Depression Isn't Normal at Any Age

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Section: CARING FOR MOM & DAD "My dad has lost interest in friends, TV, and life. His doctor says it's his age (82). I think we should pursue this with another doctor. Do you agree?"
Absolutely. Some of the most exciting advances in geriatrics these days involve the area of depression. The progress is really on several fronts: not only the discovery of new and better treatments but also better mechanisms for identifying the problem, and determining who is likely to respond to which kinds of treatment. An especially important development has been the tailoring of treatment strategies and guidelines for older adults. For example, these new guidelines take into account the fact that, as we age, our bodies may metabolize medications differently.

Not Your Usual Blues
We've said it before in this column, but it bears repeating: The face of depression in older adults can be much different than in younger people. If the doctor's criteria for depression is mostly physical, such as not eating and not getting out of bed, then an awful lot of geriatric depression will be missed. "It's actually the case in the elderly that symptoms such as sadness, or psychological symptoms, can be a bigger clue to depression than the physical symptoms," says John Docherty, MD, psychiatrist, and president and CEO of Comprehensive Neuroscience in White Plains, NY. "The doctor needs to be alert for these signs as well as pessimism and despondency."

For many older people, there are a host of psychological signs and symptoms to look for, ranging from despondency or irritability to withdrawal from social activities or inattention to hygiene. Some patients develop strange paranoid ideas or delusions as part of their depressive picture (a syndrome sometimes called psychotic depression).

Unfortunately, doctors and patients often ascribe the depression to normal aging and don't pursue treatment. Sometimes depression in older people is misdiagnosed as Alzheimer's disease or a related dementia (a syndrome sometimes called pseudodementia). Often the reason I'm consulted is for an opinion as to whether a patient has depression or dementia. To complicate matters further, patients with carefully diagnosed Alzheimer's disease frequently have accompanying depression, which is certainly an understandable response to getting any devastating diagnosis.

Also, there is an important relationship between depression and the severity of other medical conditions an older person has, particularly if they're not well treated. For example, pain from poorly controlled arthritis will certainly have an effect on a person's mood. Additionally, medications given for many common medical conditions can have psychological side effects, including depression.

Consult an Expert
For all these reasons, when a diagnosis of depression is suspected, a thorough evaluation should be conducted, ideally by someone who has experience in treating depression in older people. This will also help pick up problems such as alcohol or drug dependency, which can have many of the same signs as depression. This need not be a geriatric psychiatrist (indeed, the majority of antidepressants in the US are prescribed by primary care physicians), but a geriatric psychiatrist can be enormously helpful if the diagnosis is in doubt or if the person's depression doesn't respond at all to initial treatments.

More Options Than Ever
Therapies for depression come in many forms, and we've learned a lot about them in recent years. One of the biggest boons has been a new crop of antidepressants called SSRIs (selective serotonin reuptake inhibitors) and an even newer group of related compounds. In general, depressive states have been categorized by a deficiency of a brain chemical called serotonin. These medicines increase the levels of serotonin in the brain by inhibiting its breakdown. They have far fewer troublesome and serious side effects than the older generation of antidepressants.

But we're learning about other treatments too. It appears that medications are most helpful when used concurrently with psychotherapy whose content and goals are carefully directed. This combination of treatments has been very successful in the elderly.

Best Practices
Depression is treatable, regardless of the patient's age. One important point to remember, however: There is not a quick fix for your father's depression, especially if it has gone on for a while. He'll need to have your support and encouragement to help him stay with a treatment program. Here's what you and your dad should expect during treatment.

• Optimal treatment of other preexisting medical conditions that might be contributing to poor mood.

• An adequately long-term trial of medication. Six weeks or longer can be required before a response is seen.

• Education about possible side effects, many of which disappear after a few days of treatment.

• Adjustment of the dosage of antidepressant medication to sufficiently high levels.

• Treatment that continues for a long enough period of time. Most geriatric psychiatrists would treat a new episode of geriatric depression for 6 to 12 months; many believe that a second depressive episode should result in lifelong treatment.

• A combination of medication with supportive psychotherapy.

• A doctor who will try a variety of medications or refer the patient to a geriatric psychiatrist if the treatment is not working or the depression becomes unusual or accompanied by other psychiatric symptoms (such as delusions or hallucinations).

QUICK TIP Your local hospital may be able to refer you to a doctor with experience in geriatric depression.

For More Information
If you'd like to have more information on depression and the elderly, or If you are looking for a referral to a psychiatrist who specializes in treating the elderly, call the American Association for Geriatric Psychiatry at (301) 654-7850.

PHOTO (COLOR): The sooner depression is treated, the better

PHOTO (COLOR): Medications can affect mood for the better, or worse

PHOTO (COLOR): There's no quick fix for depression, but time is on your side

PHOTO (COLOR

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By Mark S. Lachs, MD, MPH

with Pamela Boyer, in association with the American Federation for Aging Research

Mark S. Lachs, MD, MPH, is a geriatrician, director of geriatrics for the New York Presbyterian Health System, and associate professor of medicine at the Weill Medical College of Cornell University, all in New York City. Dr. Lachs is a Beeson Physician Faculty Scholar in Aging Research with the American Federation for Aging Research. He has a private practice in New York City