Late Life Depression: What you need to know.

What is depression?

Sometimes we call ourselves "depressed" to describe the down or sad feelings that we all experience at one time or another in the course of life.  If we have a bad day or feel sad over something that has gone wrong in our lives, the mood may pass on its own or we can distract ourselves or cheer ourselves up.  We can still function well, do what we need to do at work or school, and be there for our loved ones.  Typically we can cope with this kind of a down mood without professional help.

In contrast, clinical depression is a persistently sad mood that persists (lasts two weeks or longer) and impairs one’s ability to function in work, home, or social relationships.  Clinical depression is a serious medical problem.  A clinically depressed person cannot be cheered up or pull themselves out of it any more than they could pull themselves out of another medical problem such as diabetes or heart disease. Sometimes the sad mood is obvious; sometimes it takes the form of losing interest and pleasure in usual activities

Major depression (major depressive disorder, or major depressive episode) is term for a clinical depression that meets certain criteria.  It is diagnosed when one has a persistently down mood and/or loss of interest for two weeks or more and is accompanied by poorer functioning in some important area of life (such as work, relationships, health). Furthermore, one must have at least 3 of the following symptoms as well:

• Significant decrease (or increase) in appetite and/or weight

• Insomnia (or excess sleep) nearly every day

• Agitation and/or retardation (being slowed down), noticeable by others

• Fatigue or loss of energy

• Feelings of worthlessness or inappropriate guilt

• Diminished ability to think or concentrate, or indecisiveness

• Recurrent thoughts of death or suicide

Depression affects one’s whole body, as well as their mood and thoughts. It affects how one feels about oneself and others.  Major depression can be quite debilitating and even life threatening, and it usually requires treatment.  Someone who is in a major depression also can feel a great deal of anxiety, worry and fearfulness.  Years ago, the term "nervous breakdown" sometimes was used to describe a major depression.

The causes of depression, in terms of the exact changes in brain chemistry and function, are unknown.  What is known is that these changes can be triggered by the stresses of certain life events such as illness, childbirth, death of a loved one, life transitions (such as retirement), or interpersonal conflicts.  We also know that some people are at more risk for depression, because of family history or previous episodes of depression or anxiety disorders. 

It may be that the stresses of the depressive symptoms in themselves cause permanent changes in the brain, perpetuating the cycle of depression. The exact nature of these interactions between life events and brain changes is unknown, but we know that the standard treatments, antidepressant medication and/or psychotherapy, work to resolve the symptoms.

Late-onset depression refers to depression occurring for the first time in an older person (after age 60).  In these cases, causes include physical illness and disability (especially due to stroke), grief, and social isolation.  In some cases, late-onset depression is probably caused by small stroke-like damage to areas of the brain involved in mood regulation.

Major depression seems to occur in families from one generation to the next, so that a strong family history of depression is a risk factor.  However, it is important to note that many people with depression have no family history whatsoever of psychiatric illness and, obviously, many people with strong family histories will never develop a depressive disorder.  Family history of depression may be less important in late-life depression.

What is the difference between depression and grief?

At the death of a loved one, it is certainly normal to feel sad and to withdraw somewhat from one’s usual activities; it is also common to have difficulties with sleep, appetite and energy. It is even common to have thoughts about death and dying. These symptoms are similar to those of a major depression, but clinicians do have ways of differentiating between depression and grief.

Usually, a diagnosis of major depression will not be made until 2 months after the death. However, the diagnosis can be made sooner under some circumstances. It is common for the bereaved to experience feelings of guilt about what he or she did or did not do at the time of the death, feeling to blame for the death in some way. However, if the bereaved is feeling a more generalized sense of profound guilt, feeling to blame for things other than the death itself, that person could be in a major depression. Such a person may also be feeling a dramatic loss of self esteem and worthlessness, feelings that are not common after a death. Another marker of depression is a prolonged or marked functional impairment. In other words, depression may be present if the bereaved is unable to perform most of his or her usual activities and/or can no longer socialize with family or friends at all.

Isn't depression normal in older people? 

Major depression is not normal in older people.  As with younger people, seniors go through life changes that can often lead to temporary feelings of sadness, which are considered normal.  For example, after the death of a spouse or other loved one, seniors are likely to feel the same symptoms as someone with major depression.  However, sadness that persists, is associated with the symptoms of major depression described above, and/or is accompanied by impairments in everyday function or thoughts of suicide, is not normal.  

Is late life depression treatable?

The good news about late-life depression is that it is treatable, with 60-80% of cases improving with standard treatment.  

What treatments are used for depression in older people?

There are three major types of treatment that are proven to help late-life depression: antidepressant medication, psychotherapy, and electroconvulsive therapy (ECT).  

Medication treatment usually starts with a serotonin reuptake inhibitor such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), or citalopram (Celexa).  These types of medications are typically well-tolerated; side effects include sexual dysfunction, nausea, sleep problems, diarrhea, or anxiety.  Many, but not all, of these side effects improve over time.  One common problem in treatment of depression (in all ages) is that medications do not improve symptoms immediately, but take 2 weeks or more.  During this time, patients are at high risk to stop taking the medication, perceiving it as having side effects and not helping.  A longer-term view is necessary: these side effects are likely to go away in a few days or weeks, while improvement of depression with the medication is likely to be long-term.  Other medications include venlafaxine (Effexor), mirtazepine (Remeron), bupropion (Wellbutrin), and nefazodone (Serzone), which may be suggested because they have a different mechanism of action and/or are easier to tolerate.  When a doctor prescribes one of these medications for you, it is important to make sure that they are aware of your other medications, to prevent drug interactions.

Psychotherapy is effective for mild to moderate late-life depression.  In this form of treatment sometimes called "talk therapy", the patient sees a therapist (who may have a masters' degree or a Ph.D. or Psy.D. in clinical psychology) or psychiatrist for frequent sessions (often weekly for about an hour).  At these sessions, problem areas in a patient's life are explored in a way that helps them see things in a more constructive or less depression-associated manner.  Some types of psychotherapy are interpersonal therapy, cognitive-behavioral therapy, and problem-solving therapy.  It may be that the combination of an antidepressant medication and psychotherapy provides the best hope for recovery from depression.

Electroconvulsive therapy (ECT) is typically reserved for severe forms of depression (such as depression that does not respond to medication, or depression associated with altered thinking called psychosis).  It consists of electrically causing a seizure to a patient a total of 6 to 12 times over several weeks.  It should be noted that ECT is felt to be safe and highly effective for late-life depression, and it is well-tolerated by most.  The main side effects are brief confusion after treatment (lasting a few minutes or hours) and temporary disruption of memory (often, people have dim memories of the period of time they are receiving ECT, though memory before and after the treatment course is unimpaired).

What are the risks of untreated late life depression?  

Probably the most serious risk of late-life depression is mortality -- depressed elderly are more likely to die, either by suicide or by worsening of medical illness.  It is also known that depressed elders are more disabled than non-depressed elders, and that they tend to recover or rehabilitate more poorly from medical illnesses such as stroke or hip fracture.

How can I get treated for depression?

It is important to be treated by a mental health professional under most circumstances. For example, the Late-Life Depression Evaluation and Treatment Center can provide evaluations and subsequent treatment, and it also can help with referrals in the community outside of the center.

Another place to start can often be your family doctor.  He or she will also be able to help you locate a mental health professional in your area.  A referral to a private psychiatrist, psychologist or social worker can be found through their respective professional organizations such as the American Psychiatric Association, the American Psychological Association and the National Association of Social Workers. Many communities also have geriatric assessment centers, such as the Benedum Geriatric Clinic in the Oakland section of Pittsburgh.

Should I see a mental health professional?

If you feel that you have any of the symptoms of depression, it absolutely is a good idea to see a mental health professional for an evaluation. Whether or not you are diagnosed with depression, that professional will be able to help you deal with those symptoms and feel better.

Too many people suffer needlessly when appropriate help is easy to obtain. Depression can become a significant disability and worsen the outcome of major health problems such as heart disease, cancer and strokes.

What is a geriatric psychiatrist?

A geriatric psychiatrist is a medical doctor who has special interest and training in treating the mental health problems of patients over the age of 60. These professionals are particularly knowledgeable about the factors that complicate the treatment of depression in older people such as medical illnesses and the medications that many seniors take to treat those illnesses.

You can get a referral to a geriatric psychiatrist in the U.S. or Canada through the American Association for Geriatric Psychiatry, by calling (301) 654-7850 x100 or by emailing main@aagponline.org.

How do I find out about treatment in my area?  

If you are in the Pittsburgh area, you may be eligible for treatment within our center; CLICK HERE FOR MORE INFORMATION.  If you have a medical insurance card, you can get a referral through your insurance company:  look on the back of your card for "mental health" or "behavioral" information to call.  Also, you can talk to your family doctor about treatment or a referral.

Antidepressants often are not effective when they are taken improperly or when one has not been taking an adequate dose for a long enough time. Antidepressants can take four weeks or more to begin having a positive effect, and this is only if the patient is taking them daily as prescribed. Often, the dose needs to be raised, and the patient will need to be on that higher dose for 4 weeks, at a minimum, in order to know if a particular medication will be useful. If patients do not feel better after a week or two they often stop treatment or ask for a change of medication. In this case, they have not given the medication enough time to help them. 

Sometimes a better response can be obtained by raising the dose of the antidepressant. Sometimes another treatment can be added to maximize the response.  If a patient is not receiving psychotherapy, the addition of psychotherapy can help the patient to address his or her life issues that could be sustaining any residual depressive symptoms -- in younger adults with chronic depression, the combination of medication and psychotherapy appears to give a higher chance of recovery from depression.  Another possibility is addition of a second antidepressant, sometimes called "augmentation."  At the Late Life Evaluation and Treatment Center, we often augment serotonin reuptake inhibitors with other medications such as bupropion (Wellbutrin), lithium, or nortriptyline (Pamelor), with a fair rate of success but sometimes with the risk of additional side effects.  Other options include providing psychotherapy along with medication, or switching to a medication that works in a different way, such as venlafaxine (Effexor XR).  

Antidepressant medications seem to work by increasing the levels of neurotransmitters that are available in the brain. Neurotransmitters are the chemicals that facilitate communication from one neuron to another, allowing information to move along nerve pathways.

Antidepressants do not give people a "high" or make them immediately happy. They have no value on the street and drug dealers do not push them. Also, someone taking an antidepressant typically does not lose his or her ability to have feelings or respond normally to emotional events.  There is no evidence that these drugs are addictive in the way that alcohol or street drugs are.

I'm being treated for depression and I feel a lot better. What next?

It is tempting to stop the treatment for depression when one gets better, but in late-life depression (as well as many other cases of depression) this is not a good idea.  Late-life depression has a high rate of recurrence, and maintenance treatment with medication and/or psychotherapy can reduce this chance.

A patient's story:

Morris pulls himself out of the pool after completing his workout of swimming 54 laps. Just another routine workout that he has been doing since he was in the 6^th grade. Morris returned to competitive swimming in 1985 competing in the YMCA Masters. He has known the "thrill of victory", winning national championships in the 50, 100 and 200 yard breaststroke. Morris has also known the agony of depression.

"I have experienced 5 episodes of clinical depression. You would think by now I would be able to see them coming. I guess I just don’t want to face going through it one more time, so I will usually tell myself that my loss of appetite and poor sleep patterns are nothing to worry about it. My wife is the one who picks up on my loss of interest and irritability that often accompany my episodes. I never have been ashamed or embarrassed to seek treatment once I realize that depression has returned."

Morris came to the Late Life Depression Evaluation and Treatment Center on the recommendation of a therapist who had treated him for one of his previous episodes of depression. " I was impressed with the care and attention to detail that the staff showed me right from the beginning. They seemed very confident and optimistic, while I worried that I might never come out of this depression." The combination of psychotherapy, medication, and tender loving care from the entire Late Life Depression Evaluation and Treatment Center staff proved to be all that Morris needed to return to his active and engaged lifestyle. In addition to his competitive swimming, Morris leads the Senior Men’s Fellowship discussion group at his temple. He and his wife are co-producers and co-hosts of a local cable television show, "More Than Just Learning", now in its 12^th year of production.

"It’s very discouraging to face another episode of depression, but it’s also very heartening to know that there are effective treatments. I wouldn’t hesitate to recommend seeking help for depression to anyone who is suffering with it."

written by Lee Wolfson, M.Ed.

Ten Myths about Depression in Seniors

Myth 1: "Depression is normal in older people."

Myth 2: "Of course I'm depressed; wouldn't you be if you were sick (or disabled)?"

Myth 3: "I can pull myself (or my spouse) out of it."

Myth 4: "Only crazy people see a psychiatrist (or psychologist or therapist)."

Myth 5: "Medicine for depression will make me a zombie."

Myth 6: "I'm too old to change."

Myth 7: "The last thing I need is another pill."

Myth 8: "I can't get treatment for depression right now; I have to focus on getting better from my medical problem."

Myth 9: "I don't have time to deal with depression, because I need all my energy to care for my spouse (or parent, child)."

Myth 10: "An antidepressant medicine wouldn't be safe for me because I have heart disease (or kidney or liver problems, cancer, stroke)."

The Late Life Depression Evaluation and Treatment Center is part of a federally-funded research center.  We have been conducting clinical research on depression in older people since the mid-1980's.  This center is recognized as one of the premier research centers in the area of late-life depression.  Here are some of our most important research findings:

1.  Depression in older adults is treatable.  We have found, in several treatment studies of medications, alone or in combination with psychotherapy, a high rate of recovery from depression.  

Typically 50% or more of individuals will respond (improve) on the first antidepressant medication tried.  However, for those who do not respond initially, strategies to augment medication have produced recovery rates as high as 80%.

2.  Older adults who recover from depression with treatment are more likely to stay well if they continue to receive the treatment.  

However, adults aged 70 and older appear to have a particularly "brittle" response; that is, they have a high rate of relapse (return) of depression despite adequate treatment.  We are currently examining this phenomenon in an ongoing study.

3.  Older adults with depression AND anxiety have a more severe illness, in terms of poorer social function, greater severity of symptoms, and more thoughts of suicide. We have found that these individuals appear to respond well to standard treatment for depression.

More relevant findings from our research center will be added in the near future.

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