Does it seem like just yesterday that your mom lit up when you brought the grandchildren over? So why does she hardly smile and seem irritable around the kids now? Has your dad always been a lifelong baseball fan? So when did he start turning down box seat tickets at the ballpark? Sudden changes in mood and interest can signal more than just old age. The National Institute of Mental Health (NIMH) reports that elderly depression is not only widespread but “a serious public health concern.” Recent research suggests that as many as 15 percent of elders—that’s 6.5 million Americans—suffer from depression, and still more, 25 percent, report that they suffer from persistent feelings of sadness.
A “Major Public Health Problem”
Dr. Gary Kennedy, chief of geriatric psychiatry at Montefiore Medical Center and Albert Einstein College of Medicine in New York and a leading authority on elderly depression, calls the condition a “major public health problem.” Kennedy says many health practitioners who care for the elderly are unprepared and unable to detect signs of depressed individuals. “Most don’t ask the simple questions that screen for depression,” he says.
To make matters worse, seniors themselves often ignore—even hide—their debilitating mental conditions. “Older adults are more sensitive to the mental illness stigma than any other group,” says Kennedy. “They tend to think of mental health treatment as leading to mental hospitals or nursing homes.”
While many elderly individuals may downplay their depression, the illness can have frightening consequences if not addressed. In older adult populations, it’s common for depressed individuals to stop taking critical medications such as insulin treatment or prescriptions for serious heart conditions.
Research shows that elderly depression can double the risk of cardiac disease and increase the risk of developing other serious health conditions. In studies where nursing home patients with physical illnesses were examined, the advent of depression significantly increased the chance of death from those illnesses. In addition, non-depressed elders are more likely to recover from a heart attack, while depressed seniors have a greater chance of dying after a cardiac incident.
“Depression can be a deadly illness,” notes Kennedy. “It’s associated with suicide.” In fact, the United States has seen a significant increase in the elderly suicide rate in the past 10 years, and many health experts blame untreated depression. Though adults over the age of 65 make up only 13 percent of the nation’s population, they account for 20 percent of all suicide deaths, according to the National Institutes of Health.
The National Alliance for the Mentally Ill (NAMI) reports a series of tragic statistics that underscores the lack of depression screening by many primary care physicians: Before a depressed senior commits suicide, 20 percent see a doctor the day they die, 40 percent the week they die, and 70 percent in the month they die.
Warning Signs
Do you feel that your parent’s physician hasn’t been probing deep enough to determine if depression is an issue? Geriatric psychiatrists and knowledgeable physicians who care for the elderly ask the following questions to screen for elderly depression:
Have you been sad or depressed, or had feelings of helplessness, most of the time over the last two weeks?
Have you lost interest in almost everything in the last two weeks?
While it’s natural to experience some grief in the face of major life changes, clinical depression doesn’t go away by itself, lasts for several months, and needs to be treated by a professional. According to NAMI, unresolved depression can affect the immune system, which makes the depressed person more susceptible to other illnesses. If you suspect that your parent or loved one is suffering from depression, pay attention to these health indicators:
Irritability. While your mother used to be a content and happy person, is she now cranky and easily irritated by small things? Sudden mood changes can suggest depression.
Loss of self-regard. Kennedy and other experts say that one of the most obvious signs of depression in elders is seen when they show a lack of pride in their personal appearance. Perhaps your mother has stopped wearing makeup, or your father has stopped bathing. Loss of pride in personal appearance can signal a problem.
Social withdrawal. Did you have lunch with your dad every Wednesday, but now he’s making excuses about why he can’t join you? Depressed elders, note experts, tend to take on the “hermit mentality,” shutting out others—even loved ones—and avoiding social situations.
Increased pain. One of the greatest myths about depression, says Kennedy, is that it’s only in the mind. In fact, “depression amplifies physical pain,” he says.
Has your parent suffered a stroke or had a major surgery recently? Elders recovering from major illness or surgery, says Kennedy, are “much more likely to develop a depressive episode, and some go on to have a depression disorder.” In fact, research shows that 15 percent of people who are discharged from a hospital leave with depressive symptoms.
Has your parent lost a spouse, child, or relative to death recently? “Depression in bereavement is common,” says Kennedy, who notes that elderly persons have a much higher risk of plummeting into depression after the loss of a loved one than a younger person.
Getting Help
While 50 percent of depressed elders will eventually recover on their own without any intervention, half will not—an important reason to make sure your parent gets help. “More often than not, the depressed senior is brought in by someone else,” says Kennedy. That’s good, he says, because studies show that elders who have a support network are more likely to pull through a depressive episode than those who are isolated.
But there are tactful ways of approaching such a sensitive topic, especially when an adult child approaches the matter with compassion and sensitivity. Kennedy suggests saying things like: “You don’t have to feel this way, let’s get you some help”; or “I want to understand your condition better. Let’s talk to the doctor. I’ll go with you.”
While families can be enormously helpful to their depressed loved one, occasionally the opposite is true. “Sometimes families are falsely reassuring,” explains Kennedy. “Instead of dealing with an issue head on, they can say ‘let’s look on the bright side.’” But for a depressed person, there is no bright side. That’s where a mental health practitioner comes in. “Depressed elders need to talk to a neutral third party about just how hard their depression is,” he says.
When selecting a psychotherapist, look for someone who specializes in geriatrics (care for the elderly). According to Kennedy, there are only 3,000 such specialists in the nation, so you may have to look beyond your immediate city or town, but getting specialized care may well be worth the extra travel time.
Treatment Options
When it comes to elderly depression, each patient is different and requires a customized treatment approach to his or her unique needs and circumstances. Often the treatment plan will combine the following different approaches:
Medication. “Most studies show that only half of people treated with medicine get better,” says Kennedy. Still, many respond well to medication. According to the NIMH, antidepressants influence the functioning of certain neurotransmitters in the brain. The newer medications, selective serotonin reuptake inhibitors (or SSRIs) such as Prozac® and Paxil®1, are generally preferred over older medications such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), because they are known to have fewer and less severe potential side effects.2
Whatever the medication, each dose has to be properly administered to produce the desired effect. Many practitioners, says Kennedy, “undertreat when it comes to depression in the elderly. They think older adults don’t need the full dose. But they do.”
Also, he says, one of the biggest problems in antidepressant prescriptions for seniors is the lack of follow-up by health practitioners. “Many start them off on a low does, then wait a month to increase it,” explains Kennedy. That’s too long, he says. “It’s just wrong to give the person a prescription and say, ‘I’ll see you in a month.’ We now know that in two weeks, some improvement should be seen.” If not, sometimes that means increasing the dose, other times it means changing medications altogether or prescribing a combination of two medications. A conscientious doctor will work with the senior to find the right balance of medication to treat depression.
And when the depression seems to be “cured”? Research published in a recent issue of The New England Journal of Medicine reports that elderly patients who remained on antidepressant drugs after recovering from depression are significantly less likely to relapse or have further depressive episodes than those who were taken off their medication entirely.
Psychotherapy. With most treatment methods, says Kennedy, “if you add psychotherapy, you get the best results. Most people get medication only, but the best treatment is combined with psychotherapy.”
While it does take time—10 to 12 sessions to get the person to the point where they’ve recovered from their depression, followed by one session a month to sustain progress—results can be dramatic and productive. Yet, many elderly patients resist such treatment due to steep co-pays, which can be as high as 50 percent. The expense can be a significant “obstacle for people to get treatment,” according to Kennedy, and is one of the reasons many elders are not getting the help they need. Together with the Geriatric Mental Health Foundation, he is lobbying for policy change on a national level.
Social support intervention. Kennedy recalls one of his patients—an elderly Holocaust survivor in New York City. “Her mother died in the tragedy when she was a child, so throughout her life, she was very sensitive about being separated from her daughter,” he explains.
But as her daughter grew up, she moved on and became involved with her own family and career. Feeling a tragic separation from her daughter, the 79-year-old woman sank into a depression. She stayed in, turned down social invitations, and developed a significant pain syndrome complete with severe headaches and weight loss. After a brief hospitalization for her symptoms, Kennedy was brought in to provide psychotherapy.
“Through psychotherapy, I encouraged her to stay active and do things that didn’t depend on her daughter,” says Kennedy. “Now she’s totally independent. She goes to music and theater events all the time, and volunteers at a major museum. Through psychotherapy, we were able to keep her socially engaged, and she’s done remarkably well.”
Exercise. According to researchers at Duke University Medical Center in Durham, North Carolina, exercising just three times per week can relieve and even cure the symptoms of elderly depression. In fact, according to the study, activities such as walking, light aerobics, or swimming may have greater depression-fighting properties than the leading anti-depressant medications.
Electroconvulsive therapy. For severe cases of depression that do not respond to medication or where the depression is accompanied by schizophrenia or psychosis, there is the option of electroconvulsive therapy (ECT), which uses electrical shocks to produce monitored seizures that release certain chemicals, or neurotransmitters, in the brain—a process that can provide dramatic short-term improvement for depression. While ECT today is generally considered by psychiatrists to be a very safe and effective procedure when performed under current guidelines, controversy still surrounds it. An unfortunate history of indiscriminate and sometimes abusive usage has resulted in extremely negative depictions of it in popular culture. Some psychiatrists believe ECT should be used only as a last resort, and some strongly oppose it.
Sometimes a creative approach to treating depression can provide some real breakthroughs. Kennedy remembers another one of his patients who had lost her 40-year-old son recently and presented with significant heart pain. “She had episodes where she thought she was having a heart attack,” says Kennedy. But after medical tests showed her heart was functioning just fine, he suspected that the woman might actually be suffering from a “broken heart.” He started her on a series of antidepressant medications over the period of several months, but during psychotherapy, he noticed that the woman was reluctant to talk about her family—especially those whom she had lost.
“I decided to make a house call,” says Kennedy. “I looked around the home and saw that there wasn’t a single picture of her family anywhere.” When he asked the woman about it, she said, “It’s not that I don’t have any, it’s just that it’s too painful.”
After some encouraging, the woman pulled out an old shoe box filled with pictures of her deceased husband and son. “She was so tearful, but from that day on, there was no broken heart. She learned to see the loss in a new light.” This type of intervention, says Kennedy, can have encouraging effects on elders who are grieving the loss of a loved one.
So what’s the bottom line about elderly depression? Don’t let it go untreated. If you suspect your parent is suffering from minor or major depressive symptoms, encourage him or her to seek help. By making yourself a part of the solution, says Kennedy, you’re “opening a door that the senior may be too embarrassed to open herself.”
1All pharmaceutical brand names mentioned in this article are registered trademarks of their respective manufacturers. Their usage here is for informational purposes only and does not imply any endorsement or promotion by A Place For Mom, Inc.
2Recently the FDA approved a transdermal patch form of MAOI, Emsam®, which has a much lower risk side effects from dietary and drug interactions than traditional oral MAOIs.