About Depression

Everyone feels blue or sad now and then, but these feelings don't usually last long and pass within a couple of days. When a person has depression, it interferes with daily life and normal functioning, and causes pain for both the person with depression and those who care about him or her. Doctors call this condition "depressive disorder," or "clinical depression."

Important life changes that happen as we get older may cause feelings of uneasiness, stress, and sadness. For instance, the death of a loved one, moving from work into retirement, or dealing with a serious illness can leave people feeling sad or anxious. After a period of adjustment, many older adults can regain their emotional balance, but others do not and may develop depression.

Depression is a common problem among older adults, but it is NOT a normal part of aging. In fact, studies show that most older adults feel satisfied with their lives, despite having more physical ailments. However, when older adults do suffer from depression, it may be overlooked because they may be less willing to talk about feelings of sadness or grief, and doctors may be less likely to suspect or spot it.

Of the 35 million Americans age 65 and older, about 2 million suffer from full-blown depression. Another 5 million suffer from less severe forms of the illness. If left untreated, depression can lead to suicide.

It is widely believed that suicide more often affects young people, but older adults are affected by suicide, too. Of the roughly 30,000 suicide deaths in the United States in 2004, adults age 65 and older accounted for about 16 percent of them. In fact, non-Hispanic white men age 85 and older have the highest suicide rate in the United States.

There are several types of depression. The most common types are major depressive disorder and dysthymic disorder.

Major depressive disorder, also called major depression or clinical depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy activities he or she once liked. Major depression prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic disorder, also called dysthymia, is a less severe but more long-lasting form of depression. Dysthymia is characterized by symptoms lasting two years or longer that keep a person from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetime.

Common among older adults is "subsyndromal depression" -- less severe but clear symptoms of depression that fall short of being major depression or dysthymia. Having subsyndromal depression may increase a person's risk of developing major depression.

Quiz

1. Depression is

2. Depression is

3. Of the 35 million Americans age 65 and older,

4. Dysthymia is

Causes and Risk Factors

Neuroscience, genetics, and other research studies have shown that depressive illnesses are disorders of the brain. But the exact causes for these illnesses are not yet clear and are still being studied.

Imaging technologies such as magnetic resonance imaging (MRI) scans show that the brains of people with depression look different than those of people without the illness. The scans show that the areas of the brain that control moods, thinking, sleep, appetite, and behavior are not functioning properly. The scans also reveal imbalances in important brain chemicals called neurotransmitters that allow brain cells to communicate with each other. But these images do not yet reveal WHY the depression has occurred.

In general, there is no one cause or risk factor for depression. It most likely results from many factors, such as family history, life experiences, and environment. Older adults with depression may have had it when they were younger, or they may have a family history of the illness. They may also be going through difficult life events, such as losing a loved one, a difficult relationship with a family member or friend, or financial troubles.

For older adults who experience depression for the first time later in life, other factors may be at play. Depression may be related to changes that occur in the brain and body as a person ages. For example, older adults may suffer from restricted blood flow, a condition called ischemia. Over time, blood vessels may harden and prevent blood from flowing normally to the body's organs, including the brain.

If this happens, an older adult with no family history of depression may develop what some doctors call "vascular depression." Those with vascular depression also may be at risk for other vascular illnesses, such as heart disease, or stroke.

Depression can also co-occur with other serious medical illnesses such as diabetes, cancer, and Parkinson's disease. Depression can make these conditions worse, and vice versa. Sometimes, medications taken for these illnesses may cause side effects that contribute to depression.

Because many older adults face these illnesses along with various social and economic difficulties, some health care professionals may wrongly conclude that these problems are the cause of the depression -- an opinion often shared by patients themselves.

All these factors can cause depression to go undiagnosed or untreated in older people. Yet, treating the depression will help an older adult better manage other conditions he or she may have.

Quiz

1. Depression is a disorder of

2. Depression likely is a result of

3. Vascular depression may occur when

4. Which of the following medical conditions often co-occur with depression?

Symptoms and Diagnosis

There are many symptoms associated with depression, and some will vary depending on the individual. However, some of the most common symptoms are listed below. If you have several of these symptoms for more than two weeks, you may have depression.

• feeling nervous or emotionally "empty"
• feelings of excessive guilt or worthlessness
• tiredness or a "slowed down" feeling
• restlessness and irritability

Common symptoms of depression:

• feeling like life is not worth living
• sleep problems, including trouble getting to sleep, wakefulness in the middle of the night, or sleeping too much
• eating more or less than usual
• having persistent headaches, stomach-aches or other chronic pain that does not go away when treated

Common symptoms of depression:

• loss of interest in once pleasurable activities, including sex
• frequent crying
• difficulty focusing, remembering or making decisions
• thoughts of death or suicide, or a suicide attempt

The first step to getting appropriate treatment is to visit a doctor. Certain medications taken for other medical conditions, vitamin B12 deficiency, some viruses, or a thyroid disorder can cause symptoms similar to depression. If an older adult is taking several medications for other conditions and is depressed, seeing a doctor is especially important.

A doctor can rule out medications or another medical condition as the cause of the depression by doing a complete physical exam, interview, and lab tests. If these other factors can be ruled out, he or she may refer you to a mental health professional, such as a psychologist, counselor, social worker, or psychiatrist. Some doctors called geriatric psychiatrists are specially trained to treat depression and other mental illnesses in older adults.

The doctor or mental health professional will ask about the history of your symptoms, such as when they started, how long they have lasted, their severity, whether they have occurred before, and if so, whether they were treated and how. He or she will then diagnose the depression and work with you to choose the most appropriate treatment.

Quiz

1. Symptoms of depression include

2. Depression sometimes can be caused by

3. If you feel you may have depression, you should

Treatment and Research

Depression, even in its most severe form, is highly treatable. As with many illnesses, getting treatment early is more effective and reduces the chance of recurrence. And because it often co-occurs with other illnesses in older adults, untreated depression may delay recovery from or worsen the outcome of other illnesses. It is important to remember that a person with depression cannot simply "snap out of it."

Treatment choices differ for each person, and sometimes different treatments must be tried until one works for a particular person. It is important to keep trying until you find something that works for you.

The most common forms of treatment for depression are medication and psychotherapy.

Treatment and Research - Medication

Medications called antidepressants work to normalize brain chemicals called neurotransmitters, notably serotonin, norepinephrine, and dopamine. Scientists studying depression have found that these chemicals, and possibly others, are involved in regulating mood, but they are unsure of exactly how they work.

The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa) and several others. SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta). Another newer antidepressant that is different from both SSRIs and SNRIs but is very popular is bupropion (Wellbutrin). These newer drugs are more popular than the older classes of antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs), because they tend to have fewer side effects. However, medications affect everyone differently. Therefore, for some people, tricyclics or MAOIs may be the best choice.

People taking MAOIs must follow strict food and medicine guidelines to avoid potentially serious interactions. They must avoid substances that contain high levels of the chemical tyramine which is found in many cheeses, wines, and pickles and in some medications including decongestants. MAOIs interact with tyramine in a way that may cause a sharp rise in blood pressure, possibly leading to a stroke. A doctor should give a patient taking an MAOI a complete list of foods, medicines, and substances to avoid.

For all types of antidepressants, patients must take regular doses for at least three to four weeks, sometimes longer, before they are likely to feel the full benefit. They should continue taking the medication for an amount of time specified by their doctor, even if they are feeling better, to prevent the depression from returning.

Stopping medication should be done only under a doctor's supervision. They need to be gradually stopped to give the body time to adjust. Although they are not habit-forming or addictive, antidepressants should not be stopped abruptly because that can cause withdrawal symptoms or lead to a relapse. Some people, such as those whose depression is chronic or keeps returning, may need to stay on the medication for a long time.

Older adults who are experiencing their first episode of depression also may want to stay on antidepressant medication for a while, even if their symptoms have disappeared. Recent research shows that patients age 70 and older who took antidepressant medication for two years after they became symptom-free were 60 percent less likely to experience a relapse than those who stopped taking the medication.

If one medication does not work, patients should be willing to try another. Research has shown that patients who do not get well after taking a first medication increase their chances of getting well after switching to a different medication or adding another medication to their first one.

The most common side effects of antidepressant medications include headache, nausea, insomnia or nervousness, agitation or a jittery feeling, and sexual problems. Often they are mild and temporary. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.

For older adults who are already taking several medications for other conditions, it is important to talk with a doctor about any adverse drug interactions that may occur while taking antidepressants.

In some rare cases, antidepressant medications may lead to suicidal thoughts or actions. However, there is no evidence that they may have this unintended effect among older adults.

In addition to antidepressants, some people use the herb St. John's wort to treat depression. A bushy, wild-growing plant with yellow flowers, the herb has been used for centuries in many folk and herbal remedies. Today in Europe, it is widely used to treat mild to moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health recently conducted a clinical trial to find out if the herb was effective in treating adults suffering from major depression. (A clinical trial is a research study with people to find out if a drug, treatment, or therapy is safe and effective.) The trial found that St. John's wort was no more effective than a placebo, or sugar pill, in treating major depression. Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other drugs. On February 10, 2000, the FDA issued a Public Health Advisory stating that the herb appears to interfere with certain drugs used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Because of these potential interactions, older adults should always consult with their doctors before taking any herbal supplement.

Quiz

1. The most popular kinds of antidepressant medications used today are called

2. Antidepressant medications will lift your depression

3. Possible side effects of antidepressant medications include

4. An herbal supplement sometimes used to treat depression is called

Treatment and Research - Psychotherapy

Several types of psychotherapy -- or "talk therapy" -- can help people with depression. Some treatments are short-term, lasting 10 to 20 weeks, and others are longer, depending on the person's needs.

Two main types of psychotherapies -- cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) -- have been shown to be effective in treating depression.

By teaching new ways of thinking and behaving, CBT (cognitive-behavioral therapy) helps people change negative habits that may contribute to their depression. IPT (interpersonal therapy) helps people understand and work through troubled personal relationships or events that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, sometimes psychotherapy alone is not enough. A study examining depression treatment among older adults found that patients who got better with medication and IPT were less likely to have the depression return if they continued their combination treatment for at least two years.

Quiz

1. A type of psychotherapy that helps people learn new ways of thinking and behaving is called

2. A type of therapy that can help people understand and work through troubled relationships or events is called

3. For mild depression, the best treatment is often

Treatment and Research - Electroconvulsive Therapy

When medication and/or psychotherapy does not help improve a person's depression, electroconvulsive therapy (ECT) sometimes is used. ECT, once known as "shock therapy," used to have a very bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not gotten better or improved with other treatments.

Before electroconvulsive therapy is given, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse from ECT. A patient typically will have ECT several times a week, and often will also need to take an antidepressant or mood stabilizing medication to prevent the depression from returning. Although some patients will need only a few courses of ECT, others may need follow-up treatments, usually once a week at first, then gradually decreasing to monthly for up to one year.

Electroconvulsive therapy may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear up soon after treatment.

Quiz

1. When medication or psychotherapy are not effective treatments for depression, doctors sometimes recommend

2. During electroconvulsive therapy, a person

3. Electroconvulsive therapy (ECT) may cause some short-term side effects such as

Treatment and Research - Research

Studies show that about 80 percent of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy or a combination of both. Moreover, treating depression in older adults often improves the outcomes of co-existing medical conditions, a relationship that is the focus of much ongoing research.

However, there are some special considerations that doctors must take into account when treating older adults. The commonly prescribed medications for depression may not work well for some older adults because they may interact unfavorably with other medications being taken for other conditions. Some older adults with depression may also have some problems thinking clearly, and these individuals often respond poorly to the drugs.

Research shows that, for older adults, a combination of medication and psychotherapy treatment is most effective in treating depression and reducing the number of new episodes. But for those older adults who are unable or unwilling to take medication, research shows that psychotherapy alone also can be effective in helping seniors with depression. Studies suggest that cognitive-behavioral therapy (CBT) may be an especially useful type of psychotherapy for treating older adults and improving their quality of life.

Despite progress in treatment research, late-life depression often goes undiagnosed or is inadequately treated in older adults. In fact, several studies have found that up to 75 percent of older adults who die by suicide had visited their primary care doctors within one month of their deaths.

Researchers are working to help both doctors and patients better recognize the signs of depression and the potential for suicide in older adults. To improve diagnosis, researchers funded by NIH's National Institute of Mental Health are studying the effectiveness of an education and intervention program targeted to primary care clinics and providers. The program aims to improve recognition and treatment of depression and suicidal symptoms in older patients.

Another study found that a comprehensive approach to care will lead to better treatment results. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) offered antidepressant medication and/or psychotherapy to depressed older adults, along with a "care manager" -- a social worker, nurse or psychologist -- who monitored their symptoms, side effects of medication, and progress.

The study found that those participants who had case-managed care got better more quickly, had longer periods without depression, and in general responded better to treatment than those who did not have case-managed care.

Finally, researchers are looking at the role hormone changes may play in the development of depression in older adults. They want to find out whether hormone replacement therapy with estrogens or androgens may benefit older adults with late-life depression. Other studies are looking to better understand the relationship between other medical illnesses and depression. Still others are looking to help older adults get better access to depression treatment. Findings from these and other studies will provide important information for doctors to treat late-life depression.

If you are in a crisis...

If you are thinking about harming yourself or attempting suicide, tell someone who can help immediately.

• Call your doctor.
• Call 911 for emergency services.
• Go to the nearest hospital emergency room.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to be connected to a trained counselor at a suicide crisis center nearest you.

Quiz

1. Research shows that

2. Among older adults, depression is often

3. The recent PROSPECT study (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) which offered antidepressant medication and/or psychotherapy to depressed older adults, found that participants who also had a care manager

4. If you are thinking about harming yourself or attempting suicide, you should