We all feel sad, moody or ‘down’ from time to time, it is part of being human, but depression is more than just a low mood. Depression is a serious illness that affects a person’s emotional, physical and cognitive state and has negative impacts on a person’s day-to-day life. Apart from depressed mood, depressive disorders are characterised by feelings of worthlessness, guilt, significant weight gain or loss of appetite, problems concentrating or making decisions, fatigue, insomnia or loss of interest in activities that were once pleasurable.
Depression in the elderly population may go undetected or untreated because its presentation can differ from that of younger people and is often incorrectly attributed to old age, dementia or poor health. Many depressed older people will not claim to feel sad. They more often complain about low motivation, lack of energy, poor concentration, impaired memory or physical ailments such as arthritis pain or headaches. Depression in older adults is associated with significant ill health, including deficits in cognitive functioning, physical impairment and behavioural changes. Depression in the elderly can be divided into two types. Early-life onset, which is depression that started earlier in life and reoccurs in old age and late-life onset which first develops after the age of 60 and is more commonly associated with physical health problems that accompany ageing.
Among elderly people living in the community the prevalence of clinically significant depressive symptoms ranges from 8-16% with 1-4% meeting criteria for major depression. Similar to depression in younger people, elderly women are twice as likely to suffer from depression than elderly men. Depressive disorders are also more common among elderly people who live in nursing homes. Of cognitively intact nursing home residents, the prevalence of depression is 10-20% and for cognitively impaired residents the prevalence rises to 50-60%. The prevalence of major depression in nursing home residents is around 8%. Similarly, 10-12% of elderly people admitted to hospital meet criteria for major depression.
Factors that increase the risk of depression in old age include:
- Being female
- Being single, unmarried, divorced, or widowed
- Lack of social support
- Stressful life events
- Physical illness such as stroke, diabetes, cancer and chronic pain
- Certain medicines or a combination of medicines
- Family history of major depressive disorder
- Living alone, social isolation
- Previous history of depression or suicide attempts
- Recent loss of a loved one
- Substance abuse
Suicide increases with age and is almost twice as frequent in elderly people compared to the general population. Depressive disorders are the leading risk factor for suicide in older people. Research suggests that depressive disorders are present in up to 80% of people aged over 74 who commit suicide. Psychological autopsy studies report depression to be the most common mental disorder in elderly suicide attempters and victims. A study by Cornwell (1995) found that 54% of elderly suicide victims had major depression. Similarly Chiu et al. (2004) reported that among elderly suicide victims in Hong Kong, 53% were diagnosed with major depression.
Depression in elderly people most commonly affects those with chronic illness and cognitive impairment, causing suffering, family disruption and increased mortality. Depression in the elderly is treatable but often goes under recognised and undertreated due to an overlap in symptoms of comorbid physical illnesses as well as elderly people’s tendency to under report depressed mood and suicidal ideation.
The aims of treatment are to reduce the symptoms of depression, improve cognitive functioning and prevent suicidal ideation and relapse. Treatment options for elderly people usually involve:
Antidepressants: play an important role in the treatment of moderate to severe depression in older adults. Treatment of depression with antidepressants has been found to be as effective for older adults as it is when given to younger adults. However, onset in older age is a predictor for a slower recovery and older adults have a higher rate of recurrence compared to younger adults. Thus, rigorous maintenance is suggested for the older population. As most antidepressants are equally efficacious for older adults selection should be based on drug-related factors such as side effects, potential drug interactions and cost combined with individual client information such as comorbid medical conditions and allergies.
Psychotherapy: interventions such as Cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are the preferred therapies for treatment of depression in the elderly. In clinical trials they have been found to be just as efficacious as medications for cognitively intact older adults with mild to moderate depression. CBT and IPT are short term treatments delivered over a period of two to four months and are as effective in the treatment of depression in older adults as they are the treatment of younger adults.
Combination: psychotherapy can be beneficial alone or in conjunction with an antidepressant for geriatric depression. The combination of both has been found to be more efficacious for moderate to severe depression and for individuals who have late-life major depression.
Depression in older adults is often associated with illness, deficits in functioning, pain and insomnia. Thus, strategies to manage these underlying issues can often be useful in the prevention of depression. For example, some illnesses cause chronic pain and restless sleep. Learning strategies to deal with these symptoms can help prevent them worsening and contributing to the development of mental illnesses such as depression. Other ways to reduce the risk of depression include making new friends and getting involved in social activities. Studies have shown that people with strong social networks are more resilient to depression and since losing family and friends is part of growing older, it is important for older people to make an effort to meet new people.
Depressive disorders are one of the most prevalent mental health issues and are associated with huge losses in quality of life, increased mortality rates and high economic costs. Focusing on the prevention of such a predominate health issue can reduce the burden of the illness on the individual, their family and the wider community. Prevention is better than cure.
Authors: Melanie Green and Dr. Rachell Kingsbury
Aguiar, W. M & Dunningham, W. (1993). Geriatric depression: Clinical and therapeutic aspects. Brazilian Medical Files, 67(4), 291-310.
Alexopoulos, G. S. (2005). Depression in the elderly. Lancet, 365, 1961-1970.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Bartels, S. J., Dums, A. R., & Oxman, T. E., et al. (2003). Evidence-based practices in geriatric mental health care: An overview of systematic reviews and meta-analyses. Psychiatric Clinics of North America, 26, 971-990.
Berkman, L., Berkman, C., & Kasl, S. et al. (1986). Depressive symptoms in relation to physical health and functioning in the elderly. American Journal of Epidemiology, 124, 372–388.
Blazer, D. G. (2003). Depression in late life: Review and commentary. Journal of Gerontology: Medical Sciences, 58(3), 249–265.
Blazer, D. G. & Williams, C. D. (1980). The epidemiology of dysphoria and depression in an elderly population. American Journal of Psychiatry, 13,439-44.
Blazer, D., Burchett, B., Service, C., & George, L. (1991). The association of age and depression among the elderly: An epidemiologic exploration. The Journal of Gerontology, 46(6), M210-M215.
Chiu, H. F. K., Yip, P. S. F., & Chi, I., et al. (2004). Elderly suicide in Hong Kong – a case-controlled psychological autopsy study. Acta Psychiatrica Scandinavica, 109, 299-305.
Conwell, Y., & Brent., D. Suicide and aging: patterns of psychiatric diagnosis. In: Tam, C. W. C., & Chiu, H. F. K. (2011). Depression and Suicide in the Elderly. Medical Bulletin, 16(9), 13-16.
Conwell, Y., Duberstein, P. R., Herrmann, J. H., & Caine, E. D. (1996). Relationship of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry, 153(8): 1001-1008.
Koder, D. A., Brodaty, H., & Anstey, K. J. (1996). Cognitive therapy for depression in the elderly. International Journal of Geriatric Psychiatry,11: 97-107.
Lenze, E. J, Dew, M. A., & Mazumdar, S. et al. (2002). Combined pharmacotherapy and psychotherapy as maintenance treatment for late-life depression: effects on social adjustment. American Journal of Psychiatry, 159, 466-468.
McDougall, F. A., Matthews, F. E., Kvaal, K., Dewey, M. E., & Brayne, C. (2007). Prevalence and symptomatology of depression in older people living in institutions in England and Wales. Age and Ageing, 36(5), 562-568.
Minino, A. M., Arias, E., Kochanek, K. D., Murphy, S. L., & Smith, B. L.(2002). Deaths: final data for 2000. National Vital Statistics Reports, 50(15), 1-119.
Mueller, T. I., Kohn, R., & Leventhal, N., et al. (2004). The course of depression in elderly patients. American Journal of Geriatric Psychiatry, 12(1), 22-29.
Mulsant, B. H., & Ganguli, M. (1999). Epidemiology and diagnosis of depression in late life. Journal of Clinical Psychiatry, 60(20), 9–15.
Murrell, S., Himmelfarb, S., & Wright, K. (1983). Prevalence of depression and its correlates in older adults. American Journal of Epidemiology, 117:173–185.
Reynolds, C. F., Frank, E., & Perel, J. M., et al. (1999). 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, 281:39-45.
Salzman, C., Wong, E., & Wright, C. B. (2002). Drugs and ECT treatment of depression in the elderly, 1996–2001: A literature review. Biological Psychiatry, 52, 265-285.
Tam, C. W. C., & Chiu, H. F. K. (2011). Depression and Suicide in the Elderly. Medical Bulletin, 16(9), 13-16.
Volkers, A. C., Nuyen, J., Verhaak, P. F. M., & Schellevis, F.G. (2004). The problem of diagnosing major depression in elderly primary care patients. Journal of Affective Disorders, 82, 259-263.
Wiese, B. S. (2011). Geriatric depression: The use of antidepressants in the elderly. British Columbia Medical Journal, 53(7), 341-347.