Depression in Seniors: it’s subtle

“He says he’s depressed—but he’s just getting old,” a friend recently said to me about her father-in-law, who had just turned 80. The perils of disagreeing with a parent-in-law aside, my friend did inadvertently hit on something important: the difficulties we face in differentiating depression in later life from everything else happening to our bodies and minds as we age.

Major depression is a chronic, debilitating disorder projected to be the biggest contributor to global disease burden by 2030 in Western countries. It usually first appears in early adulthood, though adolescent depression (particularly among females) is not uncommon.

But that does not mean that depression doesn’t occur in later life. Indeed, up to five percent of seniors are estimated to suffer from clinical depression at any given time. For some, it may be recurrences of a depression that started earlier in life; for others, it may be new. In either case, treating these depressions is important because studies show that untreated depression can worsen outcomes for cardiovascular disease, stroke, pain, and certain dementias. It can also shorten lifespan. Not surprisingly, the National Institute of Health has classified depression in adults 65 and over as a major public health problem.

What to Watch For Unfortunately, several subtleties can complicate the diagnosis of depression as we get older. Here are some worth thinking about.

1. Even though the criteria for the disorder are the same across ages, depression at older ages doesn’t always follow the textbook. For example, while depression at younger ages is more common among females, the gender imbalance is much less in later life. Also, while depression in adolescence and early adulthood tends to run in families, late-life depression doesn’t. So the “my mother had depression, will I get it too?” sleuthing doesn’t work. And whereas earlier-life depression typically comes and goes in episodes, later-life depression tends to be more chronic. What this all means is that population-level patterns are less reliable guideposts when it comes to diagnosing depression among older individuals.

2. As reflected by my friend’s comment, symptoms can be difficult to disentangle from the ups-and-downs of daily living. As we age, we invariably develop more chronic diseases, use more medications, and have reduced memory and mobility. To be sure, these can sometimes themselves lead to depression. But they also add a layer of fog that clouds the ability to pick up on true depressive symptoms. Is she sleeping less because of depression or because of that new thyroid medication? Is he irritable because he is depressed or because they wouldn’t renew his driver’s license? The answer can vary by person and by situation, and it takes time and an experienced clinician to differentiate between these scenarios.

3. Even though low mood is a hallmark symptom, many older patients may experience other symptoms first. These can include insomnia, agitation, gastrointestinal problems, and loss of sexual interest. Mood changes may not emerge until later. This can make screening for depression challenging, for if our spotlights are so focused on mood disturbances, we may miss some of the other early warning signs.

4. Older adults may under-report mood symptoms even when they do occur. Some may believe that their symptoms are part of the natural course of aging. But there is also stigma about mental illness, which studies show to be greater in older populations. Sharing may be quite the norm for millennials, who grew up on social media, but those who came of age before conversations about mental illness became common may still be unable to channel the right language to express their symptoms. And this is truer still for some minority populations, where having a mental illness may be viewed as a dishonor.

How to HelpWhat can we do to help? As we live longer, medical schools are devoting increasing training on the specificities and subtleties of disease management at older ages. That’s a good thing. But meanwhile, what might my friend have done differently? Perhaps the next time her father-in-law says he’s been feeling down, she shouldn’t assume he’s just getting old. Moods come in many flavors, and yes, sometimes an older family member may just be having a bad day. But the take-home message is to not jump to that conclusion reflexively. Instead, ask them about what is going on, why they might be feeling that way, or if anything has changed recently. Keep a track of their daily activities — eating, sleeping, walking, talking, even complaining — so that changes from their normal baseline become easier to identify. And try not to dismiss symptoms that seem esoteric or don’t fit neatly together (e.g., too much sleep one day, too little the next).

When possible, invite them to consult a professional with experience in later-life mental health. This could be their general practitioner, or a psychiatrist or psychologist. The good news is that there are effective medications for depression — and although side-effects need to be managed more carefully in older populations, they still work.

The advantages of recognizing and treating depression early are myriad. As mentioned, leaving depression untreated can increase the risk for other adverse medical outcomes and death. But there is broader advantage, too. Improving mood increases hope. And hope increases motivation to seek treatment. Thus, successfully treating depression can have a spillover effect, with the potential to improve treatment outcomes and quality of life for just about every other medical problem.

Ardesheer Talati, Ph.D. is an assistant professor of clinical neurobiology (in psychiatry) at Columbia University Vagelos College of Physicians & Surgeons, and a research scientist at New York State Psychiatric Institute. For more information, contact adi.talati@nyspi.columbia.edu