This
article appeared in Aging Today, January/February 1998, copyright American
Society on Aging, 1998. It appeared in the newspaper's Research Today section,
aupported by a grant from the AARP Andrus
Foundation.
SIGNS OF HOPE: UNTANGLING CHRONIC ILLNESS AND DEPRESSION
Recent research aimed at untangling the complex relationship between chronic illness and depression in older adults is converging on primary care physicians and other healthcare professionals with this message: Late-life depression is rampant, but it is not a natural part of aging. Experts say it is crucial that physicians learn to recognize and diagnose the problem, because it is a major risk factor for suicide and because depressed elders are among the most frequent and costly users of healthcare resources.
"Depression in people aged 65 years and older is a major public health problem," declares the National Institute of Mental Health's (NIMH) recent consensus statement, "Diagnosis and Treatment of Depression in Late Life." The document states, "What makes depression in the elderly so insidious is that neither the victim nor the healthcare professional may recognize its symptoms in the context of the multiple physical problems of many elderly people."
Written by Barry Lebowitz, chief of NIMH's Mental Disorders of the Aging Research Branch, and his colleagues, the statement reexamines the conclusions of a 1991 National Institutes of Health consensus panel and summarizes new research findings on late-life depression. The updated statement was published in the Oct. 8, 1997, issue of the Journal of the American Medical Association.
SIX MILLION ELDERS
Of the 33.5 million Americans aged 65 and older, more than six million are likely to experience clinical depression, yet only one million will be properly diagnosed and treated, according to the Geriatric Psychiatry Alliance (GPA), an educational partnership of the American Association for Geriatric Psychiatry. "Physicians need to be asking about and listening for signs of depression in their older patients," stressed Ira R. Katz, professor of psychiatry at the University of Pennsylvania Medical Center in Philadelphia and co-chair of the GPA Initiative on Depression in Late Life. Depression is curable in 80% of all cases, Katz said.
Many older people are unaware that they need treatment for depression, often accepting it as a normal part of aging. According to a public opinion poll commissioned by GPA, nearly 93% of adults think that depression is normal in people suffering from a serious medical condition. Also, more than half of Americans aged 75 and older believe depression is a natural part of the aging process.
The consequences of undiagnosed depression can be fatal, because depression is a leading cause of suicide among elders, according to GPA. White men older than 80 are six times more likely to commit suicide than any other demographic group in the United States, according to the organization. "Researchers have shown that approximately 35% of older individuals who commit suicide have seen their primary care doctors within one week--and 75% within one month--of their deaths," Katz said.
To both the researcher and practitioner, late-life depression is particularly tricky in that the relationships between depression, disability and illness are very difficult to disentangle. "Specific symptoms and signs of depression may impair some functions and not others. Medical disorders accompanying geriatric depression can cause disability independently of the depressive syndrome or in synergy with it," explained George Alexopoulos, professor of psychiatry at Cornell University Medical College in White Plains, N.Y.
COMPLEX PATTERNS
A study headed by Soo Borson at the University of Washington in Seattle has shown that it is safe and effective to treat depression in patients with complex patterns of comorbidity (the coexistence of multiple physical and/or mental disorders). This research suggests that treatment for depression can reduce disability and result in improved physical functioning, according to the recent NIMH consensus statement.
Research at the University of North Carolina (UNC), Chapel Hill, School of Public Health showed that the cause-and-effect relationship between physical illness and depression can reverse course. Illness can bring on bouts of depression, which, in turn, can lead to a run-down physical condition that impedes recovery, according to unc's Elizabeth J. Mutran. Her research team looked at the role of social support and depression in older women's physical recovery following hip fracture surgery.
This longitudinal study found that women who were depressed and/or had inadequate social support directly after surgery showed less improvement in their ability to walk two months later. After six months, however, "the flow of causal influence" had reversed: Low improvement in walking ability led to increased levels of depression, the researchers reported in the Journals of Gerontology (Psychological and Social Sciences), November 1995.
This and other recent studies illustrate the vicious circle of depression, disability and chronic illness. "Depression coexisting with physical illness has been shown to increase levels of functional disability, increase the use of healthcare resources and reduce the effectiveness of rehabilitation in older patients with stroke, Parkinson's disease, heart disease, pulmonary disease and fractures," says the NIMH consensus statement.
Furthermore, participants in a Gerontological Society of America symposium said in an article drawn from the session ("Depression and Medical Illness in Late Life: Report of a Symposium," Journal of the American Geriatrics Society [JAGS], February 1996), "Medical illness is the most consistently identified factor associated with the presence of late-life depression and is the most powerful predictor of poor depressive outcome."
FUTURE RESEARCH
In another study linking geriatric depression to disability, Cornell University's Alexopoulos and coauthors administered comprehensive psychiatric evaluations to 75 depressed patients age 60 or older. Impairment in instrumental activities of daily living (IADLs)--such as shopping, taking medicine and using the telephone--was significantly associated with advanced age, as well as severity of depression and chronic physical conditions, anxiety and weight loss.
Patients' level of impairment in iadls was also strongly related to "depressive ideation," medical jargon referring to thoughts resulting from depression, which include excessive guilt, worthlessness, helplessness and hopelessness. Such depressive thoughts are strongly associated with disability, according to Alexopoulos.
"These findings provide a basis for studies investigating whether psychotherapy aimed at depressive ideation and rehabilitation efforts focused on instrumental activities of daily living can improve the outcome of geriatric depression," Alexopoulos and his colleagues concluded.
Studies on the mutual reinforcement of depression and disability are among the most significant research on late-life depression to emerge in recent years, according to the NIMH consensus statement. The NIMH panel concluded that among the most pressing needs for future research are understanding "the interaction of vascular disease, other physical illnesses and psychosocial factors in the cause and pathophysiology of depression;" improving "mechanisms of translation between basic science, clinical research and services research;" and enhancing "the design of systems of care, particularly those outside the mental health sector, such as primary care, general hospital and nursing homes."
Other articles on depression in this Research Today
Depression Raises Medical Costs
Mental Health Ccampaigns Spread Truths About Depression