• Introduction
• Module 1: Substance Abuse in Older Adults
• Module 2: Supervision Specific to Older Adults
• Module 3: Depression in Older Adults
  • Overview
  • Video
  • Lecture Notes
  • Classroom Learning Activities
  • Written Assignments
  • References
  • Evaluation
• Module 4: Caregiving for Older Adults
• Acknowledgements

Module 3: Depression in Older Adults > Lecture Notes

Aging and Mental Health

• There are an estimated 430,000 adults aged 65+ with one or more serious mental health conditions in metropolitan New York City
• This population includes individuals with long-term psychiatric conditions, and those with late life diagnoses such as depression and anxiety, cognitive impairment (e.g., dementia and Alzheimer's disease) or substance abuse disorders
• The most prevalent mental health conditions among older adults are:
• Depression
• Dementia
• Paranoia
• Anxiety

Late-Life Depression

• Depression in older adults is a significant public health problem
• Depression is one of the most common (and most well-researched) mental disorders in older adults: Prevalence ranges from 1% in physically well individuals to 50% in those living with medical illness
• Over 2 million individuals over the age of 65 (or 5% of the 34 million older adults in the United States) suffer from some form of depressive illness
• Among community dwelling older adults, an estimated:
• 27 % experience significant depressive symptoms
• .1 -   1.8% experience major depressive disorder
• 20 % experience significant anxiety symptoms
• Most common diagnosis: Major Depressive Disorder
• Prevalence rates differ according to residence: 1-3% in community settings; 5-9% in primary care; 12-30% in institutional settings (Unutzer et al., 1997)
• Rates of depression are significantly higher among medically ill or frail elders (10-43%) (Steffans et al., 2000); Rates are also higher among women and Latinos, and they increase with age
• Depression affects overall functioning: For example, elders who are depressed take longer to recover from hip fracture or a stroke and medical hospital stays among older adults who are depressed is often twice as long as those who are not depressed; Untreated depression can lead to greater disability
• Older adults are more likely to complain about problems with memory and problem-solving than feelings of depression.  This may lead physicians and other professionals to assume that they have dementia (pseudodementia) instead of depression.
• Depression can be persistent, intermittent or recurrent, and result in significant physical and psychological comorbidity and functional impairment
• Depression is also the most common psychological consequence of caregiving for elder family members; Among caregivers for older adults with dementia, depression rates are as high as 52%, nearly 3x the rate among non-caregivers of the same age (Tennstedt, 1999)
• Depression is a spectrum disorder and ranges from subsyndromal depression (mild or subclinical depression) to dysthymia and major depression.  

Subsyndromal depression

• Subsyndromal, or mild depression is a level of depression that does not meet the criteria for dysthymia or major depression as defined in the Diagnostic Manual of Mental Disorders (DSM IV-TR).  
• High rates of subsyndromal depression are reported among elders.  An estimated 13%-27% of community-dwelling elders and as many as 50% of nursing home residents suffer from mild depression.

Masked depression

• Elders may be depressed without verbally expressing feelings of depression; this is known as "masked depression."  
• Elders with "masked depression" may:
• Complain of vague physical pain, bodily discomfort, sleep disturbance, and problems of memory,
• Show signs of apathy, and
• Withdraw from others without expressing mood changes.  

Dysthymia

Diagnosis of Dysthymic Disorder
Summarized from the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition

1. A person has depressed mood for most of the time almost every day for at least two years. Children and adolescents may have irritable mood, and the time frame is at least one year.
2. While depressed, a person experiences at least two of the following symptoms:
1. Either overeating or lack of appetite.
2. Sleeping too much or having difficulty sleeping.
3. Fatigue, lack of energy.
4. Poor self-esteem.
5. Difficulty with concentration or decision making.
6. Feeling hopeless.
3. A person has not been free of the symptoms during the two-year time period (one-year for children and adolescents).
4. During the two-year time period (one-year for children and adolescents) there has not been a major depressive episode.
5. A person has not had a manic, mixed, or hypomanic episode.
6. The symptoms are not present only during the presence of another chronic disorder.
7. A medical condition or the use of substances (i.e., alcohol, drugs, medication, toxins) do not cause the symptoms.
8. The person's symptoms are a cause of great distress or difficulty in functioning at home, work, or other important areas.

Major Depression

Diagnosis of Major Depressive Disorder, Single Episode
Summarized from the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition

1. The person experiences a single major depressive episode:
1. For a major depressive episode a person must have experienced at least five of the nine symptoms below for the same two weeks or more, for most of the time almost every day, and this is a change from his/her prior level of functioning. One of the symptoms must be either (a) depressed mood, or (b) loss of interest.
1. Depressed mood. For children and adolescents, this may be irritable mood.
2. A significantly reduced level of interest or pleasure in most or all activities.
3. A considerable loss or gain of weight (e.g., 5% or more change of weight in a month when not dieting). This may also be an increase or decrease in appetite. For children, they may not gain an expected amount of weight.
4. Difficulty falling or staying asleep (insomnia), or sleeping more than usual (hypersomnia).
5. Behavior that is agitated or slowed down. Others should be able to observe this.
6. Feeling fatigued, or diminished energy.
7. Thoughts of worthlessness or extreme guilt (not about being ill).
8. Ability to think, concentrate, or make decisions is reduced.
9. Frequent thoughts of death or suicide (with or without a specific plan), or attempt of suicide.
2. The person's symptoms do not indicate a mixed episode.
3. The person's symptoms are a cause of great distress or difficulty in functioning at home, work, or other important areas.
4. The person's symptoms are not caused by substance use (e.g., alcohol, drugs, medication), or a medical disorder.
5. The person's symptoms are not due to normal grief or bereavement over the death of a loved one, they continue for more than two months, or they include great difficulty in functioning, frequent thoughts of worthlessness, thoughts of suicide, symptoms that are psychotic, or behavior that is slowed down (psychomotor retardation).
2. Another disorder does not better explain the major depressive episode.
3. The person has never had a manic, mixed, or hypomanic episode (unless an episode was due to a medical disorder or use of a substance).

Risk Factors for Depression

Biomedical risk factors:

• Chronic physical illness and conditions
• Chronic physical pain
• Neurological or cognitive deficits
• Poor nutrition

Psychological and social risk factors:

• Multiple losses (e.g. loss of loved ones, loss of social roles, and financial decline)
• Adverse life events and stress (e.g. bereavement, forced retirement, trauma),
• Social isolation and lack of social support
• Lack of socioeconomic resources and income (poverty)
• Societal oppression and discrimination
• Past history of depression or alcohol and other substance abuse

Depression and Co-occurring Medical Conditions

• Medical conditions that produce depressive symptoms include: Parkinson's disease, Alzheimer's disease and dementia, rheumatoid arthritis, thyroid dysfunction, diseases of the adrenal glands, strokes, heart disease, hypothyroidism, vitamin deficiencies, cancer, HIV disease, and chronic infection
• Medication interactions can also produce symptoms of depression
• It is important to distinguish between symptoms related to medical conditions or medications, depression, delirium or dementia, and changes related to normal aging
• Psychological comorbidities include anxiety, substance abuse and eating disorders, borderline personality disorder and somatization (Stephanis & Stephanis, 1999)

Depression and Co-occurring Substance Abuse

• 1 out of 3 people with depression suffer from some form of substance abuse or dependence
• Life events that can trigger depression (i.e., the death of a spouse or partner, loss of status, and chronic health problems) can also lead to substance abuse
• Social workers should be aware that alcohol and medications that are prescribed for conditions such as insomnia, anxiety and chronic pain can be used by elders as a way to counteract feelings of depressionw

Impact of Gender, Race and Ethnicity

• More women than men suffer from depression and anxiety disorders.  Women are more likely than men to express feelings of sadness.  Men, on the other hand, are more likely than are women to mask feelings of depression with alcohol and drugs.  
• Changes in hormone levels during menopause can impact depression in women.  
• Men tend to be affected by financial and work-related stressors while women are more reactive to events occurring in their social networks.
• Older minorities are less likely to receive mental health services.
• The recognition, definition, experiences and expression of depressive symptoms differ among people of different races and ethnicity.  Mental health services have not been sensitive enough to these differences.
• It is important to understand how culture and ethnicity affect emotional disorders. The ways in which people present symptoms are often influenced by culture. Professionals must be careful of using terms such as 'depression', 'sadness' and 'anxiety' in eliciting or describing clients' symptoms because clients may have other ways of expressing symptoms of depression.
• The way in which different racial and ethnic groups interpret and present symptoms of illness may be a factor in the varied levels of depression.
• Ethnic elders are underrepresented in epidemiological studies.  
• African American, Asian American and some Latino groups report physical symptoms of depression while non-Hispanic whites frequently report dysphoria.

Assessing Depression: Symptoms of Depression in the Elderly (Medline Plus, 2008)

• Common symptoms:
• Overwhelming or persistent  sadness, anxiety, "empty" mood
• Depressed affect: Loss of interest or pleasure in common activities
• Decreased energy, fatigue
• Eating changes or problems; Unintentional weight gain or loss
• Change in sleep patterns, or sleep disturbances :
• Difficulty falling asleep (initial insomnia)
• Multiple awakenings throughout the night (middle insomnia)
• Early morning awakening (terminal insomnia)
• Feelings of hopelessness, worthlessness, helplessness
• Abnormal thoughts, excessive or inappropriate guilt
• Irritability, agitation, frequent outbursts of temper or crying
• Difficulty concentrating and memory loss
• Thoughts of suicide or death; Suicidal plans or actual attempt
• Importance of differential diagnosis that rules out depressive episodes based on co-occurring medical conditions or substance use disorders
• Commonly used assessment instruments with older adults include:
• Geriatric Depression Scale (GDS; Sheikh & Yesavage, 1986)
• Center for Epidemiological Studies Depression Scale (CES-D; Mojtabai & Olfson, 2004)
• Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960; Rapp et al., 1990)
• Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 1996)
• Primary Care Evaluations of Mental Disorders (PRIME-MD; Spitzer, et al., 1995)

Suicide

• Approximately 60% of all people who die by suicide suffer from major depression (if alcoholics are included, the rate rises to 75%) (AFSP.org, 2007)
• Suicide rates are higher in individuals over 65 than in any other age group (primarily among white men); Risks include depression, multiple losses and bereavement,  social isolation, physical illness, alcoholism and drug abuse, race/ethnicity (white elders higher rates than elders of color) and gender (males much higher rates)
• Suicide attempts are most likely to be successful after age 50 (Gelles, 2005)
• "Slow suicide": subtle, often undiagnosed, attempts to end one's life (e.g., self-starvation, medication overdose, etc.)
• Treatment: Take a proactive and direct role, focus on resolving current crisis, remove any immediate dangers (e.g.,  guns, stockpiled medications) and make short-term safety contract with suicidal individual; Involve others in individual's immediate social network by informing of suicide risk and safety plans
• Signs of suicidal intent (NOTE: Take ALL suicidal thoughts seriously, but assess for lethality by looking for the following):
• History of suicidal attempts, or family history of suicide
• A suicide plan (the more specific and feasible the plan, the higher the lethality)
• Stockpiling medications
• Sudden change of will or funeral plans
• Giving away possessions
• Sudden calm or peacefulness after long period of anxiety, agitation or depression
• Verbalizations about desire to die, or worthlessness of life (less frequent in older adults)

Treatment for Depression in Later Life

• Early screening, case management and collaboration with all involved in medical treatment is essential to appropriate management
• Use of integrated, interdisciplinary, geriatrically-trained health-care team is best practice with this population
• Evidence-based treatments include cognitive-behavioral, psychoeducation, interpersonal psychotherapy, integrated team treatment and problem-solving approaches as adjuncts to psychopharmacological antidepressants (i.e., SSRIs and tricyclics)
• Other promising treatments include exercise, cognitive bibliotherapy, reminiscence and mindfulness-based interventions;  ECT has been found to be helpful in cases where older adults are suicidal and unresponsive to medication and psychosocial treatments
• Depression is often a familial illness: Provide opportunities for support and respite for family members of depressed elders, and for caregivers who are themselves depressed

Communication strategies

• Communicate empathy and compassion through verbal and non-verbal encouragement
• Encourage and elicit expression of feelings, no matter how difficult they may be to hear
• Reflect content and feelings, and seek clarification of client concerns
• Mirror rate and volume of elder's speech; Use simple, concise and direct language
• Respect client's defenses as a survival mechanism
• Assess for depression and suicidality; Explore possible biological and psychological/social factors in depression
• Emphasize client strengths and positive self-statements
• Introduce short-term, manageable goals and tasks
• Use reality-testing and reminiscence tentatively -- may be too vulnerable
• Seek out supervision and monitor your own responses to the work; Make a self-care plan
• Be patient and expect recovery to be slow and intermittent
• Avoid:
• Cajoling, or trying to talk client out of depression
• Giving advice or being unduly directive
• Extensive probing or questioning, use of "why" questions
• Blaming client for being depressed

© 2008 Silver School of Social Work

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