As crippling as depression can be for young and middle-age adults, it’s truly severe in the elderly, and more often fatal.
And while depression and related illnesses afflict 20 percent of America’s elderly, only a fraction are getting the treatment they need.
"Depression kills not just through suicide," says Barry Lebowitz, director of treatment research at the National Institute of Mental Health. "[Elderly] people can be so debilitated by depression that they are not managing their hypertension or diabetes or they are not eating right. People die from the sort of excess disability that is created by depression in the context of other diseases."
Adds Dr. Vincent Marchello, medical director of the Metropolitan Jewish Geriatric Center in New York City: "Depression is very treatable in elderly patients. Part of the problem is that it’s not treated for a variety of reasons. Patients don’t go see their physician in the first place, or the physician is not looking for depression."
Contrary to conventional wisdom, depression is not a normal part of aging. But certain aspects of depression do become more distinctive with age.
For one thing, the elderly may have different symptoms than younger patients. "Older people will basically agree that they’re experiencing every symptom of depression except depression," Lebowitz says.
Experts often refer to this as "depression without sadness." A person may complain that his food doesn’t taste good, that he’s not sleeping and that he is having trouble remembering things and making decisions.
Memory and other cognitive problems may combine to make the person seem to have dementia, says Dr. Howard Berkowitz, director of the consultation and emergency psychiatry service at Maimonides Medical Center in New York City. "The person may also look apathetic rather than overtly depressed and is likely to deny he or she is depressed," he says.
Risk factors are also often different for older people.
"Psychological stress and family history are not so important when it comes to older people experiencing a first episode of depression," Lebowitz says. Some experts even hypothesize that there’s such a thing as "vascular depression," brought on by cerebrovascular disease.
Also, people who aren’t elderly -- including caregivers and family members -- tend to miss signs of depression in older individuals, thinking it’s normal to feel that way at that age.
Tragically, the depressed elderly are more likely to take their own lives. Comprising just 13 percent of the U.S. population, people age 65 and older accounted for 18 percent of all suicides in 2000, according to the National Institute of Mental Health. Of the nearly 35 million Americans 65 and older, an estimated 2 million have a depressive illness, and another 5 million may have depressive symptoms, federal health officials estimate.
Thanks to recent drug developments, however, there are more and safer treatment options for seniors. Two newer groups of anti-depressant medications are more commonly used among the elderly: SSRIs (selective serotonin reuptake inhibitors) such as Prozac, Zoloft and Paxil; and the even-newer non-SSRIs such as Wellbutrin and Effexor.
The medications tend to be applied a little differently, however. "With age, one tends to lower the dosage and give increases more slowly," Berkowitz says.
Treatment of depression in the elderly can be complicated by the fact that they tend to have more chronic medical conditions that require more medication.
"You have to be more sensitive to side effects and also drug interactions," says Marchello.
Psychotherapy is another option.
Social support can play a big part in a person’s recovery. "Usually the depressed patient is an isolated patient," Marchello says. "Getting patients out of the house, getting them more involved is so important." Diet and exercise are also critical. Studies have shown that support systems seem to help seniors comply with their medication regimens. One study published last December in the Journal of the American Medical Association found that an organized program of telephone support helped people take their drugs as prescribed. After a year, 45 percent of the people involved in the support program reported a reduction in depression symptoms of 50 percent or more, compared to only 19 percent of those who weren’t in the follow-up program.
Another major issue in depression is continuity of treatment.
"It’s not enough to get people well. You’ve got to work to keep people well," Lebowitz says. "This [depression] is highly recurrent in older people and recurrences happen sooner. The issue is very, very much keeping people well, not just getting them well." A person suffering a first episode of depression in late life needs to keep taking medications for a year or two years after they seem well.
In some cases, Lebowitz says, "we’re talking about continuing treatment for the rest of their lives." |
