This article originally appeared in the September 2003 Harvard Health Letter and is provided courtesy of Harvard Health Publications.

Depression in old age

Most people, surveys show, become happier, or at least more serene, as they grow older. But that does not mean depressive symptoms and clinical depression necessarily become less common. They persist and recur, complicating all the ills of later life. The symptoms are similar in old age and in youth: fatigue; appetite loss; insomnia; difficulty concentrating; loss of interest in life or the ability to enjoy it; feelings of emptiness, guilt, sadness, and hopelessness; wishing for death; and thinking of suicide. The treatments, too, are similar. But there are some variations and complications that require special attention.

At any given time about 15% of people over 65 have significant depressive symptoms, and about 3% — the same proportion as in youth — are suffering from major depression. Another 2% have dysthymia, a form of depression with less severe but longer-lasting symptoms. More women than men are depressed at all ages, but later in life the ratio comes closer to 50–50.

To the common risk factors for depression in youth — heredity, chronic and acute stress, drug and alcohol abuse, lack of material support or emotional sustenance from others — old age often adds physical disability, chronic medical illness, cognitive decline, and bereavement, especially the death of a wife, husband, or life partner. People caring for a family member with chronic illness — particularly a dementing disorder — also have a high rate of depressive symptoms and clinical depression.

Depression, mortality, and physical illness
Even more in old age than in youth, depression is a killer. Suicide is one of the reasons. In men the rate of suicide rises with age; white men over 50, 10% of the American population, make up 30% of suicides. A psychological autopsy (see Harvard Mental Health Letter, May 2003) of 80 people who committed suicide at an average age of 68 found that 50% of them had a known history of major depression.

Depression and physical illness can also be a deadly combination. Depression — or at least depressive symptoms — are common in response to serious illness of any kind. Some diseases, including multiple sclerosis, hypothyroidism, lupus, hepatitis, AIDS, vitamin deficiencies, and anemia, may produce depression in a more direct biological sense. Drugs that can cause depressive symptoms include antihistamines, anti-anxiety drugs, blood pressure medications, steroids, and antibiotics. A careful medical history and physical examination are important before diagnosing depression at any age, but especially in the elderly.

Equally important, depression itself raises the risk of physical disability, physical illness, and death from physical illness. People with major depression often fail to get the medical care they need because of isolation, passivity, and pessimism. They complain more of pain and spend more time in bed than people with heart disease or arthritis. Depression raises the risk of death after a heart attack or stroke five times (see Harvard Mental Health Letter, April 2003), possibly because it triggers the release of stress hormones, causes heart rhythm disturbances, increases blood clotting, or weakens the immune system. In one study, depression raised the death rate in a nursing home by 50% over several years, independent of a resident’s physical health at the beginning of the study.

Drug treatment
Older people are often left out of controlled trials for the treatment of depression, especially if they are cognitively impaired or have serious medical problems. There is little controlled research on the treatment of dysthymia and minor depression (a milder form of major depression), which may be especially common in old age.

Still, enough evidence is available to convince experts that antidepressant drugs work equally well early and late in life. But older people usually absorb and eliminate drugs more slowly and are more sensitive to side effects. And they are often taking several medications, which raises the risk of dangerous interactions. For all these reasons, the rule in prescribing drugs for the elderly is to start at a low dose and raise it only gradually.

The preferred drugs, because of their relatively mild side effects and low overdose risk, are the selective serotonin reuptake inhibitors (SSRIs), for example sertraline (Zoloft) and citalopram (Celexa). The most common side effects are nausea, insomnia, nervousness, agitation, tremors, headache, and sexual problems. By inhibiting certain liver enzymes, SSRIs can raise blood levels of anti-anxiety drugs, antipsychotic drugs, and drugs that control heart rhythm (see Harvard Mental Health Letter, October and November 2000).

As many as 40% of older people taking antidepressants quit or repeatedly miss doses because of side effects, memory problems, or difficulty keeping track of complicated drug regimens. The best way to ensure that they continue to take their drugs is maintaining a good relationship with a physician. Involving a family member may also help.

Electroconvulsive therapy is effective for adults of any age and can be as safe as or safer than medications. It is used especially in cases of psychotic or life-threatening depression — patients who are delusional, suicidal, or refusing to eat and drink.

Psychotherapy
Meta-analyses of many studies show that psychotherapy in all its standard forms can be helpful for older people, especially if they are under severe stress, lack social support, or will not or cannot take medications regularly. The Division of Clinical Psychology of the American Psychological Association has described cognitive behavioral, psychodynamic, and interpersonal therapies as “probably efficacious” for late-life depression. As in younger people, the combination of drugs and psychotherapy is probably better than either treatment alone. In one study, 1,800 depressed people over age 60 were followed for a year. Half of them worked with specially trained nurses or psychologists and were allowed to switch between psychotherapy, drug treatment, or a combination of the two as needed. The other half received standard care, usually consisting of antidepressant drugs and monitoring. After a year, the first group had considerably fewer serious symptoms of depression.

The outlook
Many questions remain for research. Various combinations of drugs and psychotherapy have not been tested. More needs to be learned about how medical illness and physical disability complicate the treatment of depression in old age. Many experts believe that in judging the results of treatment, we need to pay more attention to functional disability and illness, rather than just the standard depressive symptoms.

Given the human and economic costs of late-life depression, it is most important that we ensure patients a better chance of getting help. Mental health and medical services should be better coordinated to reduce the burden of depression and physical illness and their mutual effects. Physicians and the elderly need to be better educated to recognize depression and take action. And everyone needs to understand that depression can be as serious a health problem as any of the more widely acknowledged diseases of old age.