ELDERLY DEPRESSION AND HOW IT CAN BE OVERCOME

Although depression is not a normal outcome of aging, it is dangerous and one of the most significant barriers to aging well. ^[i] Fewer than 5% of older adults have major depressive disorder in any given year^[ii], but as many as 20% have significant symptoms of depression.^[iii] It is frequently unrecognized and untreated^[iv], resulting in much unnecessary suffering and lost opportunities to age well.

Fortunately, depression in old age can be overcome.  How?  There are four general, not mutually exclusive, approaches—(1) lifestyles that promote mental health in old age, (2) getting professional help, (3) developing skills to manage disturbing moods yourself, and (4) getting help informally from family, friends, and community resources such as clergy.

Mental Health Promotion: To vastly oversimplify, the keys to avoiding depression in old age are being physically healthy (a mix of luck and self-care), being physically and mentally active, being involved in personally satisfying activities and relationships, and achieving a sense that you have had a life of meaning and value.^[v]

Once depressed, however, maintaining such a life can be very difficult.  Despair can dissolve a sense of achievement in life and create the conviction that there’s no point trying to stay well, active, and involved.

Professional Interventions

Screening can be a first step towards dealing with a depressive disorder.  It should be routine in primary and specialty health care and in settings where older adults live or congregate, such as senior centers^[vi], but unfortunately it is not.

The most common screening instrument, the PHQ-9,^[vii] is filled out and scored by the person being screened, but diagnosis by a professional is needed to confirm a positive finding.

Treatment can be effective.^[viii] The most common forms of treatment are medication and psychotherapy.  Both cognitive and interpersonal therapies have been shown to be effective^[ix].  The combination of medication and psychotherapy appears to be most effective.^[x]

Great care is needed regarding medication for older adults, keeping doses as low as possible to avoid potentially severe side effects but as high as necessary to have a therapeutic effect.

Although highly controversial, electro-convulsive therapy (ECT) appears to be effective for some people with severely disabling depression who do not respond to other treatment.^[xi]

Increasingly, treatment for depression is provided by primary care physicians. They often do not have the time or training to provide sound treatment.^[xii] Various models of care management within primary care settings have emerged to provide needed follow-up and psychotherapy.^[xiii]

Many people with major depressive disorder need treatment by a mental health professional such as a psychiatrist, psychologist, clinical social worker, or nurse.  Unfortunately, there is a great shortage of trained geriatric mental health professionals.

Self-management: Some people with depression, particularly those with recurrent depressive episodes, develop effective self-management skills, sometimes on their own, sometimes with the help of a mental health professional.  These include self-observation skills that make it possible to anticipate depressive episodes, recognize them when they occur, resist the powerful urge to withdraw, remain active and involved with other people, control suicidal impulses, and know when to go for help.

It is very important not to confuse self-management, which can be effective long-term, with self-medication with alcohol and other drugs, which cannot.

Informal Interventions:  Most people who seek help turn to non-professionals—to family and friends they trust and to respected figures in their communities, especially clergy.

People who are willing, and have enough time, to spend with a person who is depressed can be extremely helpful.^[xiv] Talking—not about the depression but about anything of interest, having fun, socializing, or even  taking a walk can counter depression.

Spiritual experience is particularly helpful to people who find comfort through faith or religion.^[xv]

Informal interventions may not be enough for people with “moderate” or “severe” depression or during periods of profound hopelessness, psychosis, or suicidality.  Then professional help may be essential.

Do these approaches to overcoming depression work for all older adults who are depressed?  Of course not.  There are some who reject any offer of help because they are in a state of denial, feel too hopeless to believe that help is possible, or are too weary to make any effort.  There are people with depression who anger so easily or who are so unpleasant that they drive away all but the most saintly people who might be helpful.  And there are some people who do not respond to any form of treatment.

But these are the exceptions.  Yes, depression can be dangerous and is a barrier to aging well, but it is not an inevitable outcome of old age; and, when it occurs, it can usually be overcome.

Need help for yourself or someone you care about?

• To reach local mental health helplines call 1-800-273-TALK.
• To find a geriatric psychiatrist, go to www.gmhfonline.org/gmhf/find.asp.
• To find a clinical psychologist, go to http://locator.apa.org/
• To find a clinical social worker, go to www.helpstartshere.org/find-a-social-worker

(Michael Friedman is Adjunct Associate Professor, Columbia University Schools of Social Work and Public Health.   Lisa Furst is Director of the Training and Technical Assistance Center of The Geriatric Mental Health Alliance of New York and co-author of Depressed Older Adults: Education and Screening)

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