Depression is not a normal effect of aging, and healthy independent elders actually have a lower depression rate than the general population but this changes drastically if medical illness coexists.
Late life depression remains under diagnosed and inadequately treated. The rate of depression for seniors in the community setting is only 2 percent and slightly higher in the general adult population (6 percent). However, in those living at home with chronic illness the rate rises to 9 percent, but jumps significantly to 33 percent in the hospital population and even higher if there is a diagnosis such as heart attack, Parkinson disease or cancer. The likelihood of serious depression approaches 50 percent in stroke patients, who are more than three times more likely to die within 10 years, compared with those without depression. In heart attack patients who also have significant depression, the increase in death rate is four times higher.
To make the diagnosis, I look for depressed mood or loss of interest or pleasure in previously enjoyable activities. In addition, I ask about changes in appetite or weight, too much or too little sleep, slowing of physical or mental activity, fatigue or loss of energy, feelings of worthlessness or guilt, difficulty thinking, concentrating or making decisions and most importantly, recurrent thoughts of death or plans for suicide.
When I served as medical director of nursing homes in Lake Placid and Tupper Lake, I understood that up to 20 percent of residents with healthy brain function have significant depression and the statistic jumps as high as 70 percent in those with deteriorating mental ability.
In men, this is more likely to show up as anger or irritability and frequently there is a history of alcohol abuse, as they are less likely than women to acknowledge sadness or other psychological symptoms. Depression is a major risk factor for suicide in the elderly, who account for 13 percent of the population but nearly 24 percent of all completed suicides. White men over 85 have the highest rate of completed suicide, 55 per 100,000.
Making the diagnosis of depression is much more challenging in the elderly, especially those who are physically frail. Many physicians feel rushed and don't take enough time to look for the subtle signs suggesting depression in the older patient.
Complicating factors include deteriorating mental function, the possible side effect of medication or coexisting medical illness with overlapping symptoms.
Physical exercise can be a wonderful treatment for depression but often difficult to do in the geriatric population.
Many older patients are reluctant to take pills for depression even though medication is highly effective and usually without significant side effects when carefully chosen. In the elderly, a full improvement may take as long as 2 to 4 months of therapy but some improvement should start within 4 weeks.
I always start with lower doses of depression medicine and advance gradually until benefit is realized. Too often the elderly depressed patient is either under treated or not kept on medication, as recommended, for 6 to 12 months after achieving full remission. As in the teenage population, it's important to monitor for suicide risk particularly in the early stages of treatment.
On the other end of the age spectrum depression presents much differently. All too often, youngsters who have school problems, disruptive behavior or engage in high risk activities are actually suffering from depression. Up to 80 percent of depressed teenagers do not receive proper treatment.
Ongoing sadness is the easiest symptom to recognize, but adolescents can also be irritable and have feelings of low self esteem and changes in sleep pattern. Often there is difficulty getting along with parents or friends and completing school work. We don't know the exact cause of major depression but it is a very treatable condition once recognized.
Depression medication helps restore an imbalance in brain chemistry and, combined with counseling, has a great success rate in all ages. The depressed adolescent often has irritability and is easily annoyed. Behavior can be moody, negative and argumentative. There can be a pattern of picking fights and frequent outbursts of anger with inability to tolerate frustration. Feeling tired all the time is not unusual and school performance may decline relating to having a hard time concentrating. Any thoughts of self-harm or suicide should be taken very seriously.
Dr. Josh Schwartzberg practices in Lake Placid, Willsboro and Burlington. He can be contacted at www.docjosh.com or at home at 518-963-4355.