Geriatric Depression: A Clinical Guide, a well-written overview of late-life depressive disorders, will appeal to a broad clinical audience. Covering a wide array of clinical considerations in the diagnosis and treatment of late-life depression, the book is accessible for the general practitioner or allied mental health professional, while also relevant for the geriatrician and psychiatrist.

Kennedy posits three essential ingredients to make “old age and depression the rarest of companions” (p. 63): medication, psychotherapy, and disease management. The author focuses on these domains throughout. Initial chapters outline epidemiology, etiology, and subtypes of late-life depressive disorders, highlighting clinical factors that complicate diagnosis. He outlines medical, pharmacologic, cognitive, and psychiatric etiologies of common symptoms as well as the challenges in distinguishing subtypes of depression. For example, in one chapter he focuses on psychotic depression versus obsessive-compulsive disorder; in another chapter, on vascular depression and depression in dementia. Throughout, Kennedy strikes a fine balance between thoroughness and brevity, with only occasional sacrifices. For example, the section on “Mixed Anxiety-Depression” in Chapter 1 is rather brief given the frequency with which late-onset depression presents “atypically” in seniors, often masquerading as a late-onset generalized anxiety disorder.

Chapters on interventions are well researched, up-to-date, and thorough: from comprehensive tables of pharmacotherapy options, to non-pharmacologic approaches ranging from psychotherapy and psychosocial support to electroconvulsive therapy (ECT). Kennedy’s pragmatic summation of pharmacologic options for the treatment of geriatric depression alone makes Chapter 3, “Pharmacotherapy”, a worthwhile read. The condensed comparison of four different antidepressant algorithms offers a concise synthesis of a large body of literature of interest to the subspecialist and generalist alike, and a Canadian audience will particularly appreciate the inclusion of important Canadian research contributions here. Kennedy’s capacity to synthesize current evidence and clinical wisdom is evident throughout. Variations to treatments of subtypes of depression, such as bipolar and psychotic depression, are outlined. Common misperceptions of the treatment of depression in seniors are addressed, including the false notion of older adults being less treatable and the need for a counterintuitive, aggressive approach to the treatment of late-life depression. This includes close follow-up to watch for clinical improvement within days rather than weeks, and to move quickly to a second treatment option if improvement is not seen.

Regarding psychotherapy, Kennedy notes that “the evidence base supporting empirically validated (psycho)therapies, though sufficient, is limited compared to that which supports antidepressants, particularly for older adults” (p. 65). While the author notes a relative weakness in psychotherapy research compared to pharmacology, he asserts psychotherapy in general as an important treatment option in this age group, as a monotherapy or as an adjuvant treatment. He offers a helpful high-level overview of the nature of various types of psychotherapy and their evidence base, with a helpful summary table. The psychotherapy chapter is up-to-date and inclusive, with just a few exceptions. Phone-based cognitive behavioural therapy (CBT) and more recent problem- solving therapy are included, but age-specific considerations in formulation and treatment, current evidence of “enhanced” CBT with modifications for seniors (both individual and group formats), and promising “third wave” modalities for this age group are not specifically mentioned.

The chapter on ECT offers an overview of indications, treatment considerations, and differences in practice culture in Canada and the United States. Kennedy urges practitioners not to provide patients information upon which consent for ECT is based, if the practitioners do not administer the ECT treatments themselves. The topic of ECT for behavioural and psychological symptoms of dementia (BPSD) is omitted, as is discussion about the role of a substitute decision-maker for those who are unable to consent to ECT. Presumably, Kennedy’s cautions and omissions result from the more litigious practice environment in the United States. Meanwhile, in the Canadian context, ECT is generally viewed as a straightforward, safe procedure routinely managed in the outpatient setting, and all psychiatrists are encouraged to recommend the treatment and inform patients about it. In Canada, psychiatrists are also more willing to offer indicated treatments to those who cannot consent, including ECT to people with dementia, with the consent of a substitute decision-maker.

Chapter 5, “Other Psychosocial Interventions”, focuses on the role of social supports in lowering depression severity and in achieving remission, and Chapter 6, “Diet, Supplements, and Exercise”, reviews lifestyle factors involving diet, supplements and exercise for the depressed older patient. These chapters are interesting inclusions. First, they offer new information for many practitioners entrenched in a dominant medical model of pathology rather than one of prevention, and they signal an important culture shift in the field of geriatric psychiatry. Kennedy rightly notes, “It may be surprising for practitioners that they should be considering routine elements in the behavioural activation approach to combatting depression. Knowledgeable and optimistic practitioners may be the critical motivators for improved diet and physical activity for depressed persons at any age” (p. 141). The table on solving barriers to exercise is particularly useful (p. 137). Kennedy brings a refreshing degree of attention to some often-neglected topics such as family and caregiver depression, depression in long-term care, and telephone-facilitated depression care.

Chapter 8, “Reducing the Risk of Suicide in Late Life”, continues the theme of prevention. Kennedy references larger social elements in the prevention of depression and suicide including reduction of negative stereotypes about aging, social isolation, and need for policy change. Overall, however, two major contextual themes for geriatric depression – ageism and stigma of mental illness – are surprisingly understated throughout the book. Kennedy does highlight that societal associations of aging with “decline” and “sadness” result from societal “normalization” of depression in late life. He cites system barriers, and therapeutic nihilism in both patients and practitioners, as predictors of poor response (see table, p. 28). Kennedy also suggests that “aging successfully” is to a large extent the result of how hard one works at it (p. 129).

Presumably, the work of successful aging goes beyond the prevention of illness but in Geriatric Depression, Kennedy stops short of exploring successful aging, emotional and psychosocial health promotion, or resilience in late life. Indeed, society’s normalization of depression and decline with aging is neatly contradicted by new science surrounding the brain’s capacity for neuroplasticity across the lifespan, and our innate lifelong capacity for learning and change. Evidence suggests potential for yoga, mindfulness, and stress reduction not only to “prevent” mental illness but also to actually promote health, brain function, and even longevity, and possibly even to reverse age-related changes such as telomere length, a reliable biomarker of longevity. Our attitude towards life and aging turns out to have important implications not just for late-life depression, but also for our overall health and longevity.

In terms of geriatric psychiatry’s role in this regard, a fresh perspective on what research questions to ask might hold the secret to the field’s success and relevance. Dr. Dilip Jeste, past president of the American Psychiatric Association and Director of the Stein Institute for Research in Aging, has recently proposed the “positive psychiatry of aging” approach as offering this necessary, new perspective. Tapping into the full potential of this next generation of seniors is an exciting proposition, and one that will most certainly impact late-life depression. Canada has already begun a new national movement in this regard: “The Fountain of Health Initiative for Optimal Aging” (http://fountainofhealth.ca) is one of the first initiatives of its kind in the world, translating current science of brain health and psychosocial resilience, and offering clinical tools for knowledge translation to practice. “Positive Psychiatry of Aging” and “The Fountain of Health Initiative for Optimal Aging” will both be featured topics at the 25th anniversary of the Canadian Academy of Geriatric Psychiatry Annual Scientific Meeting in Quebec City in 2016. Clinicians will certainly need any and all effective tools and strategies available in the battle against geriatric depression if old age and depression truly are to become, as Kennedy hopes, “the rarest of companions”.