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Treating Mild Depression in Older Adults

Dr. Bernadine Healy talks to us about a new study in this week's The Journal of the American Medical Association (JAMA) that reports that anti-depressant medication is more effective than psychotherapy for treating mild clinical depression.

Until now, some researchers believed there was insufficient evidence to prescribe antidepressants to patients with mild depression. But the JAMA reports on a study that compared the effectiveness of Paroxetine, brand name: Paxil with psychotherapy for treating mild depression in older adults. The study found that Paxil showed moderate benefit for depressive symptoms and mental health function in elderly patients with mild depression and more severely impaired elderly patients with minor depression.

The benefits of Paxil plus psychotherapy were not studied, but a JAMA editorial suggests that combination would be more effective than the drug alone.

In a few decades, one in four people will be 65 years or older. In that context, the common mental health conditions of late life - such as dementia, delirium and depression command attention because of their relationship to disability, diminished quality of life, and the demands they place on family members and other caregivers.

Even among older people with symptoms not meeting diagnostic criteria for major depressive disorder ("MDD"), depression is associated with physical illness, functional impairment, and death. According to the World Health Organization (WHO), major depression was the fourth leading cause of disability worldwide in 1990, and will soon be second only to heart disease.

Background Information on Depression in Older Adults

About 6 million American adults suffer late-life depression. And only about 10% of them get treatment. Depression, especially in older people, is often misunderstood. It's not about temporary feelings of sadness or grief that follow the loss of a loved one or an illness. Healthy people go through the grief and come out of it with whatever resources they have. But clinical depression can be overwhelming, and leave victims unable to function normally or care for themselves.

Older people are particularly vulnerable. Only 13% of our population are 65 or older, yet they commit 20% of all suicides. Surprisingly, depression is not more common among older people, but is less often diagnosed. It is a common misperception that depression is an inevitable part of aging, due to the loss of loved ones or health problems.

According to Dr. P. Murali Doraiswamy, an associate professor of psychiatry at Duke University Medical Center, "When bereavement tends to persist beyond several months of loss, one should suspect depression. The clear message is that depression is not a normal reaction to either aging or physical illness."

Diagnosing depression among older people is not easy. hile as much as 50% of depression is missed in the general population, the estimate is as high as 80% among older people, according to the Alliance for Geriatric Psychiatry.

Not everyone complains of sadness when he or she is depressed, especially the elderly, Doraiswamy says. Signs of depression may appear as the classic symptoms: loss of interest in activities, crying, sadness, weight loss or gain, and changes in appetite and sleep. Or it may present itself in more subtle ways, such as disturbances in concentration and memory loss or physical complaints such as minor aches and pains, confusion, or a loss of energy and enthusiasm for activities once enjoyed.

Seniors don't always use the same language for describing depression as younger people. "You can ask them straight out if they're depressed and they'll say 'no,' but if you ask them have you thought about harming yourself, they'll say 'well yes,' " says Dr. Dan Blazer, a psychiatrist at Duke. "Or you'll ask them, 'Are you eting all right?' And they'll say 'no.' "

Friends and family members can play a crucial role in getting a depressed person help. "Often older people will not initiate coming on their own but would come with a family member," says Blazer, noting that family members bring in nine out of 10 older patients he sees for depression. "What we often will suggest is that if the family recognizes this to be a problem that they basically insist that (the older person) has got to go to see a doctor."

Treatment for Depression

Nearly 80% of depressions are treatable. Psychotherapy and newer antidepressants known as selective serotonin reuptake inhibitors (SSRI) mean there are more treatment options than ever. Unlike older tricyclic antidepressants, which tended to be habit-forming, produce unpleasant side effects and require close medical supervision, new drugs such as PAXIL, Zoloft and Prozac are thought to be safer. Physicians can determine what therapy will work best after reviewing the patient's medications and medical history.

The patient also needs to stay on medication for several months. The current recommendation is to stay on medication for at least six to nine months after feelings of depression have gone away, Doraiswamy says.

Previous studies have suggested that regular physical exercise may be associated with reduced symptoms of depression. To assess the effectiveness of an aerobic exercise program compared with standard medication for treatment of MDD in older patients, Duke researchers conducted a 16-week study. One hundred fifty-six men and women with MDD (age, > or = 50 years) were assigned randomly to a program of aerobic exercise, antidepressants (sertraline hydrochloride), or combined exercise and medication. Subjects underwent comprehensive evaluations before and after treatment.

Researchers found that exercise trining program may be considered an alternative to antidepressants for treatment of depression in older persons. Although antidepressants may facilitate a more rapid initial therapeutic response than exercise, after 16 weeks of treatment exercise was equally effective in reducing depression among patients with Major Depression.

Q: What causes Depression?

Depression has a biological component. In the elderly there can be a depletion of brain chemicals. Also neurological illnesses, like Parkinson's, or early Alzheimer’s which can present as depression and can be confused with depression. These were people with mild depression, either short term or long term. "Dysthymia" is chronic mild depression that lasts longer than 2 years.

There can be environmental factors that prompt depression, as you get older, you lose friends and loved ones, lose control of your environment. However, depression is not a normal reaction to aging, and because of that mindset, it has probably been under-diagnosed in older people.

Q: What are some of the symptoms of depression?

Depressed mood, loss of interest or pleasure in usual activities, appetite change OR weight change, sleep problems, restless or sluggish, fatigue loss of energy, feel hopeless or worthless, thoughts of death or suicide, indecisiveness

Possible Causes of Depression--biological triggers, social triggers - isolation, stress, grief, loneliness, physical wellbeing and serious disabilities.

Q: Is that a failure of General practitioners to recognize depression?

Many older people deny depression could be a problem for them. It's almost a stigma. When they come in to see a general practitioner, it is usually a family member who takes them or prompts them to go. And a doctor can only make a diagnosis if the patient comes to his attention. It could be they themselves aren’t bringing up signs of mood disturbances to the attention of doctors. A five-minute blood pressure heck doesn’t give doctors time to assess the whole patient. You have to live with the person for a while to know what's not normal for that person. A doctor can’t tell if they’ve suddenly changed from the norm. It's not that anybody’s a failure, it’s a perception that depression is a part of aging. This report stresses that we should be alert as physicians and as caregivers to the fact that depression is NOT a normal part of aging, and there are treatments can make a lot of difference.

Q: Hasn't EXERCISE been investigated as a possible treatment for Clinical Depression?

Absolutely. It’s been shown across the board that exercise can be beneficial. So can social contacts and spirituality. Not just a doctor rendering talk therapy or writing a prescription. Exercise is a well known (treatment). One of the things that jump out of this study is that even if you do NOTHING, people get better.

The placebo effect works about a third of the time.

Q: If one-third get better by doing NOTHING, why should doctors do anything?

Suicide. The pain of depression deteriorates to suicide. You can't just say, "pull up your socks and go forward" without treatment because some people will "snap out of it." But being depressed can affect your immune system, and even heart disease.

Q: What should one do if s/he suspects depression?

One should be alert to signs. As a caregiver we should be ready to call a loved one's doctor and say, "I'm bringing my family member in. I think there are signs, and would you address them?" This may not come up if a doctor is looking at blood pressure. But if the doctor is alerted about crying or sleep or lack of life enjoyment, then the doctor can confirm or deny and think about treatment. The most important thing is to be observant and then make a call to the doctor. Particularly in an environment where clinic visits are shorter and shorter. And every primary care doctor and every internist has the obligation to deal with these issues.

Q: In about 20 years, one in four of us will be 65 or older. Are we all going to take daily Paxil supplements like we pop vitamins?

However benign, we shouldn’t take medication we don’t need. Medications should be used precisely. By the way, these drugs are not forever. After someone has been on these for 6 months, you stop. Depression therapy is not a permanent state of mind. The goal is to give treatment to get through depression. As we age, yes, we face increased risk for many diseases, both of mind and body. There will be therapies that will be available. But there is no evidence that "Prophylactic Paxil" will prevent this from happening. These are real illnesses, not phony ones. The longer we live, we face more increased risks. Isn’t it great we have treatments for virtually all of these illnesses? The odds are we’re all going to be on something.

Q: Is there harm in taking Paxil to PREVENT Depression?

As we get older we are going to face illnesses of the mind and body. The goal of getting older is to get older healthier. Paying attention to mental health NOW will be a boon to you in later years. Understanding that social contacts, exercise, and optimistic attitude will influence your mood. Dealing with stress, and learning to cope with disappointments in life.

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