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Up from Depression

By: Source: AARP Bulletin Today Date Posted: 2003-09-02 15:40:00-04:00

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In recent visits with your mother, you notice she has lost her customary spark, her sense of humor. She has stopped going out, rarely sees her longtime pals and instead stays at home, staring dully at the TV. Even the grandkids can't cheer her up.

She's just slowing down, you tell yourself. Possibly, but there may be another reason: She may be among the growing number of Americans with serious depression, a draining condition that can ruin the quality of life and often goes unrecognized—especially in older people—by doctors or family members.

Some 19 million Americans experience persistent, or clinical, depression. Of these, 6 million are over age 65, a number that is rising sharply as the older population expands. Experts say the problem, if not brought under control, will only worsen as baby boomers age and confront life changes and losses that can cause depression.

"We're talking about an epidemic," says William E. Reichman, M.D., a psychiatrist at the University of Medicine and Dentistry of New Jersey and president of the American Association for Geriatric Psychiatry (AAGP). "There's a demographic imperative that compels us to pay attention to depression in late life."

On the bright side: In most cases, depression is highly treatable. A deeper understanding of what leads to the disorder is producing better ways to fight it, with everything from self-help measures like exercise and diet to new, more effective drugs.

Overcoming depression "can add years of productivity and happiness to someone who had given up on those aspects of life," says Nathan Billig, M.D., a geriatric psychiatrist in Washington and author of "Growing Older & Wiser" (Lexington Books, 1995).

But fighting depression takes more than the efforts of professionals. "The challenge for baby boomers who may care for an older adult is to gain an understanding of the issue, identify disorders early and help her or him get appropriate treatment," says Soo Borson, M.D., director of geriatric psychiatry services at the University of Washington Medical Center in Seattle.

NOT JUST THE BLUES

It's normal to be sad after major life events like illness, divorce, losing a job, moving far from home and the death of a spouse or close friend. Most people begin to bounce back after a few days or weeks.

But clinical depression is more than the blues or a reaction to grief. Untreated, the feelings of sorrow, hopelessness and anxiety can last for months or years, leading to impaired functioning, isolation, physical ailments and even suicide.

"[Depression] is a medical disorder, like hypertension or diabetes," says Billig. "It can and must be treated when it interferes with otherwise healthy functioning."

The condition, he stresses, is not a part of normal aging.

But some 90 percent of depressed older adults don't get relief, says the National Mental Health Association, because they are reluctant to seek help or because their doctors don't recognize their illness.

While younger people may be comfortable discussing their troubles, their elders may be more reticent, notes Billig. Depressed older people may hide their true feelings by focusing instead on physical ills or using alcohol.

Thus, experts say, adult children need to know the signs of depression. Asking the older person certain questions—How are you sleeping? Are you seeing your friends?—can yield some clues, too. [See 10 Warning Signs of Depression.]

If depression is suspected, it's important to help the person recognize the symptoms and seek help from a doctor or psychotherapist (or if the individual is in a nursing home, to ask for a consultation with a mental health professional).

What if the person resists such overtures? One answer is to enlist the persuasive powers of a trusted friend or member of the clergy to encourage him or her to get assistance.

Allan Anderson, M.D., medical director for geriatric psychiatry at Shore Behavioral Health Services in Cambridge, Md., says he tells reluctant patients: "Look, I'm wearing eyeglasses. It's a pain, but I choose to wear them so I can see and not suffer. Depression is an illness. You can get treatment, or you can suffer. I don't want you to suffer."

Paying for Treatment
While depression and other mental health problems are gradually being accorded more importance as a public health problem, insurance coverage for treatment is, at best, mixed. Many health plans cover all or some care, but prescription drug coverage varies widely.

Traditional Medicare pays 50 percent of most outpatient mental health care but does not pay for prescription drugs. Coverage in Medicare HMOs varies from plan to plan.

'MISSING' THE DIAGNOSIS

Primary care doctors generally are not trained in psychiatry and sometimes "miss" depression in their older patients. One study of suicides showed that 20 percent of older adults had seen their doctor about other health conditions on the same day they took their lives, 40 percent had seen their doctor within a week, and 70 percent within one month.

At the least, says Ira R. Katz, M.D., director of geriatric psychiatry at the University of Pennsylvania Medical Center, "the doctor has to ask, 'What have you enjoyed doing lately?' If the answer is 'nothing,' that's very important. The trick is to ask."

DEPRESSION TRIGGERS

Clinical depression often has no obvious cause but emerges gradually, imperceptibly.

"When I look back on my life and I'm honest with myself, I think I've had this problem all my life," says Pittsburgh resident Marian Schwartz, 85, who recently waged a successful battle against depression.

She went through some hard times that may have set the stage for her condition. She had cared for her invalid husband for about 10 years, and she had had heart surgery. Her son died at age 38, and her daughter struggled with depression.

Over time, Schwartz began having sleep problems and wide appetite swings; she stopped driving and no longer devoured newspapers and books as she once had. She felt lethargic, sad.

Sorrow over misfortune is normal. But it can be compounded in late life, a time when people may become more isolated as they lose spouses and old friends. Without social and emotional support, AAGP's Reichman says, depression can take hold.

Other risk factors:

• family history of the disorder;
• imbalance of brain chemicals that govern mood;
• chronic pain and illnesses like cancer, heart disease and Parkinson's disease;
• dementia (more than half of people with Alzheimer's disease are depressed);
• certain medications, such as beta blockers for heart problems;
• seasonal changes;
• hormonal changes (such as occur at menstruation and menopause); and
• stress.

More than twice as many women experience depression than men. Just why is unclear, but the National Mental Health Association speculates that hormonal changes and the stress of family responsibilities may explain the high rate among women.

Marian Schwartz knows about that kind of pressure. "I was the 'Let Marian do it' person," says Schwartz, a middle child in a family of six children. "All my life I have been the family caregiver."

With counseling, she came to a more realistic understanding of her own needs and the limits of what she can do for others.

DIGGING OUT

Minor depression usually lifts on its own. But it's likely to need active measures to banish a lingering case. As a first step, experts say, get adequate sleep, eat a nourishing diet and spend more time with friends and family.

Exercise is a powerful antidote. A recent Duke University study of 156 people age 50 or older showed that exercise was about as effective as medicine in relieving depression.

In more persistent cases, psychological counseling, or "talk therapy," can reveal underlying causes of depression and help the patient reverse negative attitudes and find better ways of handling problems.

Antidepressant drugs can help, too. Many are available, and more are in the pipeline. Selective serotonin reuptake inhibitors (SSRIs), a class that includes Prozac and Zoloft, boost serotonin, a mood-enhancing chemical in the brain.

SSRIs tend to have fewer side effects than the older antidepressants—tricyclics and monoamine oxidase (MAO) inhibitors—and are better tolerated, says Bruce G. Pollock, M.D., director of the Geriatric Psychopharmacology Program at the University of Pittsburgh School of Medicine.

Another new drug is venlafaxine (Effexor), which acts on at least two mood-regulating brain chemicals.

Just as adult children can be key in spotting depression, says the University of Pennsylvania's Katz, they can help determine if a given drug is working for their elder relative or causing side effects like insomnia, loss of balance or sleepiness.

"If Mom is on an antidepressant and she's still depressed, that's a time to speak up," he says, and perhaps change drugs or dosages.

Whatever the drug, relief is not immediate. "It takes a number of weeks for medication to work in treating depression," stresses Anderson of Shore Behavioral Health Services.

The most effective treatment for severe clinical depression may be a one-two punch using drugs and psychotherapy.

Researchers at Brown University said in the New England Journal of Medicine that combined treatment produced an 85 percent positive response rate among the 681 participants in their study. The drug alone elicited a 55 percent positive response rate and talk therapy 52 percent.

Electroconvulsive—or shock—therapy is generally reserved for severely depressed people who don't respond to other treatments. The controversial procedure, in which the brain is electrically stimulated to break the course of depression, is deemed highly effective by some doctors. One possible side effect: temporary memory loss.

Researchers are exploring another treatment in which the vagus nerve in the neck is stimulated with electrical impulses, sending signals to brain areas that control mood.

Says one lifelong sufferer of depression who participated in the University of Texas Southwestern Medical Center's study of the treatment, "For the first time in years, I can feel joy, real joy."

Marian Schwartz is experiencing some joy, too. She has reclaimed her life, beating her depression via therapy and an antidepressant drug. Her message to others who feel depressed: "Please get help. I have benefited greatly. I have more confidence in myself [and] see things in a different perspective now."

This article previously appeared in the AARP Bulletin. Since its original publication, there may have been some medical developments in this area. Therefore, consult your physician for the latest information and advice on treating this particular condition. The information in this article is intended only to describe this medical issue in general terms. This information should not be used as advice regarding your particular condition. Only your physician can give you proper medical advice.