Among older Americans, depression is a particularly serious public health problem affecting millions of individuals. It reduces their enjoyment of life and their productivity, strains family and social relationships and increases the number of medical visits. It is the main reason why seniors have the highest suicide rate of any demographic group.

Recognizing Depression

Everyone feels blue or sad sometimes, but persistent sadness that interferes with daily function may be true depression. Medically, the term depression really refers to several related disorders, of which three are the most important: major depression, which causes pronounced low mood and related symptoms; bipolar disorder, characterized by mood swings, with periods of extreme "highs" often alternating with "lows"; and dysthymic disorder, which causes generally milder low mood symptoms but persists for at least two years.

The formal diagnosis of most types of depression requires the presence of abnormal, sustained low mood and/or severe loss of interest and pleasure, plus some combination of the following symptoms: sleep disturbance, appetite or weight disturbance, physical and mental slowing or hyperactivity, energy loss, poor concentration, abnormal self-reproach and abnormal thoughts of death or suicide.

Depressed individuals may neglect their personal appearance or stop performing customary daily tasks. They may withdraw socially, sleep excessively or become angry and irritable. They can lose their ability to enjoy entertainment, hobbies and other activities that were once sources of pleasure. They can appear listless and forgetful.

One would think that depression would be hard to miss, but in fact the diagnosis is often overlooked, especially in the elderly. One reason is that many depression symptoms may be mistaken for indications of another illness such as cancer or a nutritional deficiency. Not infrequently, poor concentration and mental slowing lead to a suspicion of Alzheimer's disease.

Another reason is that symptoms may be written off as an understandable reaction to coexisting illnesses, or even to the aging process itself. Finally, many sufferers fail to seek help, either because they wrongly regard depression as a weakness or because the disorder itself robs them of initiative.

Overlooking depression can be a tragic missed opportunity. Most elderly suicide victims have communicated with others about their suicidal thoughts. About three-fourths of them have visited a primary care physician within the preceding month, and about two out of five have done so within the preceding week.

Treatment Issues

About 80% of depression sufferers gain improvement when treated. Medication is usually the first choice, and the development of new drugs has given clinicians more treatment choices than ever before. Psychotherapy is often beneficial, either alone or in combination with drug therapy. Electroconvulsive therapy ("electroshock treatment"), despite its negative associations, also helps some very severe or complicated cases.

One of the frustrations of treating depression is that optimal results often take weeks. Anti-depressant medications are slow to take effect, and dosage adjustments or medication changes are often necessary. Depression sufferers need lots of encouragement and reassurance to help them stick out the process.

A big mistake in treating depression is to quit too soon after improvement is experienced. To reduce the chances of relapse, most authorities recommend several months of maintenance treatment. When patients have a history of recurrent depressive episodes, indefinite treatment may be indicated.

St. John's wort, a plant containing several chemical compounds, appears of benefit in mild depression but probably not in moderate or severe cases. St. John's wort can dangerously interact with other medications. It is not regulated by the Food and Drug Administration, and the chemical composition of St. John's wort preparations can vary greatly. It is a myth that as a "natural" product it is necessarily safer than other alternatives.

Anyone who suspects he or she has depression should see a primary care physician to establish the diagnosis and obtain appropriate specialty referrals, if necessary. Someone who suspects a friend or relative has the disorder should encourage and assist the person to get attention. If confronted, the "black dog" can be driven off!

Where to get additional information:
Information for the general public, including print and online publications, is available from the following sources:

National Institute of Mental Health (301) 443-4513 http://www.nimh.nih.gov
American Association for Geriatric Psychiatry (301) 654-7850 http://www.aagpgpa.org
National Foundation for Depressive Illness, Inc. (800) 239-1265 http://www.depression.org

February, 2003