Assessing And Treating Late-life Depression: A Casebook And Resource Guide

CHAPTER ONE

Setting the Stage

Older adults who become depressed often have a number of interacting problems, as well as personal resources upon which to draw. Marie’s challenges include coping with grief, physical discomfort, vision loss, decreased independence, distant social supports (children), limited access to affordable medical care, and tough decisions (like where to live). Her strengths include a long history of positive coping, strong relationships, and spiritual commitment. Helping clients like Marie means appreciating this complexity and being open to a range of interventions that can decrease depression and improve quality of life.

Who Is an “Older Adult”?

The definition of “old” seems to get older as we do. As people are commonly living well into their eighties and nineties, we apply the word at later and later ages. Even if we identify 65 as roughly the beginning of “late life,” in keeping with the start of social benefit programs, we recognize that, on average, the experiences of the “young-old” differ greatly from those of the “old-old.” The meaning of an individual’s age, particularly as relevant to understanding and treating depression, depends on the interaction of developmental, historical, and societal factors (Knight and McCallum, 1998).

People who have lived for 75 years, like Marie, have that many years of experience informing who they are and how they have coped with life’s ups and downs. They maintain an ongoing sense of themselves (i.e., as generally the same people they were at thirty) as well as an awareness of improvements and areas of decline. The years have likely provided them with some expertise, some perspective on “how the world works,” and some degree of self-acceptance (for better and worse). The years may also have led to a physical or mental slowing down, an increase in irritating aches and pains, and, for some, more trouble concentrating or thinking of the right words to say. However, the age of a person tells us little about his or her individual health, personality, or functioning–any particular 75-year-old could still be working successfully as president of a large corporation or, at the other extreme, could have multiple disabilities requiring nursing home care.

Being 75 also means having been born into a particular historical era and joining a particular generation, or cohort, who shared similar economic, sociocultural, and educational experiences. Marie and the rest of her cohort were raised with an entirely different relationship to the health care system than people born later; they were socialized to view doctors as authority figures who always knew best. With very different notions about mental illness and treatment, they did not often speak openly about emotional concerns and viewed psychiatric care as reserved for those who were truly “crazy”

Further, the generation born in the 1920s lived through events unimaginable to those born later–the Great Depression, World War II, the Cold War–and experienced societal megashifts as well–rapid technological developments, dramatic changes in family structures and communities, and increased ease and frequency of travel. Living through such times undoubtedly influenced their values and attitudes and approaches to solving problems; for example, unquestioning patriotism, frugality, and marital commitment were common ideals for that generation.

Finally, older adults in the United States face certain normative experiences: They are currently likely to become grandparents, exit full-time work roles, have decreased incomes, depend on Medicare or Medicaid for health insurance coverage, and face the loss of spouses, friends, and relatives to disabling illness and death.

What we know now about “aging” and “older people” is based largely on what we have learned from people born early in the twentieth century; of course, what we know about depression in late life is based on research and clinical experience with those same people. Given the complex interplay between adult development and historical context, it is difficult to predict how Baby Boomers and younger generations will experience aging or depressive illness late in life. With the aging population and predictions that rates of mental illness will be higher in subsequent generations of elderly, the need to understand the relationship between aging and depression–and to provide geriatric mental health care–is growing (Jeste et al., 1999).

A Biopsychosocial Theoretical Framework

Depression can be multiply determined, maintained, and treated. Attending to the interplay of biomedical, psychological, social, and systemic factors that affect geriatric depression allows for multiple avenues of intervention–psychotherapy, antidepressant medication, case management programs, and/or some combination of these and other treatments.

Marie’s case illustrates the importance of a biopsychosocial conceptualization of factors that relate to her depression. She was recently started on an antihypertensive medication that can cause depressive symptoms, and unstable blood sugars may affect her mood and energy. Also, she has a prior psychiatric history, with one episode of depression in her thirties. For the most part, she has been a woman who coped with stress and loss by taking action and getting involved with work, hobbies, and her community. But her options for such action have decreased with successive losses of her job, her husband, her best friend, and her mobility.

What are the implications of Marie’s feeling more dependent and less able to cope through activity? How accessible are her children for help and support? What about her needs for transportation and assistance with chores at home? What is her eligibility for affordable mental health services? What are her needs and wishes for future living arrangements? A comprehensive treatment plan will acknowledge and attempt to address this broad range of issues.

Pragmatic, Relational and Ethical Considerations

Communication

The critical ingredients for successfully engaging older adults into mental health care are the empathy and skill to communicate with clarity, kindness, and respect. False assumptions about the elderly all too often compromise how clinicians interact with them, however. It pays to question these assumptions.

Imagine visiting a doctor (or other health care professional) you had never met to discuss your concern that you’ve been uncharacteristically fatigued, and say you decided to bring a friend along for support. Imagine the doctor coming in to the examining room and asking your friend what seems to be the trouble with you. Or, imagine he is talking to you as if you were a child or not very bright.

Or, suppose you had trouble hearing and your doctor seems to be mumbling questions from behind his computer screen. Or, at the other extreme, suppose you could hear quite well but for some reason the doctor is shouting at you. And, how would you feel if you were anxious and thinking kind of slowly and, after being rapidly presented for five minutes with complicated information and treatment options, you were asked to decide which treatment you wanted and felt shy to ask the rushed doctor to explain further?

In general, the golden rule is a fairly good guide for communicating with older patients: Talk to them as you hope a doctor would talk to you. Communication should be adapted according to observations about the individual’s capacity to hear and see and grasp information. The reward is discovering, as students new to gerontology do, that even among frail elderly in nursing home settings, each body housing medical and cognitive problems contains an individual with a rich history.

Interprofessional Collaboration

Marie was somewhat unusual for someone of her generation in that she brought her concerns about depressive symptoms directly to the attention of her primary care doctor. The doctor was also somewhat unusual in appreciating the depressive symptoms expressed by his 75-year-old patient and offering her a treatment. However, he could not possibly address all of Marie’s contributing problems on his own. Plus, he may not have been aware that she could barely afford the treatment that he did offer. Depending on the most salient concerns, as well as the availability of services, Marie might benefit from consultation with one or more of these professionals: a social worker, psychologist, geriatric psychiatrist, community care nurse, dietician, low-vision rehab specialist, or others.

Good geriatric care often entails interprofessional collaboration, including coordination of care among different providers. In some settings, a geriatric care team is already in place, allowing for an interdisciplinary treatment plan to address the biological, psychological, and social aspects of the elder’s care. In many settings, however, such a team does not exist but can be informally put together with a few telephone calls and an attitude of cooperation that says, “How can we help each other to help this patient?” With the older adult’s permission, referrals can be made and information shared as appropriate.

Advocacy and Outreach

A final theme that guides our work with depressed elders is the relatively active stance we take vis-à-vis our patients’ care. This stance most often applies to cases in which the older adult has disabilities that affect her capacity to follow through with recommended treatments. While we never want to “take over” functions that an older adult can do for herself, thus creating unnecessary dependency, we do want to be alert to areas of limited capacity. For example, when an older adult with memory problems does not come in for her medical or mental health appointment, we call to see if she forgot and reschedule. For those who need reminders, we might employ the family’s help or, in the absence of such help, call the older adult the morning of her appointment to remind her. This approach is atypical for most care systems, where it is up to the patient to reschedule if they don’t show for an appointment.

This active stance is important in considering, for example, the older adult’s ability to take medications as directed, to get transportation to appointments, to live safely on her own, to obtain information about alternative medical treatments, and to access various systems of care. If an older client is having problems in any of these areas, we work to determine the cause of the problem and to optimize the client’s ability to access care and make decisions consistent with her values.

An important ethical issue in working with frail older adults is to maintain a balance between working to promote the elder’s autonomy while at the same time advocating for her safety (Haley and Mangum, 1999). In these situations, a comprehensive evaluation of the older adult’s capacity to make rational decisions consistent with her values is necessary (Moye, 1999). In most cases, depressed older adults remain capable of making rational decisions for themselves and we work as their advocates in this context, even if we don’t always agree with their decisions. In other cases, depressed elders are not capable of making rational decisions (e.g., due to advanced dementia or psychotic thinking secondary to depression) and in these situations we work as advocates to protect their safety.

The Book

Part I defines late-life depression (Chapter 2) and presents approaches to its assessment and treatment (Chapter 3), all in the context of our commitments to a biopsychosocial framework for conceptualizing it, a respectful relational stance toward the patient, and interprofessional collaboration.

Part II embodies fourteen case studies representing the range of presentations of depression in late life as well as a range of interventions in different care settings. Each is intended to demonstrate the positive potential for improving the older adult’s mood, functioning, and quality of life.

The appendices compile practical resources. They review (A) the use of antidepressant medication, (B) recommended assessment tools, (C) new models of integrated geriatric mental health care that promise to improve services, and (D) recommended readings, Web sites, and organizational resources.

CHAPTER TWO

Defining the Problem

Depression in late life takes many forms–in terms of severity, symptoms, and coexisting problems. Especially prevalent among older adults is minor depression, which is frequently experienced in the context of changing physical abilities. Usually, these “minor” depressive symptoms cause further, but avoidable, disability. For example, 82-year-old Bernice doubts she’ll walk comfortably again despite successful knee replacement surgery, and she feels it’s too much effort to bother with her physical therapy exercises. Brief psychotherapy to address her poor motivation and hopelessness can ultimately help her to walk into town every day as she used to, rather than sit inside feeling useless. At the other extreme, older adults can experience life-threatening psychotic and/or suicidal depression. Joanna stopped eating because she was convinced she no longer had a throat; she required inpatient hospitalization and electroconvulsive therapy to prevent her death (see Chapter 17).

This chapter provides an overview of DSM-IV depressive syndromes and their distinct implications for older adults, as well as of depressive syndromes particular to the geriatric population. It also reviews the risks for and costs of depression in late life. As the case studies in Part II will illustrate, late-life depression and its treatment vary according to coexisting problems (e.g., medical illness, chronic pain, dementia, alcohol abuse, grief, trauma), psychiatric history (e.g., history of depression or bipolar disorder), individual differences (e.g., gender, ethnicity, personality), and treatment setting (e.g., community versus nursing home). Comprehensive assessment, as emphasized in the next chapter, helps to guide a treatment plan that takes into account these various factors.

Prevalence and Cost of the Problem

Defining the extent of “the problem” is not easy and is open to some debate. We do know that the large majority of older adults are not depressed. We also know, based on results of the Epidemiological Catchment Area Study of the early 1980s, that a very small minority of older adults (1–2%) suffer from a DSM-III-defined major depressive episode within a given year; this rate is lower than for younger adults (3–4%) (Weissman et al., 1991). A relatively large gray area lies between “no depression” and “major depression.” A significant minority of older adults does report high levels of depressive symptoms that do not meet diagnostic criteria. For example, on a self-report depression rating scale, an older adult may admit to having trouble sleeping and concentrating, decreased motivation for activity, and diminished feelings of self-worth, but not have the number, intensity, or severity of symptoms to warrant a major depression diagnosis. From a diagnostic standpoint, these symptoms can reflect a related problem such as dysthymia or an adjustment disorder, or they may not fit neatly into any current diagnostic category. Rates of clinically significant depressive symptoms among older adults range from 10–15% in community settings to 25–30% in inpatient medical and long-term care settings (Blazer, 1994).

Some people argue that subsyndromal depressive symptoms in older adults represent normal, expected discouragement as opposed to a psychiatric condition amenable to treatment. We view this as a complex question. Certainly, late-in-life loss can bring sadness and chronic illness can bring changes in physical or mental activity, and these are normal experiences. On the other hand, depressive symptoms that have a negative impact on the individual’s health or functioning (e.g., that lead to the kind of poor self-care that can exacerbate chronic illness), and that have been found by researchers to be amenable to treatment, should be considered “clinically significant.”

The evidence is strong that depression, even minor depression, is costly to the individual and the society. In adults of all ages, depression relates to individual suffering, declining physical health, lost work, family burden, and increased health care costs (Johnson, Weissman, and Klerman, 1992; Judd et al., 1996; Wells et al., 1989). Let’s look in more detail at the relation of depression to excess functional disability, mortality, increased health service use, and individual suffering among older adults.

Depression causes excess disability in older adults. That is, whatever impact a chronic illness has on an elder’s functioning, depression is likely to make it worse (Bruce et al., 1994). Unfortunately, this can create a downward spiral in health, functioning, and quality of life. For example, Bernice–who developed depression in the context of grief and immobility secondary to arthritis and knee surgery–was less motivated to work on her rehabilitation exercises, more sensitive to pain, and more likely to isolate from friends who would normally encourage her. If these changes persist, she will likely become physically weaker and less confident in her ability to feel better, thus the downward spiral. A number of studies have shown that depressed patients are less likely to benefit from rehabilitation in the case of stroke, heart attack, chronic obstructive pulmonary disease, arthritis, hip fracture, and Parkinson’s disease (Katz, 1996). Other health implications of depression can include malnutrition, increased sensitivity to pain, and decreased likelihood of following through with prescribed medications or other treatments.