03/23/2010 - Articles

By: Heinz Redwood

"It is unacceptable for depression to be dismissed as a natural consequence of ageing. Never again should a GP explain to an older person that depression is something they should expect at their age." Age Concern England ¹ .

"La dépression chez la personne âgée est souvent méconnue ou tardivement reconnue et insuffisamment traitée." ["Elderly depression is often misunderstood or recognised belatedly and inadequately treated."] ² .

These quotations from the literature of Elderly Depression could be multiplied ad lib. They represent serious problems in the relationship between doctors and elderly patients in primary care where depression is generally the place of initial diagnosis and treatment. Specialists, psychiatrists and hospitals will normally enter at a later stage, especially in countries where the GP acts as 'gatekeeper' to secondary and tertiary care.

On the one hand, Age Concern 's campaign expresses anger at the attitude of those doctors who have already diagnosed elderly depression or accepted the patients' self-diagnosis, but regard the condition as 'natural at your age'. This message - tantamount to 'Keeping a Stiff Upper Lip' - is close to a century out of date and will surely make nine out of ten elderly patients more depressed than when they first asked their doctor for help.

Obstacles to effective diagnosis

However, the concept of elderly depression as a natural phenomenon of ageing is probably less widespread than the sheer difficulty in general practice of accurately diagnosing the condition and the patient's type and stage of depression: minor, major, episodic or chronic, double depression , depressive symptoms, or at the borderline between depression and dementia. Most GPs are not trained in the intricacies of elderly depression, and the customary few minutes spent face-to-face by doctor and patient will tend to confirm each in their preconceived attitudes and provoke disagreement.

The observation that many of the present cohort of elderly patients will conceal their depression (not only from doctors but also from themselves) is widely reported. A fictional case study of a 78-year-old widower who has lost interest in life and eventually commits suicide, is described by Bruce & Pearson ³ . It illustrates what can go wrong when "depression remains unrecognized by the patient and the primary care physician". This patient is not visibly depressed but has withdrawn from previously enjoyable activities and from his responsibilities; his comorbidities make detection of depression more difficult and take priority in the doctor's limited time with the patient; and the fear of stigma induces the patient to deny depression.

The use of screening scales

The problem is not lack of knowledge. Numerous screening tools are available and are widely regarded as capable of detecting depression by docto...

03/23/2010 - Articles

By: Heinz Redwood

Depression does not become more common as you get older, but it may become more complex.  Recent findings on age and depression confirm the so-called ‘U-curve’ of well being and happiness over the human life cycle.  Put simply, we’re at our most dissatisfied in our mid-forties – a finding that’s so in 47 of 55 countries surveyed. Depression seems to have much less of an impact in terms of daily disability in the older age groups.

But depression in the elderly is complicated by other diseases and it’s often hard to sort out cause and effect. Do you get depressed because you’ve had a heart attack? Does depression make it more likely that you’ll get diabetes ? We really don’t know! Elderly depression is not so much about the numbers of people who are depressed, but more a matter of knowing how best to treat it.  Higher costs in terms of time, money and health care resources are involved in treating elderly depression and, too often, such resources simply aren’t adequate.  Moreover, the growing number of people over 60 (and, proportionately, even more so those over 80), means that elderly depression is set to rise dramatically. As yet, society seems unprepared for this.   Recent findings from the Zürich Study of younger persons (stretching over 20 years and with an age range of 20-41) have pointed to high levels of chronic depression existing alongside heart and lung problems, insomnia, pain (other than backache and headache) and sexual problems. Interestingly, the authors ascribe the heart and lung problems   in this age group as probably ‘associated with increased anxiety’.

In the elderly, by contrast, depression tends to exist alongside age-related conditions like stroke, high blood pressure, atrial fibrillation, diabetes, cancer and dementia.

The Zürich Study also found that other mental health problems co-exist with depression in the   20-41 age group. The six leading risk factors were found to be tobacco dependence, substance abuse, generalized anxiety disorder, obsessive-compulsive syndrome, panic attacks and alcohol use disorder. Again, with the exception of anxiety, these are probably more prominent risk factors for depression in younger persons than for the elderly. The psychosocial impact of bereavement, loneliness and growing physical and cognitive problems in coping with the normal activities of daily life are more characteristic associations with depression in old age.

The next article in this series looks at current   practice in the diagnosis and treatment of elderly depression.

Sources:

J. Angst, A. Gamma et al, “Long-term depression versus episodic major depression: results from the prospective Zürich study of a community sample”, J. Affective Disorders 115, 112-121, 2009
N. G. Choi & J. S. Kim, “Age group differences in...