Major depression, a significant predictor of suicide in elderly Americans, is a widely underrecognized and undertreated medical illness. According to one study, many older adults who commit suicide have visited their primary care physician very close to the time of the suicide: 20 percent on the same day, 40 percent within one week, and 70 percent within one month of the suicide. These findings point to the urgency of enhancing both the detection and the adequate treatment of depression as a means of reducing the risk of suicide among the elderly.
Older Americans are disproportionately likely to commit suicide. Comprising only 13 percent of the U.S. population, individuals ages 65 and older account for 20 percent of all suicide deaths, with white males being particularly vulnerable. The highest rate is for white men ages 85 and older: 65.3 deaths per 100,000 persons in 1996 (the most recent year for which statistics are available), about 6 times the national U.S. rate of 10.8 per 100,000.
More than 2 million of the 34 million Americans age 65 and older suffer from some form of depression. In contrast to the normal emotional experiences of sadness, grief, loss, or passing mood states, major depression is extreme and persistent and can interfere significantly with an individual's ability to function. Less severe forms of depression are also common among the elderly and are associated with an increased risk of developing major depression. Depression, however, is not a normal part of aging.
Both doctors and patients may have difficulty recognizing the signs of depression. In an effort to improve recognition of the illness and promote discussion about depression during medical visits, the National Institute of Mental Health (NIMH) has developed this cue card for older adults.
Research and Treatment
Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters-chemicals used by nerve cells to communicate-are out of balance. Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better treatments.
Antidepressant medications are widely used effective treatments for depression. Existing antidepressant drugs are known to influence the functioning of certain neurotransmitters in the brain, primarily serotonin and norepinephrine, known as monoamines. Older medications-tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)-affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to side effects or, in the case of MAOIs, dietary and medication restrictions. Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for patients including older adults to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.
Psychotherapy is also an effective treatment for depression. Certain types of psychotherapy, cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), are particularly useful. More than 80 percent of people with depression improve when they receive appropriate treatment with medication, psychotherapy, or the combination.
In fact, recent research has shown that a combination of psychotherapy and antidepressant medication is extremely effective for reducing recurrence of depression among older adults. Those who received both interpersonal therapy and the antidepressant drug nortriptyline (a TCA) were much less likely to experience recurrence over a three-year period than those who received medication only or therapy only.
Studies are in progress on the efficacy of SSRIs and short-term specific psychotherapies for older persons. Findings from these studies will provide important data regarding the clinical course and treatment of late-life depression. Further study will be needed to determine the role of hormonal factors in the development of depression, and to find out whether hormone replacement therapy with estrogens or androgens is of benefit in the treatment of depression in the elderly.
NIH Publication No. 99-4593