Claire Hamilton was getting worried about her Aunt Julia. Julia always seemed to have some new excuse to stay home. She had already, months ago, stopped volunteering at a local Head Start program because her arthritis was bothering her. Now Claire found herself on the phone pleading with her aunt to join the family for birthdays and other celebrations. Claire finally went to visit Julia. She found that her aunt had lost weight and appeared tired, and Julia's normally tidy apartment was a mess.
When Claire expressed concern, Julia admitted she'd been thinking a lot about death and said it might be better than going on the way she was.
Or take Al Cannon: His wife, Betty, was worried by a change in his personality. For 15 years, the couple had enjoyed retirement, traveling, and spending time with their eight grandchildren. Al had been a natural leader -- someone his fellow firefighters had looked to for leadership and support. But now he had become withdrawn, forgetful, and irritable. He no longer seemed to enjoy his favorite foods or activities. He also slept poorly and often awakened as early as 4 a.m., when he would go to the kitchen and make a racket until Betty finally got up to see what he was doing.
Both Julia and Al sought help from their doctors, and each was diagnosed with depression, a disorder that's as common in the elderly as it is in younger people. And both, fortunately, were successfully treated. Without treatment, both would they have risked getting worse physically as well as becoming increasingly despondent and even suicidal.
Elderly Harder to Diagnose
People who are clinically depressed experience at least two weeks during which their mood is depressed for most of the day and a decreased interest in almost all activities. Other possible symptoms include:
In cases of serious depression, thoughts of death or even of death by suicide are common.
The trouble is, depression can be hard to diagnose in older people. That's because they're likely to have other medical conditions that can mimic some of depression's symptoms. Julia's arthritis limited her ability to get around, and this helped hide the fact that she felt less and less energetic because she was depressed. And Al's stomach condition had led him to turn down his favorite foods long before depression took away his appetite.
It is not a normal part of aging to have any of the symptoms of depression. They deserve medical attention -- whether they are caused by depression or by something else. Ignoring the symptoms can lead to an increase in the severity of the depression or other medical illness. And severe untreated depression can even end in suicide.
Suicidal thoughts or actions are a medical emergency that requires immediate evaluation by a healthcare professional.
Treatment With Antidepressants
Both Julia and Al went to their primary care physicians for treatment. Both got complete physical exams and laboratory workups.
Julia chose to try antidepressant medication and asked her doctor to refer her for psychotherapy, as these had both worked well for her when she had become depressed in the past -- after the death of her sister 30 years ago and then again after she retired from teaching third grade. The doctor was also able to improve the treatment of Julia's arthritis, and with her niece's help she began to increase her social and physical activity.
Al's doctor referred him to a psychiatrist. Like Julia, he decided to try antidepressant medication. He also joined a support group for retired men run by his senior center, which he enjoyed a lot.
Choosing an antidepressant for an older patient can be complex. They're often already on many different medications for other medical problems. Doctors need to take into account drug interactions and side effects and the slower metabolisms of older patients when considering which antidepressant drug to choose.
This is why, if you're an older patient, it's especially important to let your doctor know about all medications you're taking -- including vitamins, herbs, supplements, and over-the-counter drugs. And it's important to remember that all antidepressants can take from four to six weeks to provide relief and that they have to be taken as prescribed in order to work.
'Start Low, Go Slow'
There are many more antidepressants available now than 10 or 15 years ago. The most commonly prescribed class of antidepressants is the selective serotonin reuptake inhibitors (SSRIs), which include
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Paxil (paroxetine)
- Celexa (citalopram)
Celexa, the newest, is especially useful because it has fewer drug interactions than the others.
Common side effects of SSRIs include jitteriness, insomnia, and sexual dysfunction. Most of the time, though, these side effects are mild, and a doctor can help reduce them and even prevent many of them by simply following a guiding principle of geriatric medicine: "Start low and go slow."
Psychotherapy is also an important treatment for depression, though it is often overlooked in older patients. Whether someone is sad about the past or the present, having a trained professional to listen and provide support can be extremely important.
Besides all of the treatments mentioned above, both social and physical activities are essential. Both Julia and Al found ways to add activities to their routine as they began to recover from their depressions. With treatment, they were both able to be productive members of their families and communities again.
Rebecca Lundquist, MD, is a staff psychiatrist in the department of psychiatry of Beth Israel Deaconess Medical Center and an instructor in psychiatry at Harvard Medical School.