Detecting and Treating Geriatric Depression
by Elizabeth Fried Ellen, LICSW
| Geriatric Times |
 |
May/June 2001 |
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Vol. II |
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Issue 3 |
Approximately 15% of American seniors are depressed, according to figures from
the American Association for Geriatric Psychiatry (AAGP) (2001). That figure
jumps to 25% among patients with chronic illness; and depression is especially
prevalent in seniors with stroke, Parkinson's disease, cancer, arthritis,
Alzheimer's disease and ischemic heart disease. As many as 50% of elders who
live in institutionalized settings meet diagnostic criteria for depression
(AAGP, 2001).
Despite these statistics, depression continues to be underdiagnosed and
undertreated in primary care settings (Rush et al., 1993). Patients and doctors
may share the erroneous belief that depression is a normal part of aging, given
the common stressors of physical illness, loss, and role changes associated
with retirement and other psychosocial factors.
Cognitive difficulties, such as decreased attention span, may be more
commonly observed in elderly patients with depression, while the sadness
generally thought to be a hallmark of depression may be absent. Irritability,
especially in male patients, can be another diagnostic tip-off. While such
difficulties may bear an initial resemblance to dementia, depressed seniors are
more likely to demonstrate problems with attention, motivation and
concentration, as well as decreased speed of information processing. Since
depression and dementia can exist concurrently, a thorough assessment is
required to determine the best course of clinical action (Boswell and
Stoudemire, 1996).
Depressed elders are far more likely to show up in primary care offices than
they are to see mental health care professionals (Gallo et al., 1995, as cited
in Gallo et al., 1999). Common signs of depression observed in primary care
settings may include weight loss, headaches, fatigue, gastrointestinal
symptoms, pain and multiple vague somatic complaints (AAGP, 2001; Boswell and
Stoudemire, 1996).
Many seniors may be reluctant to talk about depression, based on
generational stigma about mental illness. "They'll be sitting at home with
terrible depression and then get themselves together to come to the doctor's
office," said Massachusetts geriatric psychiatrist Gary Moak, M.D., in an
interview with Geriatric Times. "They can manage to look good in the
doctor's office and tend to underreport symptoms [psychiatric and otherwise] to
the doctor…They'll even crack jokes and not disclose that most of the
time they're pretty miserable."
He added that some seniors are reluctant to disclose psychological
difficulties because they mistakenly believe they have Alzheimer's disease and
worry that they'll end up in an institutionalized setting if they share their
concerns with others. "They're thinking, 'If I can get through the doctor's
appointment, then I can get home.' Their families also believe that."
The open-ended exploration that is often required to make the diagnosis can
intensify the time crunch experienced by physicians. "Primary care doctors are
trained to think about depression the way it's presented in the textbook,"
William Reichman, M.D., past president of the AAGP, told GT. "You have
to really probe and devote more time to it. The physician has a lot to
do…talking about mental health is not a big part of the visit,"
particularly when there are already existing medical conditions that require
follow-up.
If a clinician suspects that an older person is depressed, there are a
variety of assessment tools to help make -- or rule out -- the diagnosis.
Differential diagnoses include organic (secondary) disorders, early onset
dementia, delusional disorders, bipolar illness and substance-induced mood
disorders (Rush et al., 1993). Among the numerous diagnostic tools that gauge
depressive symptoms is the Geriatric Depression Scale, a simple self-rating
questionnaire that can be easily administered in the primary care setting and
is sensitive to differences in clinical presentation often observed in elders.
A close look at a senior's existing medication regimen also can provide
important clues. Moak remembered a case in which an elderly woman's depression
cleared rapidly once she was taken off hypertension agents known to precipitate
depression. This intervention occurred after a series of unsuccessful
psychotherapy sessions based on the belief that the woman's depression was the
result of increased dependency rooted in physical disability. "You can't assume
that someone is depressed because their life is miserable," Moak said. "The
opposite may be true."
Including family members in history taking and treatment planning is
critical, according to Stephen Ryan, M.D., M.P.H., a Rochester, New York-based
geriatrician and co-author of a 1999 study examining the attitudes, knowledge
and behavior of family physicians treating late-life depression (Gallo et al.,
1999). Without them, he told GT, "You're not looking at the whole person
and the pieces that contribute to who they are now…We frequently turn to
the family to give us the story."
Medication, electroconvulsive therapy (ECT) and cognitive-behavioral
psychotherapy have all been successfully used to treat depression in elderly
patients.
Since seniors often are on multiple medications for a variety of medical
conditions, adding psychotropics can complicate an already delicate balancing
act. Both selective serotonin reuptake inhibitors (SSRIs) and tricyclic
antidepressants (TCAs) can be used safely and effectively. When prescribing any
medication, it is essential to consider normally occurring changes in cardiac,
hepatic and renal function, which create the necessity for regular monitoring
to avoid toxicity (particularly when using TCAs) (Rush et al., 1993).
When prescribing an antidepressant, clinicians should keep in mind that the
first -- or second -- choice of medication either may not work or may present
an unmanageable side-effect profile. Candid, proactive discussion with patients
about side effects and the length of time/dosage required to achieve
therapeutic effect is essential to fostering a positive treatment alliance and
encourages medication adherence. Regularly scheduled appointments to address
questions and concerns as they arise can be particularly effective.
Electroconvulsive therapy can be a lifesaving intervention for severely
depressed (i.e., suicidal) seniors, those whose symptoms have not responded to
medication or those who cannot tolerate a medication's side effects.
Regardless of the treatment options chosen by doctors and their patients,
"collaboration and open, sustained communication is vitally important," said
Reichman. "We should be doing much better than we're doing. With older people
who are frail, it's very important for primary care physicians to know how the
mental health issues affecting the patient can have an impact on the physical
issues. Conversely, it's important to know how a patient's physical status may
be impacting psychological feelings…Patients can only benefit from
that."
References
AAGP (2001), Late Life Depression: A Fact Sheet. Available at:
www.aagpgpa.org/p_c/depression.asp. Accessed March 22.
Boswell EB, Stoudemire A (1996), Major depression in the primary care
setting. Am J Med 101(6A):3S-9S.
Gallo JJ, Ryan SD, Ford DE (1999), Attitudes, knowledge, and behavior of
family physicians regarding depression in late life. Arch Fam Med
8(3):249-256.
Rush AJ, Golden WE, Hall GW et al. (1993), Depression in Primary Care: Vol.
2. Treatment of Major Depression. Clinical Practice Guideline No. 5. Rockville,
Md.: Agency for Health Care Policy and Research, U.S. Department of Health and
Human Services. AHCPR Pub. No. 93-0551.