Recognizing Depression In Later Years

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"It's difficult to see the field when you're standing in it."
- Anonymous

A Matter of Definition

Depression? We all know a little something about depression, right? It's about feeling sad or blue, moping around, feeling sorry for yourself, down in the mouth . . . something that happens to other people. Yeah, we all know a little about depression. And like the man said: It ain't what we don't know that's the problem; it's what we know that ain't so.

Misconceptions about psychiatric disorders abound, more so than in just about any other area of medicine. Which is no surprise. There are many historical, cultural, and personal reasons why some of us have a distorted, even trivialized, notion about mental disorders — in particular, one referred to as depression. But, trivial it is not!

Depression, a lethal killer
Consider: in 1997 (the most recent year for which complete data are available), suicide was the 8th leading cause of death in the U.S. — deadlier than chronic kidney or liver ailments, Alzheimer's Disease, or homicides . . . and twice as deadly as the modern scourge of AIDS. Twice as deadly as AIDS! And as terrifying as the thought is of being gunned down in the streets of "Anycity, USA", each of us, before that ever happened, stands a better chance of taking his or her own life . . . thanks to a lethal killer known — all too innocuously — as depression.

Prevalence of depression
Or, consider this: a decade ago, researchers estimated the economic burden of depression in the U.S. to exceed $43 billion annually — $12.4 billion in direct treatment costs; $7.5 billion in mortality costs; and $23.8 billion in lost productivity. That's a lot of moping around. Each of us, over the course of a lifetime — what researchers call lifetime prevalence — stands roughly a 14% chance (around 19% for women and 9% for men) of having at least one serious episode of depression. And the point prevalence for depression — the number of active cases at any given time — falls between 5-10% for women and 3-6% for men, depending on the research methodology and populations studied.

With more than 70% of the economic burden of depression (i.e., mortality costs and lost productivity) being attributable to untreated, and under-treated, illness — not to mention the human burden of suffering and loss (including suicide and premature death), both for the individuals afflicted, as well as their loved ones — learning how to recognize depression, and seeking early intervention, become essential tools for healthy aging — even a matter of life and death, in some cases.

How, then, do we recognize depression?

Recognizing Depression: Through a Glass, Darkly

"When I was a child, I spoke as a child,
I understood as a child, I thought as a child:
but when I became a man, I put away childish things.
For now we see through a glass, darkly."
— 1 Corinthians 13:1

Hans Christian Andersen's allegorical tale, The Emperor's New Suit, speaks of a child's innocent view of the world — unsullied by the myriad considerations clouding the perceptions of his elders. Our quote from Corinthians also speaks of an unassuming, open-minded clarity of vision in childhood, which age, experience, and life's fortunes render dim as we grow older. If, then, we are to learn how to recognize depression, as a tool for healthy aging, we must first ask: Are there certain considerations — specific to aging, or not — that cause us to see through the glass, darkly . . . where depression is concerned? The answer, I believe, is yes.

Let us turn again to childhood a minute, to learn something about what makes recognizing depression in later years so difficult. With all due respect to Mr. Andersen, the innocence so famous in children does not necessarily for clarity of vision make. Not where depression is concerned anyway. There is a good reason for this.

Alexithymia
Children, by and large, as a matter of intellectual and emotional development, do not begin to develop a ‘mature' understanding of their emotions until their early teens; in consequence, they often lack a vocabulary for all but the simplest emotions until reaching that age. We have a fancy-shmancy term for this in psychiatry: alexithymia — from the Greek: a (without) - lexi (speech, language) - thym(os) (soul, spirit, mind). Without a vocabulary of emotions, children have difficulty telling us what's wrong with them when, for example, they become depressed.

How is alexithymia relevant to recognizing depression in later years?

The Difficulties of Diagnosing Depression in the Elderly

"Old men are children for a second time."
— Aristophanes (423 B.C.)

After working with seniors for nearly two decades, I have come to the conclusion that many are, indeed, alexithymic, not as a result of their aging, but as a result of the times in which they were born. All of today's seniors — those 65 and older — were born before 1936. It was a time when children were still thought best seen, not heard; when big boys didn't cry; a time before child labor laws were enacted; a time when depression was what happened to the economy when the stock market collapsed.

It was also a time when mental illnesses were still routinely stigmatized, as evidence of a weak moral character, or a poor physical constitution. Is it any wonder, then, that many of today's seniors don't, or won't, talk about such pressing concerns as depression when troubled by them?

There are other reasons, besides alexithymia, why seniors have difficulty recognizing depression and/or reporting it to their care providers. Many symptoms of depression — e.g., weight loss, fatigue, insomnia — are common to a number of physical ailments, often resulting in mistaken diagnoses. Depression is also sometimes associated, particularly in the elderly, with a reversible decline in intellectual functioning known as pseudo-dementia — making depression even that much more difficult to see when you're standing in the middle of it.
 

Depression, A Dangerous Prospect

For these reasons, and others, many seniors, even if they sense that something is wrong, often can't explain it to their doctors — if they make it that far, even. As a result, treatment is often delayed for those suffering later-life depression, or treatment is never received at all. For instance, one study found that 75% of seniors with diagnosed depression were not even receiving antidepressants. Another study found that the diagnosis of Major Depression in seniors is delayed, on average, by 36 weeks — 9 whole months during which all sorts of terrible things can happen, beyond depression's inexpressible misery.

For some, this delay can be deadly. Aside from suicide, depression in later life is associated with higher mortality rates in many situations. Apart from other diseases and health risks, Major Depression by itself is associated with nearly a two-fold increase in mortality for both men and women. Major Depression has also been found to be a significant risk factor for developing coronary artery disease, and patients who are depressed immediately after a heart attack are 3½ times more likely to die than patients who are not depressed.

How do we help seniors learn how to recognize depression — who, because of their experience, life's fortunes, and depression itself, may find doing so difficult?  Fortunately, there are people already working on this very question.
 

A Clue to Diagnosis

Almost everyone today knows that minutes can mean the difference between life and death after a heart attack. Yet many heart attack victims delay seeking treatment. The late Tom Hackett, M.D., psychiatrist at Massachusetts General Hospital in Boston, was intrigued by this behavior of heart attack victims. Why did so many of them wait — too long, frequently — before seeking medical care? The answers Dr. Hackett found will surprise no one: fear and denial. He then set out to study which interventions would modify the behavior of heart attack victims and motivate them to seek medical attention sooner — thereby possibly saving their lives.

Dr. Hackett, a clever fellow, tried all the things a clever fellow would, to modify the potentially lethal, foot-dragging behavior of heart attack victims. And guess what? Nothing worked! No amount of teaching, cajoling, or brow-beating could overcome the fear and denial that kept many heart attack victims from seeking early treatment.

But, Dr. Hackett figured a way to finesse this problem and still achieve the desired result of getting heart attacks victims into treatment earlier. The answer, he found, was to focus his teaching efforts not on the potential heart attack victims, but on their loved-ones: the husbands and wives, sons and daughters, friends and relatives. They were the ones who could make a difference — emphasis on make. For, it is axiomatic: If you suspect someone of having a heart attack, make them go to the hospital. Don't take no for an answer! A precautionary trip to the hospital never killed anyone; failing to do so has cost countless thousands their lives.
 

Helping Your Loved-One Get Treatment

So, with a tip of the hat to Dr. Hackett for the silver bullet left behind, let me address my remaining remarks to the loved-ones of those who suffer — or who may in the future suffer — from depression. You can make a difference. How, then, do you recognize depression in your husband or wife, mother or father, friend or relative? Let me answer that in two ways: first, with a textbook answer; second, with what that textbook answer looks like in real life.

Recognizing depression, the textbook answer: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association, is our authoritative reference for diagnosing and classifying mental disorders. The main criteria found in DSM-IV for diagnosing a Major Depressive Episode are described as follows:

Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

Symptoms:

  • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
  • Insomnia or hypersomnia (oversleeping) nearly every day.
  • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Recognizing depression, the real life answer
In real life, more often than not, seniors with depression do not complain of depressed mood or a loss of interest or pleasure. The latter, however — loss of interest or pleasure — usually can be inferred from someone's prior behavior and functioning. Social withdrawal, abandoning hobbies, decreased activity (without apparent physical cause), or the onset (or worsening) of alcohol (and/or prescription medication) abuse, all are presumptive evidence of a loss of interest or pleasure in things previously enjoyed — what we in psychiatry call anhedonia — and, therefore, of depression.

Chronic physical complaints
By far, chronic physical complaints (i.e., pain, dizziness, weakness, nervousness) unexplained by demonstrable physical illness — especially after two or more trips to the doctor for the same complaint(s) — are presumptive evidence of depression. I am often asked to see such patients in the hospital, after they already have had a kazillion dollar workup. The more such patients (or their loved-ones) insist that the real cause of their complaints has been overlooked, the more likely it is that certain fears (or denial) need to be addressed — sooner rather than later.

Loss of appetite, weight loss, insomnia, fatigue, and restlessness all are common symptoms of depression, and of physical illness. Here, again, one competent, thorough medical examination is all that is necessary; after that, depression should rise to the top of your list of suspicions.

Feelings of worthlessness
Seniors often express feelings of worthlessness as: being a burden, or a bother; in the way; feeling like others (and the world) would be better off without them. This is especially true of seniors who have lost a spouse and who, due to illness, disability, or substance abuse, are no longer capable of independent living. The rate of suicide among such individuals is extremely high.

Suicidal thoughts
Many seniors, for religious reasons, will never admit to having suicidal thoughts. However, there is an accepted truism in psychiatry: those who want desperately enough to kill themselves, will find a way — given a chance. Don't give someone that chance.
 

Don't Take No For An Answer

If you even suspect a loved-one of being depressed or suicidal, make them see their doctor, or, better yet, a psychiatrist. Don't take no for an answer! It's one of the easiest ways I know to potentially save a loved-one's life.