Depression in Older Persons

What is depression?

We all feel sad at times. However, clinical depression is a serious matter. Clinical depression, sometimes called major depression, is a biologically based brain disorder that affects one's thoughts, feelings, behavior, and physical health. It is an "affective disorder," which means that changes in mood occur in the depressed person. When people complain that they "feel lousy", they have no interest or take no pleasure in things, have trouble sleeping, lack energy, have poor appetite, or cannot concentrate, depression is a definite possibility. Depression is second only to heart disease as a cause of disability according to the World Health Organization. Clinical depression does not discriminate -- it can develop in anyone at any age. Depression is a serious medical illness that affects more than 11.6 million Americans, including older persons, in any given year. Depression has been reported to be more common among the baby boomers than it is among those born before World War II. Unfortunately, less than one-third of the persons with clinical depression actually seek treatment for their illness. The good news, however, is that treatments for depression work -- a broad range of treatments is available and results are robust and restorative. New research findings even open the possibility for prevention of depression by identifying people very early in the course of depression or those at very high risk.

How common is depression in later life?

Depression in its many forms affects more than 6.5 million of the 35 million Americans who are 65 years or older. Most older people with depression have been suffering from episodes of the illness during much of their lives. For others, depression has a first onset in late life -- even for those 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.

Why does depression in the older population often go untreated?

Depression is a disease of the brain -- numerous studies have clearly shown that. Research has also shown that treatment changes the brain when it is effective. Nonetheless, many people think that depression is a normal part of aging. "Who wouldn’t be depressed if …" is a common thought in the face of chronic illness, loss, and social transition. Added to that is the stigma that those with depression and other serious mental disorders confront in their everyday lives. Moreover, depression comes in different sizes and shapes. Many older 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 dementia. Also, many older people think that depression is a character flaw and are worried about being stigmatized, so they blame themselves for their illness and are too ashamed to get help. Others worry that treatment would be too costly.

What are the consequences of untreated depression in older people?

Older persons with depression rarely seek treatment for the illness. Unrecognized and untreated depression has fatal consequences in terms of both suicide and non-suicide mortality. The highest rate of suicide in the US is among older white men. Depression is the single most significant risk factor for suicide in that population. Tragically, many of those people who go on to commit suicide have reached out for help -- 20% see a doctor the day they die, 40% the week they die, and 70% in the month they die. Yet depression is frequently missed.

Are symptoms of depression different in older persons than in younger persons?

Symptoms in older persons may differ somewhat from symptoms in other populations. Depression in older people is often characterized by memory problems, confusion, social withdrawal, loss of appetite, inability to sleep, irritability, and, in some cases, delusions and hallucinations. Older depressed individuals 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 from persons suffering from depression is "no". "Depression without sadness" is one of those seeming paradoxes that impedes its recognition. Some general clues that someone may be suffering from depression in such cases are persistent and vague complaints and help seeking, along with frequent calling and demanding behavior.

How can clinical depression be distinguished from normal sadness and grief?

It's natural to feel grief in the face of major life changes like those so many older people experience, such as leaving a home of many years or losing a loved one. Sadness and grief are perfectly 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. It needs to be treated professionally. Any unresolved depression can affect the immune system, which makes the depressed individual more susceptible to other illnesses. This complication is often found in older individuals.

What causes depression in older people?

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. Certain brain chemicals -- like norepinephrine, serotonin, and dopamine -- are probably 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.

Are some older persons at highest risk for depression?

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 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 may be suspected if recovery is delayed, treatments are refused, or problems with discharge are encountered.

Can depression in older persons be treated?

Fortunately, the prognosis is good. Once diagnosed, 80 percent of clinically depressed individuals, including older persons, can be effectively treated by medication, psychotherapy, electroconvulsive therapy (ECT) or any combination of the three. The drugs are effective in a majority of people with depression. Four groups of antidepressant medications have been used to effectively treat depressive illness: tricyclics, monoamine oxidase inhibitors (MAOIs), selective serotonin re-uptake inhibitors (SSRIs), and norepinephrine and serotonin reuptake inhibitors (NSRIs). Medication compliance is especially important, but can be a problem among older patients. It has been estimated that 70 percent of these patients fail to take 25 percent to 50 percent of their medication. Of course, practically all the treatments have side effects, and the choice of treatment may depend on the types of side effects that can be best tolerated by that person.

ECT may be useful in the treatment of severe depression in older adults. Unfortunately, ECT is generally underused, unavailable, or burdened with myth and misinformation about its safety and efficacy.

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. 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 in late life, most experts would recommend treatment for 6 months to a year after acute treatment that achieves remission. For those that have had two or three episodes during their lifetime, treatment should extend up to two years after remission. And for those 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.

In 1999 the Surgeon General of the United States, Dr. David Satcher, issued a report on mental health. His conclusions are our conclusions: mental illnesses such as depression are real; treatment works; get help.

Reviewed by Dilip V. Jeste, MD, May 2003

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