Mental health's age-old issue
Diagnosing — and treating — depression in the elderly poses challenges
Older Americans are generally happier than the young, surveys show. Seniors are less stressed, enjoy more free time, and have a more positive outlook. Yet they also endure great losses: the end of their careers, deaths of loved ones, illness, disability, and reduced independence.
It’s a lot for anyone to bear, and for some it can trigger major depression.
They may sit idly for hours, and stop eating, bathing, going out — even getting out of bed. Some take their lives: The suicide rate for Americans over 65 is second only to the rate for adolescents, and for white men over 65 it’s more than four times the national average.
Barbara Elman, 79, a Brookline widow and grandmother who has experienced several bouts of depression, describes it as “awful, awful,’’ so crippling that being around people is unbearable.
“You’re like a fake,’’ she said, “faking being well. You want everyone to think that you’re fine, and your stomach is in a knot. It’s a terrible sickness.’’
Depression also has physical impacts: It has been linked to higher mortality for patients with heart disease and to poorer self-care among diabetics — and worse outcomes.
But in the elderly, experts say, depression can be tricky to diagnose. Many physical illnesses and medications can cause similar symptoms, and if a patient is facing real hardship, it can be hard to draw the line between appropriate sadness and a clinical problem.
One thing is clear, said Dr. Eran D. Metzger, associate director for geropsychiatry at Hebrew Rehabilitation Center: If an elder is persistently sad or dejected, that requires attention. “Don’t fall into accepting the myth that it’s natural to get depressed when we get older,’’ he said.
Major depression afflicts 1 to 5 percent of seniors living in the community, and it’s far more common among those in home care and institutions, according to the National Institute of Mental Health. Another 5 million — about 12.5 percent of those over 65 — have milder depression.
Meanwhile, 10.7 percent of Medicare’s fee-for-service enrollees nationwide — and 13.5 percent in Massachusetts — had a depression diagnosis in 2008 (the most recent year for which data were available). Among Medicare Part D (prescription-drug benefit) enrollees, 7.1 million, or 28 percent, took an antidepressant in 2008.
Dr. John R. Anderson, chief of geriatric medicine at Mount Auburn Hospital, said the good news is that depression in the elderly is “eminently treatable, with an array of excellent medications and support through counseling.’’
Older patients are generally started on very low doses, Anderson and Metzger said, because they’re often more sensitive to the drugs than younger people. There are also increased risks from side effects, Metzger noted — lightheadedness can be dangerous for an elder whose balance is already impaired, and interactions with some heart medications can be severe.
Yet the benefits can be life-changing, Anderson said. One of his patients, he recalled, saw him periodically for years, reporting “a raft of physical complaints’’ that he believed were due to depression. He kept offering her an antidepressant, but she was “dead set’’ against it.
“After three and a half years, she said yes, and within weeks she was transformed.’’ She reconciled with her family, he said, and lived much more happily for her last few years.
Seeking help for depression doesn’t come easily for this generation, though, said Dr. M. Cornelia Cremens, a geriatric psychiatrist at Massachusetts General Hospital.
“Most of these patients, having grown up in the Depression, through World War II, have difficulty coming to see a psychiatrist on their own,’’ she said. “I think there’s a bit of shame that you can’t improve your mood on your own.’’
Dr. James Chengelis, a consulting psychiatrist at Boston Medical Center, said older patients “are not as keen as younger people about psychiatry, and they get a little taken aback by it.’’
Some elders do seek help on their own, Cremens said, “because they know that something’s wrong,’’ but many are referred by their doctors, or brought in by their worried children.
“Family members often recognize the depression before the patient does,’’ she said. “I think maybe the children of patients are more educated about depression than their parents are, so they’re more likely to recognize the symptoms.’’
Sometimes it takes a crisis: Chengelis has seen his share of elders who’ve tried to commit suicide and finally get treatment in the hospital. If someone has stopped eating or is talking about wanting to die, he said, family members may want to call emergency services.
Yet follow-up can still be a challenge in those cases, said Dr. Louis Marino, chief of the Senior Treatment Program at Butler Hospital, in Providence. Elderly patients stay for an average of 12 days, he said, and they usually show a “very marked improvement.’’ But to truly get well, they’ll need “much longer,’’ he said, and there’s “a paucity’’ of geriatric psychiatrists.
For patients who need continued intensive support, Butler offers a “partial hospitalization’’ program, in which seniors come in for several hours each day. Almost all patients also stay on antidepressants for the rest of their lives, Marino said, overseen by community psychiatrists or their primary care physicians.
Elman, who now lives at Hebrew SeniorLife in Roslindale, is unusual for her generation in that she was diagnosed when she was only 19. She’s taken antidepressants since, she said, and has been “very fortunate’’ to have a supportive family and good doctors to help her through crises.
“Some people don’t believe in psychiatry, and I don’t know if I believe in it, either,’’ she said. “But you have to believe in it when you have depression, because that’s who takes care of you.’’
Marion Davis can be reached at firstname.lastname@example.org.
Keeping up on information
Depression doesn’t come out of nowhere, experts say — it’s usually triggered by an event (a death in the family, moving into a nursing home, getting diagnosed with a serious illness), or it may build up over time. Here are some tips to protect yourself or your loved ones.
Stay connected. Regular contact with friends and family enriches seniors’ lives and provides a safety net — people who will notice major mood changes.
Stay active, physically and mentally. Along with social connections and personal hobbies, consider some of the programs offered by community groups, senior centers, colleges, and universities.
Don’t let retirement bring you down. It’s easy to be defined by your work, but even before you retire, find other things you enjoy and that use your skills.
Know the signs of depression: apathy, loss of energy, loss of appetite, impaired concentration, loss of interest in favorite activities, feeling guilty, worthless, or hopeless.
Talk to your primary care doctor about how you feel, mentally and physically. A marked increase in aches and pains may reflect depression. Conversely, depressive symptoms may actually be signs of physical illness or a medication problem.
Don’t blame yourself if you feel depressed. Even active, upbeat people (of any age) can get depressed, and especially if there’s a biological cause, you can’t just shake out of it.
Don’t presume that feeling listless — or miserable — is just part of old age. Millions of happy, fulfilled older Americans prove it’s not. M.D.