Listening For The Blues

Depression, sometimes called the common cold of psychiatry, affects an estimated 10% of all Americans. But unlike the common cold, depression usually doesn't go away by itself. People age 65 and older are particularly susceptible. Of the 34 million older people in this country, about 6 million suffer from chronic depression.

In addition to the factors that often seem to trigger depression in people of all ages, especially during the dark winter months and around the holidays, older people must cope with the loss of loved ones, social isolation and the physical limitations that often come with age. Physical changes in the brain caused by illnesses such as Alzheimer's disease and vascular (i.e., stroke-related) insufficiency, alcohol and drug abuse, and some antihypertensive medications also predispose the elderly to depression. Studies conducted by the National Institute of Mental Health and the New York Presbyterian Hospital, Westchester division, confirm that medical illnesses, such as heart disease, stroke and cancer, are major correlatives of depression in older people.

Left untreated, the sustained sadness and loss of pleasure in life that are indicative of depression can be deadly. Each year 20% of the suicides in this country are committed by people 65 and older, although they make up only 13% of the population.

In general older men are less likely than women to tell their doctors they are depressed. Men may be embarrassed, or they--and their doctors--may erroneously think that depression is an unavoidable part of growing old. The symptoms are often described as insomnia, fatigue or loss of appetite. As many as 70% of older people who commit suicide have visited their primary-care physician within the previous four weeks. Older people are less likely than younger adults to seek or respond to offers of help. They make few suicidal gestures, but a greater number succeed in carrying out their suicides. Despite what many people believe, young people between the ages of 15 and 24 have the lowest suicide rate in the nation (13.3 per 100,000), while white men in their 80s have the highest (63.1 per 100,000).

Little known but devastating among the aged is a phenomenon described as chronic suicide. Depressed old people may eat improperly, refuse to take medications and in general passively fail to take care of themselves until they die. Others may enter into a suicide pact with a partner. This usually occurs in response to one partner's developing dementia or being admitted to a nursing home.

Fortunately there are techniques to help doctors detect and treat depression in the many cases where the patient doesn't tell. The Geriatric Depression Scale and the Hamilton Depression Rating Scale are diagnostic tests clinicians use to pinpoint the symptoms of depression and make a diagnosis. The scales test for indicators like weight loss, loss of libido, hypochondriasis, anxiety and agitation.

Depression is not an inevitable disease of old age, and people with depression need not be written off. Effective treatments include psychotherapy--which helps patients understand the root cause of depression and revise their approach to the problem--and antidepressants. The preferred treatment is a combination of both.

Tricyclics, monoamine-oxidase inhibitors and selective serotonin reuptake inhibitors are the most commonly prescribed antidepressants. Doctors and family members should be alert both to appropriate levels of medication (older adults frequently need lower doses) and to possible complications from interaction with other medications. Older Americans take an average of 4.5 prescription and two nonprescription drugs daily. On rare occasions, especially in the presence of suicidal intent, electroconvulsive therapy can be lifesaving.

Depression often descends when people feel they are a burden to their families or when they feel useless. In studies with older subjects that go back to the 1950s and '60s, personal goals and structure in everyday life were found to be vital to maintaining mental health. Often depression can be overcome by engaging in purposeful activities such as continued paid work, volunteer work, education, hobbies and social contacts. Regular exercise, even walking, is also effective.

Ultimately, the number of depressed older people in our country will decrease when we get better at acknowledging their importance in our society. As baby boomers approach their mid-50s and move toward Golden Pond, it is essential that we transform society's attitudes toward older people and build institutions that provide constructive cultural, economic and social roles for them. Depression is not only more common than the common cold but also infinitely more dangerous. Depression and suicide in old age send a negative message to all who would grow old. The first baby boomer will turn 65 just 10 years from now, and 10 years later, boomers will make up nearly 20% of the nation's population. It is time to prepare.

Robert N. Butler is president of the International Longevity Center and professor of geriatrics at New York's Mount Sinai School of Medicine