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Combatting Late-Life Depression, System-Wide and One Loved One at a Time

Recognizing that isolation, depression, and anxiety -- if unaddressed -- create a downward spiral of health that exacts a financial and human toll, we must continue to create services for the homebound elderly that address their mental as well as physical needs.
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When Janice T. came from Minnesota to New York to visit her 82-year-old mother for the holidays, she found the apartment's shades drawn and her mother still in a bathrobe at 3 p.m. Janice was not surprised. Her father had died two years ago, and many of her mother's friends had either passed away or moved to Florida. She knew her mother was lonely.

Since she lived 1,200 miles away and could only visit every few months, Janice was not sure what her mother did all day. She used to love cooking and baking, but now with diabetes and hypertension -- and no family around to cook for -- Mrs. T. said she had lost interest in food. A retired school teacher and lifelong reader, her mother had cataracts and said she hadn't picked up a book or newspaper in months.

Janice thought her mother's depressive symptoms must be a normal part of aging, until a chance conversation with a visiting nurse in the building led her to explore the condition further. It's important to note that late-life depression, while not uncommon, is not simply a natural outgrowth of aging or a normal reaction to chronic illness, limited mobility and loss. Rather, depression is diagnosable and, more importantly, treatable.

The National Alliance on Mental Illness (NAMI) estimates that depression affects more than 6.5 million of the 35 million Americans aged 65 years or more. For those who are homebound, the prevalence is even greater, from 13.5 percent to as high as 46 percent of that population. The good news is that 80 percent of clinically depressed individuals can be effectively treated, including by medication and psychotherapy, according to NAMI.

"There's a difference between 'Things aren't as nice as I'd like them to be,' and 'I'm clinically depressed,'" explains Kathleen Wolfe, LCSW, director of social work and behavioral health at my organization, VNSNY CHOICE Health Plans. "It's important for older people to know: You don't have to feel this way. Depression can happen at any age, and there are most certainly ways to treat it, pharmacologically and behaviorally. The most important things to do are understand it, give options, offer connections and instill hope."

Kathleen is charged with infusing behavioral health strategies across VNSNY CHOICE, including working with primary care physicians to explore such issues as depression and anxiety with their older patients. One innovative service available to members of our Fully Integrated Duals Advantage program, or FIDA, is engagement with peer specialists, carefully trained individuals who have lived with and overcome mental illness themselves and can share coping strategies and resources. "They have a shared experience," notes Kathleen, "and they send a powerful message of hope."

Recognizing that isolation, depression, and anxiety -- if unaddressed -- create a downward spiral of health that exacts a financial and human toll, we must continue to create services for the homebound elderly that address their mental as well as physical needs.

On an individual level, Kathleen notes that the holidays are a good time to check in with elderly friends and relatives, and begin the conversation if you notice signs of late-life depression, which include:

• Feelings of hopelessness or pessimism
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia or excessive sleeping
• Overeating or appetite loss
• Persistent aches or pains that do not get better, even with treatment

Kathleen encourages loved ones, as well as primary care physicians, to ask two key questions if they suspect depression: 1) Are you feeling down, depressed or hopeless? 2) Have you lost interest in things you once found pleasurable? A "yes" answer to either should prompt an exploration of depression. "I believe in asking direct questions," says Kathleen. "It opens the conversation."

She also suggests asking your loved one to describe a typical day. "When does your mother get out of bed?" she says, by way of example. "Does she get outside? Does she see anyone? Is there anything she looks forward to during the day?"

If you continue to suspect depression, take action, including:

Schedule an appointment with the primary care physician (PCP). Don't simply suggest that the loved one go to the doctor, because inability to follow through is a symptom of depression. Make the appointment yourself and, if possible, accompany your parent.

Revisit medications with the PCP. Certain medical conditions and medications can contribute to depression, so make sure that your loved one is taking only the medication he or she needs. Depression can be a side effect of medications to treat hypertension, and conditions such as heart attack, stroke, hip fracture or macular degeneration are known to be associated with the development of depression. In addition, make sure all medications are being taken correctly. Ask your loved one to describe when and how she takes the medications, and check this against the prescribed instructions.

Call your loved one's insurer to see what the behavioral health benefits include. If it's hard for your loved on to get out, explore the possibility of in-home therapy. "We emphasize to our members that while depression might be new for you, it's not new for us," says Kathleen. "If you're feeling depressed, we can explore ways to treat it, including right in your home."

Schedule physical activity. If you take your mother shopping, don't drop her off at the door. If she can walk, have her take those few extra steps with you. Activity goes a long way against depression, including helping improve sleep.

Create opportunities for social activity, and follow through. "We are, like it or not, social beings," says Kathleen. In fact, a recent study by University of Chicago researchers found that extreme loneliness can increase an older person's chances of premature death by 14 percent. You can start small, with a daily walk to the apartment lobby. Also explore visits to nearby adult and social day facilities, which offer a range of social, cultural and health activities, including yoga, nutrition, arts classes and even some behavioral health services.

Ask what activities bring pleasure. If the answer is, "Nothing," explore further. Revisit past hobbies, and see how your loved one might return to them. Large-print books or books on tape are good alternatives for a book lover whose eyesight is failing. If your 80-something father loved big band music, get hold of an iPod and create playlists of his favorite genres. Can a photography passion be resurrected with an iPad or a smart phone?

"Remember that this is a population that grew up in a culture that didn't recognize and certainly didn't talk about depression," notes Kathleen. "Some of them don't really believe mental illness exists. It does exist, it's real, but the good news is that it's treatable. The road to hope begins with awareness."

In a future column, I'll explore how to recognize the differences between late-life depression and dementia, as well as between depression and normal bereavement.

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If you -- or someone you know -- need help, please call 1-800-273-8255 for the National Suicide Prevention Lifeline. If you are outside of the U.S., please visit the International Association for Suicide Prevention for a database of international resources.