Depression and the elder person: the enigma of misconceptions, stigma, and treatment.

Depression and the elder person: the enigma of misconceptions, stigma, and treatment.

Article Type:	Report
Subject:	Depression in old age (Care and treatment) Psychiatric counseling (Demographic aspects)
Authors:	Benek-Higgins, Mary McReynolds, Connie J. Hogan, Ebony Savickas, Suzanne
Pub Date:	10/01/2008
Publication:	Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2008 American Mental Health Counselors Association ISSN: 1040-2861
Issue:	Date: Oct, 2008 Source Volume: 30 Source Issue: 4
Topic:	Canadian Subject Form: Mental health counselling
Geographic:	Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:	188489914
Full Text:	It is estimated that half of the 35 million people in the United Slates who are over the age of 65 are in need of mental health services, though fewer than 20% are actually being treated (Comer, 2004). Coexisting mental and physical problems make recognition of depression in elder persons more difficult because presenting symptoms of depression are often masked by physical problems. In addition, most elder people who have depression never seek or obtain treatment because of the commonly held myth that depression is a normal part of the aging process and that elder people cannot benefit from psychotherapy. The purpose of this article is to survey these issues as they relate to mental health counseling. ********** The fields of geropsychology and geropsychiatry have developed almost entirely in the last 30 years, with fewer than 4% of clinicians working primarily with elder patients. Because so few clinicians have been trained to work specifically with elder individuals, many never receive needed mental health treatment. Of the 35 million people in the United States over the age 65, it is estimated that half are in need of mental health services but fewer than 20% actually receive treatment (Comer, 2004). In fact, depression has been found to be the most frequent psychiatric diagnosis in the elder population (Lebowitz, Pearson, Schneider, Reynolds, Alexopoulos, Bruce, Conwell, et al., 1997). An estimated 2 million elder persons have a depressive illness and another 5 million may have symptoms not fully meeting the diagnostic criteria for depressive disorder (Conwell, 2001). One reason this population does not get appropriate treatment may be that physicians fail to notice or properly diagnose depression in their elder patients (Lin, Simon, Katzenick, & Pearson, 2001; Haley, 1999; Rost, Nutting, Smith, Werner, & Duan, 2001). For example, a survey of primary care providers found that only 33% used a standardized screening instrument specifically designed to detect depression in patients. Up to 65% of elder persons who have major depression may not have been accurately diagnosed; the consequences could be devastating considering that elders represent 19% of suicides in the United States (Conwell & Duberstein, 2001). Accurate diagnosis of depression among elder persons is often complicated by multiple issues, not the least of which is that older adults generally do not seek mental health services on their own. Those who do generally do so at the request of others (Hinrichsen, 1999). The lessening of social connections with others who might observe increased depressive symptoms further reduces the likelihood that elder people will present for treatment for depression (Hinrichsen). Yet once properly diagnosed, treatment of depression in an elder person can be very successful (Katona, 2000). This article will therefore address the following issues of depression in the elder population: (a) symptomotology, (b) diagnosis, (c) potential causes of depression, (d) treatment, (e) the need for mental health coverage, and (f) mental health counseling issues. SYMPTOMATOLOGY Many symptoms of depression (e.g., thoughts of dying, fatigue, loss of libido, reduced sleep, sleeplessness) are often considered normal signs of aging (Katona, 2000). In fact, some physicians still do not consider depression as a potential diagnosis in the elder population because it mimics features of existing physical problems (Katona; Unutzer, Katon, Sullivan, & Miranda, 1999). For example, a stroke can cause many of the same symptoms as depression, as can side effects from medications for heart disease, hypertension, and arthritis (Gottfries, 2001; Unutzer, et al.) and co-occuring disorders of cancer and diabetes mellitus (Bell, 1999). Thyroid dysfunction and low estrogen levels in women can likewise complicate diagnosis of depression (Blazer, 2002). Furthermore, although memory loss is a common symptom of depression in elder people, it is often attributed instead to dementia. Symptoms of depression in elder individuals vary but can include insomnia, hypersomnia, eating too much or too little, loss of energy, fatigue, and a general diminished ability to concentrate (Blazer, 2002). Irritability is a frequent sign of depression in elder men, as are complaints of stomach problems, palpitations, and shortness of breath (Karel, Ogland-Hand, Gatz, & Unutzer, 2002). Observable signs of depression are changes in appearance, stooped posture, social withdrawal, hostility, suspiciousness, slowed speech and movements, wringing of hands, picking of skin, pacing, and outbursts of aggression (Blazer). Five areas of functioning that are adversely affected by depression tend to exacerbate one another: (1) emotional, (2) motivational, (3) behavioral, (4) cognitive, and (5) physical aspects of an individual's life (Blazer; Karel, et ah). Emotional Symptoms Many individuals who experience emotional symptoms of depression report gaining little pleasure from almost any activity. Some report feeling angry, dismal, agitated, humiliated, often melancholy to the point of tears, sad, miserable, meaningless, and even anxious (Blazer, 2002). At least half the population diagnosed with major depressive disorder also have a co-ocurring anxiety disorder that can mask depressive symptoms and complicate accurate diagnosis of depression (Blazer). Motivational Symptoms Elder persons who are experiencing depression may lose the drive to pursue their usual activities, leading to a state that has been referred to as a "paralysis of will," also known as apathy. This motivational state can cause individuals to feel they must force themselves to eat, work, or even talk to friends (Blazer, 2002). They also may lose interest in normal sexual activities. In worst case scenarios, suicide is either considered or attempted (Conwell & Duberstein, 2001). Behavioral Symptoms Behavioral characteristics of depression may be reflected in the person's demeanor, in particular how he or she reacts to various types of situations. For example, many depressed people report reduced activity indicated by increased time in bed, lethargy in moving and speaking, and an overall lack of vigor (Joiner, 2002; Sobin & Sackheim, 1997). Elder persons who experience depression may exhibit both positive and negative behaviors (i.e., phobias, panic attacks, fears of social interaction). They may also ruminate on financial stability and security and fear isolation. Sometimes, to avoid experiencing sad feelings or a low mood, the person may convert emotional energy into sarcasm (Rahman, 2005). Over 3% of elder individuals with depression also experience psychosis (Jeste, Blazer, & First, 2005), which is accompanied by delusions that generate feelings of nihilism, guilt, persecution, jealousy, and hypochondriasis (Alexopouios, 2005; Blazer, 2002). Cognitive Symptoms Depressed people tend to hold extremely negative views of themselves, which may be related to the cognitive symptoms of depression (Blazer, 2002). Intellectual abilities may decline, leading to confusion and distractability; as cognitive processing speed and mental functioning decrease, the person may be unable to remember details or solve simple problems. This combination of confusion and lack of focus may cause the person to become more agitated (Blazer). Furthermore, self-negativity may lead to increased feelings of inadequacy, inferiority, undesirability, and self-blame for every unfortunate event. Although these negative feelings may turn into remorse, it is more typical for the person to experience memory loss or somatization. A person experiencing such symptoms may have a difficult time believing the situation will ever improve (Blazer). People experiencing these symptoms may begin to ruminate and catastrophize as they become obsessed with their current situation (Blazer, 2002). Unfortunately, the pessimism and feelings of helplessness and hopelessness that are often generated in this state of mind may leave the person more vulnerable to suicidal ideation (Comer, 2004). Although laboratory analysis has proven there is a decrease in the memory, attention span, and reasoning abilities of depressed compared to nondepressed persons, reseachers have been unable to determine whether the difficulties are related to cognitive or motivational problems (Comer). Physical Symptoms Physical symptoms of depression may include headaches, changes in bowel functioning such as constipation, indigestion, dizzy spells, fatigue, and general pain (Fishbain, 2000). Disturbances in appetite and sleep are particularly common; many people experience difficulty with general eating and sleeping patterns. Deprivation of the deep sleep cycle has been linked to increased musculoskeletal complaints and depressive effects, besides contributing to intensified pain experiences (Unutzer, et al. 1999). Also, some elder people experience a vicious cycle of pain and sleeplessness in addition to other symptoms of depression (Blazer, 2002). The depressed person frequently denies that the symptoms are psychologically based and focuses on the physical discomfort. This presentation often results in misdiagnosis by mental health professionals or physicians who also mistakenly attribute symptoms to physical problems (Blazer). CAUSES OF DEPRESSION IN THE ELDER POPULATION According to Gottfries (2001), post-mortem studies have shown that the neurotransmitters serotonin and noradrenalin are less available in the aging brain. Because of the reduction in serotonin, it has been postulated that reduced neurotransmitter levels may lead to an increase in depression in the elderly. Moreover, a new subtype of late-life and late onset depression, referred to as vascular depression, can occur as a result of an enlargement of the lateral ventricles, cortical atrophy, enlargement of perivascular spaces, white-matter lesions, basal ganglia lesions, and smaller caudate and putamen (Unutzer et al., 1999). Some changes in the brain occur slowly and are caused by long-term physical conditions, such as deficiencies in essential nutrients, hypertension, diabetes, and excessive stress (Comer, 2004); other types of brain changes occur suddenly because of strokes or head injuries (Gottfries, 2001; Unutzer et al., 1999). Strokes can be a causative factor in depression because the impact on the physical functioning of the brain leads to impairments in cognitive abilities as well as increased depressive symptoms. An estimated 60% of stroke patients suffer from clinically significant depression during the two years following the stroke (Gottfries, 2001). Essential nutrient deficiencies also affect the cognitive functioning of the brain and contribute to depression. Deficiencies of vitamin B12, which is essential to the nervous system, have been linked to cognitive impairments (Gottfries, 2001; Taylor, 1988). Folate (folic acid), an essential element in maintaining the chemical balance of the brain, has also been linked to cognitive impairments and depression (Fava, Borus, Alpert, Nierenberg, Rosenbaum, & Bottiglieri, 1997; Gottfries; Taylor). Lower folate levels appear to correlate with failure of electroconvulsive therapy (ECT) and antidepressants, which may explain why some individuals have not found these treatments efficacious. Therefore, when treating depression with ECT and antidepressant therapy, normal to higher folate levels appear to be essential to effective treatment (Gottfries). DIAGNOSIS OF DEPRESSION Depression in elder individuals is often mis- and underdiagnosed because symptoms are sometimes masked by physical changes in the aging brain. Also, unlike other age groups, an elder person is more likely to go to a general practitioner rather than a specialist for treatment (Katona, 2000; Unutzer, et al., 1999), perhaps due to stigmatized beliefs about mental illness and the view that a mental illness may significantly limit their independence and lifestyle (Jorm, Christensen, Medway, Korten, Jacomb, & Rodgers, 2000; Katona; Unutzer et al.). Finally, the cost and stipulations of mental health services are also key factors. There are many misconceptions about elder people and the diagnosis of depression. One of the most prevalent is that depression is a natural consequence of aging. In fact, many believe that an elder person should expect to feel depressed with the onset of illnesses that affect the ability for self-care and with the passing of loved ones, such as a spouse or friends (Katona, 2000; Unutzer et al., 1999). Unfortunately, the fact that many physicians share these beliefs exacerbates the problem of accurately diagnosing depression in this population (Katona). Overlaps in the characteristics of symptoms of depression with other mental illnesses, such as anxiety and cognitive disorders, which are also common in this population, can also mask symptoms of depression (Katona). Further complicating accurate diagnosis of depression is the tendency of elder people to be less demonstrative of low moods; younger people tend to manifest more overt signs of their depression. Because elder peple who are depressed may not meet the DSM-IV-TR criteria for major depression (Katona, 2000), asking if the person often feels sad or depressed has been found effective in screening for depression in the elder person (Unutzer et al., 1999). Furthermore, disruptions in social interactions can be a cause of depression in elder people, who typically do not talk about significant life stressors or changes in their social environment and support systems. Asking about such disruptions can give the clinician valuable diagnostic information (Blazer, 2002). Psychological predispositions, such as levels of emotional control, neuroticism, and personality disorders, may also contribute to depressive episodes but mask an accurate diagnosis. People with personality disorders have been found to be four times more likely to develop symptoms of depression than people without personality disorders (Blazer II & Hybels, 2005). Many elder people will not seek assistance because of the stigma attached to mental health problems. They do not want others to think of them as "crazy" (Haley, 1999; Gottfries, 2001 ; Katona, 2000); this may be related to the fear of losing their independence. Because of these fears, elder persons may be ashamed or unwilling to admit their symptoms. If they do seek out a physician, they are more likely to report somatic symptoms, such as sleep disturbances and fatigue, rather than specifically speaking about feeling depressed. Most elder people simply will not mention depression unless asked directly and are unlikely to discuss with their physician any suicidal thoughts they may be experiencing (Katona). Haley (1999) reported that, unlike other age groups, people aged 65 to 74 were five times more likely to seek help from a medical provider than from a mental health professional. Haley also found that none of the individuals in the study who were over 75 and had mental health concerns obtained services from a mental health provider but instead sought treatment from a physician. Unfortunately, many elder people who are experiencing depression generally are not referred for psychotherapy based on the incorrect assumption that they are "too set in their ways" to benefit (Katona, 2000). Furthermore, physicians may be reluctant to prescribe antidepressants due to the belief that the elder person may be unable to cope with the side effects (Mulrow, William, Chiquette, Aguilar, Hitchcock-Noel, Lee et al., 2000). Side effects often result in early discontinuation or change in medication before it reaches a therapeutic level (Mulrow et al.). SOURCES OF FUNDING FOR TREATING THE ELDER POPULATION To receive adequate mental health treatment, elder people need access to mental health care coverage. Organized mental health treatment in the United States can be traced back to 1965, when the Social Security Act initiated the Medicare and Medicaid programs to help alleviate the personal financial burdens of medical treatment. Currently, Medicare provides health insurance coverage to approximately 42 million Americans age 65 or older or under the age of 65 who have disabilities (Centers for Medicare and Medicaid Services, 2008). Medicaid is the largest source of funding for 43 million individuals with low income who utilize it for medical and health-related services. Medicaid covers many mental health services provided in physicians' offices, hospitals, nursing homes, and related agencies (Centers for Medicare and Medicaid Services, 2008). It covers at no cost a wide array of prescription drugs, including those needed for mental illnesses like depression, although a few medications may require a nominal copayment. However, if the recipient cannot afford the medication, the pharmacist must dispense it without charge (Centers for Medicare and Medicaid Services). According to the U.S. Department of Health and Human Services (1999), the service system for mental health is divided into private and public divisions. Private services are controlled by private agencies and private resources, such as employer-provided insurance programs. The public sector encompasses two types of services: those financed with government funding like Medicaid and Medicare and those run by state and county mental hospitals. In 1998, the public sector funded 53% of mental health services and the private sector funded 47%; total expenditure for both was $69 billion. Nevertheless, many believe that current funding is not enough. Because numerous health care systems and insurance companies still do not recognize the need for mental health services for the elder population, they provide fewer services and less financial coverage for them than for young people (Unutzer et al., 1999). Furthermore, general practice physicians are often not supported by the healthcare and insurance systems when they diagnose depression in the elder person (Lin et al., 2001; Rost, Nutting, Smith, Werner, & Duan, 2001; Unutzer et al.), making it even more difficult to refer elder patients for mental health treatment. Availability of Coverage Complicating the treatment of depression in elder persons is the issue of the availability of coverage through Medicare and Medicaid. Medicare requires a 50% copayment for outpatient mental health services, compared with a 20% copayment for general medical services; it also imposes a 190-day lifetime limit on inpatient mental health treatment (Centers for Medicare and Medicaid Services, 2008). Such policies shift the costs of mental health care to primary care physicians, who are often unable to recognize and effectively treat depression and who may actually discourage elder persons from using specialty mental health services (Unutzer et al., 1999). Though community mental health centers may provide care to elder patients on a sliding fee basis, they may have small catchment areas or may not exist at all in rural areas. Medicare is comprised of Part A and Part B. Medicare Part A (Hospital Insurance) helps cover inpatient care in a hospital, including specialty care for individuals with mental illnesses. Medicare Part B (Medical Insurance) helps cover such medical services as physician visits, ambulance services, diagnostic tests, outpatient therapy, and related professional services. Most people are automatically eligible for Part A when they reach 65, and no monthly premium is required. The premium for Part B varies from state to state (Medicare.gov, 2005). Medicare will pay for mental health care provided by doctors or other qualified mental health professionals who accept such payments. Part A will cover services for inpatient treatment in a general hospital or a psychiatric hospital, but only for a lifetime total of 190 days in a psychiatric hospital (Centers for Medicare and Medicaid Services, 2008). This can be a problem for those who become mentally ill at an early age and whose illness continues into older adulthood. Medicare will also cover health care provided by doctors or qualified mental health professionals (i.e., clinical psychologist, clinical social worker, clinical nurse specialist, physician assistant) through Part B (Centers for Medicare and Medicaid Services). However, in some cases an individual must pay half the Medicare-approved amount, pay a copayment for services received, and pay a deductible of $110 per year before Medicare will cover Part B services and supplies. Medicare Part B will cover partial hospitalization, an intensely structured treatment program that a person may access if a doctor indicates the person would otherwise need full inpatient treatment (Centers for Medicare and Medicaid Services, 2008). This option is normally used by individuals who have exhausted their 190 days of lifetime care in a psychiatric hospital. TREATMENTS FOR DEPRESSION The support that mental health counselors (MHCs) can provide is particularly helpful to elder persons, many of whom have lost major supports due to the death of a spouse or a significant other. MHCs can help educate the person with depression and family members about the nature of depression and possible manifestations. They can also provide a valuable service not only to the elder person but as a source of support to busy physicians, who often spend just 10-15 minutes with a typical patient (Blazer, 2002). In working with the elder person, MHCs may have access to important psychosocial information that may be contributing to the depression, such as loss of social supports, adjusting to new family roles, decline in sexual functioning, changes in body image, and the symbolic significance of physical illness (Blazer). By building a collaborative relationship with the elder person's physician, MHCs can facilitate the accurate diagnosis of depression, thereby improving the person's quality of life more quickly. The outcome of treatment and rehabilitation can make a major difference in the life of an older person with depression; treatment encompasses a variety of interventions, such as (a) addressing communication, (b) cognitive therapy, (c) pharmacologic therapy, (d) multimodal therapy (U.S. Department of Health and Human Services, 1999), (e) spiritual beliefs (Cooper, Brown, Vu, Ford, & Powe, 2001), and (f) external activities. Communication Communication has been consistently noted as an effective treatment of depression, whether in the formal setting of psychotherapy or counseling (mental health specialists; Karel et al., 2002) or informally (friends, family). Friendships rather than familial relationships tend to provide elder individuals with more diverse contacts, since depression has been highly correlated with a low sense of belonging and loneliness. Social supports are highlighted as the most significant factor related to successful treatment of depression in the elderly population (Hagerty & Williams, 1999). Countering the low sense of belonging and loneliness has in part led to the development of retirement villages as an avenue to increasing social networking and enhancing the involvement of others through closer proximity to individuals with similar lifestyles (Buys, 2001). Cognitive Therapy Contrary to long-held beliefs, therapy for elder people can be quite successful (Blazer, 2002); cognitive, interpersonal, and group therapy have been found to be effective (Blazer). Elder people have also been found to benefit from anti-depressant medications, psychotherapy, or a combination of both. However, changes associated with aging, drug interactions, and the increased vulnerability of the elder to drug side effects must be taken into account (Katona, 2000). Elder people often feel reluctant to participate in psychotherapy due to issues of stigma and the fear of being told they are just imagining their problems (Haley, 1999). A MHC can greatly enhance the therapy process by helping elder patients understand why they have been referred for services, providing information about depression and related treatments that are effective in combating depressive symptoms, and explaining how depression may affect them now and in the future. MHCs need to be willing to work as a team with the person's family and physician to help an elder person recover from depression (Haley). Psychotherapy may also be beneficial to the family as well as the patient (Blazer, 2002). Pharmacologic Therapy Pharmacologic therapy can bring significant changes in an elder person's life and is just as effective as with younger patients; however, more care must be taken with an elder person due to the potential side effects of antidepressant medications (Bell, 1999; Katona, 2000) related to differences in metabolic functioning (Blazer, 2002). Selective serotonin reuptake inhibitors (SSRIs) are beneficial in treating mood disorders, anxiety, fear, panic, and aggressiveness in the elder population. Post-stroke crying and depression have been treated successfully with Citalopram, which has been widely used to help elder people improve their moods without compromising their intellectual capacity or motor performances (Gottfries, 2001). SSRIs are the medications of choice rather than tricyclic antidepressants (TCA) because this population is more sensitive to medication side effects and the dosing schedule of TCAs can be more difficult for elder persons to manage than single-dose SSRIs. The side effects of TCAs can include blurred vision, exacerbation of glaucoma, confusion, and increased risk of urinary retention. TCAs have also been associated with hypotension and dizziness when standing, which increases the risk of falling. Some TCAs have also been associated with increased heart rate and cardiovascular events (Katona, 2000). Some SSRIs have the added benefit of controlling anxiety. Multimodal Therapy For elder persons a combination of medication and psychotherapy is associated with a considerably lower rate of depression relapse than either treatment alone (Katona, 2000). Unfortunately, about 40% of clients stop taking their medication within four to six weeks of initiation, and less than 40% remain on antidepressant medication for more than 180 days, perhaps because of side effects and associated costs (Unutzer et al., 1999). However, client and family education, client and family therapy (Blazer, 2002), the availability of community resources, and a teamwork approach to medical care can greatly improve an elder person's commitment to remain on the prescribed treatment. The recovery rate from depression for elder persons who receive treatment is nearly 70% (Unutzer et al.). Spiritual Beliefs Spiritual beliefs can be an important means of coping with depression for elder individuals and can make a major contribution to psychological well-being, especially after a diagnosis of depression (Cooper et al., 2001). Comer (2004) stated that though for many years spirituality was viewed as a negative factor in mental health, recent studies are showing the opposite. People who have spiritual beliefs have been shown to cope better with major life stressors and recover from illness and injury with fewer complications; therefore, MHCs may want to consider exploring a spiritual component when treating clients (Comer). External Activities For elder people who are able to do so, work or volunteering can be an effective part of the treatment plan for depression. Work is a central aspect of people's lives (Moos, 1986) and an integral part of human existence; it serves as a means of self-definition in society (Neff, 1985; Szymanski, Ryan, Merz, Travino, & Johnston-Rodriquez, 1996). Work also gives purpose to one's very existence and influences a person's perceived worth and place in society (Szymanski & Parker, 1996). Elder people often find it more difficult to acquire and maintain meaningful external activities (work or volunteering) as they begin to age. Typically, people assume that once adults reach the age of 55 or beyond, retirement is the primary goal; however, "Americans over the age of 55 account for 22% of the nation's job growth and represent 18 million persons in the workforce" (Finch & Robinson, 2003, p. 39). Kirsh (2000) found that employment has a positive impact on the quality of life of people who have experienced mental health challenges. Unfortunately, older adults frequently face age discrimination; society may stereotype and prejudge them. Not only society but employers at large assume that as people pass the age of 55, they no longer value work and attempt to retire as early as possible (Dixon, Richard, & Rollins, 2003). If elder people do continue to work, employers are concerned with their adaptability and productivity and may fear problems, such as injuries or health issues, because agility lessens with age (Dixon et al.). However, older adults in the workforce have a strong work ethic and are willing to learn new skills. "These workers often bring a maturity, experience, and work ethic to employers that is lacking in younger workers. They can also serve as role models and mentors to younger workers" (Finch & Robinson, 2003, p. 40). As people live longer and sustain a higher quality of life at an older age, adults desire meaningful employment well past the age of 55 (Finch & Robinson, 2003). MHCs need to consider that, regardless of age, rehabilitation goals need to include "suitable income, independent living arrangements, driving privileges, and job satisfaction" (Finch & Robinson, p. 38). When they are provided with appropriate treatment interventions for depression and with help in identifying suitable external activities, elder persons have a better chance of achieving enhanced life satisfaction. CONCLUSION For several reasons, depression in the elder population is not a simple matter. Coexisting mental and physical problems make recognition of depression in elder persons difficult. Presenting symptoms of depression are often masked by physical problems, and most elder persons with depression do not exhibit emotions the same way as would a younger person. A majority of elder persons never seek treatment because of the common belief that depression is part of the aging process and elder people cannot benefit from therapeutic interventions (Haley, 1999). The stigma attached to depression in this population also causes many people to not seek treatment or delay receiving mental health services. 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