Depression

Depression

Professionals diagnose depression using criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), the official listing and definition of psychiatric disorders by the American Psychiatric Association. The following symptoms, which must be present for at least two weeks and impair the individuals normal daily functioningare included in the diagnosis of a major depressive episode:

  • feeling sad, blue, or depressed or experiencing a loss of interest or enjoyment in life
  • at least four of the following symptoms:
    • changes in appetite (may be accompanied by weight loss or gain)
    •  changes in sleep (too much or not enough)
    • agitation or retardation of movement
    • fatigue or decreased energy
    • feeling worthless or guilty
    • problems with attention and concentration or difficulty making decisions
    • thoughts of suicide.

 

To be considered part of depression, these symptoms cannot be the direct result of an organic factor (i.e., medication, medical illness, or an abused drug). The symptoms also cannot be part of usual bereavement after the loss of a loved one (see the Bereavement and Grief section of this chapter for more information).

Depression in Later Life

Depression in later life is much like that of younger adults, but there are some differences. First, some depressed older adults deny feeling sad, reporting instead a loss of interest or pleasure in life.

Second, rates of completed suicide are higher among older adults, particularly Caucasian men over the age of 74. Younger adults attempt suicide more often than older adults, but older adults are twice as likely to complete the suicide. Women attempt suicide more than men across the life span, but men are more likely to complete the suicide, often because they use more lethal means (e.g., men more frequently use guns, while women are more likely to overdose on pills).

Third, older adults have more medical illnesses than younger adults do. Depression is more prevalent among the medically ill elderly (an average of 12 percent) than healthy older adults (Koenigh et al., 1992). Rates of depression increase among those with more severe illnesses. Later-life illnesses and the medications used to treat them may also cause problems with energy, attention and concentration, appetite, and sleep. The overlap between these symptoms and those of depression may cause an older adult to appear depressed when they are not. Conversely, depression may be overlooked if symptoms are attributed to medical problems or side effects of medication. Further, many in the current cohort of older adults are reluctant to report feeling depressed to heir medical providers but will report physical symptoms.

Some medical problems have been associated with distinct patterns of depressive symptoms. For example, older adults with vascular disease or cardiovascular symptoms (e.g., congestive heart failure, multiple strokes, hypertension, high cholesterol) often experience what is sometimes called vascular depression (Alexopolous et al., 1997). Individuals with this depressive syndrome often experience relatively little guilt or sadness but have poor motivation or initiative, move very slowly, and do not recognize that what they are experiencing is related to a mental disorder.

                                                                                   Depression vs. Dementia

While both older and younger adults may experience deficits in attention and concentration, older adults tend to have more significant cognitive problems in the context of depression. This is sometimes called pseudodementia. Below is a summary of symptoms of depression and symptoms of dementia.

  • Depression

    Dementia

    • sleep disturbance
       
    • sleep disturbance
    • loss of interest in pleasurable activities
    • loss of interest in pleasurable activities
    • poor attention/concentration
    • poor attention/concentration
    • loss of appetite/unexpected weight loss
    • loss of appetite/unexpected weight loss
    • agitation/retardation of movement
    • agitation/retardation of movement
    • irritability
    • irritability
    • memory impairment
    • memory impairment
    • loss of energy
    • difficulty organizing; losing things
    • feelings of guilt or regret
    • language deficits
    • thoughts of suicide
    • incontinence in later stages

    Notice the overlap of more than two-thirds of the symptoms. The overlap challenges mental health professionals to determine whether an older adult is experiencing depression, dementia, or both. Often neuropsychologicaltesting is required to make a definitive diagnosis. Another issue is that many older adults experience depressive symptoms in the early stages of dementia in reaction to losses associated with cognitive decline. Diagnosis and treatment by a mental health professionalspecializing in geriatrics or with extensive experience with depression and dementia are optimal.

  • Dysthymia

    Dysthymia is a chronic, less severe form of depression. People with dysthymia experience depressed moods most of the time for at least two years, causing significant distress or impairment in daily functioning. Some older adults have dysthymia their whole lives, while for others it begins in later life. Dysthymia also includes changes in appetite and sleep, low energy, low self-esteem, difficulty concentrating or making decisions, and feeling hopeless. Dysthymia is not a normal part of aging.

    Adjustment Disorders

    People often experience distress following an upsetting event. When the distress is beyond what most people experience or is getting in the way of an individuals daily functioning, he or she may be experiencing an adjustment disorder. Adjustment disorders occur within three months following a specific event and do not last longer than six months after the stressful event has ended. Note that some stressors common in later life and longstanding (e.g., care giving for an elderly family member, multiple medical problems), thus adjustment disorders may persist much longer than six months if not appropriately treated. If symptoms persist beyond six months, other disorders may be considered. Bereavement is not included as a stressor for this disorder.

    Treatment of Depression

    The effective treatment of depression in later life comes through three basic types of intervention: psychotherapy, antidepressant medication, and-for severe depression-electroconvulsive therapy (ECT). It is notable that psychotherapy and medication each have been found to be effective alone or in combination in the treatment of depression.

    Psychotherapy

    Psychotherapy is an effective treatment for later-life depression among older adults. Psychotherapy includes cognitive behavior therapy, interpersonal psychotherapy, and psychodynamicpsychotherapy. Cognitive behavior therapy and interpersonal psychotherapy, both time-limited therapies, have been studied and shown to be effective treatments for depression (Reynolds et al., 1999; Thase et al., 1997). Cognitive behavior therapy helps patients to understand the link between their thoughts, behaviors, and emotions and to modify unhelpful thoughts and behaviors. Interpersonalpsychotherapy for depression focuses on depression's associated interpersonalfactors, including grief, role transitions (e.g., retirement, care for an infirm relative), interpersonalconflict, and interpersonal deficits.

    Medications

    Tricyclic antidepressants (TCA's, such as imipramine [Tofranil] and nortriptyline [Pamelor]) and selective serotonin reuptake inhibitors (SSRIs, such as citalopram [Celexa], fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil}, venlafaxine [Effexor], mirtazapine [Remeron], escitalopram oxalate [Lexaprol], and bupropion [Wellbutrin]) have all been found to be very effective in the treatment of depression among older adults. TCAs tend to have more side effects that can be very dangerous for older adults. Thus clinicians rarely prescribe TCAs, instead prescribing SSRIs, which have fewer side effects. Because older adults tend to metabolize medications more slowly than younger adults, these medications are started at lower doses and increased more gradually than for younger people.

    Electroconvulsive Therapy

    Electroconvulsive therapy involves inducing a brain seizure by passing an electrical current through the brain for a few seconds via small electrodes attached to the head. Although the notion of passing electricity through the brain to treat depression is unsettling to some, ECT is a very effective treatment for severe depression. It is not used for mild depression. During the procedure, patients are kept quite comfortable with the use of anesthesia. Most people experience confusion for about an hour following the procedure, and they experience mild memory loss for a few weeks. Most return to their previous level of cognitive functioning. ECT appears to be a more effective treatment for later-life depression with hallucinations and delusions (read further for a description of these symptoms) than medications (Parker, Roy, Hadzi-Pavolvik, & Pedic, 1992).

    The above information was provided by the Society of Certified Senior Advisors (SCSA).