Late-Life Depression: Coming Out of the Shadows

The good news is that with the appropriate medication and/or psychotherapy, 80 percent of depressed older adults will improve.
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Can you solve this medical riddle? What strikes one in five Americans, raises their risk of death and disability, and doubles their health care costs?

If you said depression, congratulations, you were correct. If you said heart disease (America's leading cause of death), you were also correct.

These devastating diseases have much in common. The difference is that unlike heart disease, depression frequently goes undetected and under-treated, particularly in older adults.

Why should this be? Partly because depression, like old age itself, is widely misunderstood. I shudder when I conduct hospital rounds and hear the throwaway line: "I'd be depressed, too, if I were 80 years old and had her problems."

While it is true that some aspects of aging, such as the death of a spouse or a chronic disease, would challenge anyone's mood, younger people suffer from depression more frequently. And coping skills increase with age. Late-life depression can be harder to recover from but typically represents the return of a problem that first appeared in youth or middle age. And two recent studies now suggest that at least 40 percent of depression risk is genetic and thus not age-determined, even if it occurs in old age.

Depression at any age is a health issue just as much as heart or any other organ disease. It should not be dismissed as an inevitable result of aging or overlooked just because many seniors exhibit different, less obvious symptoms, or don't want to admit feelings of sadness.

For one thing, the stakes are too high. Depression increases the risk of death, not just from suicide, but also from other conditions. For example, patients who became depressed after a heart attack were four times more likely to die than heart attack patients who were not depressed. And it's expensive: depression costs this country at least $83 billion annually in lost productivity and increased medical expenses.

The good news: depression's very real pain is treatable, and the "before and after" can be as dramatic and uplifting as any medical success story. Listen to how Robert, age 75, described his recovery: "When I was depressed, it felt like I was walking very slowly through a deep swamp. When they bumped up my medication dosage, the next day it was like somebody drained the swamp."

A New Look At An Age-Old Problem

Most depression will be diagnosed and treated in a primary care setting. The first step is spotting it. We know, however, that many cases are still being missed, in part because nearly half of older patients who committed suicide had seen a physician within their last month of life. Although we do not know that the suicide would have been preventable, the presumption is that intervention would have been of use, and we need further study.

For older adults, the Welcome to Medicare visit (which mandates depression screening) is one valuable opportunity that more seniors should take advantage of. (Depression screening is unfortunately not part of the annual Medicare wellness visit.)

Doctors and patients should also be aware that some medications can actually cause depression or make it worse for older adults. These include some anti-hypertensive drugs, corticosteroids, hormones (e.g., estrogens), sedatives and medicines used to treat Parkinson's disease.

Be Prepared To Change Treatment

There are many effective treatments for late-life depression, including over 25 FDA-approved antidepressant medications. All antidepressants can have side effects, but if patients do not improve, or if they experience side effects with a particular medication, this does not mean that another medication would not be helpful. So be prepared to change treatment.

Even so, older patients should avoid certain antidepressants because of bad side effects and interactions with other drugs. These include certain drugs in the SSRI class (selective serotonin reuptake inhibitors) and one of the first drugs to come on the market nearly 50 years ago, amitriptyline (Elavil). SSRIs can cause low blood pressure leading to dizziness and falling, disrupted sleep and appetite, reduced ability of the liver to metabolize other drugs (fluoxetine [Prozac] is the worst offender), increased risk of cancer and increased fractures.

In spite of evidence that certain drugs are generally not recommended for older patients, many are still being given the wrong antidepressants.

Still, antidepressant drugs are the mainstay of treatment for depression regardless of age, and it is almost always possible to find a medication that is well tolerated. In most circumstances, escitalopram (Lexapro), citalopram (Celexa) or sertraline (Zoloft) are preferred for older patients. Matching the least dangerous side effect profile with a patient's coexisting diseases and medications is a one-at-a-time clinical calculation.

For patients who prefer non-drug treatment, several counseling interventions, such as cognitive behavioral therapy, interpersonal therapy or problem-solving treatment can be helpful when provided by a trained therapist.

Proven Winners In Defeating Depression

Evidence-based depression care has an excellent track record and promises to integrate well into patient-centered medical homes or primary care in accountable care organizations (ACOs). Some leading programs include:

IMPACT(Improving Mood-Promoting Access to Collaborative Treatment) is a team-based approach in which a depression care manager (typically a trained social worker, case manager or nurse) works with the older adult and his/her primary care provider to educate, track outcomes and deliver evidence-based treatments, including antidepressant medications and counseling with consultation from a team psychiatrist.

In the largest randomized controlled trial for depression ever conducted in the United States, IMPACT was proven twice as effective as usual depression care. As Walter Borschel, L.C.S.W., of Kaiser Permanente Southern California, one of the organizations participating in the study, put it, "these findings are so dramatic that if they were about any other disease ... it would be on the front page of every newspaper in the country."

PEARLS (Program to Encourage Active Rewarding Lives for Seniors) focuses on minor depression or dysthymia, and uses problem-solving treatment (PST). PEARLS provides "house calls" to homebound elderly and connects people with existing community-based programs.

Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) serves older adults who also have chronic illnesses or functional limitations. Rather than introducing a separate care manager, Healthy IDEAS works by embedding depression care in existing case management or caregiver support programs.

A lesser known and less understood option is electroconvulsive therapy (ECT). Sometimes incorrectly referred to as "shock therapy," ECT is the single most effective antidepressant therapy we have for severe depression, especially in patients who have failed drug treatment or already must take a large medication cocktail for other diseases. With high effectiveness and modest short-term side effects on memory, it is also often the safest treatment.

The good news is that with the appropriate medication and/or psychotherapy, 80 percent of depressed older adults will improve. So just because an initial treatment (be it medication or counseling) has not been effective, don't give up.

As Margaret, 72, said after receiving treatment through IMPACT, "nothing is so dramatically negative anymore... I appreciate each day a little more. Despite everything, life is so much better."

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