What to Know About Late-Life Depression and the Challenges of Getting the Right Diagnosis
As you get older, you may find yourself becoming more relaxed and enjoying your grandchildren, hobbies or travel that were harder to find time for in your working life. A study published a few years ago in the Journal of Clinical Psychiatry even found that older adults tend to be happier than people in their 20s.
But that doesn’t mean that depression doesn’t find older adults, too. While estimates vary, many health experts suggest that about 17 percent of older adults experience depressive symptoms and around 7 percent could be diagnosed with major depressive disorder. For some older adults, depression is nothing new. It’s a condition they have carried with them for much of their lives.
Others may be dealing with depression for the first time—or the first time in many years. Regardless of when this common mood disorder first appears, when older adults experience it, the condition is known as late-life depression, and it can present a unique set of coping, diagnostic, and treatment challenges.
“Late-life depression may represent a recurrence of early-onset depression that may or may not have been diagnosed and treated earlier in life,” explains David Mischoulon, MD, PhD, director of the Depression Clinical and Research Program at Massachusetts General Hospital. “However, many people who have gone through their entire lives without getting depressed may experience a new-onset episode of depression later in life. Research suggests that about half or more of cases of geriatric depression represent new onset episodes.”
Risk Factors
As with depression at any age, late-life depression can develop as a result of biological, psychological, social, and other factors.
The biology of depression is complex, with a range of age-related health and physiological changes affecting depression risk. The neurotransmitter serotonin, which is commonly associated with depression, tends to diminish over time. Other neurohormonal changes can also develop as you get older, further raising the risk of late-life depression.
Older adults are also more likely to have chronic illnesses or physical health concerns that can affect their mental health. It’s not uncommon, for example, for depression to follow a diagnosis of heart disease, cancer, or other serious illness.
Psychological and social factors affecting late-life depression can cover events and circumstances from childhood through your later years. Research suggests, for example, that emotional neglect and abuse endured in childhood may result in late-life depression. Older adults who are lonely and more isolated than they used to be are also more vulnerable to the onset of late-life depression. Other factors that may raise the risk of late-life depression include having a dependent personality disorder, which can make people feel helpless and unable to make even simple decisions. Losing a spouse or experiencing some other form of profound grief may also contribute to depression risk.
Diagnosing Symptoms
Experiencing symptoms or exhibiting signs of depression can sometimes mask what is really going on, Dr. Mischoulon explains. For example, many older individuals take multiple medications, some of which cause side effects that mimic depressive symptoms. “Some medications for high blood pressure or for immune disorders, or hormonal treatments, may have a negative impact on mood, as well as cause sedation and cognitive difficulties, which may present as depression,” he says. “Likewise, older people often experience mild age-related cognitive decline, which is considered benign but could represent depression. Difficulties with memory or concentration can be symptoms of depression and, as such, it may be difficult to determine the cause without a more thorough assessment.”
Dr. Mischoulon adds that depressive symptoms, in general, are not always specific to major depressive disorder and may be caused by medical illnesses, neurologic illnesses (such as dementia or stroke), and medication side effects, as well as reactions to personal losses that become increasingly common with advancing age. “All of this makes depression challenging to diagnose and treat in older individuals,” Dr. Mischoulon says. “If an older individual is presenting with depressive symptoms, a careful diagnostic assessment needs to be done to rule out any medical causes before a diagnosis of major depressive disorder is made.”
Treatment Challenges
Under any circumstances, depression treatment can be challenging. But for many older individuals, there can be added complications. There may be a greater tendency to experience stigmas related to depression and mental illness in general, Dr. Mischoulon says. “Consequently, older people may be reluctant to seek help for depressive symptoms, or may have difficulty accepting the diagnosis as well as following treatment recommendations. A good understanding of the patient’s beliefs about depression and mental illness is important to obtain during the diagnostic interview. In cases where the diagnosis is hard to accept, patient education and reduction of stigmas is very important.”
He adds that many older individuals may have cognitive difficulties that may make it difficult for them to fully understand their condition and the rationale for treatments. “Again, patient education and, where possible, support from family or other caretakers can be helpful in promoting adherence to treatment,” Dr. Mischoulon says. “Finally, it is important to remember that antidepressant medications may cause side effects and may also have adverse interactions with other medications that the patient may already be taking. Side effects can cause great discomfort in the patient, and often lead to nonadherence with treatment. Doctors who prescribe medications for depression need to be mindful of this and always inquire with the patient and/or family members about whether the patient may be experiencing adverse effects.”
Education and counseling are usually the keys in helping older adults better understand depression and why it is important to treat it. “In particular,” Dr. Mischoulon says, “helping patients understand that depression is not a personal weakness or character flaw is very important in the promotion of successful treatment.”
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