“It is the aloneness within us made manifest,” Andrew Solomon wrote in his book The Noonday Demon: An Atlas of Depression, “and it destroys not only connection to others but also the ability to be peacefully alone with oneself.”
Depression is the most common of all mental illnesses, afflicting an estimated 7 percent of the population. More than one in 10 Americans have prescriptions for antidepressants, now among the most widely used of all medications. But some doctors are questioning the efficacy of these drugs in treating depression. And even with new advances in understanding depression, many cases still go undiagnosed and untreated, experts say—especially among older people.
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The depression debate
Many researchers now believe that depression is caused by chemical imbalances in the brain. A predisposition to depression is known to run in families, and there’s also evidence that traumas, certain illnesses and childhood abuse can lead to depression later in life.
For all that is known about depression, however, there’s still plenty of debate about how best to diagnose and treat it.
The most recent furor was sparked by a report published in January in the Journal of the American Medical Association. A team led by psychologist Jay Fournier of the University of Pennsylvania, evaluating data from several studies, concluded that antidepressants, despite their popularity, are no more effective than sugar pills for most people with mild or moderate depression. For severe forms of the disease, the pills do help, the scientists acknowledged. Still, they’re far from a cure-all.
Irving Kirsch, professor emeritus at the University of Connecticut and a professor of psychology at the University of Hull in England, who is widely regarded as one of the world’s leading experts on psychiatric drugs and the placebo effect, says this latest study reinforces earlier findings: “Our studies show that placebos are about 80 percent effective, which is exactly how effective antidepressants are in the short term.”
But, he adds, the “placebo effect is very powerful when you’re treating depression. Placebos offer hope. And one of the chief features of depression is a sense of hopelessness, the belief that you’re not going to get better.” Anything that instills a sense of hope, he says, “will at least temporarily help treat depression.”
For researchers, the placebo effect makes evaluating the effectiveness of mood-altering drugs even more complicated. There is no objective test for depression, as there is for high cholesterol or elevated blood pressure. The only way to gauge if antidepressants are working is to ask people how they’re feeling.
Still, plenty of experts—including many psychiatrists—insist that the widely used medications do work. “We know from years of clinical experience that these medications help people who are moderately or severely depressed,” says Gary Small, M.D., professor of psychiatry at the David Geffen School of Medicine at UCLA and director of the UCLA Center on Aging.
One reason their effectiveness may not be captured in studies, he explains, is that a medication that works for one patient may not work for another. “We often find that we have to try several different medications before we find the one that works for a particular patient.” Unfortunately, doctors have no way to know in advance which antidepressant is likely to help.
The pills also require time to take effect—up to six weeks in some patients. “So one problem we often see is that people start taking antidepressants. Then, when they don’t feel better right away, they stop, thinking the pills aren’t working,” he says.
In fact, antidepressants can be effective, many doctors contend, and most prescribe them as the first-line treatment. For older patients, who are often on other medications that may interact with the antidepressants, doctors typically begin with small doses and increase as needed.
Depression linked to physical ills in older people
“Serious depression can ruin people’s lives and destroy families,” says Small.
But a reliable definition of depression is difficult in part because it takes many forms. “Depression is often associated with persistent sadness and melancholy, but sadness isn’t always part of it,” says Susan W. Lehmann, M.D., assistant professor in the department of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine. “The symptoms of depression can also be a loss of pleasure and enjoyment in the things people used to enjoy, or a change in one’s sense of oneself, a feeling of worthlessness and uselessness, a kind of blankness.”
In older people, depression frequently shows up not as sadness but as a constellation of physical complaints—one of several reasons it is frequently overlooked.
“Older patients come in saying, ‘I can’t sleep, nothing tastes good, my back hurts,’ ” says Small. “The physical complaints may be real, but the underlying problem is depression. When we treat the depression, the physical complaints improve.”
Thoughts of suicide, one of the hallmarks of severe depression, also take a different, more passive form in older people, says Small. “Instead of someone saying, ‘Yes, I’ve thought of killing myself,’ they might say, ‘If God took me now, I wouldn’t mind.’ ”
Depression in older people may be accepted because younger family members tend to assume it’s an inevitable part of growing old, says Lehmann. “There’s a tendency to think, ‘No wonder Grandpa is depressed. I’d be depressed if I had to give up driving, or use a walker, or was losing my vision.’ ”
It’s not inevitable
In reality, the vast majority of older people go through life’s ups and downs without suffering depression. Depression isn’t a part of normal aging, experts insist.
Next: When to seek help. >>
When depression strikes, however, it can affect not only mental but also physical health. Being diagnosed with any serious illness can lead to depression, says Lehmann. “One-third of people who have had a stroke go on to develop depression, for example. Forty percent of people with Parkinson’s develop depression.”
Depression, in turn, can make these diseases worse. “Studies show that depression slows recovery from a heart attack or hip or knee replacement surgery,” says Lehmann. “When people with diabetes are depressed, their blood sugar is less well controlled.”
Depression also can aggravate symptoms of memory loss and dementia. “So depression is really a double or a triple whammy for older people who are dealing with serious medical conditions,” says Lehmann.
Finding a way out
Of course, when patients are mired in severe depression, all they want is some relief.
The first step is seeking help. The symptoms of severe depression are usually obvious. Overwhelmed by feelings of hopelessness, sufferers find themselves unable to manage even the simplest daily activities.
The distinction between moderate depression and garden-variety sadness over the loss of a job or a troubled marriage is less clear-cut. One clue, says Lehmann, is how persistent the sadness or hopelessness is. “Even if something really tough has happened, most people can be distracted or cheered up for a short period of time. That’s often not true when people are suffering depression.”
Perhaps the best indication that it’s time to seek help is when persistent changes in mood get in the way of everyday life. “Anytime someone begins to have problems carrying out the basic activities of daily life—managing money, putting meals together, going to church—it’s worth talking to a doctor,” says Lehmann.
A variety of psychotherapeutic approaches have also been shown to help. Indeed, a combination of drug treatment and counseling may offer the best chance of banishing the shadows of depression for good. Psychotherapy takes many forms, from addressing relationship problems that may be causing distress to practicing ways to counter negative thoughts. Research suggests that techniques such as these may have long-lasting results, reducing the risk that depression will return.
“The important message to get out there is that people do get better,” says Small. “Depression may feel hopeless, but it isn’t.”
Also of interest: Are doctors overprescribing antidepressants?
Peter Jaret is a freelance health writer in Petaluma, Calif., and the author of Nurse: A World of Care.