One of the most prevalent mental health disorders in the United States today, and the single greatest mental health issue facing the elderly, is depression. As many as 7 million Americans over age 65 experience depression each year, according to the Centers for Disease Control and Prevention.
Even though older adults are at an increased risk for depression, the condition isn’t considered a “normal” part of the aging process, and can be treated successfully in the vast majority of cases. The first step, of course, is to recognize the signs of depression and differentiate it from the occasional slumps most of us experience.
The National Institute on Aging defines depression as a condition in which people have feelings of sadness or anxiety that last for weeks at a time. Symptoms may include:
• Feelings of hopelessness and/or pessimism
• Loss of interest in activities that were once pleasurable
• Feelings of guilt, helplessness or worthlessness
• Thoughts of suicide or attempts at suicide
• Restlessness and/or irritability
• A decrease in energy
• Medical problems such as headaches, cramps or digestive problems that don’t respond to treatment
Karen L. Starr, MD, an internist specializing in geriatrics at Sentara Martha Jefferson Hospital, notes that a number of factors can trigger clinical depression. One of the biggest such factors is loss.
“Loss can take many forms,” says Dr. Starr. “Sometimes it’s situational in nature—maybe a person has broken a hip and isn’t able to drive or get about the way he or she once did—but loss can also include the death of a loved one. In some instances, an elderly person who is depressed not only has lost his or her spouse of many years, but his or her children and friends as well.”
Dr. Starr also cites the loss of cognitive ability as a potential trigger for depression.
“Patients with mild cognitive impairment may not have dementia, but they’re also not able to perform tasks as they once could,” she explains, noting that not all cognitive impairment is considered dementia. “These people may be at increased risk for behavioral issues, including anxiety and depression. Patients with mild memory loss as well as depression may experience a faster rate of cognitive decline than patients without depression. Therefore, it’s important to recognize and treat these patients.”
In addition, she adds, physical ailments frequently can be a cause of depression in the elderly. People who suffer from chronic pain, cardiac problems and Parkinson’s disease often are depressed—so often, in fact, that Sentara Martha Jefferson routinely screens these and other patients for signs of depression.
“There are a lot of potential risk factors, so you have to really think it all through on a case-by-case basis,” says Dr. Starr. “Screening questionnaires are helpful, but responses on these forms may not give the clinician all the information that’s needed. The clinician often has to integrate the information with the patient’s clinical scenario. The diagnosis may require information not only from the patient but also from family members.”
Dr. Starr notes that anxiety is another leading mental health problem among the elderly. In many cases, she says, anxiety leads to loss of sleep, overall deteriorating health, a decrease in the ability to perform daily activities and a decline in feelings of self-worth. Like depression, says Dr. Starr, generalized anxiety disorder (GAD) is under-recognized and undertreated in adults 60 and older. She says that while GAD is equally prevalent among adults of all age groups, it isn’t reported as frequently by seniors, and therefore isn’t as accurately diagnosed and treated as it is in younger adults.
A study by the International Journal of Geriatric Psychiatry found that up to 14 percent of older adults meet the criteria for diagnosable GAD. The same study also showed that more than 27 percent of older adults under the care of a service provider have symptoms of anxiety that may not amount to a diagnosis, but still significantly affect their day-to-day functioning.
“No one treatment works for everyone, whether for depression or anxiety,” says Dr. Starr. “Drugs are not always the mainstay of treatment, but if a patient isn’t sleeping well or is in a lot of pain, perhaps we need to address that medically. When used correctly, medication can have amazing results. Patients often feel better, sleep better, experience improved interaction with others, and enjoy an increased ability to simply get out and do things.”
There are, of course, other treatments for depression and anxiety. Exercise can often serve as a “first-line treatment” for mild to moderate depression and anxiety, according to Dr. Starr.
“And then there are behavioral treatments,” she says. “Maybe the patient needs counseling. Counseling can be enormously valuable as a way to help people work through their depression and anxiety.”
With whichever techniques these conditions are treated, in many cases patients also see improvements in other ways. According to Dr. Starr, when patients are depressed or anxious, they are less likely to see the point of treating existing health conditions, leading to medical problems that linger and worsen.
“Getting a patient’s depression and anxiety under control can have a significant effect beyond mental health, positively impacting medical morbidity and mortality as well,” she says.
The Role of Counseling
Robin Breeden, LCSW, a Life Recovery coordinator at Sentara RMH Medical Center who works with elderly patients in a counseling capacity, says she has seen time and again the effectiveness of this type of treatment. No matter what the reason for a patient’s depression—retirement, the deaths of loved ones, increased isolation, medical problems—simply having a skilled professional to talk to can drastically improve a patient’s outlook.
“It’s important to be creative when treating depression through counseling, because not every situation is the same,” says Breeden. “Yes, a doctor might have prescribed some antidepressants, which have their place, but I try to get my patients to look at lifestyle changes that will help combat their depression. These changes can include volunteering, diet, exercise, joining a social network, getting a pet and learning new skills.”
Among the tools Breeden employs is what she calls “radical acceptance.” She works with patients to get them to see that some of the transitions they are experiencing in life—such as losing the ability to do things that were once effortless—are a natural part of the aging process, and simply to accept them.
“Losing these abilities affects our energy, appetite, sleep, and physical and mental health, but learning to radically accept something we have no control over is important,” she says. “I use this technique a great deal because it’s all about learning how to live a life worth living, in spite of painful events.”
Mindfulness is another crucial tool. Breeden stresses to her elderly patients the need for learning to be “in the present moment.” We don’t have control over yesterday or tomorrow, she counsels—only the present.
“I know it sounds elementary in a way, but being mindful of the moment, of today, helps us stop worrying so much about the future and the past, neither of which is in our power to control,” she says. “Sometimes I actually walk outside and practice it with patients, enjoying the beautiful sky, the scenery, the joys of the moment. Practicing mindfulness can help reduce the symptoms of depression, stress and anxiety.”
Breeden also uses an action-based treatment called “opposite action,” a behavioral therapy skill known to lessen the impact of depression and anxiety.
The technique is based, in part, on the maxim that while you can’t think your way into right action, you can act your way into right thinking.
If, for example, depression makes the sufferer want to sit around and do nothing, the goal is to find something that will get that person out and about. Breeden says a catch-22 situation may develop if the person has medical issues that hinder going for a walk, or getting out in other ways, so that’s where creativity again comes into play—finding a solution that works for that individual.
“If there’s some good news in all this, it’s that fully 80 percent of people suffering from depression can and will recover if they seek treatment,” she says. “Yes, we experience a lot of losses and changes as we get older. But it’s important to remember that while change is inevitable, growth is optional. Reaching out for the help you need is the first—and biggest—step.”