Fixing The Blues:Tackling Late-In-Life Depression

BY MARY ANN LITTELL

Darkness visible. Well-known author William Styron coined this phrase to describe the way he felt while in the throes of a depression so severe it made him contemplate ending his life. It hit him at the age of 60, at the peak of his career. He wrote, “The pain is unrelenting and what makes the condition intolerable is the foreknowledge that no remedy will come….It is hopelessness even more than pain that crushes the soul….” Styron was successfully treated, but only after seeing many different physicians and eventually being hospitalized. His book, Darkness Visible, recounts his experience with the illness.

Styron is not alone. Approximately 5 to 15 percent of older Americans suffer from depression in any given year, making it the most common mental health problem of seniors. The percentage rises to 25 percent among those who have a chronic illness, and up to 50 percent in elderly people living in nursing homes, according to the American Association for Geriatric Psychiatry (AAGP).

In spite of these statistics, depression among seniors is underrecognized and undertreated.

Some 30 percent of geriatric depression is missed, says Stephen M. Scheinthal, DO, director of clinical geriatric psychiatry at UMDNJ-School of Osteopathic Medicine (SOM)’s Center for Aging. “Most older people with depression don’t see a geriatric psychiatrist or geriatrician,” he notes. “They go to their primary care doctor instead. Their blood pressure, diabetes, heart, weight, and a variety of other things are checked, but the depression is often not picked up. It’s not from lack of caring by the doctor, but simply lack of time.”

Signs of Depression

“Many patients and physicians regard depression as a normal part of aging, but it’s not,” says psychiatrist William Reichman, MD, professor of psychiatry and senior associate dean for clinical affairs at UMDNJ-Robert Wood Johnson Medical School (RWJMS). The symptoms include a persistent sadness lasting two weeks or more, excessive anxiety, weight changes, irritability, sleeplessness, and withdrawal from activities that were once enjoyable. Complaints of lack of energy and initiative are also common. While everyone has sad or low days, most people are able to carry on with regular activities and feel better in a short period of time. In contrast, those suffering from depression feel unable to function.

Cognitive problems may be present in older people suffering from depression, but should not be confused with dementia. Older people who are depressed often describe problems with motivation, concentration and decreased attention span.

Geriatric patients who suffer from other illnesses often take many medications, and signs of depression may be masked by the drugs’ side effects, or these drugs may even cause depression themselves. In addition, they must cope with serious issues, simply by the nature of being old. They may be fearful of losing a spouse, being alone, losing independence, loss of income and having to live in a nursing home.

“Depression isn’t something that can be evaluated quickly,” points out Reichman. “As a physician you really have to ask questions and devote a lot of time to it.” Scheinthal agrees, saying he generally needs two 50-minute office sessions to pinpoint the diagnosis. Screening tools can be useful in helping primary care practitioners make an assessment. One of the best is the Yesavage Geriatric Depression Scale, which poses a series of 30 “yes or no” questions about a patient’s state of mind and mood. A short form of this scale, also very effective, includes 15 questions (see page 31). The scales are widely available in many languages on the Internet, so primary care physicians can access and use them quite easily. If a physician is pressed for time, trained office staff can administer the test, or it can even be self-administered.

Depression in older people follows different patterns. In some, it occurs for the first time late in life. In others, it’s a recurrence of an earlier depression. “Those with late onset depression are often reluctant to see a specialist,” says Lee Hyer, PhD, professor of psychiatry at RWJMS. “They’re not familiar with mental health services and are uncomfortable seeking them out. On the other hand, older people who have experienced depression at earlier ages are more likely to see a specialist if it recurs.”

Such was the case of 88 year old Richard Blake (not his real name), a retired businessman from Brooklyn, NY. Blake is in overall good health and had always led an active life, exercising regularly and helping his son manage the family business. He says he had a few “breakdowns” while in his 30s and 40s. “But the worst one came in 1990, when my wife died,” he says. “It’s difficult to explain how I felt. There was a sense of overwhelming sadness, and I didn’t want to do anything. I stopped driving, stopped socializing, stopped exercising, and pretty much stopped functioning.”

Over time, Blake saw several psychiatrists and was prescribed many different medications, but nothing helped. One physician told him there was no hope for him and he might as well enter a nursing home. Finally, his married daughter, who lives in New Jersey, suggested he move in with her family. She had heard about Reichman’s work with elderly patients and thought he might be able to help.

Trial and Error

Reichman, a geriatric psychiatrist and past president of the AAGP, says a medical school elective sparked his interest in geriatric medicine. As a medical student at SUNY–Buffalo School of Medicine in New York, he started an “Adopt a Grandparent” program which paired medical students with senior patients at an upstate VA hospital. He did his residency and a fellowship in neurodegenerative diseases of the elderly at UCLA.

“Finding the right treatment for depression takes a great deal of detective work,” he says. “You have to look at what has been tried in the past. Did the patients receive psychotherapy, and for how long? Are they socially active? Are their families supportive? Did they take any medications? Which ones, and for how long?”

“Though there are some new drugs on the market for depression, it has not received the attention—or the research dollars—of other mental disorders, for instance, dementia,” says Scheinthal. SSRIs (selective serotonin reuptake inhibitors), which include Zoloft and Paxil, and TCAs (tricyclic antidepressants) have been used for several years with great success to treat depression. But they don’t work for everyone. Among the newer drugs are Celexa and Lexapro (a single isomer of Celexa and made by the same company). Another medication, Remeron, is dissolvable and therefore good for older people who have difficulty swallowing. Remeron is also believed to enhance sleep and appetite.

In Blake’s case, none of the newer medications had helped. However, Reichman’s detective work revealed that one category of antidepressants had not been tried: MAO (monoamine oxidase) inhibitors. He explains that with the development of new antidepressants, this category of medications has fallen out of favor among many physicians. “These older medications are not prescribed as much because they’re perceived as obsolete, but they can be very effective, particularly with resistant depression,” he says.

Blake began taking the MAO inhibitor Nardil. Right away, he noticed an improvement in his mood and spirits. “It was like a miracle drug,” he recalls. “I couldn’t believe it. After all this time, I was finally feeling better.” Before too long, he began driving and socializing again. Today, 13 years later, he is still taking the drug and has not had a relapse of the depression that so crippled him. “I have low days every once in a while, like anyone else,” he says. “But now I’m always able to get back up.” He drives, takes classes, exercises, and travels to Florida each winter, where he has an apartment.

Gerontologists agree that finding the right treatment is not a matter of luck. It involves patience, trial and error, and a good rapport between physician and patient. The good news is that help is widely available in the Garden State. “New Jersey is so fortunate,” says Scheinthal. “The resources for growing old in the state are truly excellent.”

One of them is the Center for Aging at SOM, which specializes in medical care for those over 55. The center sees some 6,000 patients annually through its ambulatory care services, and treats many others at approximately 20 nursing homes in south Jersey. Patients come for primary care as well as consultative services. The staff includes the largest group of geriatricians in the state, three geriatric neurologists and two geriatric psychiatrists: Scheinthal and David McComb, DO, both graduates of SOM.

This year the Center received designation from U.S. News and World Report magazine as having one of the top 10 geriatric fellowship training programs in the country. The training is multidisciplinary, offering medical, dental and mental health treatment (including psychiatrists, psychologists, and social workers).

Psychotherapy, Medication, or Both?

“The most satisfying aspect of geriatric psychiatry is that the physician canmake a difference,” says Reichman. “If you can find the right approach, most patients respond very well.”

A challenge is getting treatment to patients who need it. “Many older people won’t seek psychiatric help even when referred,” says Hyer. He estimates that only one-third of elderly patients follow through on a referral. Others may come once or twice, and never return. In general, older patients are more comfortable in a primary care clinic setting, with many services grouped under one roof. “That’s why we are working to develop better health care models, with integrated care, so older people don’t have to travel here and there to get what they need,” Hyer adds.

As director of geriatric services at UMDNJ’s University Behavioral HealthCare (UBHC) in Edison, Hyer and a team of gerontological specialists see older patients with multiple problems. They also have an outreach program with senior centers and housing, outpatient clinics and nursing homes. UBHC offers a wide range of geriatric mental health care, including neuropsychological testing, dementia assessment and management, and both group and one-on-one psychotherapy for depression.

Most patients with late onset depression require longer-term care. A patient coming to the center first receives a complete workup to rule out certain disorders (including dementia and psychosis). If depressed, they are assessed for cerebrovascular risk factors, since depression with first onset in old age is often associated with vascular changes.

“This biologically-based depression can be particularly resistant to treatment,”says Hyer. MRI is often used to determine the presence of lesions in the brain that can indicate depression, particularly the late-onset variety. The presence of these lesions is related to poorer outcome. Additionally, there are other risk factors, including high blood pressure, diabetes, and heart problems of all types. Other factors leading to depression at late life include social or environmental stressors (such as the death of a spouse or parent).

There are some 10 or 15 designations of depression. One of these, depression executive dysfunction syndrome (DEDS), is also related to an organic depression, and occurs at late onset. It is more resistant and less responsive to medications. Says Hyer: “If you look at 100 first-time older depressives, one-third to one-half have what I call ‘garden variety depression,’ which is easier to treat; one-third have DEDS; and the remainder fall somewhere in between.”

There are several psychotherapeutic approaches to treating depression. Interpersonal therapy (IPT) focuses on teaching people how to better manage relationships, cope with grief, and resolve disputes. Problem solving therapy (PTT) is just what it sounds like: learning skills for analyzing and resolving problems. CBT, or cognitive behavior therapy, the most common, addresses behavior, moods and thinking. “CBT has been around for 40 years,” says Hyer. “Its basic premise is: Bad behavior is a function of bad thinking.”

So what is bad thinking? Hyer offers this scenario: “You’re elderly and live alone. Your grown daughter calls and says she’s left her husband. You blame yourself for her problems and feel depressed. Your feelings of sadness are a direct result of those thoughts.”

CBT attempts to alter behaviors by changing thoughts. Through some 16 to 18 group sessions, or “modules,” patients are educated to feel a sense of why they are becoming depressed, and given the tools to change their behavior. The sessions are run by Hyer and postgraduate students as part of a University-wide graduate internship and postdoctoral program. They can be helpful for those with mild to severe depression. Patients also have the option of individual sessions as well.

CBT at Work

Charles Stokes (not his real name) is one patient of Hyer’s who has benefited from CBT and IPT. The 79 year old college professor had no history of depression until January 1995, when he and his wife of 40 years were divorced after a seven-year separation. He describes the split as amicable. “I’m not sure whether the divorce contributed to my depression, or vice versa,” he says. “It did not leave me in a happy state, but I was satisfied it was the best thing for both of us.”

Stokes has seen more than his share of family tragedy. His father died the day he was born, in fact while his mother was giving birth to him. His ex-wife had been married before and had a son by this previous marriage. Stokes and the child were not close. As an adolescent, the stepson had severe substance abuse problems requiring hospitalization. He became estranged from his mother and stepfather, and they have not heard from him in years. “The illness of my stepson and the tensions that this produced were detrimental and harmful to my marriage,” he says.

After the divorce, Stokes moved from his home in northern New Jersey to a small apartment near the college where he taught. “The first year, I was busy teaching, and things seemed to be okay,” he recalls. “But when I retired in 1996, I became very lonely and unhappy.” To counter this, he went to singles events and spent a great deal of time in his local library. His occasional sleep problems, triggered by severe allergies, now blossomed into full-blown insomnia. He felt tired all the time and had no energy. “I stayed in my apartment more and more,” he says. A self-described computer buff, he spent hours on the Internet, in isolation.

Finally, he went to the sleep disorders clinic at RWJMS, where he was told his real problem was depression. Hyer says there is a close correlation between sleeplessness and depression, with some 45 percent of older depressives suffering from insomnia. Stokes was referred to Hyer and began seeing him regularly for CBT and IPT. However, unlike most depressive patients, he did not take any medication, fearing side effects.

After a year and a half, Stokes was less depressed and sleeping better. He began exercising at a gym, taking short trips and volunteering one day a week at a local hospital. Today, he continues to see Hyer periodically, and has no plans to stop. He is more active and involved with other people, including his ex-wife. They speak on the phone once a week and occasionally spend time together.

While Stokes went “drug-free,” most patients do well with a combination of therapy and medication. Though many depressives derive great benefit from psychotropic medicines, there is disagreement over combining them with CBT. Some experts believe the medication actually interferes with the recovery process, while proponents say they have an energizing effect on patients. Within the next few years Hyer plans to do a study separating medications from CBT to compare the effectiveness of each alone.

Defining Recovery

How is recovery from depression evaluated? There are no biological markers for defining recovery, and most measures of depression are based on younger people. There are assessment laboratories for evaluating depression, but there too, the tests are based on younger people. So it’s difficult to measure scientifically.

“Depression in older people is different. As one example, they tend not to negativize as much as younger people,” says Hyer. In general, with the exception of a few scales (like the GDS or General Depression Scale), most of the measures for depression are normed on younger age groups. Additionally, the components that assemble to form depression at later life may be different in a nursing home, community, or clinical outpatient setting.

“As a general rule, older people tend to have a lower positive affect, and their negative affect is not very high,” Hyer continues. What this means is that generally, the highs are not as high, and the lows not as low, as with a younger person. An elderly person who is not depressed may be upbeat, but is seldom euphoric. So sometimes, a patient saying he or she feels better is enough of an indicator.

Following a trial of CBT or other psychotherapy, many patients will in fact say they feel better. Some, like Charles Stokes, will remain on some form of therapy indefinitely, as the socialization and “booster” sessions are empowering and stabilizing. Most people who took medication will continue to take it.
Reichman says, “Those who are depressed—regardless of their age—need to have opportunities to feel good. Sometimes they have to push themselves to access activities and focus on social involvement as a way of feeling better.”

Frequently the therapy itself is a positive social activity. “We surveyed patients who took the CBT modules, asking them what they liked: the modules or us,” Hyer says. “Their answer was they liked us! Developing a relationship with the therapist is a common factor in successful therapy.”

Says Reichman: “The bottom line is, collaboration and open communication are vitally important, and are the best way to evaluate recovery.”