Depression in older adults all too common
By Judith Graham
With age and the advance of illness, depression often strikes older adults.
How often? Estimates vary. The Centers for Disease Control and Prevention suggests that up to 5 percent of adults age 65 and older have major depression. Other experts believe that figure hovers around 7 percent to 9 percent.
The numbers are much higher for seniors who are hospitalized (11.5 percent are clinically depressed) or who require home healthcare services (13.5 percent), according to the CDC. Again, estimates from other sources are higher. The take-home point is that depression is even more common in seniors who need institutional care or nursing care in their homes.
Depression often co-exists with chronic illness in older adults. For instance, 40 percent to 60 percent of patients with heart disease (young and older adults included here) have clinical depression, while 30 percent to 50 percent of patients with depression are at risk of developing cardiovascular disease. Why? That’s being studied but some experts think stress and inflammation are culprits.
“Depression in older adults is an unwanted co-traveler with common medical and neurological conditions,” said Charles Reynolds, M.D., a geriatric psychiatrist who runs the Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders at the University of Pittsburgh.
In addition to major depression, 15 percent to 20 percent of older adults are thought to have minor depression, dysthmia or “subsyndromal depression” – less serious but still concerning variants of this illness.
Reporters oftentimes err by confusing major depression with these other varieties. That’s a mistake because they’re not synonymous. Major depression is a serious mental health disorder that must meet well-defined diagnostic criteria. As the Mayo Clinic explains:
To be diagnosed with major depression, you must have five or more of the following symptoms over a two-week period. At least one of the symptoms must be either a depressed mood or a loss of interest or pleasure. Those symptoms include:
Depressed mood most of the day, nearly every day, such as feeling sad, empty or tearful
Diminished interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day
Insomnia or increased desire to sleep nearly every day
Either restlessness or slowed behavior that can be observed by others
Fatigue or loss of energy nearly every day
Feelings of worthlessness, or excessive or inappropriate guilt nearly every day
Trouble making decisions, or trouble thinking or concentrating nearly every day
Recurrent thoughts of death or suicide, or a suicide attempt
By contrast, minor depression, dysthymia, or depressive symptoms – these terms are sometimes used interchangeably, unfortunately – are less intense. Here’s how the National Institute on Mental Health defines the first two:
Dysthymic disorder, or dysthymia, is characterized by long-term (two years or longer) symptoms that may not be severe enough to disable a person but can prevent normal functioning or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.
Minor depression is characterized by having symptoms for 2 weeks or longer that do not meet full criteria for major depression. Without treatment, people with minor depression are at high risk for developing major depressive disorder.
Dysthmia is especially important because it puts seniors at a much higher risk of a full-blown episode of major depression while sapping their energy and sense of purpose in life at a time when they might be especially vulnerable. As the Harvard Mental Health Letter noted in a write-up of this condition:
In old age, dysthymia is more likely to be the result of physical disability, medical illness, cognitive decline, or bereavement. In some older men, low testosterone may also be a factor.
It’s critical to understand that depression in older adults often looks different than it does in younger people. Frequently, depressed seniors show less sadness and more apathy or listlessness. They tend to have more cognitive problems and physical ailments – for instance, gastrointestinal problems, headaches, or pain – than younger people. It’s widely accepted that depression is under-recognized in older adults; these differences may account for that, at least in part.
For an overview of late-life depression, take a look at this 2009 review article. It explains that about half of seniors with late-life major depression are experiencing this condition for the first time; the other half had one or more bouts of major depression earlier in their lives and is having a repeat episode.
Why is depression in older adults important?
Depression in later life is associated with a significantly increased risk of death, disability and suicide, as another review article in BMJ observes. Astonishingly, the World Health Organization projects that depression will become the No. 1 contributor to the burden of illness in developed countries worldwide by 2030.
Depression is also associated with a higher risk of developing Alzheimer’s disease and vascular dementia, as I wrote for the New York Times’ New Old Age blog earlier this year. Once again, stress and chronic inflammation are thought to be implicated.
Trends related to suicide in older adults are especially sobering. As BMJ’s review article notes:
According to WHO (World Health Organization) data, proportionately more people aged over 65 commit suicide than any other age group, and most have major depression. Older people who attempt suicide are more likely to die than younger people, while in those who survive, prognosis is worse for older adults.
Extra costs associated with depression are significant, as this condition frequently complicates care for people with chronic illnesses. Depressed seniors are less likely to follow medical recommendations and more likely to neglect to care adequately for themselves, research indicates. They’re also more likely to be high utilizers of emergency medical services and other forms of healthcare, research shows.
In 2009, when Jurgen Unutzer, M.D., M.P.H., of the University of Washington – one of the nation’s leading experts on late-life depression – examined records for nearly 15,000 Medicare fee-for-service beneficiaries with diabetes, congestive heart failure, or both conditions, he found that patients with depression had higher total health care costs than those without – $20,046 per year versus $11.956 per year.
What about treatment?
The good news about late-life depression is that is can be treated successfully – often, but not always. In model programs, a first attempt at treatment – either with drugs or behavioral therapies – is successful in achieving full remission about 50 percent of the time. When seniors go back for second or third rounds of treatment, remission rates can rise to 70 percent or even higher, according to Reynolds at the University of Pittsburgh.
Also, successful models for improving the care of depression in seniors have been developed. Especially notable is the Project IMPACT, spearheaded by Unutzer, now expanding into rural communities across Washington, Wyoming, Montana, Idaho and Alaska.
How effective are anti-depressant drugs in people with late life depression? This is still far from clear. A 2011 meta-analysis by researchers from Italy found that these drugs appear less effective in older patients than they are in younger patients. But another earlier meta-analysis published in 2008 indicated that anti-depressants had “modest,” though variable, effects.
The bad news about late-life depression is that primary care doctors often don’t feel comfortable talking about it with patients and often don’t treat it adequately, if at all. The number of geriatric psychiatrists is shockingly small – since 1990, only 2,500 psychiatrists have received subspecialty certification in geriatric psychiatry.
What efforts are being made to integrate mental health services into medical homes and other new care arrangements for seniors (accountable care organizations, other innovative models of care) being spurred by the Affordable Care Act?
What programs exist in your area to address mental health concerns in the growing population of people with dementia? If no such programs exist, are they under development? If not, why is this issue being overlooked?
What about depression among non-white elders – African Americans, Asian Americans, Native Americans, Hispanics? How do rates of depression among these groups differ from those of white seniors? Do services for these groups exist in your area; are they being developed?
Depression and Suicide in Older Adults Resource Guide, American Psychological Association
Psychology and Aging: Addressing Mental Health Needs of Older Adults, American Psychological Association
The Mental Health and Substance Abuse Workforce for Older Adults: In Whose Hands? Institute of Medicine, 2012