You may hear a loved one or friend say, “I’m so depressed today” or “so depressed to hear that.” Comments like these and increased use of mental health terms in our day to day often indicate shifts in stigma related to mental health. However, true clinical depression episodes are very different from a bad day or the negative experience of hearing unwanted news.
In my clinical practice, I focus on the mental health of seniors, including the diagnosis and treatment of depression. In this article, I’ll answer questions like:
- Is depression a normal part of aging?
- What is clinical depression?
- The role of social connections and medical conditions
- Treatment and prognosis
Is depression a “normal” part of aging? Clinical depression in seniors
Seniors are not immune to depression, but contrary to perceptions sometimes portrayed in the media or day to day conversation (e.g., of older age bringing us the “blues”), clinical depression is not a normal part of aging. Most older adults experience a great deal of happiness and satisfaction in their lives. Seniors experience changes unique to this stage of life (e.g., retirement, parenting shifts, relocation) just like any that have come before, with possibly even more resiliency given previous life experience. I have worked with many individuals who seem surprised by how well they think they are navigating their older years, given previous perceptions that things would be difficult and “unfortunate” as they age.
Grief experiences also complicate how we view or understand depression in seniors. We can mistakenly view grief experiences, which can impact seniors more often than younger cohorts, as “depression.” Interestingly, however, someone recently in the throes of grief (i.e., within the first six months) cannot be diagnosed as experiencing clinical depression per psychiatric guidelines. Experiences of grief can mimic depression at times, but the reasons for the symptoms are important to note when considering a depression diagnosis.
Even though depression is not a normal part of aging, it can frequently be underreported and undertreated in seniors. This failure in diagnosis and treatment appears to be impacted by a few factors. One factor is that symptoms of clinical depression can look different in older adults. Older adults may experience physical pain as a depression symptom more frequently than other age groups. Physicians may not consider a depression diagnosis since physical pain is not traditionally noted as a symptom in psychiatry manuals. If you (or a senior in your life) are experiencing physical pain and some of the other depression symptoms below, it might be a good idea to mention this to your doctors. Additionally, sleep struggles or insomnia may be a more prevalent sign of clinical depression than in younger cohorts. Older adults may have many sleepless nights or extreme difficulties falling asleep while experiencing depression. Confusion or difficulty paying attention may initially be attributed to cognitive or memory decline when, in reality, it’s a symptom of sleeplessness due to depression. Although it is important for physicians to consider cognitive changes in patients, depression can impact our ability to concentrate or encode new memories. Due to some of the stereotypical ways of thinking about the “lows” that come with getting older, seniors and providers may incorrectly perceive depressive symptoms as a natural part of aging, not as a mental illness requiring treatment. Another key factor concerning the underreporting of depression in seniors is that those from older generations tend to be less open to sharing their distress and more in the “don’t share your feelings” mindset. On top of this, seniors may not seek help since they have not been informed that symptoms can improve with treatment.
There is one statistic worth noting related to the underreporting and undertreatment of depression in older adults. According to WHO data,1 more people 65 and older commit suicide than any other age group. Of those seniors who commit or attempt suicide, most have clinical depression. The suicide rate for those aged 80 to 84 is more than twice that of the general population.2 In addition, those who attempt suicide in this age group are more likely to die than younger people, and suicide attempt survivors have a worsened prognosis. While seeing these numbers may be jarring, I hope it allows readers to think a little more flexibly when considering lower mood, pain, sleep, and cognitive changes in older adults. I hope it also shifts some of the stigma and stereotypes that can impact diagnosis.
What is clinical depression?
An episode of clinical depression means that a person’s day to day functioning is significantly impacted. These functions can include getting things done and participating in daily activities such as eating, sleeping, bathing, socializing, parenting, and working. Those affected by such an episode experience significant changes in how they think, feel, and act. Also, to be considered clinical depression, symptoms need to be present for at least two weeks. Individuals I work with who are managing depression can experience a real sense of being stuck, lack the energy to do things they consider important, and get caught in thinking that leads to negative beliefs about themselves.
Here are the symptoms of major depressive disorder per the DSM5 (Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition):3
- Depressed mood most of the day, nearly every day (either subjective or observed)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day (observed)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
These depression episodes may be periodic or persistent for individuals diagnosed with a depressive disorder, and they can have thoughts that the situation is hopeless and unending. Overall, clinical depression is a serious illness that often needs treatment for symptom relief and a return to functioning.
Medical conditions and depression in seniors
The presence of chronic medical conditions and disabilities increases the likelihood and length of clinical depression episodes for any age group. Also, conditions that impact our cardiovascular or neurological systems (e.g., diabetes, heart disease, stroke, Parkinson’s disease, MS) can be associated with higher clinical depression rates. Those carrying a cancer diagnosis and experiencing cancer treatment also experience depression more frequently. There is a relationship between depression and these medical conditions, with one making the other worse. If depression is present, it can make it harder to rehabilitate or recover. Medications used to treat these conditions, and the side effects that may occur, further complicate matters and can contribute to depressive symptoms (e.g., weight gain, sleep changes, sluggishness). It is important to communicate closely with your treatment team to optimize your health and address these concerns.
Additionally, the CDC states that about 80 percent of older adults have at least one chronic health condition.4 With the greater risk of depression due to chronic illness, older adults can experience higher depressive episodes rates. However, depression is not something that usually starts later in life. It is more likely you experienced a depressive episode when you were younger. For those experiencing depression for the first time, it may be due to age-related declines in health or the conditions previously mentioned.
Social connection and depression
Shifts in support systems as we age, including the loss of loved ones (e.g., widowhood), relocation, and retirement, can contribute to social isolation and loneliness. Caregiving for a spouse or loved one can also add new demands that separate us from previous social engagements and routines. Social isolation and loneliness have been linked to many physical and mental health conditions, including depression.
On the bright side, seniors who take steps toward social connection improve their health outcomes, life expectancy, and depression risk. Social connection is a crucial safeguard for wellness and mental health regardless of other health-related factors and conditions. Despite the perceived declines in quality of life and social connection as we age, many seniors live very engaged lives and often expand and deepen their social relationships in their older years.
Treatment and prognosis for seniors managing depression
Seniors respond to treatment for depression as well as other age groups, including psychiatric medication management and therapy.
Antidepressants are often prescribed when seniors experience clinical depression, and it may take some time to find the most effective medication. Your psychiatric prescriber will likely want to consider medication options with the fewest anticholinergic effects, given the impact of these on cognition, confusion, and fall and fracture risk.
Within non-pharmacological options, a therapist will likely target ways of thinking or acting while you are in a depressive episode. As we age, we may develop more ingrained patterns or habits, making it challenging to identify what we can change. However, once we bring attention to how we would rather approach these moments, there is nothing about our age that makes managing our thoughts and actions more difficult. From my clinical experience working with older adults, the relief experienced by altering or breaking these less helpful depression-related cycles can feel quite empowering. It may also be beneficial to note that treatment for depression in seniors with chronic medical conditions or cognitive/memory struggles can still be very effective.
Here is more information on finding a psychiatric prescriber or therapist for seniors.
If there are related topics we can provide advice or information on, please reach out to us.