A depressing trend: Growing old and feeling down

12/16/2013

Depression is alarmingly common in older Americans. It’s highly treatable, but a number of obstacles, led by a nagging generational stigma surrounding mental health, often stand in the way of proper care.

About 20 percent of people ages 55 and older experience mental health concerns, federal data show. And depression, by far the most common condition, is treatable in 80 percent of cases.

But the majority of older Americans do not receive the mental health services they need, according to the American Psychological Association. Less than 3 percent of adults over age 55 see a mental health professional.

Experts say this must change.

“We have to do more,” says Richard Birkel, senior vice president at the National Council on Aging. “Depression is not just a separate condition. It’s the key to treating so many other health conditions. Depression will, in fact, short-circuit other treatments. You’ve got to tackle it to really get the patient’s cooperation and engagement in working on other health conditions.”

With Americans ages 65 and up accounting for 13 percent of the population and estimated to grow to 19 percent by 2030, according to the Health and Human Services’ Administration on Aging, a significant number of lives are affected by the mental health of older people.

We talked to health care professionals about how and why our approach should evolve.

The risks: At its most severe, depression is a major risk factor for suicide. The elderly have a slightly higher suicide rate (14.22 of every 100,000 people) than the general population (11.16 per 100,000), according to the Centers for Disease Control and Prevention, and men 65 and older die from suicide at more than twice the national rate.

“Depression is not simple sadness,” says Birkel, who has also served as the executive director of the National Alliance on Mental Illness. “It’s a very serious illness.”

And its effects are many. Even mild depression lowers a person's immunity and can compromise the body's fight against infections and cancers, according to the American Psychological Association.

"Depression is a co-traveler with lots of other health conditions," Birkel says. "The guidelines now for treating diabetes urge physicians to test for depression. Same with heart disease, hearing loss, eyesight loss.

"You have to get them out of that cycle of feeling defeated, feeling like they have no energy and can't take care of themselves."

The hurdles: "Most older people grew up in a generation taught to tough it out and suck it up," says Dolores Gallagher-Thompson, associate professor at the Stanford University school of medicine and director of the school's Older Adult and Family Research and Resource Center. "It was believed that one should be able to handle one's own problems. Or if you needed help, you would go to family or friends or a clergy member."

Sadness and anxiety, Birkel says, are often viewed as personal failures by older adults.

"Today's seniors grew up in a society where mental health issues were not freely discussed, and there was great shame associated with mental illness," he says.

Early impressions of mental health treatments only added to the stigma.

"The availability of psychotherapy and other mental health services was not great before the ‘60s, when President Kennedy formed a series of federally funded mental health centers," Gallagher-Thompson says. "Prior to that, the average person couldn't pay for private psychotherapy, and the treatments were extremely long and severe."

"Since then we've developed a number of evidence-based models and approaches to psychotherapy, many of which are relatively short term," she continues. "You don't have to sign up for three or four years of treatment. Often you're looking at 10 to 20 sessions, very focused on a particular problem."

Easily misdiagnosed symptoms and a scarcity of mental health professionals who specialize in geriatrics also prevent many older adults from finding proper care.

The American Psychological Association reports that just 3 percent of psychologists view geriatric patients as their primary target. This leaves the vast majority of elderly adults tackling their mental health with their primary care physician, if at all.

And they may be loath to discuss their ailments with health care providers who are, in some cases, several decades younger. "It probably goes beyond mental health to all health areas," Birkel says. "‘What could they know about the aches and pains and weakness I feel?'"

"Older adults as a group tend to view mental health problems as an extension of their physical health concerns," says Robert Hill, an expert in adult development and author of "Positive Aging: A Guide for Mental Health Professionals and Consumers." "Lack of motivation, sleeping concerns, obsessive worry — all signs and symptoms of depression — often go untreated as part of a medical concern such as chronic pain or are misjudged as physiological changes due to old age.

"Medical treatment for these kinds of symptoms can err in the direction of ameliorating a physical health concern," Hill says. "A general practitioner might be persuaded to treat these symptoms with opioids that address a chronic pain complaint, but, in reality, these are symptoms of depression that would be best treated with antidepressant therapy combined with psychotherapy for depressive affect."

Gallagher-Thompson says the number of geriatric mental health professionals is likely to increase as baby boomers age.

"My expectation is there will be tremendous pressure and need for mental health services from the boomers as more of them get to the point where they're more frail and dependent, have had more losses, experience more depression," she says. "They will drive the marketplace to create more trained professionals."

Getting help

Older adults and their families should utilize the mental health resources they can access, says Dolores Gallagher-Thompson, associate professor at the Stanford University school of medicine and director of the school's Older Adult and Family Research and Resource Center.

"Tell your doctor: ‘I'm feeling depressed.' ‘I've been drinking more.' ‘I don't want to get out of bed.' There are people with specialized skills and training in geriatric social work and psychiatry and psychology who can help," she says.

"There's no way a primary care physician can possibly go over all the issues an elderly patient needs to talk about in 15 to 20 minutes," says Richard Birkel, senior vice president at the National Council on Aging. "They should be screening for falls, substance abuse, memory impairment. If you simply ask an older person, ‘Are you feeling depressed?' They'll say ‘no.' That's a no-go. The clinician has to be very artful."

Most counties, Gallagher-Thompson says, operate mental health centers, to which a primary care physician can direct patients. Birkel says senior centers can also direct people to the proper professionals.