Depression

Depression is the number one mental health problem among older adults and one of the most treatable. It affects more than 2 million older Americans and nearly twice as many women are affected as men (NIMH, 1999). The prevalence of depression is particularly high among older adults in nursing homes and or hospitalized for an illness. Depressive illness frequently occurs with heart attack, stroke, diabetes, and cancer. In addition, individuals with a history of major depression are four times as likely to suffer a heart attack compared to people without a history of depression. Minor depression in older men and major depression in both older men and women increases the risk of death. (1999,Penninx)

Depression may look differently in older adults

Depression in older adults differs from that of younger adults. It often develops very gradually and because it may occur simultaneously with other events (e.g., death, illness) it often goes unrecognized and untreated. Some even attribute symptoms of depression to "aging".

Undiagnosed depression can lead to suicide

Although older adults often see physicians, they are seldom assessed, diagnosed or treated for depression. Depression is not a normal part of aging and it can be life threatening when it goes unrecognized and untreated. Older adults account for 20 percent of all suicide deaths, even though they comprise only 13 percent of the total population.In direct and indirect costs, depression costs the United States more than $30 billion per year.

The most common types of depression in older adults are major depression, chronic low-grade depression (dysthmia), and subsyndromal depression. They can range from mild to severe in their symptoms.

Types of Depression

Major Depression

According to the World Health Organization, major depression is the leading cause of disability in the United States and worldwide. Major depression affects 1 to 2% of older adults in the community. The diagnosis of major depression is made based on depressed mood or loss of interest and pleasure which persists for at least 2 weeks and four other signs and symptoms. More information on Major Depression can be found on the Internet Mental Health. You may want to bookmark this site which provides information on the 54 most common mental disorders and the 72 most common psychiatric drugs.

The criteria for major depression required for diagnosis include depressed mood that persists most of the day or loss of interest and pleasure in activities (Required for diagnosis) and four of the following symptoms:

• Significant weight loss (5% of body weight) or gain in past month
• Insomnia or sleeping too much
• Slowed cognitive function or agitation
• Fatigue or loss of energy
• Feelings of worthlessness
• Excessive or inappropriate guilt
• Difficulty concentrating
• Indecisiveness
• Recurrent thoughts of death or suicide

Dysthmic Disorder

This form of depression is very common among older adults living in the community and affects as many as one on two older adults in hospitals or in nursing homes.

Subsyndromal Depression

This form of depression affects up to one in four older adults in the community. The prevalence among elderly with medical illness or in nursing homes may be as high as 50%. Subsyndromal depression is characterized by depressive symptoms that affect well-being and quality of life, but that do no meet the criteria for major depression or dysthymia.

Risk factors for depression

Age and Gender

Depression is more common with age, the frequency of suicide is highest among the very old. Twice as many women suffer from depression than men.

Illness

Older adults who are ill are particularly vulnerable to depression. Up to 40% of acutely ill individuals in hospitals are significantly depressed (Koenig, 1996) compared to 3% of healthy, community-dwelling individuals (NIMH, 1991). Individuals with chronic conditions may experience depression secondary to other disease processes. Conditions associated with depression include Alzheimer's disease, Parkinson's disease, multiple sclerosis, thyroid disorders, diabetes, renal disease, liver disease, dementia, pancreatic cancer, adrenal disorders, congestive heart failure, post-myocardial infarction, stroke, electrolyte disorders, and vitamin B12 deficiency.

Disability

Older adults with functional limitations are at greater risk for depression, particularly when their disability interferes with meaningful activities, (Blazer, 1993). Severe hearing loss (Kalayam et al., 1991) or visual impairment can lead to social isolation and thus contribute to depression.

Medications

A variety of medications can initiate or heighten depression in older adults. The table below lists some of the medications that may cause depression as a side effect.

Hypochondriaisis

Older adults who are depressed may appear hypochondriacal in their preoccupation with physical health complaints (e.g., constipation, heartburn). These complaints are often dismissed rather than recognizing them as representative of difficulties in coping with the stresses of illness or loss. Depressed individuals overuse medical service and therefore failure to recognize depression can lead to costly hospitalization.

Grief

Grief is a universal human response to loss. Unresolved (i.e. chronic) grief or multiple losses may contribute to depression. Adjustment to bereavement is a normal, dynamic and highly individual process with no specific point when grieving ends (e.g., feelings of guilt, anger, sadness) and mourning is over. Each person's culture, religious/spiritual beliefs, support, coping systems, and social environment influence how they express grief. Bereavement is stressful and many older adults become ill during this difficult time. Widowers frequently die during the first year after a loved one's death. Coping with the loss of a loved one may take from one to two years or even longer. Many years after bereavement is resolved, anniversaries and experiences can still trigger painful episodes of acute grief. Click on the link to learn more about Coping with Loss-Bereavement and Grief

Existential grief

Depression may also be related to anticipation of death. Older adults become aware that their time is limited and this can give rise to a feeling of loneliness and despair as mortality can no longer be ignored.

Institutions

Depression can be related to the impact of an institutional environment such as a skilled nursing home. Neither religious beliefs or social supports appear to buffer the impact of institutional environments in which individuals must relinquish considerable control (Barder et al., 1994).

Symptoms of Depression

In older adults, depression is not always characterized by a depressed mood. However, there are a number of observations on the elderly that may be helpful in spotting depression. Older adults are more likely to present with loss of appetite, insomnia, and lack of pleasure in life. Sleep disturbances are strongly associated with depression. Older adults may withdraw from their regular social activities and say: "It's too much trouble", "I don't feel well enough", or "I don't have the energy" rather than saying "I feel depressed". The table below summarizes some of the common symptoms of depression in older adults.

Common Symptoms of Depression in Older Adults:

• Change in eating patterns (e.g., loss of appetite, weight loss)
• Loss of interest or pleasure in usual activities (e.g., apathy, sense of emptiness, exaggerated feelings of helplessness).
• Physical complaints (e.g., gas, constipation, heartburn, pain, fatigue)
• Change in sleeping patterns (e.g., early morning awakening, sleeping more)
• Decrease in sex drive or other problems with sexual function
• Slowed cognitive function (e.g. poor memory, slowed thinking, attention deficits, indecisiveness, difficulty concentrating)
• Thoughts of death, suicide or wishes to be dead.

Older adults may perceive depression as a character flaw that they should be able to overcome rather than realizing that depression is a medical illness that requires treatment. In some cultures, older adults attribute symptoms of depression to fatigue or stress which are more culturally acceptable and less stigmatizing than mental illness.

Consequences of Depression

Late-life depression is associated with increased risk of disease, death, and disability. Depression increases the risk for accidents and suicide. In addition, it is associated with overuse of health care services and greater health care costs. Depression causes longer hospital stays and interferes with recovery from medical illness, particularly rehabilitation efforts.

Treatment of Depression

The goals of treatment are to reduce morbidity and mortality, increase functional capacity and improve quality of life. About 7 out of 10 people with depression improve with treatment. Usually a combination of medications and psychotherapy is more effective than either alone.

• Drug Therapy
• Electroconvulsive Therapy (ECT)
• Psychotherapy
• Support Groups

Drug Therapy

Antidepressants are all relatively efficacious and the choice depends upon patient tolerability and response to therapeutic effects with minimum side effects. Usually older adults need less medication to achieve therapeutic benefits so the general rule is to "go low and start slow". Medications are started at a low dose and increased slowly until the desired therapeutic effect is achieved, while monitoring closely for side effects. Compliance is a common problem; as many as 3 in 4 older adults don't take their medications as prescribed. Side effects are the most common reason for discontinuing medications.

Some Common Antidepressants

• Selective Serotonin Reuptake Inhibitors
• Tricyclic Antidepressants
• Monamine Oxidase Inhibitors (MAOI)
• Atypical Antidepressants.
• Methylphenidate
• St. John's Wort

Electroconvulsive Therapy (ECT).

If drug therapy is ineffective in treating depression, than ECT may be tried. Older adults are the largest age group that receives ECT; about 50% of those receiving ECT are over age 60. ECT is a safe and effective treatment for older adults that can be lifesaving for those who are actively suicidal, psychotically depressed, or for whom antidepressant medications were ineffective or contraindicated. ECT is effective in the short-term but the relapse rate is high. Patients receive a muscle relaxant and a short acting anesthetic before the ECT. A course of 10 treatments administered every other day is often sufficient. The most common side effects of ECT include headache, mild acute confusion and memory loss. Newer treatment techniques using brief pulse stimulus have reduced cognitive side effects. For example, unilateral ECT on the nondominant side of the brain minimizes confusion and memory loss after seizures because the dominant side of the brain which contains speech and memory areas is not affected. The lowest electrical stimulus necessary for an adequate seizure is used. There is no agreement on how or why ECT works or whether maintenance treatments prevent relapse. You can get more information on Electroconvulsive Therapy at the American Psychiatric Association website.

Psychotherapy.

The goal of psychotherapy is to help individuals develop more effective coping behaviors. Psychotherapy can be effective by: teaching new skills, promoting assertive behaviors, engaging in problem solving, and assisting patients in modifying their relationships or expectations about relationships. Most individual effective therapies (behavioral, cognitive, psychodynamic) are time-limited, focused, and problem-oriented.

Support Groups.

Support groups should be led by an experienced and competent therapist Many older adults grew up with values about keeping personal business and emotions private. However, in group therapy, people need to communicate, participate, and talk about their problems and feelings. The ideal situation occurs when the older adult feels safe in group to share fears and anxieties so problems can be solved and behaviors can be examined and changed. The group can provide a sense of universality as people discover others share their problems; a sense of support and relatedness; peer feedback; modeling of new behaviors; social skill building; reality testing, and a laboratory experience. In a support group, a person can try out new behaviors such as asking for help or confronting others. In a bereavement group, people can talk about their feelings of loss, confront their problems, and develop a safe and supportive network. In one bereavement group for those whose loved one had committed suicide, older adults can share their agonizing questions: "Why did he or she commit suicide?" "Could I have prevented it?" "Could I have done something differently?" and "Was it my fault?" They can confront problems such as when and how to tell others of the suicide. In a supportive group, members allow each other to grieve, to laugh at the funny memories, to express feelings without being judged, and to go on with life.