Everyone experiences the occasional blues or lethargy. But if feelings of sadness or tiredness occur more often than not, do not ignore them. It is important to pay attention to how long these emotional waves last, as they may signal something more alarming – depression.

Depression is not an easy topic to discuss. It is a real condition, and it can be treated. In older adults, depression can be even more tricky to understand.

We are here to help you recognize depression as an older adult and determine what treatments are most effective. Depression is not a normal process of aging. It is a misconception that depression inevitably occurs in older adults and is untreatable. Rather than ignoring the signs, let’s learn how you can treat depression.

How Do I Know I Have Depression?

Depression in older adults takes on various forms that differ from what’s observed in younger adults. Younger people tend to have more stereotypical signs of depression. Most older adults may not recognize that they are experiencing depression because of the popular belief that a person must only feel ‘down’ or sad in order to be depressed. Because of this stereotype, older adults dismiss important signs that actually point towards depression.

Being able to tease out whether you may be experiencing signs of depression requires close attention to changes in your daily life. Have there been changes in your routine? What physical changes have you noticed? Have you noticed yourself having new, unexplainable health complaints?

Believe it or not, a depressed mood is often not the main complaint among older adults experiencing depression. Signs of depression vary for each person. Knowing the common issues reported by older adults experiencing depression can help put things into perspective:

• Physical complaints such as fatigue
• Weight loss or gain
• Pain
• Multiple unexplained medical symptoms
• Memory loss
• Social withdrawal
• Refusal to eat, drink, or use medication
• Problems keeping up with self-care or hygiene
• New or increasing use of sedative medications or alcohol

Some experts disagree as to whether mild depression should be categorized as clinical depression in older adults. Despite these disagreements among clinicians and scholars, your personal concern for depression is most important.

Mild forms of depression are referred to as minor depression, depressive episodes, or depressive symptoms. Clinical depression, or Major depressive disorder (MDD), is a formal diagnosis that is made from a healthcare professional based on specific criteria. Whether mild or severe, both require attention and should be addressed.

The Giveaways of Depression

How do you know when it’s depression or just feeling a bit ‘down’? Symptoms and duration are the two giveaways. Admittedly, these may sound scary or even tough to hear. Consider these the ‘nuts and bolts’ to determine if depression is formally roaming around.

See below for the signs and symptoms:

• Depressed most of the day, nearly every day (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
• Significant weight loss or weight gain when not dieting, or daily decrease or increase in appetite
• Lack of sleep or too much sleep nearly every day.
• A slowing down of thinking and reduced physical movement (observed by others, not just subjective feelings).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or inappropriate guilt nearly every day.
• Diminished ability to think or concentrate, or indecisiveness, nearly every day.
• Recurring thoughts of death or suicide.

If you experience at least two persistent signs/symptoms during the same two-week period, mild depression may be present. If you experience five or more of the signs/symptoms during the same two-week period with either (1) depressed mood or (2) loss of interest or pleasure, MDD may be present.

Now that we understand the ‘nuts and bolts’ of depression, the truth is that the criteria listed above largely pertain to younger adults. Most scientists, researchers, and doctors don’t have a clear picture of depression in older adults.

Depression in older adults is often overlooked and not given the attention it deserves. This is largely due to the fact that depression gets quite muddy in older adults.

Recognizing Depression

Depression among older adults can be tied to the ‘chicken or the egg’ dilemma. Were you depressed before the several life changes during the aging process or did the several life changes lead to your depression?

As you get older, medical difficulties and emergencies will emerge. You may have new and complicated medication routines that annoy you enough to cause a headache in and of itself. Accepting that you won’t be able to beat your kids at a sport may just be around the corner. The loss of close friends and family will become more common.

• Did the new medical difficulties lead to giving up the activities that you love?
• Did the new medications cause a disturbance in your sleep pattern or change your mood?
• Are you accepting of the new physical changes of your body?
• How did you feel when you lost a loved one?

These are difficult questions to answer. There are no definitive answers, so researchers tend to look at the patterns in older adults who are suspected of being depressed. To better understand, let’s look at how to recognize depression among older adults:

• Women are typically more depressed than men
• Unexplained chronic sensation(s), such as pain, fatigue, shortness of breath, or weakness that is not otherwise explained by a medical condition
• Impairment or changes with cognition, such as memory, slowed thinking or thought processes, and forgetfulness
• Impairment with walking or doing daily tasks (e.g., grocery shopping, cooking, cleaning, bathing, toileting, self-hygiene)
• Lack of close social contacts
• Stressful life events (e.g., recent loss of a loved one)
• A previous history of depression
• Reduced energy and interest in life
• Irritability
• Feelings of hopelessness
• Poor sleep
• Excessive worry over health problems
• Having a major physical or chronically disabling illness
• Simultaneous use of many medications/drugs
• Having caregiving responsibilities for a loved one
• Excessive alcohol use
• Social isolation
• Transition from home to alternative living situation

Medical illness, anxiety, and disability coexist in older adults. Detecting depression thus becomes complicated. A positive force when dealing with depression is the involvement of family and friends.

A research study found that when family is involved, older adults follow the rules of treatment better, which ultimately leads to reduced depression. Friends and family are excellent resources for pointing out things about yourself that you may not recognize as signs of depression. You may initially meet them with resistance, but keep your door open when you’re ready for them to be involved in your care.

For more resources about family education and depression in older adults, visit familyaware.org.

Screening Tools for Depression

When healthcare professionals suspect depression, they often give questionnaires to help understand your condition. They sometimes give questionnaires during visits even if they do not suspect depression. Consider it as a ‘better safe than sorry’ approach to ensure that they do not miss an opportunity to treat or address undiagnosed depression.

In these questionnaires, you self-rate your responses to the questions that either ask for the presence or frequency of potential depressive signs and symptoms. The score will ultimately tell you whether you are high or low risk. The questionnaires are also used to track the progress of your depression if receiving active treatment.

As an example, Patient Health Questionnaire (PHQ-9) asks:

1. Over the last two weeks, how often have you been bothered by any of the following problems?
   • Little interest or pleasure in doing things.
   • Feeling down, depressed, or hopeless.
   • Trouble falling/staying asleep, sleeping too much.
   • Feeling tired or having little energy.
   • Poor appetite or overeating.
   • Feeling bad about yourself or that you are a failure or have let yourself or your family down.
   • Trouble concentrating on things, such as reading the newspaper or watching television.
   • Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.
   • Thoughts that you would be better off dead or of hurting yourself in some way.

Your responses for each question include:

• Not at all
• Several days
• More than half the days
• Nearly every day

2. If you checked off any problem in this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Your responses for this question include:

• Not difficult at all
• Somewhat difficult
• Very difficult
• Extremely difficult

Questionnaires become even more important because depression is underreported and stigmatized in older adults. A research study found that older adults underreport depressive symptoms due to memory problems.

Family members or caregivers often become the main source for identifying depression in forgetful older adults. Secondly, depression is underreported because it has a tedious rule-out process. Healthcare professionals need to rule other potential causes that mimic depression in older adults such as:

• Hypothyroidism: slowing down of an important hormone in your body responsible for metabolism. Symptoms include fatigue, constipation, weight gain, muscle weakness, pain, impaired memory.
• Anemia: low amount of healthy red blood cells in your body with main symptom of fatigue.
• Heart failure.
• Neurologic conditions such as dementia or delirium.

Older adults are more accepting of physical illness than a mental illness. The saying, “if you can’t see it, it’s not there,” holds no merit when it comes to depression in older adults.

Why is it so important to shift the attitudes and beliefs about depression in older adults? Research has shown that depressed people are three times more likely to not follow medical treatment recommendations compared to non-depressed people.

Not following medical treatment leads to a vicious circle of poor health, increased time in the hospital, and higher chances of depression. Stigma needs to be thrown out the door. Depression in older adults cannot be ignored.

Treating Depression

Treating depression is not easy and it doesn’t happen as often as it should, but it is possible. Most older adults do not receive treatment at all, receive lower-than-recommended doses of medications, or are treated for only brief periods. Two main treatments for depression in older adults involve pharmacological and non-pharmacological treatment.

Pharmacological Treatment

Antidepressants are the most popular medication for treating depression. Older adults have coexisting medical illnesses in addition to their depression that require their own medications. Combining multiple medications to treat medical conditions can cause further health problems.

What are some of the complications with anti-depressants?

• Contraindications: Antidepressants should not be taken if a condition or circumstance may pose further harm to you. Examples include a recent heart attack, glaucoma, or a recent liver implant.
• Poor drug to drug interactions: Treating multiple medical problems can increase unwanted side-effects.
• Gastrointestinal bleeding: Antidepressants can decrease your blood’s ability to clot, leading to risk of internal bleeding in your stomach.
• Hyponatremia: Common in older adults, there is a risk of abnormally low salt levels in the blood. This can lead to nausea with vomiting, fatigue, headaches, irritability, and weakness.
• Insomnia: Poor ability to sleep.
• Decreased appetite: This can lead to unplanned weight loss.
• Increase appetite: This can lead to unplanned weight gain.
• Sexual dysfunction: Experiencing issues with any phase during the sexual response cycle (e.g., excitement, plateau, orgasm, and resolution).

How effective are antidepressants? A study of antidepressants was shown to reduce a relapse or recurrence of depression up to 28 percent. Different types of antidepressants exist. The most often prescribed and considered the most effective are ‘selective serotonin reuptake inhibitors’ (SSRIs).

Discuss antidepressants with your primary care physician before you make any sudden changes to your medication routine. All medications you are currently taking need to be thoroughly reviewed by your physician. If not reviewed thoroughly, antidepressants can actually create new depression or worsen depressive symptoms.

Non-Pharmacological Treatment

‘Psychotherapy’ is a fancy way of saying you are treating a mental illness without the use of medication. Psychotherapy has proven to have similar effectiveness to antidepressants. For older adults with mild forms of depression, psychotherapy is recommended as the first form of treatment.

Why consider psychotherapy over antidepressants? Mentioned earlier, antidepressants come with a long list of potential risks. Psychotherapy, on the other hand, allows you to develop life-long skills to manage your depression.

This is particularly beneficial when it comes to depression relapses. You can use the learned techniques from psychotherapy rather than need a new prescription that will require another visit to your primary physician’s office.

What Forms of Psychotherapy Exist?

Cognitive behavioral therapy (CBT)

CBT’s goal is designed to give you the skills to change your irrational emotional responses by changing the way you think and behave. Several different skills can be learned under CBT:

• The first goal is to allow yourself to recognize and challenge your immediate feelings or behaviors about particular situations. Was it rational for me to yell at my kids because they want someone in the home to watch over me?
• The second goal is to get rid of your rash feelings by gathering objective information about a particular scenario or situation. I felt anger and disrespected initially. Were these accurate feelings? I had a fall the other day and my children just want me to be safe. They planned to have someone in the home to keep me safe temporarily. Maybe I shouldn’t have become angry or felt disrespected.
• The last goal is to come to a rational conclusion about a particular scenario or situation. My kids were actually just looking out for my safety to prevent another fall from happening. I actually feel grateful that they care about me. I should apologize and explain why I initially felt angry and disrespected.

Problem solving therapy (PST)

PST provides you with the ability to learn how to improve your coping skills with minor and major stressors in life. Four key strategies are included in PST:

• Learn how to define the source of your problems.
• Create a wide range of possible solutions to the identified problems.
• Individually go through each created solution such as a ‘pro-con’ approach, pick top solutions, and use your top solutions.
• Monitor how useful the outcomes were with the chosen solutions.

Reminiscence and life review (RLR)

RLR takes many forms, but the main goal is to decrease depression, increase life satisfaction, and improve taking care of oneself. Skills are developed to better deal with moments of crises, loss of loved ones, or life changes. Things to expect in RLR:

• Evaluate your own life experiences, both positive and negative. While you go through reconstruction of your life story, you will be coached by a therapist.
• Materials may be used to trigger memories. These can include old pictures, trophies, music, or things that hold value to you.
• Perspective will be a learned skill. Learn how to accept your life with a new perspective that does not provide you with regret, anxiety, or depressive thoughts.
• Develop resolutions to past conflicts.

CBT is the most studied and popular form of psychotherapy of the three.

Exercise

Another form of treatment that is often overlooked is exercise. For instance, a group exercise class is beneficial for improving depression in older adults by increasing social interactions, forming new relationships, and becoming part of a community. You may want to consider yoga, tai chi, and mindfulness meditation specifically for improving depression.

A combination of antidepressants, psychotherapy, and exercise can provide the greatest benefit for depression. Now that you have the tools, start the conversation. Don’t ignore depression nor let it dominate your life. By changing your perspective and using your newly acquired knowledge, you can beat depression.