Depression

Definition

Depression is the most common mental disorder. It is an illness that affects emotions, moods, thoughts, energy, behavior, and physical health and interferes with daily life.

Description

There are two major types of depression—major depressive disorder and dysthymia. Major depressive disorder is defined as five or more symptoms of depression lasting at least two weeks. It is also called:

• major depressive illness
• clinical depression
• major affective disorder
• unipolar mood disorder

Depressive episodes may recur monthly, annually, or several times during one's life. Dysthymia is a long-lasting or chronic depressed mood that is less severe than major depression but may be just as disabling.

Less common types of depression include:

• seasonal affective disorder, usually occurring in the winter months
• psychotic depression, severe depression that is complicated by psychosis or loss of contact with reality
• vascular depression, associated with blood vessel damage or “silent” strokes that cause lesions in the brain, particularly in the prefrontal cortex

Many older adults with depression had depressive episodes earlier in life. Others seniors experience their first depressive episode at age 80 or 90. A first episode of depression occurring late in life is usually brought on by another medical condition, a disability, or forced dependence on others.

The World Health Organization states that depression will be the second most common cause of death after heart disease by the year 2020. Unrecognized and untreated depression is a major problem among seniors. Older depressed patients often stop eating and/or sleeping and can easily become debilitated. Older adults have a far higher suicide rate than any other age group and depression is the most important risk factor for suicide among seniors. Suicide attempts are much more likely to be successful in seniors than in younger people. Depression in the elderly has become a very active area of research in many countries.

Demographics

Depression can affect anyone regardless of age, ethnicity, or socioeconomic class. At some point in their lives, 24% of all women and 15% of men experience depression. Depression most often first occurs between the ages of 25 and 44. Estimates of the prevalence of major depression in older people vary greatly, in part because older adults are much less likely to report symptoms of depression. Some epidemiological studies have indicated that older people are generally less depressed than younger people, whereas other studies have found that the incidence of depression is similar in the two groups. Major depression is estimated to affect 5–20% of Americans over age 65. The prevalence of major depression declines with age, but symptoms of depression—perhaps constituting dysthymia—increase with age, particularly among women. Dysthymia is thought to affect about 37% of older adults in hospitals an nursing homes .

Depression in seniors is sometimes mistaken as a normal sign of aging and is thus underreported. Seniors may be reluctant to seek help for depression because they do not understand mental disorders, they are ashamed of their symptoms or because Medicare offers very few benefits for psychiatric care. Depression can mimic dementia and some experts believe that as many as 10% of seniors diagnosed with dementia actually have reversible depression.

Unmarried older adults and those lacking a supportive social network are more susceptible to depression. Susceptibility to depression may be increased by:

• low self-esteem
• a family history of depression or suicide
• less than a high school education
• stressful life events such as death, divorce, relocation
• exposure to violence, abuse, or neglect
• poor economic situation
• alcohol or drug abuse
• giving birth

The prevalence of clinical depression in seniors is about 25% in those with chronic illness, especially:

• heart disease

• stroke

  Percentage of people in the United States age 65 and over with clinically relevant depressive symptoms, by age group and sex, 2004

  	Men	Women	Both sexes
  Clinically relevant depressive symptoms refers to four or more symptoms out of a list of eight depressive symptoms from an abbreviated version of the Center of Epidemiological Studies Depression Scale (CES-D) adapted by the Health and Retirement Study (HRS).
  source: Adapted from Health and Retirement Study, Institute of Social Research, University of Michigan
  (Illustration by GGS Information Services. Cengage Learning, Gale)
  65–74	9.7%	15.6%	13.1%
  75–84	10.6%	17.7%	14.8%
  85 and over	19.2%	19.2%	19.2%

• cancer
• lung disease
• arthritis
• Alzheimer's disease
• Parkinson's disease
• HIV/AIDS

Among people with diabetes, 10–15% have had at least one major depressive episode.

Other medical conditions associated with depression in seniors include:

• surgery
• trauma such as an automobile accident
• hip fractures
• macular degeneration
• hyperthyroidism
• dementia or other nervous system and brain disorders

Causes and symptoms

Biological causes

Although the exact cause of depression is unknown, imbalances or low activity of brain chemicals called neurotransmitters (such as serotonin and norepinephrine) are known to play a role. Levels of all neurotransmitters decline with age. People in their 80s have serotonin levels that are half of what they had in their 60s, although it is not clear whether this is associated with increased depression.

Depression may have a genetic component since the disorder can run in families. A first onset of depression after age 60 is less likely to be associated with a genetic predisposition.

Hypothyroidism, caused by deficient thyroid gland activity, is a common disorder that causes depression. Other conditions that can cause depression include:

• vitamin deficiency
• potassium deficiency
• a brain tumor
• stroke on the left side of the brain
• cancer

Medications that can cause depression include:

• corticosteroids
• some antihypertensives for treating high blood pressure, such as methyldopa and reserpine
• digoxin for treating heart disease
• opiod analgesics

The vascular hypothesis of late-onset depression suggests that disorders causing vascular damage—such as high blood pressure , coronary artery disease, and diabetes—induce brain changes that result in susceptibility to depression.

Changes in brain chemistry that may contribute to depression can be triggered by:

• hormonal changes, particularly in older women
• substance abuse
• cancer or other illness
• a traumatic event

Experiential causes

Persistent insomnia , which occurs in 5–10% of older adults, is a risk factor for late-onset depression. At least 10–20% of widows and widowers develop clinical depression within the first year of their spouse's death. Other factors that can trigger or contribute to depression in seniors include:

• life experience
• retirement
• a changing neighborhood
• moving to a new situation
• loss of friends or loved ones
• feelings of worthlessness or isolation
• loss of mobility
• anxiety over loss of control or inability to deal with daily tasks
• loss of independence
• worsening of a chronic disease
• changes in hearing or vision

Symptoms

Symptoms of depression in seniors may differ from those in younger people and may include:

• sadness lasting at least two weeks
• a feeling of emptiness
• apathy, emotional bluntness, or overreaction
• excessive worrying about finances or health
• restlessness, poor concentration
• memory problems
• social withdrawal
• fatigue
• weight gain or loss of appetite
• constipation
• irritability
• paranoia, delusions, or hallucinations
• dizziness
• confusion
• thoughts of death or suicide

Insomnia and sleep disturbances are particularly common in older depressed adults.

Instead of recognizing their depression seniors often complain of physical problems including backaches, joint pain , headaches , or stomach problems.

Symptoms of major depression include:

• unexplained crying spells
• low self-esteem, feelings of inadequacy, lack of self-confidence
• guilt, brooding about the past
• anger, anxiety, agitation
• pessimism, hopelessness, despair
• lethargy
• indecisiveness
• excessive alcohol or drug use

Symptoms may be worse at certain times of day, especially in the morning. Some older people who are depressed stop performing daily activities or caring for themselves.

Late-onset depression (a first episode after age 60) can be distinguished by greater apathy, less lifetime personality dysfunction, and increased cognitive deficits.

Vascular depression shares symptoms with other forms of depression but has some distinctive features:

• Anhedonia, the inability to look forward to pleasurable events, is common.
• Patients are less likely to have a family history of mood disorders.
• Patients are less likely to have a history of substance abuse or previous depression.
• Patients are generally more impaired.

Diagnosis

Many experts advocate using a series of questions during regular physical exams to screen seniors for depression. Depression is more difficult to diagnose and assess in seniors for the following reasons:

• Older people may be reluctant to talk about their symptoms.
• The elderly may have fewer social interactions.
• Family and friends may attribute symptoms to normal aging.
• Common medical conditions, such as Parkinson's disease, heart disease, or dementia, may mask symptoms of concurrent depression.
• People with dementia or stroke may be unable to express their feelings of depression.

One criterion for distinguishing depression from dementia is that older people who are depressed are confused and bothered by their forgetfulness, whereas those with dementia may deny any forgetfulness.

A diagnosis of depression should include a family history and complete physical examination to rule out other medical conditions that may be causing symptoms. Depression can be distinguished from sadness and grief at the loss of a home or loved one or other traumatic event if symptoms persist for more than two months or are accompanied by:

• guilt unconnected with the death of a loved one
• feelings of worthlessness
• insomnia
• weight loss
• inability to function normally
• thoughts of dying

Since dysthymia is not necessarily debilitating, seniors may be unaware that they are ill. Dysthemia is diagnosed when symptoms last more than two years without a break of more than two months.

Treatment

Although alleviating pain and nausea, getting support from family and friends, peer-support groups, self-help, proper care, and relaxation techniques may relieve symptoms of mild depression, mild to moderate depression is usually treated with either medication or psychotherapy. Severe depression usually requires both. Treatment for major depression is especially important for seniors because of the higher risk of depression-associated suicide. Geriatric psychiatrists specialize in treating late-life depression.

Antidepressants

The antidepressants prescribed for seniors are similar to those prescribed for younger patients but their selection is more complex because of side effects and interactions with other medications. Side effects that may be annoying in younger patients can lead to severe problems in the elderly. Normal aging and menopause can affect brain chemistry and may require a change in dosage or type of medication. Antidepressants can be highly effective in people nearing the end of life.

Selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed antidepressant. These medications have side effects, contraindications, and interactions with other medications. SSRIs selectively increase the level of serotonin available to the brain and central nervous system by blocking its reuptake. Citalopram and escitalopram are least likely to cause side effects and may relieve symptoms faster than other antidepressants. Fluoxetine and paroxetine are more likely to interact with other medications.

Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine; bupropion, which increases dopamine; and trazodone, which affects serotonin; have side effects that may be better tolerated by older patients. Older antidepressants such as tricyclics and monoamine oxidase inhibitors (MAOIs) affect numerous neurotransmitters, brain cell receptors, and brain processes, increasing the likelihood of serious side effects. MAOIs can also have dangerous interactions with certain foods and medications. These drugs are rarely used in older people.

It is often necessary to try different antidepressants or combinations of medications and they may have to be specially adjusted for seniors who are being treated for other illnesses. An SSRI that is effective after three weeks in a middle-aged adult may take 12 weeks or more to be effective in an elderly patient. Therefore, an antipsychotic medication is sometimes prescribed until the antidepressant takes effect.

Since depression is more likely to lead to malnourishment in seniors, psychostimulants such as methylphenidate, which can be effective within days and which stimulates appetite, may be prescribed for seniors who are not eating. Psychostimulants are also used for rapid relief in dying patients.

Seniors experiencing their first episode of depression are usually advised to continue the medication for 6–12 months after symptoms improve. Those with previous depressive episodes are advised to continue treatment for up to two years. Seniors with three or more previous depressive episodes may continue on medication for the remainder of their lives.

Psychotherapy

Psychotherapy has been shown to be particularly useful for older adults who cannot or will not take antidepressants. Sessions may be individual, include family members, or occur in a group of people with similar disorders. The goals of psychotherapy can include:

• separating personality from mood swings
• identifying triggers that worsen symptoms
• improving personal relationships
• establishing a stable routine
• addressing sleeping or eating irregularities
• overcoming fears and insecurities
• understanding previous traumatic experiences
• coping with anger, anxiety, irritations, and stress
• developing a plan for coping with crises
• ending destructive behaviors such as alcohol or drug use

Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been shown to be effective for treating late-life depression. They are usually short-term, lasting 10–20 weeks. CBT attempts to replace negative thinking and behaviors that contribute to depression with positive thoughts and behaviors. IPT focuses on improving personal relationships and on grief and role transitions. Problem-solving therapy and brief psychodynamic psychotherapy, lasting three to four months, have also been shown to be effective for treating late-life depression. Reminiscence therapy involves reflecting on positive and negative past life experiences to help overcome feelings of depression and despair. This therapy was developed specifically for older adults.

Other treatments

The use of electroconvulsive therapy (ECT) to treat severe depression in seniors is increasing, particularly for those who are unable to take antidepressants or for whom psychotherapy and medications are ineffective or too slow to relieve psychosis or suicidal thoughts. The rapid response to ECT can be crucial for a severely depressed patient who is not eating, drinking, or sleeping. A small electrical current is applied to the brain in a hospital under general anesthesia . The seizures caused by ECT may help relieve depression by causing the release of neurotransmitters.

S-adenosyl-L-methionine (SAM-e), an essential substance that regulates serotonin and dopamine levels in the brain, has been widely used in Europe to treat depression. Some studies have shown SAM-e to be as effective as antidepressants or to increase their effectiveness when used in combination.

Phototherapy is sometimes used to treat seasonal affective disorder. This type of therapy has patients sit in a room with a special light box or spend time outdoors.

Nutrition/Dietetic concerns

Healthy eating is important for managing depression. Depressed seniors should:

• eat plenty of raw fruits and vegetables and whole grains
• moderate intake of fat, cholesterol, sugars, and salt
• drink at least eight glasses of water per day
• limit or avoid caffeine and alcohol
• not skip meals
• avoid radical diets
• be aware of changes in appetite that could be signs of depression

Prognosis

Depression in seniors tends to be more chronic than in younger adults with recurrences lasting longer and remissions shorter. The risk of recurrence is particularly high in patients with late-onset depression. Fortunately, depression is one of the most treatable of all mental disorders and response rates to treatment are similar in older and younger adults. Response to treatment is slower and more variable in older patients though. About 80% of older adults with depression respond positively to medication, psychotherapy, or a combination, and ongoing treatment is very effective in reducing recurrences. Patients in psychotherapy often see significant improvement after 10–15 sessions. ECT is 50–70% effective in older patients. Even those who do not respond well to treatment usually experience some improvement in their ability to function and perform daily activities. Vascular depression is generally more difficult to treat but often responds as well.

QUESTIONS TO ASK YOUR DOCTOR

• How will my other medical conditions affect my treatment for depression?
• Is there a generic form of the prescribed medication?
• When should I take the medication? Should I take it with food?
• Are there any foods, medications, supplements, or activities that should be avoided while taking this medication?
• What if I miss a dose?
• What are the possible side effects of this medication and what can be done about them?
• How long before the medication takes effect and what type of improvement should I expect?
• Can I choose to stop taking this medication?
• Are there alternative treatments?
• Are there other things such as diet, physical activity, or lifestyle changes that may help with my depression?
• What type of psychotherapy might help?
• Are there support groups available that might be helpful?

Predictors of recurrence and relapse for late-life depression include:

• a history of frequent episodes
• severe pretreatment depression and anxiety
• first episode after age 60
• a concurrent illness
• infarction or vascular disease
• cognitive impairment, especially frontal-lobe dysfunction

Untreated, depression can affect the immune-system , leaving seniors susceptible to other illnesses. Studies have shown that chronic depression in older adults can increase the risk of certain cancers by 10–25%. Some research suggests that tumors grow faster in depressed people and depression at the time of cancer diagnosis is a predictor of a poor outcome. Depression also increases the risk of developing heart disease, osteoporosis , obesity , adult-onset diabetes, and chronic pain. The prognosis for hip fractures is worse in depressed seniors. Depression can also exacerbate substance abuse, eating and anxiety disorders.

Prevention

Several factors can help prevent episodes of depression:

• physical and mental activity
• social support systems
• regular sleep
• healthy eating
• avoidance of drugs, alcohol, and risky behaviors
• recognizing triggers and early warning signs

Aerobic exercise , in addition to improving immune and cognitive functions, increases the body's production of endorphins, which both prevents and treats depression.

Lifestyle changes that can help manage depression include:

• reducing stress and learning healthy coping strategies
• recognizing and managing the causes of stress
• communicating feelings through talking, writing, or other creative outlets
• relaxation methods including walking or light exercise, music, yoga, or meditation

Caregiver concerns

Caregivers often overlook symptoms of depression, mistaking them for normal aspects of aging. Some indicators of depression in the elderly are persistent and vague complaints, frequent phone calls, and a demanding behavior.

KEY TERMS

Cognitive behavioral therapy (CBT) —Psychotherapy for depression that attempts to replace negative thought patterns with positive ones.

Dopamine —A neurotransmitter in the brain.

Dysthymia —A milder chronic depression.

Electroconvulsive therapy (ECT) —A treatment for depression in which an electric current is applied to the head of an anesthetized person to induce seizures.

Endorphins —Brain peptides that bind to opiate receptors to produce pain relief and feelings of pleasure.

Hypothyroidism —Deficient activity of the thyroid gland that lowers the metabolic rate and causes fatigue and depression.

Interpersonal therapy (IPT) —Psychotherapy for treating depression that focuses on interpersonal relationships.

Major depressive disorder —Five or more symptoms of depression lasting at least two weeks and interfering with daily life.

Neurotransmitter —A substance that helps transmit impulses between nerve cells.

Norepinephrine —A neurotransmitter.

Psychostimulant —A fast-acting antidepressant.

S-adenosyl-L-methionine (SAM-e) —A substance in the body that regulates serotonin and dopamine levels and is used as an antidepressant in Europe.

Seasonal affective disorder —Depression that tends to recur with the shorter days of fall and winter.

Selective serotonin reuptake inhibitor (SSRI) —An antidepressant that increases serotonin in the brain.

Serotonin —A neurotransmitter in the brain.

Serotonin and norepinephrine reuptake inhibitor (SNRI) —An antidepressant that increases serotonin and norepinephrine in the brain.

Vascular depression —Depression associated with blood vessel damage or brain lesions.

Talk of suicide by older adults should always be taken seriously. It is appropriate to ask depressed people whether they:

• feel that life is no longer an option
• have thoughts of harming themselves
• are planning to harm themselves
• are often alone
• have pills or guns in their home

Seniors may need help remembering to take medications. It is estimated that 70% of seniors fail to take 25–50% of their prescribed medications. Medications should be taken at the appropriate times and side effects recorded. Caregivers should watch for possible drug interactions and indications that medications are affecting moods. Antidepressants should never be stopped without a physician's instructions for gradual withdrawal.

Resources

books

Chew-Graham, Carolyn A. Integrated Management of Depression in the Elderly. Cambridge, UK: Cambridge University Press, 2008.

Hart, Archibald D. Help! Someone I Love Is Depressed. Carol Stream, IL: Tyndale House, 2006.

Kramer, Peter D. Against Depression. New York: Viking, 2005.

periodicals

Bower, Bruce. “Depression Defense.” Science News 172 (August 18, 2007): 101–2.

“Depression; Home Care Program Seeks to Identify Depression in Senior Citizens.” Science Letter February 21, 2006: 418.

Wang, Shirley S. “The Graying of Shock Therapy.” Wall Street Journal December 4, 2007: D1.

other

American Psychiatric Society. “Let's Talk Facts About Depression.” November 2006 [cited April 6, 2008]. http://www.healthyminds.org/factsheets/LTF-Depression.pdf.

“Depression in Late Life: Not a Natural Part of Aging.” Geriatric Mental Health Foundation [cited April 6, 2008]. http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html.

“Depression in Older Adults.” Mental Health: A Report of the Surgeon General [cited April 6, 2008]. http://mentalhealth.samhsa.gov/features/surgeongeneralreport/chapter5/sec3.asp.

“Depression in Older Persons.” May 2003 [cited April 6, 2008]. National Alliance on Mental Illness. http://www.nami.org/Content/ContentGroups/Helpline1/Depres-sion_In_Older_Persons.htm.

Duckworth, Ken. “Understanding Major Depression and Recovery: What You Need to Know About this Mental Illness.” National Alliance on Mental Illness [cited April 6, 2008]. http://www.nami.org/Content/Content-Groups/Helpline1/NAMI_Major_Depression.pdf.

“Mental Health, Mental Illness, Healthy Aging: A NH Guide for Older Adults and Caregivers.” [cited April 6, 2008]. National Alliance on Mental Illness-New Hampshire. http://www.nami.org/Content/ContentGroups/Home4/Home_Page_Spotlights/Spotlight_1/Guidebook.pdf.

organizations

American Association for Geriatric Psychiatry, 7910 Woodmont Avenue, Suite 1050, Bethesda, Md, 20814, (301) 654-7850, http://www.aagponline.org.

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35-PSYCH, [email protected], http://www.healthyminds.org.

Depression and Bipolar Support Alliance, 730 N. Franklin Street, Suite 501, Chicago, IL, 60610-7224, (800) 826-3632, (312) 642-7243, [email protected], http://www.ndmda.org.

National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA, 22201-3042, (703) 524-7600, (888) 950-NAMI, (703) 524-9094, http://www.nami.org/.

National Mental Health Information Center, P.O. Box 42557, Washington, DC, 20015, (800) 789-2647, (240) 221-4295, http://mentalhealth.samhsa.gov.

Margaret Alic Ph.D.