Mind and Body
Growing old, not grumpy
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Research suggests that psychotherapy and new medications can often relieve depression in elders. |
By Richard Saltus, Boston Globe
``There's less and less to say. ... I got new eyes. Everything looks far away,'' an aging Bob Dylan sings on his latest album. ``It's not dark yet, but it's gettin' there.''
That growing older should be accompanied by a bleak view of life - however many years remain - seems inevitable to many people. After all, old age is a time of increasing loss - of friends, family, health, possibilities.
And we know that suicides among the elderly have risen. Today, Americans older than 65 account for one-fifth of the country's 30,000 annual suicides, though they make up only 13 percent of the population.
Yet, a growing body of research on the mental health of older Americans suggests that depression, while a significant problem, doesn't have to come with the territory. It's a disease, although one often difficult to untangle from other illnesses that can afflict the elderly, and its symptoms can be relieved.
Until quite recently, the prevailing attitude was that older people were understandably depressed and that treatment wasn't likely to help much because they were so set in their ways. ``This has resulted in a very serious problem of neglect,'' says Barry D. Lebowitz, of the National Institute of Mental Health, in Bethesda, Maryland. He is the lead author of an article published last month in the Journal of the American Medical Association aimed at primary-care physicians, who often are in a position to detect depression - if they know what to look for.
It's not easy, the researchers acknowledge. Seldom do elderly depressed people, especially of the current generation, describe their morose feelings as such. Today's elders, Lebowitz says, are more likely to say, ```I feel lousy. I have aches and pains I can't identify. I'm not sleeping well; food doesn't taste as good.' But they never say the `D' word.''
Of course, many elders must cope with declining health and chronic illness. Coping with heart disease, pulmonary problems, arthritis, or cancer would seem to be depressing in itself. Still, the research has found, some of the depression is separable, and when it's successfully treated, disability from the physical illnesses improves.
One previously unappreciated link between physical disease and depression has surfaced, however. ``Science is starting to demonstrate that some people who become depressed for the first time in life in their 60s or 70s have a lot of medical illness and vascular disease,'' such as strokes, Lebowitz says, that can cause actual brain abnormalities.
This type of late-life depression may be accompanied by thinking and memory problems and movement difficulties. Antidepressant medications may help, but the symptoms sometimes foreshadow the development of Alzheimer's disease or some other kind of dementia.
The report by Lebowitz - he heads research on adult and geriatric treatment and prevention at the institute - and others in the October 8 issue of JAMA is an update of a National Institutes of Health conference on late-life depression that was held in 1991. The update was prompted by new data and also by wider experience with antidepressants of the Prozac type, which have fewer side effects than the previous generation of antidepressant drugs and are a boon for older patients.
It's now believed that from 1 to 2 percent of the 33 million Americans older than 65 suffer from major depression and that another 2 percent suffer depression to a milder degree, according to the report. In addition, there may be 13 percent to 27 percent or even more (especially those in nursing homes) who have some symptoms of depression but don't meet textbook criteria.
It's up to primary-care physicians, along with family members, to differentiate normal sadness in older people from actual depression. Sometimes, though, especially if the person has a long list of physical troubles, it may take a psychiatrist or psychologist with expertise in geriatrics to sort out the diagnosis.
Signs of depression include a loss of interest in normal pleasures; dwindling enthusiasm; changes in eating patterns; and, especially, sleep disturbances. The last, whether it's sleeping too much or too little, is a common signal of depression in the elderly.
It used to be thought that older people had such ingrained behavior that they really couldn't be helped much by psychotherapy. While it may indeed be more difficult to get the over-65 person to agree to therapy, says Lebowitz, ``the good news in all this is that treatment works. The same treatments that work in midlife adults work in older adults.''
The newer antidepressants, known as selective serotonin reuptake inhibitors - Prozac, Zoloft, Paxil, and others - can more safely treat older patients, who tend to be more sensitive to drug side effects. Psychotherapy, especially interpersonal, problem-solving, or cognitive types of therapy, has been shown to help relieve depression.
However, Lebowitz cautions, depression ``isn't like the flu, which goes away, and that's it.'' The report stressed that ``older patients with recurrent depression may need antidepressant treatment indefinitely'' - especially because the findings suggest that older people may be somewhat more susceptible to relapses.
But with the greater safety of the new medications and a better understanding of how psychotherapy of various kinds can help, treating an elderly person even for the rest of his or her life seems much more thinkable than it used to be.
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