Depression Among Seniors
Dateline: 03/20/99I feel that life is--is divided up into the horrible and the miserable.
Woody Allen and Marshall Brickman, Annie Hall (1977)
Depression among the elderly is a major health problem, affecting between 10 and 20 percent of seniors aged 60 years and older, whether or not they are institutionalized. Paralleling the rise in depression in older people is an increase in the incidence of suicide: suicide rates in the U.S. are highest among those 65 years old and older.
Despite its prevalence, depression is often misdiagnosed, unrecognized, or masked by underlying medical illnesses or cognitive changes. Diagnosis is not a natural outcome of aging, though such misunderstandings complicate both its diagnosis and treatment. This article should dispel such misconceptions and foster an enlightened and informed approach to depression, especially among seniors.
Depression and Suicide: The Facts
According to the National Alliance for the Mentally Ill, five million of the 33 million Americans aged 65 and older suffer from serious and persistent symptoms of depression, and an additional one million suffer from major depression. Among nursing home and residential care residents, the prevalence is especially high: perhaps 20 percent of seniors in long-term or hospital facilities have major depression.
With depression comes an increased risk of suicide. The Centers for Disease Control says that the suicide rate among seniors is more than triple the rate for younger Americans. Senior men commit suicide at the rate of 38.4 per 100,000, compared to 11.1 per 100,000 for the general population. For senior women, the rate is less--only 6 per 100,000. Even within this age group, suicide rates increase with age. Men aged 80-84 commit suicide at the rate of 58.6 per 100,000. And all these rates appear to be on the rise.
Though the rates of depression are higher among the elderly, the risk factors for depression are similar. Women, people who are unmarried (and, especially, widowed), those whose lives are marked by stressful events, and those who lack supportive social networks face higher rates of depression. Add to these risks the increased prevalence of medical illness and disability among the elderly and the heightened risk of depression comes as no surprise.
Seniors present slightly different risk factors for suicide, compared to their younger counterparts. Older people abuse alcohol at a higher rate, experience depression more commonly, use highly lethal methods more often, and face a greater degree of social isolation. Older victims of suicide make fewer attempts per completed suicide, have a higher male:female ratio, have more physical illnesses, and are more likely to have visited their physician before committing suicide. Finally, seniors are more likely to be victims of silent suicide, the intention--often masked--to kill themselves by nonviolent means, such as self-starvation or noncompliance with their essential medical treatment.
Effective Therapies for Depression
The good news about depression is that safe, effective therapies abound. Evidence from carefully controlled clinical trials supports the effectiveness of drug therapy, somatic treatments like ECT (electroconvulsive therapy), psychotherapy and counseling, and combinations of these approaches.
Most antidepressants are thought to be as effective among elderly patients as among younger patients. Various medical conditions and differing side effects of the medications often dictate the particular medication prescribed. Regardless of the specific medication employed, the response depends upon an adequate duration of therapy, an appropriate dosing regimen, and a therapeutic blood level of the medication. Because elderly patients may take longer to respond to antidepressant therapy, drugs should probably be given for 6 to 12 weeks before declaring them to have failed. And once therapy proves effective, it should probably be continued for some time of remission--up to 40 percent of depressed persons experience long-term recurrences, but 80 percent of people maintained on medication that brought about their recovery maintain extended remissions.
ECT plays an important role in the treatment of some depressed seniors, particularly among those who are suicidal or who have become catatonic or stuporous from severe depression. A series of grand mal seizures can be induced by electrical stimuli, resulting in remission rates of up to 85% of patients who have failed drug therapy. Unlike drug therapy, there are few guidelines on how long to continue ECT to maintain remissions. Some studies suggest continuing ECT until symptoms have been absent for as long as five months, then maintaining antidepressant medication for some time thereafter--perhaps an additional four or five months.
Psychosocial interventions are important in addressing the causes of depression in elderly patients, because prevention strategies are both effective and simpler than treatments. Social support is critical, and such approaches as cognitive therapy, behavioral therapy, interpersonal therapy, and short-term psychodynamic therapy have proven to be moderately effective, especially among seniors with less marked depression.
Effective therapy requires accurate, timely diagnosis. If you are a senior with any of the following symptoms, or if you notice any of these symptoms in anyone you care for, it's worth contacting a physician or mental health provider for a thorough evaluation:
- generalized, widespread physician complaints out of proportion to any medical condition
- irritability or mood swings
- difficulty thinking straight, remembering things, or feeling sad or apathetic
- feeling worthless, useless, or excessively guilty
- difficulty sleeping or eating or engaging in other normal daily activities
Suicide Prevention
Like depression treatment, suicide prevention requires recognition of its existence. Here are some danger signs of suicide:
- preoccupation with death
- talking about suicide
- talking about hopelessness, helplessness, or worthlessness
- loss of interest in things or people one cares about
- getting one's affairs in order
- giving things away
- suddenly feeling happier and calmer
Contrary to popular belief, people who talk about suicide MAY do it. In fact, bringing up the subject of suicide and discussing it openly can often bring great relief to depressed, suicidal people. Most suicidal people don't want to die; they just want the pain of depression to go away.
What can you do if you are suicidal or know someone who is? Anyone who feels suicidal urgently needs to see a doctor or a psychiatrist. As noted above, most suicidal people are deeply depressed. They need to be treated so that their depression can be relieved and their suicidal thoughts allayed. Remember: effective treatment of depression significantly reduces the risk of suicide.
While the depressed person is undergoing treatment, work to ensure they take their medications properly and make their medical or mental health appointments. See that any weapons are removed from the home until they have fully recovered. And continue to create a supportive, caring environment.
Resources
For more in-depth reading about specific antidepressant therapy among the elderly, check out these links:
- Diagnosis and Treatment of Depression in Late Life (from the National Instituted of Health)
- Neuropsychiatric Assessment and Treatment of Geriatric Depression (from Psychiatric Times)
- Assessing Antidepressant Safety in the Elderly (from Psychiatric Times)
And for a variety of resources, visit Suicide Awareness\Voices of Education (SAVE), an organization dedicated to educating the public about suicide prevention, and National Alliance for the Mentally Ill (NAMI), "the nation's voice on mental illness."
Depression is treatable and suicide is preventable. All that's required are attention and action at the right time. Watch for depression in yourself and in those you love. An early diagnosis could be life-saving.
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