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Late-Life Depression Widespread, But Under-Diagnosed And Under-Treated,
Reports NAMI Decade Of The Brain
Arlington, VA - Suicide rates in older persons are on the rise and, yet, symptoms of depression are rarely recognized and treated in this population, reports the current issue of the Decade of the Brain, a quarterly science-based publication of the National Alliance for the Mentally Ill (NAMI). As many as nine out of ten older persons who have depression do not get treatment for this disorder.
"Depression is not the outcome of natural processes of aging and should not be considered normal," writes Barry D. Lebowitz, Ph.D., chief of the Mental Disorders of the Aging Research Branch of the National Institute of Mental Health, in the first of four featured Decade of the Brain articles.
Of the 33 million Americans age 65 and older, a reported five million suffer from serious and persistent symptoms of depression. Another one million suffer from major, or clinical, depression. Suicide on the Rise in Older Persons
From 1980 to 1992, the suicide rate among persons age 65 and older increased nine percent, and most striking was a 35 percent rise in rates of suicide for men and women age 80 to 84. The suicide rate among males 85 years and older is six times the rate of the general population.
All but a handful of older people who commit suicide are suffering from depression, but "…misunderstandings about the nature of the aging process itself may cause the individual, the family, and even the health care professional to fail to recognize the symptoms of the disorder in older persons afflicted with multiple illnesses," Lebowitz reports.
Most older persons who are suicidal visit their primary care physician in the month before killing themselves, with nearly 40 percent making that visit in the week before committing suicide. One explanation given is that doctors may not associate an older person's behavior with depression. In older patients, the classic symptoms of sadness and withdrawal are frequently replaced with irritability or apathy. The Costs of Depression in older adults not only causes immense personal suffering, but it also takes an enormous financial toll on the family, community, and society.
According to Martha L. Bruce, Ph.D., M.P.H., associate professor of sociology in the Department of Psychiatry at Cornell University, in her Decade of the Brain article, the best available figure for direct treatment costs is approximately $800 million. Bruce asserts that this figure greatly underestimates actual costs because it doesn't include treatment for depression provided by primary care and other general medical clinicians, whom older persons are three times more likely to use than mental health care providers.
"Less obvious, but far more costly, are the indirect costs…[that] accrue in the use of other health care resources on the path to treatment or in lieu of treatment," notes Bruce. "Other less tangible but equally significant indirect costs derive from lost productivity of the depressed individual and from care given by family and friends." Across all age groups, the loss of productivity associated with depression is at least twice as great as the direct cost of treatment. Biology of Late-life Depression
The mechanisms that lead to depression in older people can differ from those that account for mood disorders in otherwise healthy young adults, according to Ira R. Katz, M.D., Ph.D., professor of psychiatry and director of the Section of Geriatric Psychiatry at the University of Pennsylvania and the Philadelphia Veterans Administration Medical Center.
Katz reports in his Decade of the Brain article that there are two types of older persons with depression:
1. Those whose depression started earlier in life and who now are experiencing a recurrence. Early-onset depression that recurs late in life likely includes genetic factors similar to those in younger persons with depression.
2. Those whose depression began for the first time in late life and who seem to have increased rates of chronic medical and neurological disease. People who experience depression for the first time when they are elderly may be subject to the effects on the brain of medications and physiological abnormalities associated with medical illnesses; to structural changes in the brain related to other disease; and to the death of nerve cells and the loss of brain tissue.
TREATMENT OF DEPRESSION IN OLDER PERSONS
The recent explosion of research into depression in late life has yielded significant progress in the understanding of the nature, clinical course, and treatment of this serious disorder. Early recognition, diagnosis, and treatment can translate into the prevention of suffering or premature death and enhanced independence and functioning for this population. Treatment can, in fact, very quickly and effectively resolve the problem.
However, some cases are "stubbornly intractable and treatment resistance is common in the elderly, frequently because of medication side effects," writes Herbert W. Harris, M.D., Ph.D., chief of the Geriatric Clinical Neuroscience Program in the Mental Disorders of the Aging Research Branch of the National Institute of Mental Health. "Choosing an antidepressant with the least likelihood of serious adverse effects is a complex process."
Harris describes the many pharmacological treatment options that are now available for older persons, including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs).
The Summer 1997 issue of the Decade of The Brain also highlights the importance of social supports, especially from the family, in treating an older person with depression. The publication also notes the importance of employing strategies to circumvent the development of depression in those at risk, to avoid worsening disability in those with early symptoms, and to avoid recurrence or relapse.
Editor's Note: Subscriptions to The Decade of the Brain, a quarterly science-based publication of the National Alliance for the Mentally Ill, are available free to the media. Call Jackie King at (703) 516-7961 and ask for a media subscription. Subscriptions are available to the public for $20 a year. Send requests (with a check payable to The Decade of the Brain) to NAMI, Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042.
NAMI is the nation's largest grassroots organization solely dedicated to improving the lives of persons with severe mental illnesses, including schizophrenia, bipolar disorder (manic-depressive illness), major depression, and anxiety disorders. NAMI has more than 165,000 individual members and 1,140 state and local affiliates in all 50 states, the District of Columbia, Puerto Rico, and Canada. NAMI's efforts focus on support to persons with serious brain disorders and to their families; advocacy for nondiscriminatory and equitable federal and state policies; research into the causes, symptoms and treatments for brain disorders; and education to eliminate the pervasive stigma toward severe mental illness.
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