The issues surrounding depression in the elderly are complicated, often quite serious, and even more often, misunderstood. As a result, older adults and the elderly can be unfairly treated by loving family members who just don't understand that their loved one needs something different. This is the first of the three-part series examining various aspects of these concerns. 

Any successful treatment of depression in the elderly begins with an accurate, comprehensive diagnostic work up to look at one's total physical, social, and psychological picture. Based on that information there are several options for treatment from which you and your doctor can chose. Any treatment will depend on a variety of factors. Are you having an acute episode? Is the depression related to a bipolar disorder of long-standing? What other medical conditions need to be taken into consideration? Is this depression so severe that it has become life threatening?

Medication

The decision to use medication depends upon the physician's preference and the person's physical and emotional condition. People with both major or less severe depression often respond well to antidepressant medication. The use of these drugs, as with any drug therapy, involves a careful weighing of both the benefits and risks.

Before taking an antidepressant drug, your physician will take into account all aspects of your health and prescribe the drug least likely to cause any serious side effects. The kind of medication prescribed, the duration of its use is highly individualized. Low initial doses are given to people of all ages to allow the body to adjust to the medication slowly. In older adults it takes six to twelve weeks for a drug to reach therapeutic levels. For this reason an older person starting on medication needs to be patient. Symptom relief may not be immediate.

Like many medications, antidepressants have side effects that might prohibit their use with older people. Different drugs can create different effects from minor ones, such as a dry mouth, to more serious ones, such as a drop in blood pressure, when a person changes position. However, there are several drugs that are well tolerated by older adults that may cause little or no side effects. Your physician will choose one which offers the greatest benefit and least likelihood of risk. You should not be discouraged if your medication needs to be changed until the proper one is found.

Psychotherapy

It has only been in recent years that psychotherapy has been used with greater and greater frequency with older adults. Previously there has been a historical bias against psychotherapy as a treatment for older people. This is due in large part to the fact that Freud felt that it was too difficult to work with older people. He believed that as people grew older they became too rigid to benefit from psychotherapy. This myth has shaped perception about older people and psychotherapy for decades.

Some people speculate that many of the issues that older people face toward the end of their lives were too difficult, even for Freud, to deal with. There has also been the mythology that depression was a natural part of the aging process and physicians did not refer their older patients for treatment. More recently it has been felt that a variety of psychotherapeutic approaches are of great benefit to older people.

There are many different approaches to therapy. Very often psychotherapy with older people is problem oriented. The focus is to help people to deal with immediate issues such as the loss of a loved one, a change in residence, or retirement. Others approaches can focus on making behavior changes such as learning to adopt new views on life or restructuring daily activities. Family Therapy is also very helpful in assisting older people and their children in working out unrealistic expectations, guilt, and any unresolved issues that parents and children may have with each other.

Electroconvulsive Therapy (ECT)

Just the mention of this therapy can bring shudders to people and memories of movies where people are strapped down against their will while a roomful of people hold them down. It is true that ECT may have been misunderstood and misused in the past but modern ECT, is a safe and effect method of treating depression. The procedure is done in a hospital under the care of a physician trained in its use. ECT can be the treatment of choice for depression in the older people if cardiac factors or severe, life threatening depression precludes the use of medications. In many cases ECT works well when other treatments have failed. ECT can include a series of treatments over a period of time and may be followed up with medication and /or psychotherapy.

Things to Remember

• Don't be ashamed of your illness. Depression is one of the more treatable diseases. One beginning a course of treatment has every reason to be hopeful.

• Find a mental health provider who is knowledgeable in treating older patients. It can be a psychiatrist, a psychologist, or a social worker. A psychologist and a social worker will work in conjunction with a physician if medication therapy is warranted.

• Discuss your treatment plan with your therapist.

• If medication is recommended don't be afraid to ask why that medication was chosen, what the possible side effects might be, and how long the side effects are likely to last?

• Always take medication as prescribed.

• Keep your goals in mind. Whatever the cause of the depression, the treatment goals should include decreasing symptoms, reducing the risk of relapse, improving the quality and pleasures of life and improving your overall health and well being.

For help in finding a geriatric practitioner you may contact:

The American Psychiatric Association
1400 K Street NW
Washington DC 20005
202-682-6220
They will refer you to a branch of the Association in your state for an appropriate referral.

American Psychological Association
750 First Street NE
Washington DC 20002
800-374-2721
They will refer you to someone in your area.

National Foundation for Depressive Illness
P.O. Box 2257
New York, New York 10116
Publications and referrals available.

Continued in Part Three

Updated 7/18/08
by Marlene M. Maheu, Ph.D. 

Emily Carton MA, LISW, is a licensed social worker who works with Elder Options, a private care social service firm in the DC Metropolitan Area. She is also an is an intern in Bibliotherapy at St. Elizabeth's Hospital in Washington D.C.