Depression affects more than 6.5 million of the 35 million Americans aged 65 years or older. Most people in this stage of life with depression have been experiencing episodes of the illness during much of their lives. For others, depression has a first onset in late life—even persons in their 80s and 90s. Depression in older persons is closely associated with dependency and disability and causes great suffering for the individual and the family.
Depression in elderly people often goes untreated because many people think that depression is a normal part of aging and a natural reaction to chronic illness, loss and social transition. Elderly people do face noteworthy challenges to their connections through loss and also face medical vulnerability and mortality. For the elderly population depression can come in different sizes and shapes. Many elderly people and their families don't recognize the symptoms of depression, aren't aware that it is a medical illness and don't know how it is treated. Others may mistake the symptoms of depression as signs of:
• Alzheimer’s Disease
• Heart disease
• Thyroid disorders
Also, many older persons think that depression is a character flaw and are worried about being made fun of or of being humiliated. They may blame themselves for their illness and are too ashamed to get help. Others worry that treatment would be too costly. Yet research has also shown that treatment is effective and in fact changes the brain when it works.
Late-life depression increases risk for medical illness and cognitive decline. Unrecognized and untreated depression has fatal consequences in terms of both suicide and nonsuicide mortality. The highest rate of suicide in the U.S. is among older white men. Depression is the single most significant risk factor for suicide in the elderly population. Tragically, many of those people who go on to die by suicide have reached out for help—20 percent see a doctor the day they die, 40 percent the week they die and 70 percent in the month they die. Yet depression is frequently missed. Elderly persons are more likely to seek treatment for other physical aliments than they are to seek treatment for depression.
Symptoms in older persons may differ somewhat from symptoms in other populations. Depression in older persons is at times characterized by:
Older individuals who are depressed often have severe feelings of sadness but these feelings frequently are not acknowledged or openly shown; sometimes, when asked if they are "depressed," the answer is "no." Some general clues that someone may be experiencing depression are:
It's natural to feel grief in the face of major life changes that many elderly people experience, such as leaving a home of many years or losing a loved one. Sadness and grief are normal, temporary reactions to the inevitable losses and hardships of life. Unlike normal sadness, however, clinical depression doesn't go away by itself and lasts for months. Clinical depression needs professional treatment to reduce duration and intensity of symptoms. Any unresolved depression can affect the body. For example, depression, if left untreated, is a risk for heart disease and can suppress the immune system raising the risk of infection.
Although there is no single, definitive answer to the question of cause, many factors—psychological, biological, environmental and genetic—likely contribute to the development of depression. Scientists think that some people inherit a biological make-up that makes them more prone to depression. Imbalances in certain brain chemicals like norepinephrine, serotonin and dopamine are thought to be involved in major depression.
While some people become depressed for no easily identified reason, depression tends to run in families and the vulnerability is often passed from parents to children. When such a genetic vulnerability exists, other factors like prolonged stress, loss or a major life change can trigger the depression. For some older people, particularly those with lifelong histories of depression, the development of a disabling illness, loss of a spouse or a friend, retirement, moving out of the family home or some other stressful event may bring about the onset of a depressive episode. It should also be noted that depression can be a side effect of some medications commonly prescribed to older persons, such as medications to treat hypertension. Finally, depression in the elderly population can be complicated and compounded by dependence on substances such as alcohol which acts as a depressant.
Older women are at a greater risk because women in general are twice as likely as men to become seriously depressed. Biological factors like hormonal changes may make older women more vulnerable. The stresses of maintaining relationships or caring for an ill loved one and children also typically fall more heavily on women, which could contribute to higher rates of depression. Unmarried and widowed individuals as well as those who lack a supportive social network also have elevated rates of depression.
Conditions such as heart attack, stroke, hip fracture or macular degeneration and procedures such as bypass surgery are known to be associated with the development of depression. In general, depression should be assessed as a possibility if recovery from medical procedure is delayed, treatments are refused or problems with discharge are encountered.
A physical exam can determine if depressive symptoms are being caused by another medical illness. Medical concerns and their treatment are common in this population. A review of the individual’s medications is important as a simple medication change can reduce symptom intensity in some cases. A clinical and psychiatric interview is a key aspect of the assessment. Speaking with family members or close friends may be helpful in making a diagnosis. Blood tests and imaging studies (like a CT scan) are helpful insofar as they rule out other medical conditions that would require a different path of intervention.
Fortunately, the treatment prognosis for depression is good. Once diagnosed, 80 percent of clinically depressed individuals can be effectively treated by medication, psychotherapy, electroconvulsive therapy (ECT) or any combination of the three. A novel treatment transcranial magnetic stimulation (TMS) has been cleared by the FDA and may be helpful for mild depression that has not been helped by one medication trial. Medication is effective for a majority of people with depression. Four groups of antidepressant medications have been used to effectively treat depressive illness: selective serotonin re-uptake inhibitors (SSRIs) and norepinephrine and serotonin reuptake inhibitors (NSRIs), and less commonly, tricyclics, monoamine oxidase inhibitors (MAOIs), Medication adherence is especially important, but can present challenges among forgetful individuals.It is important to note that all medicines have side effects as well as benefits., and the selection of the best treatment is often made based on tolerability of the side effects.
ECT (also known as shock treatment) may be very useful in the treatment of severe depression in older adults. For carefully selected people, ECT can be a lifesaving intervention. For example, an 80 year old man who lives alone, has been depressed for months, lost 60 pounds and has delusions about his body as a kind of presentation that may improve quickly with ECT. ECT can impact memory so that is an important consideration in comparing it to other interventions.
Medications can be beneficial for elderly individuals in treating the symptoms of depression. Medications are frequently combined with supportive psychotherapy or cognitive behavioral therapy to improve their effectiveness. Research has shown that some depressed individuals may need to try more than one medication to get an optimal response.
Psychosocial treatment plays an essential role in the care of older patients who have significant life crises, lack social support or lack coping skills to deal with their life situations. Because large numbers of elderly people live alone, have inadequate support systems or do not have contact with a primary care physician, special efforts are needed to locate and identity these people to provide them with needed care. Natural supports like church or bridge friends should be encouraged. There are services available to help older individuals, but the problem of clinical depression must be detected before treatment can begin.
Like diabetes or arthritis, depression is a chronic disease. Getting well is only the beginning of the challenge—staying well is the real goal. For people experiencing their first episode of depression later in life, most experts would recommend treatment for six months to one year after acute treatment that achieves remission. For those that have had two or three episodes during their lifetimes, treatment should extend up to two years after remission. For peopled with more than three recurrences of depression, treatment may be life-long. The treatment that gets someone well is the treatment that will keep that person well.
Reviewed by Ken Duckworth, M.D., October 2009