus in our study that elderly people living in geriatric nursing homes do not have access to the same treatments (antidepressants, psychotherapy, ECT, etc.) as those living in the community. It seems evident that therapeutic resources vary widely according to place of residence and type of geriatric institution, which has an impact on both care and prevention. Professional Training to Address Depression in the Elderly Addressing depression in elderly patients poses significant challenges for professionals. Its clinical characteristics could partly explain why it is an infradiagnosed disease. Clinical comorbidity (105), the presence of cognitive impairment, different phenomenology and clinical expressions, or frequent self-justification of the symptoms as due to poor health or accumulation of adversities make identification of depression in old age difficult (106). In cases of sub-syndromic depression, the problem of infradiagnosis is even greater (107). Is the Training Currently Received by Medical Residents in Psychiatry Good Enough to Successfully Address Depressive Disorders in Older Adults? The mostly negative answer to this question reflects the opinion that the training in geriatric psychiatry that is provided during the training of psychiatrists is insufficient. A survey reported that in Spain, around 60% of the psychiatry residents lack any type of specific training in psychogeriatrics, despite awareness (87.7%) of it being an especially relevant area of training. Psychiatry residents’supervisors believe (61.9%) that the former are not provided with adequate training and consider (81%) that this should be a compulsory subject (108). Do General Psychiatrists Require Specific Training to Successfully Address Depressive Disorders in Older Adults? The most common answer is yes. The detection of affective disorders in the elderly presents complexities that can only be addressed if psychiatrists have the adequate skills. Thus, low rates of identification of depressive symptomatology have been documented among psychiatrists (109). The need for training in geriatric psychiatry has been identified and requested on several occasions (110–112). More generally, there is evidence of deficiencies in the training in psychogeriatrics of psychiatrists (113). Because of its Complexity, Should Depression in Older Adults Mainly be Treated by Psychiatrists? While there are certain nuances, it is acknowledged that psychiatrists are the right specialists for the diagnosis and therapeutic management of depression in older adults, especially in the most severe cases, although many depressive episodes are currently addressed in primary care. The difficulties experienced by general practitioners in detecting geriatric depression have to do among other causes, with patients’ reasons for consulting—being the most common physical ailments (114)—with lack of familiarity with the use of diagnostic criteria and clinical assessment scales (115) and the greater presence of incomplete, mild, or sub-syndromic depressive disorders (116). Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38017 CONCLUSIONS In summary, a broad degree of consensus was achieved, reaching two thirds of the questions raised. Clinical differences between depression in the elderly and in younger adults and the need for these differences to appear in current classification systems (including the concepts of late-onset and vascular depression) were highlighted. Specific criteria for depression in the context of dementia are also needed. Routine laboratory tests but not neuroimaging is recommended in the regular clinical assessment of geriatric depression. The presence of late-onset depression makes it necessary to consider the subsequent onset of a neurodegenerative disorder such as dementia or Parkinson’s disease or of serious medical conditions such as cancer or heart disease. The onset of psychotic symptoms in geriatric depression confers an increased risk for evolution into dementia and is also related to a higher risk for suicide. Combined therapy with antipsychotics and antidepressants is considered the first therapeutic option in psychotic depression in the elderly. ECT is the best therapeutic option when pharmacological treatment fails. The experts were in favor of preforming laboratory tests and an electrocardiogram prior to choosing the appropriate pharmacological antidepressant treatment. Although SSRI antidepressants were regarded as the first choice, dual-action antidepressants were considered more effective than SSRI in geriatric depression. Experts consulted agreed on the presence of an increased antidepressant response latency in older adults. Once response is achieved, one year is deemed necessary for maintenance therapy after an isolated episode in old age and recommendations are made for indefinite pharmacological treatment from the second depressive episode onwards. In terms of pharmacological treatments, agomelatine was the most widely mentioned drug recommended in comorbid conditions in terms of safety. Desvenlafaxine, sertraline, and vortioxetine, were the most frequently recommended antidepressants in comorbid conditions in general. Combining parameters of efficacy and safety, experts recommended to follow some gradual steps to address cases of treatment resistance. These are: 1. Escalation to the maximum tolerated dose; 2. Change of antidepressant; 3. Combination with another antidepressant; 4. Potentiation with an antipsychotic or with lamotrigine; 5. Potentiation with lithium; 6. Potentiation with a dopamine agonist or methylphenidate. There is broad agreement about the effectiveness of ECT in elderly patients especially in cases of severe depression or in the presence of a significant physical condition. ECT can also be recommended in vascular depression and in severely depressed patients with dementia. Although it might be less effective than in adults, the experts recommend the use of psychotherapy for clinical and subclinical geriatric depression even in the presence of mild cognitive impairment or mild dementia. Interventions aimed at reducing social isolation and promoting physical exercise are strategies that can be effective in the prevention of depression in older adults. Psychiatrists are considered the adequate specialists for the diagnosis and therapeutic management of depression in older adults, especially in severe cases. Thus, all psychiatry medical residents should receive a specific training in geriatric psychiatry in general and in geriatric depression in particular We hope that this consensus can contribute to reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders, but further formal research is needed to shed light on the still unclear and controversial aspects of this disease DATA AVAILABILITY STATEMENT The datasets generated for this study are available on request to the corresponding author. ETHICS STATEMENT Ethical approval and written, informed consent was not required according to local legislation and national guidelines. AUTHOR CONTRIBUTIONS All the authors contributed equally to the study design and manuscript preparation. LA-O coordinated the expert group. FUNDING The Spanish Psychogeriatric Association received economic support from Pfizer Spain for the technical aspects of this study (Delphi analysis). Pfizer was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication. ACKNOWLEDGMENTS Dr. Manuel Franco MD, PhD, President of the Spanish Psychogeriatric Association provided all kind of support for the development of the manuscript. Dr. Fernando Caballero MD, PhD provided technical support for the Delphi technique and analysis. Julia Sevilla Llewellyn-Jones PhD revised the manuscript for the quality of the English language. SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2020. 00380/full#supplementary-material Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38018 REFERENCES 1. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jonsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol (2011) 21(9):655–79. doi: 10.1016/ j.euroneuro.2011.07.018 2. Olivera J, Benabarre S, Lorente T, Rodriguez M, Pelegrin C, Calvo JM, et al. Prevalence of psychiatric symptoms and mental disorders detected in primary care in an elderly Spanish population. The PSICOTARD Study: preliminary findings. Int J Geriatr Psychiatry (2008) 23(9):915–21. doi: 10.1002/gps.2004 3. Global Burden of Disease Study C. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (2015) 386(9995):743–800. doi: 10.1016/S0140-6736(15)60692-4 4. Valiengo Lda C, Stella F, Forlenza OV. Mood disorders in the elderly: prevalence, functional impact, and management challenges. Neuropsychiatr Dis Treat (2016) 12:2105–14. doi: 10.2147/NDT.S94643 5. Sjoberg L, Karlsson B, Atti AR, Skoog I, Fratiglioni L, Wang HX. Prevalence of depression: Comparisons of different depression definitions in populationbased samples of older adults. J Affect Disord (2017) 221:123–31. doi: 10.1016/ j.jad.2017.06.011 6. Diniz BS, Lin CW, Sibille E, Tseng G, Lotrich F, Aizenstein HJ, et al. Circulating biosignatures of late-life depression (LLD): Towards a comprehensive, datadriven approach to understanding LLD pathophysiology. J Psychiatr Res (2016) 82:1–7. doi: 10.1016/j.jpsychires.2016.07.006 7. Steffens DC, Wang L, Manning KJ, Pearlson GD. Negative Affectivity, Aging, and Depression: Results From the Neurobiology of Late-Life Depression (NBOLD) Study. Am J Geriatr Psychiatry (2017) 25(10):1135–49. doi: 10.1016/j.jagp.2017.03.017 8. Palmer K, Di Iulio F, Varsi AE, Gianni W, Sancesario G, Caltagirone C, et al. Neuropsychiatric predictors of progression from amnestic-mild cognitive impairment to Alzheimer’s disease: the role of depression and apathy. J Alzheimers Dis (2010) 20(1):175–83. doi: 10.3233/JAD-2010-1352 9. John A, Patel U, Rusted J, Richards M, Gaysina D. Affective problems and decline in cognitive state in older adults: a systematic review and metaanalysis. Psychol Med (2019) 49(3):353–65. doi: 10.1017/S0033291718001137 10. Avasthi A, Grover S. Clinical Practice Guidelines for Management of Depression in Elderly. Indian J Psychiatry (2018) 60(Suppl. 3):S341–S62. doi: 10.4103/0019-5545.224474 11. MacQueen GM, Frey BN, Ismail Z, Jaworska N, Steiner M, Lieshout RJ, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Can J Psychiatry (2016) 61(9):588–603. doi: 10.1177/0706743716659276 12. Canadian Agency for Drugs and Technologies in Health. Diagnosing, Screening, and Monitoring Depression in the Elderly: A Review of Guidelines. In: CADTH Rapid Response Reports. Ottawa (ON): CADTH (2015). 13. Peck S. Clinical guideline for the care and treatment of older people with depression in a general hospital setting: Isle of Wight Healthcare. (2003). Available from: http://www.iow.nhs.uk/Department/mental/older/pdfs/ Depression%20Guideline.pdf. 14. Baldwin RC, Chiu E, Katona C, Graham N. Guidelines on depression in older people: practicing the evidence. London: Martin Dunitz Ltd. (2002). 15. Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF3rd, GS A, ML B, et al. Diagnosis and treatment of depression in late life. Consensus statement update. JAMA (1997) 278(14):1186–90. doi: 10.1001/jama.278.14.1186 16. Canadian Coalition for Seniors’Mental Health. The Assessment and Treatment of Depression. Toronto: CCSMH (2006). 17. Martin-Carrasco M, Aguera-Ortiz L, Caballero-Martinez L, Cervilla- Ballesteros J, Menchon-Magrina JM, Montejo-Gonzalez AL, et al. Consensus of the SEPG on depression in the elderly. Actas Esp Psiquiatr (2011) 39(1):20–31. 18. Goodman LA. Snowball Sampling. Ann Math Stat (1961) 32:148–70. doi: 10.1214/aoms/1177705148 19. Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PloS One (2011) 6(6):e20476. doi: 10.1371/ journal.pone.0020476 20. Hutchings A, Raine R, Sanderson C, Black N. A comparison of formal consensus methods used for developing clinical guidelines. J Health Serv Res Policy (2006) 11(4):218–24. doi: 10.1258/135581906778476553 21. Custer RL, Scarcella JA, Stewart BR. The modified Delphi technique: A rotational modification. J Vocational Tech Educ (1999) 15(2):1–10. doi: 10.21061/jcte.v15i2.702 22. Dalkey NC. The Delphi Method: an experimental study of group opinion. Santa Monica (California): The Rand Corporation (1969). 23. Haigh EAP, Bogucki OE, Sigmon ST, Blazer DG. Depression Among Older Adults: A 20-Year Update on Five Common Myths and Misconceptions. Am J Geriatr Psychiatry (2018) 26(1):107–22. doi: 10.1016/j.jagp.2017.06.011 24. Power C, Reene E, Lawlor BA. Depression in Late Life. Etiology, Presentation, and Management. In: Chiu H, Shulman K, editors. Mental Health and Illness of the Elderly Mental Health and Illness Worldwide. Singapur: Springer (2017). p. 187–218. 25. Ismail Z, Fischer C, McCall WV. What characterizes late-life depression? Psychiatr Clin North Am (2013) 36(4):483–96. doi: 10.1016/j.psc.2013.08.010 26. Belvederi Murri M, Amore M, Respino M, Alexopoulos GS. The symptom network structure of depressive symptoms in late-life: Results from a European population study. Mol Psychiatry (2018). doi: 10.1038/s41380-018-0232-0 27. Cervilla Ballesteros J. Sindromes depresivos. In: Agüera Ortiz L, Martin Carrasco M, Cervilla Ballesteros J, editors. Psiquiatrı  a Geriatrica. Barcelona: Elsevier (2006). p. 409–25. 28. Grayson L, Thomas A. A systematic review comparing clinical features in early age at onset and late age at onset late-life depression. J Affect Disord (2013) 150(2):161–70. doi: 10.1016/j.jad.2013.03.021 29. Aizenstein HJ, Baskys A, Boldrini M, Butters MA, Diniz BS, Jaiswal MK, et al. Vascular depression consensus report - a critical update. BMC Med (2016) 14(1):161. doi: 10.1186/s12916-016-0720-5 30. Leyhe T, Reynolds CF3rd, Melcher T, Linnemann C, Kloppel S, Blennow K, et al. A common challenge in older adults: Classification, overlap, and therapy of depression and dementia. Alzheimers Dement (2017) 13(1):59–71. doi: 10.1016/j.jalz.2016.08.007 31. Smithson S, Pignone MP. Screening Adults for Depression in Primary Care. Med Clin North Am (2017) 101(4):807–21. doi: 10.1016/j.mcna.2017.03.010 32. Hall CA, Reynolds-Iii CF. Late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas. (2014) 79(2):147– 52. doi: 10.1016/j.maturitas.2014.05.026 33. Joo J, Hwang S, Gallo JJ. Death Ideation and Suicidal Ideation in a Community Sample Who Do Not Meet Criteria for Major Depression. Crisis. (2016) 37(2):161–5. doi: 10.1027/0227-5910/a000365 34. Goldfarb D, Sheard S, Shaughnessy L, Atri A. Disclosure of Alzheimer’s Disease and Dementia: Patient- and Care Partner-Centric Decision-Making and Communication. JClinPsychiatry(2019) 80(2). doi: 10.4088/ JCP.MS18002BR1C 35. Parker G, Hadzi-Pavlovic D, Hickie I, Boyce P, Mitchell P, Wilhelm K, et al. Distinguishing psychotic and non-psychotic melancholia. J Affect Disord (1991) 22(3):135–48. doi: 10.1016/0165-0327(91)90047-V 36. Gournellis R, Oulis P, Howard R. Psychotic major depression in older people: a systematic review. Int J Geriatr Psychiatry (2014) 29(8):789–96. doi: 10.1002/gps.4065 37. Cuevas-Esteban J, Iglesias-Gonzalez M, Rubio-Valera M, Serra-Mestres J, Serrano-Blanco A, Baladon L. Prevalence and characteristics of catatonia on admission to an acute geriatric psychiatry ward. Prog Neuropsychopharmacol Biol Psychiatry (2017) 78:27–33. doi: 10.1016/j.pnpbp.2017.05.013 38. Hyett MP, Parker GB, Proudfoot J, Fletcher K. Examining age effects on prototypic melancholic symptoms as a strategy for refining definition of melancholia. JAffectDisord(2008) 109(1-2):193–7. doi: 10.1016/ j.jad.2007.11.005 39. Almeida OP, Hankey GJ, Yeap BB, Golledge J, Flicker L. Depression as a risk factor for cognitive impairment in later life: the Health In Men cohort study. Int J Geriatr Psychiatry (2016) 31(4):412–20. doi: 10.1002/gps.4347 40. Almeida OP, Ford AH, Hankey GJ, Yeap BB, Golledge J, Flicker L. Risk of dementia associated with psychotic disorders in later life: the health in men study (HIMS). Psychol Med (2019) 49(2):232–42. doi: 10.1017/ S003329171800065X Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38019 41. Alexopoulos GS. Pharmacotherapy for late-life depression. J Clin Psychiatry (2011) 72(1):e04. doi: 10.4088/JCP.7085tx2cj 42. Agüera Ortiz L, Morı  ñigo A, Olivera J, PlaJ, Azanza Perea JR. Documento de la Sociedad Española de Psicogeriatrı  a sobre el uso de antipsico ticos en personas de edad avanzada. Psicogeriatrı  a. (2017) 71:S1–S37. 43. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry (2000) 157(4 Suppl.):1–45. 44. Flint AJ, Rifat SL. Two-year outcome of psychotic depression in late life. Am J Psychiatry (1998) 155(2):178–83. doi: 10.1176/ajp.155.2.178 45. van Schaik AM, Comijs HC, Sonnenberg CM, Beekman AT, Sienaert P, Stek ML. Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: a systematic review. Am J Geriatr Psychiatry (2012) 20(1):5–17. doi: 10.1097/JGP.0b013e31820dcbf9 46. Navarro V, Gasto C, Torres X, Masana G, Penades R, Guarch J, et al. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two-year randomized study. Am J Geriatr Psychiatry (2008) 16(6):498–505. doi: 10.1097/JGP.0b013e318170a6fa 47. Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA (2001) 285 (10):1299–307. doi: 10.1001/jama.285.10.1299 48. Bennett S, Thomas AJ. Depression and dementia: cause, consequence or coincidence? Maturitas. (2014) 79(2):184–90. doi: 10.1016/j.maturitas.2014.05.009 49. Steffens DC. Late-Life Depression and the Prodromes of Dementia. JAMA Psychiatry (2017) 74(7):673–4. doi: 10.1001/jamapsychiatry.2017.0658 50. Asmer MS, Kirkham J, Newton H, Ismail Z, Elbayoumi H, Leung RH, et al. Meta-Analysis of the Prevalence of Major Depressive Disorder Among Older Adults With Dementia. J Clin Psychiatry (2018) 79(5). doi: 10.4088/ JCP.17r11772 51. Reynolds CF3rd, Lenze E, Mulsant BH. Assessment and treatment of major depression in older adults. Handb Clin Neurol (2019) 167:429–35. doi: 10.1016/B978-0-12-804766-8.00023-6 52. Taylor WD. Clinical practice. Depression in the elderly. N Engl J Med (2014) 371(13):1228–36. doi: 10.1056/NEJMcp1402180 53. Mukai Y, Tampi RR. Treatment of depression in the elderly: a review of the recent literature on the efficacy of singleversus dual-action antidepressants. Clin Ther (2009) 31(5):945–61. doi: 10.1016/j.clinthera.2009.05.016 54. Mulsant BH, Blumberger DM, Ismail Z, Rabheru K, Rapoport MJ. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med (2014) 30(3):517–34. doi: 10.1016/j.cger.2014.05.002 55. Thorlund K, Druyts E, Wu P, Balijepalli C, Keohane D, Mills E. Comparative efficacy and safety of selective serotonin reuptake inhibitors and serotoninnorepinephrine reuptake inhibitors in older adults: a network meta-analysis. J Am Geriatr Soc (2015) 63(5):1002–9. doi: 10.1111/jgs.13395 56. Kok RM, Reynolds CF3rd. Management of Depression in Older Adults: A Review. JAMA (2017) 317(20):2114–22. doi: 10.1001/jama.2017.5706 57. Sheline YI, Pieper CF, Barch DM, Welsh-Bohmer K, McKinstry RC, MacFall JR, et al. Support for the vascular depression hypothesis in late-life depression: results of a 2-site, prospective, antidepressant treatment trial. Arch Gen Psychiatry (2010) 67(3):277–85. doi: 10.1001/archgenpsychiatry.2009.204 58. Price A, Rayner L, Okon-Rocha E, Evans A, Valsraj K, Higginson IJ, et al. Antidepressants for the treatment of depression in neurological disorders: a systematic review and meta-analysis of randomised controlled trials. JNeurol Neurosurg Psychiatry (2011) 82(8):914–23. doi: 10.1136/jnnp.2010.230862 59. Robinson RG, Schultz SK, Castillo C, Kopel T, Kosier JT, Newman RM, et al. Nortriptyline versus fluoxetine in the treatment of depression and in shortterm recovery after stroke: a placebo-controlled, double-blind study. Am J Psychiatry (2000) 157(3):351–9. doi: 10.1176/appi.ajp.157.3.351 60. Costa FH, Rosso AL, Maultasch H, Nicaretta DH, Vincent MB. Depression in Parkinson’s disease: diagnosis and treatment. Arq Neuropsiquiatr (2012) 70(8):617–20. doi: 10.1590/S0004-282X2012000800011 61. Menza M, Dobkin RD, Marin H, Mark MH, Gara M, Buyske S, et al. A controlled trial of antidepressants in patients with Parkinson disease and depression. Neurology (2009) 72(10):886–92. doi: 10.1212/01.wnl.0000336340. 89821.b3 62. Varteresian T, Lavretsky H. Natural products and supplements for geriatric depression and cognitive disorders: an evaluation of the research. Curr Psychiatry Rep (2014) 16(8):456. doi: 10.1007/s11920-014-0456-x 63. Arandjelovic K, Eyre HA, Lavretsky H. Clinicians’Views on Treatment- Resistant Depression: 2016 Survey Reports. Am J Geriatr Psychiatry (2016) 24(10):913–7. doi: 10.1016/j.jagp.2016.05.010 64. Cooper C, Katona C, Lyketsos K, Blazer D, Brodaty H, Rabins P, et al. A systematic review of treatments for refractory depression in older people. Am J Psychiatry (2011) 168(7):681–8. doi: 10.1176/appi.ajp.2011.10081165 65. Unutzer J, Park M. Older adults with severe, treatment-resistant depression. JAMA. (2012) 308(9):909–18. doi: 10.1001/2012.jama.10690 66. Knochel C, Alves G, Friedrichs B, Schneider B, Schmidt-Rechau A, Wenzler S, et al. Treatment-resistant Late-life Depression: Challenges and Perspectives. Curr Neuropharmacol (2015) 13(5):577–91. doi: 10.2174/1570159X1305151013200032 67. Maust DT, Oslin DW, Thase ME. Going beyond antidepressant monotherapy for incomplete response in nonpsychotic late-life depression: a critical review. Am J Geriatr Psychiatry (2013) 21(10):973– 86. doi: 10.1016/j.jagp.2013.01.030 68. Cristancho P, Lenard E, Lenze EJ, Miller JP, Brown PJ, Roose SP, et al. Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM): Study Design and Treatment Characteristics of the First 396 Participants Randomized. Am J Geriatr Psychiatry (2019) 27(10):1138–52. doi: 10.1016/j.jagp.2019.04.005 69. Bernardo M, Gonzalez-Pinto A, Urretavizcaya M. Consenso Español sobre la terapia electroconvulsiva. Madrid: Consenso Español sobre la terapia electroconvulsiva (2018). 70. Spaans HP, Sienaert P, Bouckaert F, van den Berg JF, Verwijk E, Kho KH, et al. Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication. Br J Psychiatry (2015) 206(1):67– 71. doi: 10.1192/bjp.bp.114.148213 71. Geduldig ET, Kellner CH. Electroconvulsive Therapy in the Elderly: New Findings in Geriatric Depression. Curr Psychiatry Rep (2016) 18(4):40. doi: 10.1007/s11920-016-0674-5 72. Tew JDJr., Mulsant BH, Haskett RF, Prudic J, Thase ME, Crowe RR, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry (1999) 156(12):1865–70. doi: 10.1176/ajp.156.12.1865 73. Currier MB, Murray GB, Welch CC. Electroconvulsive therapy for poststroke depressed geriatric patients. J Neuropsychiatr Clin Neurosci (1992) 4 (2):140–4. doi: 10.1176/jnp.4.2.140 74. Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, et al. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry (2015) 30(3):265–73. doi: 10.1002/gps.4137 75. Glass OM, Forester BP, Hermida AP. Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) - a promising option. Int Psychogeriatr. (2017) 29(5):717–26. doi: 10.1017/S1041610216002258 76. Pettinati HM, Mathisen KS, Rosenberg J, Lynch JF. Meta-Analytical Approach to Reconciling Discrepancies in Efficacy between Bilateral and Unilateral Electroconvulsive Therapy. Convuls Ther (1986) 2(1):7–17. 77. Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, et al. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry (2010) 196(3):226–34. doi: 10.1192/ bjp.bp.109.066183 78. Zervas IM, Calev A, Jandorf L, Schwartz J, Gaudino E, Tubi N, et al. Age- Dependent Effects of Electroconvulsive Therapy on Memory. Convuls Ther (1993) 9(1):39–42. 79. Rami L, Bernardo M, Boget T, Ferrer J, Portella MJ, Gil-Verona JA, et al. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study. J Neuropsychiatr Clin Neurosci (2004) 16(4):465–71. doi: 10.1176/jnp.16.4.465 80. Cristancho MA, Helmer A, Connolly R, Cristancho P, O’Reardon JP. Transcranial magnetic stimulation maintenance as a substitute for maintenance electroconvulsive therapy: a case series. J ECT. (2013) 29 (2):106–8. doi: 10.1097/YCT.0b013e31827a70ba 81. Cuijpers P, van Straten A, Smit F. Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. Int J Geriatr Psychiatry (2006) 21(12):1139–49. doi: 10.1002/gps.1620 Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38020 82. Wilson KC, Mottram PG, Vassilas CA. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev (2008) 23(1):CD004853. doi: 10.1002/14651858.CD004853.pub2 83. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry (2006) 163(9):1493–501. doi: 10.1176/ ajp.2006.163.9.1493 84. Parikh SV, Segal ZV, Grigoriadis S, Ravindran AV, Kennedy SH, Lam RW, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord (2009) 117(Suppl. 1):S15–25. doi: 10.1016/ j.jad.2009.06.042 85. Huang AX, Delucchi K, Dunn LB, Nelson JC. A systematic review and metaanalysis of psychotherapy for late-life depression. Am J Geriatr Psychiatry (2015) 23(3):261–73. doi: 10.1016/j.jagp.2014.04.003 86. Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. Int J Geriatr Psychiatry (2016) 31(5):526–35. doi: 10.1002/gps.4358 87.WeiW,SambamoorthiU,OlfsonM,WalkupJT,CrystalS.Useof psychotherapy for depression in older adults. Am J Psychiatry (2005) 162 (4):711–7. doi: 10.1176/appi.ajp.162.4.711 88. Claver-Martı  n M. Psicoterapia en el anciano. Psicogeriatrı  a(2009) 1(3):175–8. 89. Frazer CJ, Christensen H, Griffiths KM. Effectiveness of treatments for depression in older people. Med J Aust (2005) 182(12):627–32. doi: 10.5694/ j.1326-5377.2005.tb06849.x 90. Miller MD, Reynolds CF.3rd. Expanding the usefulness of Interpersonal Psychotherapy (IPT) for depressed elders with co-morbid cognitive impairment. Int J Geriatr Psychiatry (2007) 22(2):101–5. doi: 10.1002/gps.1699 91. Alexopoulos GS, Raue PJ, Kiosses DN, Mackin RS, Kanellopoulos D, McCulloch C, et al. Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction: effect on disability. Arch Gen Psychiatry (2011) 68(1):33–41. doi: 10.1001/ archgenpsychiatry.2010.177 92. Cuijpers P, De Wit L, Weitz E. The combination of psychotherapy and pharmacotherapy in the treatment of adult depression: a comprehensive meta-analysis. J Evid Based Psychother. (2015) 15:147. 93. Portellano-Ortiz C, Garre-Olmo J, Calvo-Perxas L, Conde-Sala JL. Depression and associated variables in people over 50 years in Spain. Rev Psiquiatr Salud Ment (2018) 11(4):216–26. doi: 10.1016/j.rpsmen.2016. 10.002 94. Deschenes SS, Burns RJ, Schmitz N. Associations between depression, chronic physical health conditions, and disability in a community sample: A focus on the persistence of depression. J Affect Disord (2015) 179:6–13. doi: 10.1016/j.jad.2015.03.020 95. Giner J, Saiz Ruiz J, Bobes J, Zamorano E, Lopez F, Hernando T, et al. Spanish consensus on the physical health of patients with depressive disorders. Rev Psiquiatria Salud Ment (2014) 7(4):195–207. doi: 10.1016/ j.rpsmen.2014.10.003 96. Cho HJ, Lavretsky H, Olmstead R, Levin M, Oxman MN, Irwin MR. Prior depression history and deterioration of physical health in communitydwelling older adults–a prospective cohort study. Am J Geriatr Psychiatry (2010) 18(5):442–51. doi: 10.1097/JGP.0b013e3181ca3a2d 97. Holahan CJ, Pahl SA, Cronkite RC, Holahan CK, North RJ, Moos RH. Depression and vulnerability to incident physical illness across 10 years. J Affect Disord (2010) 123(1-3):222–9. doi: 10.1016/j.jad.2009.10.006 98. Gene-Badia J, Comice P, Belchin A, Erdozain MA, Caliz L, Torres S, et al. Profiles of loneliness and social isolation in urban population. Aten Primaria (2020) 52(4):224–32. doi: 10.1016/j.aprim.2018.09.012 99. de Hoyos Alonso MDC, Gorronogoitia Iturbe A, Martin Lesende I, Baena Diez JM, Lopez-Torres Hidalgo J, Magan Tapia P, et al. Actividades preventivas en los mayores. Actualización PAPPS 2018. Aten Primaria (2018) 50(Suppl. 1):109–24. doi: 10.1016/s0212-6567(18)30365-2 100. Dauwan M, Begemann MJH, Slot MIE, Lee EHM, Scheltens P, Sommer IEC. Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials. J Neurol (2019). doi: 10.1007/s00415-019-09493-9 101. Seo JY, Chao YY. Effects of Exercise Interventions on Depressive Symptoms Among Community-Dwelling Older Adults in the United States: A Systematic Review. JGerontolNurs.(2018) 44(3):31–8. doi: 10.3928/00989134-20171024-01 102. Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. JPsychiatrRes(2016) 77:42–51. doi: 10.1016/j.jpsychires.2016.02.023 103. Okolie C, Dennis M, Simon Thomas E, John A. A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people. Int Psychogeriatr. (2017) 29(11):1801–24. doi: 10.1017/ S1041610217001430 104. Lapierre S, Erlangsen A, Waern M, De Leo D, Oyama H, Scocco P, et al. A systematic review of elderly suicide prevention programs. Crisis (2011) 32 (2):88–98. doi: 10.1027/0227-5910/a000076 105. Weinberger MI, Roth AJ, Nelson CJ. Untangling the complexities of depression diagnosis in older cancer patients. Oncologist. (2009) 14(1):60– 6. doi: 10.1634/theoncologist.2008-0147 106. Burroughs H, Lovell K, Morley M, Baldwin R, Burns A, Chew-Graham C. ‘Justifiable depression’: how primary care professionals and patients view late-life depression? A qualitative study. Fam Pract (2006) 23(3):369–77. doi: 10.1093/fampra/cmi115 107. VanItallie TB. Subsyndromal depression in the elderly: underdiagnosed and undertreated. Metabolism (2005) 54(5 Suppl. 1):39–44. doi: 10.1016/ j.metabol.2005.01.012 108. Cuevas-Esteban J, Baladon L, Rodrı  guez MJ, Fernandez A, Fuste-Boadella M, Dı  az D, et al. Formacion en psicogeriatrı  a en España: opinion de tutores y residentes de psiquiatrı  a. Psicogeriatria (2012) 4(1):39–49. 109. Brühl KG. ¿Quecapacidad tienen los enfermeros y los auxiliares de enfermerı  a para reconocer y tratar la depresion en las personas mayores? Informaciones Psiquiatricas (2009) 195:196. 110. Camus V, Katona C, de Mendonca Lima CA, Abdel-Hakam AM, Graham N, Baldwin R, et al. Teaching and training in old age psychiatry: a general survey of the World Psychiatric Association member societies. Int J Geriatr Psychiatry (2003) 18(8):694–9. doi: 10.1002/gps.900 111. World Health Organization. Education in psychiatry of the elderly: a technical consensus statement. Geneva: WHO (1998). 112. Gustafson L, Burns A, Katona C, Bertolote JM, Camus V, Copeland JR, et al. Skill-based objectives for specialist training in old age psychiatry. Int J Geriatr Psychiatry (2003) 18(8):686–93. doi: 10.1002/gps.899 113. Pelegrı n-Valero C. La formacion en psicogeriatrı a en nuestro paı s. Psicogeriatrı  a(2009) 1:65–6. 114. Mitchell AJ, Rao S, Vaze A. Do primary care physicians have particular difficulty identifying late-life depression? A meta-analysis stratified by age. Psychother Psychosom (2010) 79(5):285–94. doi: 10.1159/000318295 115. Schwarzbach M, Luppa M, Hansen H, Konig HH, Gensichen J, Petersen JJ, et al. A comparison of GP and GDS diagnosis of depression in late life among multimorbid patients - results of the MultiCare study. J Affect Disord (2014) 168:276–83. doi: 10.1016/j.jad.2014.06.020 116. MacDonald AJ. Do general practitioners “miss”depression in elderly patients? Br Med J (Clin Res Ed). (1986) 292(6532):1365–7. doi: 10.1136/ bmj.292.6532.1365 Conflict of Interest: LA-O has received honoraria by Exeltis, Janssen, Lundbeck, Neuraxfarm, Otsuka, Servier and Pfizer. MM-C has received honoraria by Pfizer, Servier, and Lundbeck. MR-P has received honoraria by Janssen, Ludnbeck, Neuraxpharm, Otsuka, and Pfizer. MS-P has received honoraria by Exeltis, Lundbeck, Otsuka, Pfizer, and Servier. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Copyright © 2020 Agüera-Ortiz, Claver-Martı  n, Franco-Fernandez, Lopez-A  lvarez, Martı  n-Carrasco, Ramos-Garcı  aandSa nchez-Perez. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Agüera-Ortiz et al. Expert Consensus on Geriatric Depression Frontiers in Psychiatry | www.frontiersin.org May 2020 | Volume 11 | Article 38021