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Information About Late-Life Depression
March 3, 2005 – Depression in older people, which
is often associated with suicide, is “widely under-recognized and
under-treated, according to the National Institute of Mental Health.
Below is their overview of the illness, followed by information from the
American Association for Geriatric Psychiatry on the illness and
suicide.
National Institute of Mental Health (Click
to Site)
Older Adults: Depression and Suicide Facts
A brief overview of the statistics on depression
and suicide in older adults, with information on depression treatments
and suicide prevention. This version was revised in 2003.
Depression, one of the most common conditions associated with
suicide in older adults,1
is a widely under-recognized and under-treated medical illness. In fact,
several studies have found that many older adults who die by suicide—up
to 75 percent—have visited a primary care physician within a month of
their suicide.2
These findings point to the urgency of improving detection and treatment
of depression as a means of reducing suicide risk among older persons.
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For reports on four research projects
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Older Americans are disproportionately likely to
die by suicide. Comprising only 13 percent of the U.S. population,
individuals age 65 and older accounted for 18 percent of all suicide
deaths in 2000. Among the highest rates (when categorized by gender and
race) were white men age 85 and older: 59 deaths per 100,000 persons in
2000, more than five times the national U.S. rate of 10.6 per 100,000.3
Of the nearly 35 million Americans age 65 and
older, an estimated 2 million have a depressive illness (major
depressive disorder, dysthymic disorder, or bipolar disorder) and
another 5 million may have “subsyndromal depression,” or depressive
symptoms that fall short of meeting full diagnostic criteria for a
disorder.4,5
Subsyndromal depression is especially common among older
persons and is associated with an increased risk of developing major
depression.6
In any of these forms, however, depressive symptoms are not a
normal part of aging. In contrast to the normal emotional experiences of
sadness, grief, loss, or passing mood states, they tend to be persistent
and to interfere significantly with an individual's ability to function.
Depression often co-occurs with other serious
illnesses such as heart disease, stroke, diabetes, cancer, and
Parkinson’s disease.7
Because many older adults face these illnesses as well as various social
and economic difficulties, health care professionals may mistakenly
conclude that depression is a normal consequence of these problems—an
attitude often shared by patients themselves.8
These factors together contribute to the underdiagnosis and
undertreatment of depressive disorders in older people. Depression can
and should be treated when it co-occurs with other illnesses, for
untreated depression can delay recovery from or worsen the outcome of
these other illnesses. The relationship between depression and other
illness processes in older adults is a focus of ongoing research.
Both doctors and patients may have difficulty
identifying the signs of depression. NIMH-funded researchers are
currently investigating the effectiveness of a depression education
intervention delivered in primary care clinics for improving recognition
and treatment of depression and suicidal symptoms in elderly patients.9
Research and Treatment
Research has revealed varying patterns of clinical
and biological features among older adults with depression.8
As compared to older persons whose depression began earlier in life,
those whose depression first appears in late life are likely to have a
more chronic course of illness. In addition, there is growing evidence
that depression beginning in late life is associated with vascular
changes in the brain.
Both antidepressant medications and short-term
psychotherapies are effective treatments for late-life depression.8
Existing antidepressants are known to influence the functioning of
certain neurotransmitters in the brain. The newer medications, chiefly
the selective serotonin reuptake inhibitors (SSRIs), are generally
preferred over the older medications, including tricyclic
antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), because
they have fewer and less severe potential side effects.10
Both generations of medications are effective in relieving depression,
although some people will respond to one type of drug, but not another.
Research has shown that certain types of short-term
psychotherapy, particularly cognitive-behavioral therapy and
interpersonal therapy, are effective treatments for late-life
depression.8
In addition, psychotherapy alone has been shown to prolong periods of
good health free from depression. Combining psychotherapy with
antidepressant medication, however, appears to provide maximum benefit.
In one study, approximately 80 percent of older adults with depression
recovered with combination treatment.11
The combination treatment was also found to be more effective than
either treatment alone in reducing recurrences of depression.12
More studies are in progress on the efficacy and
longer-term effectiveness of SSRIs and specific psychotherapies for
depression in older persons. Findings from these studies will provide
important data regarding the clinical course and treatment of late-life
depression. Further research will be needed to determine the role of
hormonal factors in the development of depression in older adults, and
to find out whether hormone replacement therapy with estrogens or
androgens is of benefit in the treatment of late-life depression.
Older Adults...
Before you say,
"I'm fine"...
Ask yourself if
you feel:
-
nervous or "empty"
-
guilty or worthless
-
very tired and slowed down
-
you don't enjoy things the way you used to
-
restless and irritable
-
like no one loves you
-
like life is not worth living
Or if you are:
-
sleeping more or less than usual
-
eating more or less than usual
-
having persistent headaches, stomach aches, or
chronic pain
These may be syptoms
of Depression, a treatable
medical illness.
But your doctor can only treat you if you say how
you are really feeling.
Depression is
not a normal part of aging.
Talk to your
doctor
For More Information
Please visit the following links for more
information about organizations that focus on
depression and
older adults.
References
1Conwell Y, Brent D. Suicide and aging.
I: patterns of psychiatric diagnosis.
International Psychogeriatrics, 1995; 7(2): 149-64.
2Conwell Y. Suicide in later life: a
review and recommendations for prevention.
Suicide and Life Threatening Behavior,
2001; 31(Suppl): 32-47.
3Office of Statistics and Programming,
NCIPC, CDC. Web-based Injury Statistics Query and Reporting System
(WISQARSTM): http://www.cdc.gov/ncipc/wisqars/default.htm.
4Narrow WE. One-year prevalence of
depressive disorders among adults 18 and over in the U.S.: NIMH ECA
prospective data. Unpublished table.
5Alexopoulos GS. Mood disorders. In:
Sadock BJ, Sadock VA, eds.
Comprehensive Textbook of Psychiatry, 7th Edition, Vol. 2.
Baltimore: Williams and Wilkins, 2000.
6Horwath E, Johnson J, Klerman GL,
Weissman MM. Depressive symptoms as relative and attributable risk
factors for first-onset major depression.
Archives of General Psychiatry,
1992; 49(10): 817-23.
7Depression Guideline Panel.
Depression in primary care: volume 1.
Detection and diagnosis. Clinical practice guideline, number 5.
AHCPR Publication No. 93-0550. Rockville, MD: Agency for Health Care,
Policy and Research, 1993.
8Lebowitz BD, Pearson JL, Schneider LS,
Reynolds CF 3rd, Alexopoulos GS, Bruce ML, Conwell Y, Katz
IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis
and treatment of depression in late life. Consensus statement update.
Journal of the American Medical
Association, 1997; 278(14): 1186-90.
9Bruce ML, Pearson JL. Designing an
intervention to prevent suicide: PROSPECT (Prevention of Suicide in
Primary Care Elderly: Collaborative Trial).
Dialogues in Clinical Neuroscience,
1999; 1(2): 100-12.
10Reynolds CF 3rd, Lebowitz
BD. What are the best treatments for depression in old age?
The Harvard Mental Health Letter,
1999; 15(12): 8.
11Little JT, Reynolds CF 3rd,
Dew MA, Frank E, Begley AE, Miller MD, Cornes C, Mazumdar S, Perel JM,
Kupfer DJ. How common is resistance to treatment in recurrent,
nonpsychotic geriatric depression?
American Journal of Psychiatry, 1998; 155(8): 1035-8.
12Reynolds CF 3rd, Frank E,
Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA,
Stack JA, Pollock BG, Kupfer DJ. Nortriptyline and interpersonal
psychotherapy as maintenance therapies for recurrent major depression: a
randomized controlled trial in patients older than 59 years.
Journal of the American Medical Association,
1999; 281(1): 39-45.
All material in this fact sheet is in the public
domain and may be copied or reproduced without permission from the NIMH.
Citation of NIMH as the source is appreciated.
NIH Publication No. 03-4593 - Printed January 2001
- Revised May 2003
American Association for Geriatric Psychiatry
Late Life
Depression - A Fact Sheet
Depression –
Defined
All people feel sad or unhappy at times during
their lives, but persistent sadness may be depression, a serious illness
affecting 15 out of every 100 adults over age 65 in the United States.
Depression is not a normal part of growing old but rather a treatable
medical illness that impacts more than 6 million of the more than 40
million Americans over age 65.
When depression occurs in late life, it may be a
relapse of an earlier depression. If it is a first time occurrence, it
may be triggered by another illness, hospitalization, or placement in a
nursing homeUnlike the onset of depression in non-elderly populations,
depression in the elderly is thought to be a psychological disorder
triggered by specific stressors, such as medical illness. Another causal
factor is grief following the death of a loved one.
An estimated 6 percent of people ages 65 and older
in a given year, or approximately 2 million individuals in this age
group, have a diagnosable depressive illness.
Depression affects approximately 25 percent of
those with chronic illness and is particularly common in patients with
ischemic heart disease, stroke, cancer, chronic lung disease, arthritis,
Alzheimer’s disease, and Parkinson’s disease. Most disturbing among
depression statistics is the fact that depression affects upwards of 50
percent of nursing home residents.
Clinical depression is characterized by symptoms
that interfere with the ability to function normally for a prolonged
period of time. The symptoms of depression in older adults vary greatly
and may include:
-
Persistent sadness lasting two or more weeks
-
Difficulty sleeping or concentrating
-
Feeling slowed down
-
Withdrawing from regular social activities
-
Excessive worries about finances and health
problems
-
Pacing and fidgeting
-
Feeling worthless or helpless
-
Weight/appearance changes or frequent
tearfulness
-
Thoughts of suicide or death
Families and friends should watch for signs of
depression in older people and these clues should not be ignored.
Serious depression may lead to disability; may worsen symptoms of other
illnesses or may result in premature death or suicide. Clinical
depression is often undiagnosed and under treated in elderly adults
because symptoms go unrecognized in the context of multiple physical
problems. Often, depression in older adults is mistaken for dementia, or
the symptoms are so disabling that the individual cannot articulate
their distress and reach out for help.
In clinical practice, when an older person
experiences a significant loss distinctions between grief and
depression. Grief following the death of a loved one is normal. It is
distinguished from major depression by the limited duration of
functional impairment – usually less than 2 months, as compared to 2
months or more for individuals with depression. It is common and normal
for waves of grief to resurge periodically; if a person displays
prolonged and consistent signs of sadness coupled with expressions of
hopelessness and morbid preoccupation with one’s own worthlessness or
death, clinical depressions should be suspected and immediate measures
taken to seek professional help.
Depression among elderly Americans is widespread.
Most often it occurs in the context of the multiple physical
psychosocial problems that beset this population. Awareness of a variety
of clinical and behavioral clues is useful. Persistent complaints such
as pain, headaches, fatigue, insomnia, GI symptoms, arthritis, multiple
diffuse symptoms and weight loss are well known primary presentations of
depression in the elderly. However, they may be particularly confusing
in the elderly because co-existing medical disorders may also cause some
of these symptoms.
The lowest rate of clinical depression is found
among elderly persons living independently in a community; prevalence
increases with the prevalence and severity of medical co morbidity and
disability.
Mood changes and signs of depression may also be
caused by medication taken for heart disease or blood pressure.
Treatment For
Depression
Depression is one of the most successfully treated
illnesses. When properly diagnosed and treated, more than 80 percent of
those suffering from depression recover and return to their normal
lives. Most depressed elderly people can improve dramatically from
treatment.
The reasons for treating depression in the elderly
are compelling. Untreated, the condition is likely to persist causing
distress, disability, wasted health care dollars, substance abuse, and
medical complications or death.
Common treatments for depression include
psychotherapy, antidepressant medications, and electro convulsive
therapy (ECT).
Psychotherapy can play an important role in the
treatment of depression with or without medication. This type of
treatment is utilized in cases of mild to moderate depression and is
usually for a defined period of time (10-20 weeks).
Antidepressant medications work by increasing the
level of neurotransmitters in the brain. Many feelings such as pain and
pleasure are a result of the functioning of the neurotransmitters and
when the supply of neurotransmitters is imbalanced, depression may
result. It is critical that patients take prescribed medication as
directed. Missing doses or taking more than the prescribed amount of the
medication compromises the effect of the antidepressant. Medication is
typically prescribed for 6 months to 1 year and results from the
medication may not be evident until at least 4 weeks after the initial
dosage.
Electro convulsive therapy (ECT) is a treatment
that is safe and effective for severe depression. This treatment is used
for life threatening depression that does not respond to
antidepressants.
If you are caring for an individual displaying what
may be symptoms of depression, consult a physician. The first evaluation
is to assess whether the depression is a side effect of a pre-existing
medical condition, a medication, or another cause. If the evaluation
determines that the person is depressed, ask for a referral to a
geriatric psychiatrist---geriatric psychiatrists are the specialists
best suited to effectively and efficiently treat mental illness in older
adults. Treatment for depression is highly successful and is not a
normal part of growing older.
Suicide
The rate of suicide among older adults is higher
than that for any other age group---and the suicide rate for persons 85
years and older is the highest of all, twice the overall national rate.
Several studies have found that many older adults
who commit suicide have visited a primary care physician very close to
the time of the suicide – 20 percent on the same day and 40 percent
within 1 week of the suicide. This fact demonstrates the need for
primary care physicians to be alerted to the signs and symptoms of
depression.
Costs of Depression
The direct and indirect costs of depression have
been estimated at $43 billion each year, not including pain and
suffering and diminished quality of life. Late life depression is
particularly costly because of the disability that it causes and the
impact on the physical health of the older person.
AAGP RESOURCES & REFERRALS
REFERRALS
Referrals to a geriatric psychiatrist in the U.S.
or Canada is available by calling (301) 654-7850 x100 or by emailing
main@aagponline.org. You will need to note the city and zip code for the
region in which you are or would like the doctor to be.
AAGP PUBLICATIONS
Depression in Late Life: Not a Natural Part of
Aging
Management of Geriatric Depression: Complicated by
Co morbid Illness
Part I (Monograph and Slide Kit)
Part II (Video)
Part III (Workbook)
Diagnosis and Treatment of Late-life Depression:
Making A Difference
ADDITIONAL ASSOCIATION RESOURCES
National Mental Health Association
1021 Prince Street
Alexandria, VA 22314
1-800-969-NMHA
National Alliance for the Mentally Ill
200 North Glebe Road, Suite 1015
Arlington, VA 22203
1-800-950-NAMI
National Depressive and Manic-Depressive
Association
730 N. Franklin, Suite 501
Chicago, IL 60610
1-800-82-NDMDA
American Geriatric Society
770 Lexington Avenue
Suite 300
New York, NY 10021
212-308-1414
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