by Jessica Pitcher
Clinical depression is the same at every age, but for older people, who are actually more at risk of developing the illness, social stigma combines with isolation and physical deterioration, making treatment a much more problematic and multifaceted affair.
In the online literature of many geriatric psychiatry units, including the Institute of Geriatric Psychiatry at Weill Cornell Medical College, it is a common attitude that depression in older adults is simply a natural result of growing old, and even an expected one. “That’s a myth and it’s actually a prejudice,” argues Dr. Gary Kennedy, Director of Geriatric Psychiatry at the Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx. “Depression is not a natural consequence of aging, and it’s also not a natural consequence of physical illness.”
The National Alliance on Mental Health (NAMI) says that depression affects more than 6.5 million of the 35 million Americans aged 65 years or older, and is the single greatest risk factor for suicide in those over 65. “Older people are at a higher risk for depression, as they have to go through major life changes,” says Alexandra Greenfield, the Research Coordinator at the Weill Cornell Geriatric Psychiatric unit.
Helen Richman is one of many seniors in New York City who has dealt with the crippling effects of clinical depression. After having surgery to implant a pacemaker in her heart, she developed a debilitating tremor that ultimately planted her in a state of mental and emotional distress. While she jokes now about getting to skip the line at airport security, she reflects on her depression with gravity. “I was so sick, I was scared” she says. “I couldn’t deal with it.”
Kennedy explains that physical illness in older people often precipitates depressive symptoms, and if those symptoms are not treated, the emotional component can make the physical disability even more debilitating. “If you’re working with an older person with a psychiatric disorder, they very likely have a physical disorder too,” he says. Weill Cornell also states that depression in later life is the leading cause of disability, and will increase by 73 percent in 2020.
For Nancy Klein however, an independent clinical social worker and therapist, each person’s depression is very case specific. “The vast majority of my patients have a lot of unresolved early issues,” says Klein. “One woman came to me when she was seventy-three to improve her relationship with her husband, but really she was working on the damage caused by her father.”
Klein, who runs a High Functioning Psychotherapy Group along with her private sessions, reveals that for many of her clients, she is not their first therapist, meaning that their depression is not a direct cause of them getting older. She explains that young people with depression often have low self-esteem and a lack of self-worth, and that it is the very same case for older adults.
Nonetheless, Klein does feel that isolation and loneliness often plays a major role in triggering depressive episodes, whether or not the person had experienced them before. The death of spouses and friends, as well as a change of dynamic in their relationships with their adult children are some of the common factors at play. “It’s hard to make new relationships when you’re older,” says Klein. “When you have adult children, the boundaries change, and you’re also losing more and more of your contemporaries. All of these things conspire.” A 2007 Community Health Survey conducted by the city’s Department of Health and Mental Hygiene verifies this, finding that 16.9 percent (around 143,000 people) of new yorkers aged sixty-five and older are at risk for social isolation.
Kennedy explains that one of the key components for all psychotherapies is something called “self-activation,” meaning that you get the person going again and doing things of their own volition. “Even if you don’t find [the activities that you once enjoyed] pleasurable, you need to go back to that, because as your depression lifts this will reinforce your good spirits.”
Ester Gurian, a friend of Richman’s, feels grateful that she is physically well enough to keep her pocketbook filled with activities such as knitting and bingo. “One of my girlfriends loves reading and painting, but she has macular degeneration and now she can’t do these anymore,” she says. Gurian used to work for an investment bank, and says she is even busier now that she’s retired. Although both mentally and physically well, she is highly aware of the dangers of not being active. “If you keep busy, you don’t get depressed,” Richman chimes in. “I’d rather be active and do things.” It is as much a preventative measure as it is a means of treatment.
Klein is adamant that after sustaining losses all of their lives, the older population are often more resilient than we realize. Nonetheless, for older adults who are suffering from physical disabilities, such as many of Kennedy’s patients, resilience of character is often insufficient and potentially dangerous. On top of social stigma deterring people from seeking help, many patients reach full remission of their depressive symptoms, and so choose to cease treatment, resulting in a dangerous relapse of their illness. “They say [to themselves] that they’re fully well, and that ‘I don’t need to take the medication,’ and so they stop it prematurely,” says Kennedy.
Treatment with anti-depressants such as Selective Seretonin Reuptake Inhibitors (SSRIs) or Lithium, used specifically for manic depression, or bi-polar disorder as it is officially known, are commonly used alongside counseling and psychotherapy. A myth prevalent in the realm of psychology, however, is that anti-depressants become less effective the older you get.
“SSRIs are as affective in older persons as they are in younger persons,” explains Kennedy. “The problem is that most physicians in primary practice [general practitioners] are not prescribing them at an adequate dosage [for older adults].” He feels strongly that depression in the older population is just as treatable as it is with younger people.
While SSRIs can be taken in the same quantity whatever your age, Lithium, a drug which induces much more drastic side-effects has to be taken with greater care. As well as damaging the kidneys, lithium can cause difficulties with gait, thyroid function, and bone marrow. It also causes a sort of wild tremor in almost everyone who takes it, explains Kennedy. “[But] this is all relatively easy to monitor,” he says, “so the notion that lithium is too toxic for older adults is just not the case.”
Richman reveals that the anti-depressants she was prescribed made her nauseous, and that it was ultimately psychotherapy that helped her get better. “I helped myself a lot and listened to what she [her psychiatrist] said,” she says. “When you’re sick, you get frightened and you want everyone to help you do everything.” It was Richman’s son who pushed her into getting professional help. NAMI maintains that older people are more likely to seek treatment for physical problems rather than mental ones, and so it often takes the support and encouragement of family members for them to make that first step, as Kennedy contends.
Greenfield speaks of a recent study at Weill Cornell called “Open Door” that identifies barriers to the treatment of depression in older adults. Divided into two categories, external issues such as transportation and financial expense, and internal issues such as stigma and embarrassment, the goal of the study is ultimately to discover the best means of collaborative problem solving between the likes of social workers and case-management agencies. For Greenfield, Kennedy, and other professionals in the field, it is this holistic approach to treatment that will make dealing with and overcoming depression that much more realistic.
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