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Age Is No Barrier to Lifting Depression's Heavy Veil
By Jane E. Brody, New York Times
May 30, 2006
Depression afflicts people of all ages, but it can be particularly devastating for older people, who are less likely to seek treatment and more likely to commit suicide than younger adults similarly afflicted. The problems include the failure to recognize the symptoms of depression in the elderly and the belief that nothing can be done for people with ample reason to be depressed.
Some elderly people continue to regard depression as shameful or a sign of weakness that should not be acknowledged even to physicians. Physicians, in turn, often fail to ask the questions that will find depression in their older patients.
The elderly came of age when little could be done for depression or when the only treatments caused serious side effects. These are some of the quite different facts about the problem:
•Depression is an illness of the brain, no different from diseases of other organs. It should be diagnosed and treated just like any other disease.
•Regardless of health, treating depression is as effective in the elderly as in younger people.
•Relieving depression for an older person not only improves mood, outlook and enjoyment, but it can also reduce physical symptoms and prolong life. Even among those with dementia, effective treatment often reduces their symptoms.
•Treatments have come an extremely long way in recent years. There are now many choices of effective antidepressants, including those with minimal side effects, and even the much-feared "electroshock" therapy is much safer today.
Diagnosis Can Be Tricky
The size of the problem is startling in itself. One person in seven over 65 suffers from depression, but 70 to 90 percent, depending on who's counting, receive no treatment for it.
A major reason for the huge gap between the numbers of people in need of treatment and the numbers receiving it is the difficulty in diagnosing depression when symptoms are not typical or are easily confused with a physical ailment.
Classic signs include persistent sadness, withdrawal from activities once enjoyed, difficulty sleeping and concentrating, and poor appetite.
Although some or all of these conditions may also be present in depressed older people, their symptoms may also include signs of dementia like memory problems and confusion, neglect of personal appearance, feelings of irritability or anxiety, pacing and fidgeting, lack of energy and even delusions and hallucinations. And people can be depressed without feeling sad. Rather, their emotional disorder is expressed more in physical terms, like vague complaints of aches and pains or gastrointestinal upset.
Many common stressful events can be seen as an explanation for depression: the death of a spouse or close friend; retirement with nothing satisfying to do; having to move from a family home or familiar neighborhood; losses in vision, hearing or mobility; or the developing a chronic or life-threatening illness.
Although any of these factors can result in temporary feelings of grief, loss and sadness, when such feelings persist for more than, say, six months, clinical depression is the more likely diagnosis. Clinical depression rarely, if ever, cures itself. It needs to be treated professionally.
Clinical depression is all the more likely if the person had previous depressive episodes or if the person's parents, siblings or children experienced depression. Among those with a genetic vulnerability, any major life change can bring on clinical depression.
People lacking such vulnerability typically bounce back within weeks or months of an emotionally challenging event and may remain cheerful even when death is imminent.
Certain disorders, particularly strokes and ministrokes, can cause depression by injuring the brain. Many medications commonly taken by older people can make the depression worse, among them steroids, anticancer drugs, tranquilizers, anti-anxiety agents and drugs for Parkinson's disease, high blood pressure, heart disease, rheumatoid arthritis and pain.
But it is also important to realize that depression can take hold of a person without any apparent reason. Clinical depression involves a disruption in brain chemicals that can occur with or without a precipitating event.
Older women are nearly twice as likely as older men to become seriously depressed, a fact that some attribute to hormonal or other biological factors. A vitamin B12 deficiency has also been linked to severe depression in older women. People who live alone without supportive social networks also have higher rates of depression.
Value of Treatment
Untreated depression can shorten life and make what time remains not worth living. It is also hard to live with or be around a depressed person, leading to a withdrawal of family and social support, in turn feeding the depression.
Depression has been shown to worsen the symptoms of dementia and to make existing physical ailments like heart disease worse, possibly because depressed people are less conscientious about following prescribed remedies.
By suppressing the immune system, depression may render people more vulnerable to infectious diseases. Depressed older people may be so despondent that they become incontinent, unable to walk or unable to care for themselves.
Remedies Are Abundant
Depression should be regarded as a chronic disease, no less in need of therapy than heart disease or diabetes. The therapeutic possibilities in the modern medical armamentarium are large, and if one remedy fails, others are available. Experts say that more than 80 percent of older depressed people respond well or completely to one or another therapeutic approach.
A recent study indicated that many of them would prefer talk therapy first, resorting to medication only if that is not helpful enough. Most psychiatrists today, however, consider antidepressant medication to be a necessary first step that can make talk therapy more effective.
Compared with older antidepressants, the modern S.S.R.I.'s (for selective serotonin reuptake inhibitors) and the N.S.R.I.'s (for norepinephrine and serotonin reuptake inhibitors) have fewer side effects and do not interact with as many other medications.
Each drug works a little differently from others in its class. If one does not bring noticeable relief in 6 to 12 weeks, another can be tried. If none of the newer drugs help, older ones — MAO (monoamine oxidase) inhibitors and tricyclic antidepressants — can be tried. Sometimes combining two drugs works.
Medication can be used with psychotherapy or by itself. Psychotherapy can also be used alone, although studies indicate that it is rarely enough to counter severe depression. Psychopharmacologists warn that, to reduce the risk of a relapse, antidepressants should be taken for six months to a year after depression lifts. In some cases, the drugs may needed for life.
If both these approaches fail — and especially if a person is at risk of suicide — electroconvulsive therapy is often useful, especially when depression is accompanied by psychosis or delusions. Its beneficial effect is immediate.
Also, it uses far less electricity than it once did. Its only known side effect is temporary memory loss, but for some the loss is prolonged.
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