Depression, one of the most
common conditions associated with suicide in
older adults,1 is a widely underrecognized and undertreated medical
illness.
In fact, several studies have found that many older adults who die by
suicide—up to 75 percent—have visited a primary care physician within a
month of their suicide.2 These findings point to the urgency of
improving
detection and treatment of depression as a means of reducing suicide
risk
among older persons.
Older Americans are disproportionately likely to die by suicide.
Comprising
only 13 percent of the U.S. population, individuals age 65 and older
accounted for 18 percent of all suicide deaths in 2000. Among the
highest
rates (when categorized by gender and race) were white men age 85 and
older:
59 deaths per 100,000 persons in 2000, more than five times the national
U.S. rate of 10.6 per 100,000.3
Of the nearly 35 million Americans age 65 and older, an estimated 2
million
have a depressive illness (major depressive disorder, dysthymic
disorder, or
bipolar disorder) and another 5 million may have “subsyndromal
depression,”
or depressive symptoms that fall short of meeting full diagnostic
criteria
for a disorder.4,5 Subsyndromal depression is especially common among
older
persons and is associated with an increased risk of developing major
depression.6 In any of these forms, however, depressive symptoms are not
a
normal part of aging. In contrast to the normal emotional experiences of
sadness, grief, loss, or passing mood states, they tend to be persistent
and
to interfere significantly with an individual's ability to function.
Depression often co-occurs with other serious illnesses such as heart
disease, stroke, diabetes, cancer, and Parkinson’s disease.7 Because
many
older adults face these illnesses as well as various social and economic
difficulties, health care professionals may mistakenly conclude that
depression is a normal consequence of these problems—an attitude often
shared by patients themselves.8 These factors together contribute to the
underdiagnosis and undertreatment of depressive disorders in older
people.
Depression can and should be treated when it co-occurs with other
illnesses,
for untreated depression can delay recovery from or worsen the outcome
of
these other illnesses. The relationship between depression and other
illness processes in older adults is a focus of ongoing research.
Both doctors and patients may have difficulty identifying the signs of
depression. NIMH-funded researchers are currently investigating the
effectiveness of a depression education intervention delivered in
primary
care clinics for improving recognition and treatment of depression and
suicidal symptoms in elderly patients.9
Research and Treatment
Research has revealed varying patterns of clinical and biological
features
among older adults with depression.8 As compared to older persons whose
depression began earlier in life, those whose depression first appears
in
late life are likely to have a more chronic course of illness. In
addition,
there is growing evidence that depression beginning in late life is
associated with vascular changes in the brain.
Both antidepressant medications and short-term psychotherapies are
effective
treatments for late-life depression.8 Existing antidepressants are known
to
influence the functioning of certain neurotransmitters in the brain. The
newer medications, chiefly the selective serotonin reuptake inhibitors
(SSRIs), are generally preferred over the older medications, including
tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs),
because they have fewer and less severe potential side effects.10 Both
generations of medications are effective in relieving depression,
although
some people will respond to one type of drug, but not another.
Research has shown that certain types of short-term psychotherapy,
particularly cognitive-behavioral therapy and interpersonal therapy, are
effective treatments for late-life depression.8 In addition,
psychotherapy
alone has been shown to prolong periods of good health free from
depression.
Combining psychotherapy with antidepressant medication, however, appears
to provide maximum benefit. In one study, approximately 80 percent of
older
adults with depression recovered with combination treatment.11 The
combination treatment was also found to be more effective than either
treatment alone in reducing recurrences of depression.12
More studies are in progress on the efficacy and longer-term
effectiveness
of SSRIs and specific psychotherapies for depression in older persons.
Findings from these studies will provide important data regarding the
clinical course and treatment of late-life depression. Further research
will be needed to determine the role of hormonal factors in the
development
of depression in older adults, and to find out whether hormone
replacement
therapy with estrogens or androgens is of benefit in the treatment of
late-life depression.
