Depression in Late Life Research Paper

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Abstract

The 1999 Surgeon General’s Report on Mental Health revealed that almost 20% of older adults experience mental disorders. Depression, although not the most prevalent mental disorder among older adults, is a very significant source of suffering. From a clinical perspective, it is a particularly complex and challenging phenomenon, due in part to age-related differences in the experience and presentation of depressive symptoms, risk factors, and the many potential causes of depressive symptoms (e.g., medications, comorbid diseases, and stroke).

Outline

1. Epidemiology of Late-Life Depression
2. Conceptual and Diagnostic Issues
3. Relations among Depression, Physical Diseases, and Medications
4. Assessment of Depression
5. Instruments for the Assessment of Depression
6. Treatment of Late-Life Depression

1. Epidemiology Of Late-Life Depression

Depression in older adults is often overestimated and underrecognized, and it is not the most prevalent psychiatric disorder among older adults, as many believe. Indeed, the prevalence of depression is lowest among adults aged 65 or older. Prevalence rates for major depressive disorder among community-dwelling older adults (65+ years) range from 1 to 4%. The North Carolina Epidemiologic Catchment Area Study estimated a prevalence of 0.8% for major depression, 2% for dysthymia, and 4% for minor depression. Incidence estimates of depression in long-term care facilities have ranged from 12.4 to 14%. If one considers clinically significant depressive symptoms that do not meet diagnostic criteria (subsydromal symptoms), the rate of depression ranges from 8 to 15% for community-dwelling older adults, 25 to 33% for hospitalized older adults, 10 to 15% for nonpsychiatric outpatients, and 30 to 40% for long-term care residents. The Epidemiological Catchment Area Studies reported bipolar I and bipolar II prevalence rates of approximately 0.1% among older adults.

2. Conceptual And Diagnostic Issues

There is increasing evidence that depression among older adults differs from that of younger adults along several dimensions (e.g., etiology, presentation, and phenomenology). In 1988, Alexopoulos et al. suggested that the etiology of depression among older adults appears to be somewhat related to the age of onset. Gatz and Fiske noted that among depressed older adults, approximately 50% are cases of late onset depression. The etiology of late-onset depression may be quite different from that of depression occurring in earlier years. The experience and presentation of depression among many older adults appears to be different than that of younger adults. For example, depressed older adults are less likely to report dysphoria than younger adults with the same level of overall depression. Gatz and Hurqitz revealed that older adults are also more likely than younger individuals to endorse test items suggesting a lack of positive feelings, whereas younger adults are more likely to endorse test items suggesting depressed mood. Older adults are also less likely to report ideational symptoms (e.g., guilt) than younger adults and more likely to report somatic symptoms. These somatic symptoms, such as fatigue and changes in appetite and sexual activity, may be related to coexisting medical conditions or normal age-related changes. Reports of lack of interest, sleep disturbance, and lowered energy level, however, may be useful in differentiating depressed and nondepressed older adults.

In addition to the content of age-related symptoms of depression, there is evidence that symptom levels and patterns that would not currently meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), criteria for major disorders are nevertheless problematic for older adults. Many older individuals present with somatic complaints and experience symptoms of depression that do not meet the criteria for depressive disorders. The effects of these subsyndromal conditions may be just as consequential as those of the disorders that do meet diagnostic criteria.

In summary, depression among older adults appears to be different in a number of ways from that encountered in younger adults. The etiology of depression among older adults appears to vary depending on the age of onset. Moreover, the nature and pattern of depressive symptoms of older adults appear to deviate from those one would expect based on depression criteria found in the DSM-IV.

3. Relations Among Depression, Physical Diseases, And Medications

One of the complicating factors faced by clinicians and depression researchers regarding the nature and etiology of depression among older adults is that older adults have a higher incidence of medical disorders than younger adults. Approximately 80% of older adults suffer from at least one chronic health problem. Consequently, it is relatively common for depressed older adults to have comorbid medical disorders; that is, they exhibit the cooccurrence of two disorders or syndromes.

Although the relations between depression and comorbid disorders can be rather complex, they are generally well established. Depression can precede, follow, or simply co-occur with unknown directional relations. Depression is a risk factor for physical disease (e.g., cardiovascular disease) and diminished cell-mediated immunity. Symptoms of depression can also arise directly from various physical diseases (e.g., hypothyroidism, stroke, Parkinson’s disease, and pancreatic cancer) and from the psychological reaction to a disease (e.g., Alzheimer’s disease). Depressive symptoms may also follow a disease process (e.g., myocardial infarction). Similarly, depression is very common among cancer patients, with rates varying from 25 to 50%; there is a greater prevalence among individuals experiencing higher levels of pain, physical disability, and illness. When considering the relations between physical disease and depression, it is important to understand that one need not meet criteria for depression for the symptoms of depression to affect physical health.

The complexity of the relations between depression and physical diseases is often amplified by the adverse effects of medications used to treat medical diseases (e.g., parkinsonism, pain, cancer, arthritis, and hypertension) because many of these medications can produce symptoms of depression. Older adults consume more medications than any other age group and are at higher risk of adverse drug reactions than any other age groups because of age-related changes in physiology and increased use of multiple medications.

4. Assessment Of Depression

The assessment of depression among older adults can be quite challenging, particularly in light of the issues discussed previously. Age-related differences in the presentation of depression as well as the potential for coexisting physical aliments, medication side effects, and natural age-related changes increase the complexity of diagnosing depression when assessing older adults.

Methods of assessment for depression include self-report, clinical interview, report by others, physical examination, and direct observation. Given the intricacy of identifying depression in older adults, there may be no single best method for assessing depression. Each method has its own relative strengths and weaknesses; however, combining methods during the assessment process can enable a clinician to obtain a more complete understanding of depressive symptomatology in older adults. Here, discussion is limited to the most commonly used self-report and clinician-rated instruments.

5. Instruments For The Assessment Of Depression

The most widely used instruments for assessing depression use the self-report method due to the relative ease of administration and brevity. Clinician rating scales, although often taking slightly longer to administer, offer the advantage of objective observation of the depressive symptoms, which can be particularly useful with cognitively impaired older adults.

5.1. Self-Report Instruments

5.1.1. Beck Depression Inventory

The Beck Depression Inventory (BDI) is a 21-item, multiple-choice inventory. Respondents are asked to rate each item based on four response choices according to the severity of the symptoms, ranging from the absence of a symptom to an intense level, during the past week. A 13-item version of the BDI is also available. Both the original and short forms have reasonable internal consistency for normal and depressed older adults and adequate test–retest reliability in older adult patient and nonpatient populations.

A second version of the BDI (BDI-II) was published in 1996 so that items would be consistent with the revised criteria for depressive disorders in the DSM-IV. The number of items on the BDI-II is the same as that for the original version. Edelstein et al. suggest that the BDI-II be used with caution with older adults given the lack of empirical support for its use with this population.

5.1.2. Center for Epidemiological Studies-Depression Scale

The Center for Epidemiological Studies-Depression Scale (CES-D) is a 20-item instrument with good psychometric properties. A 10-item version of the CES-D also has adequate psychometric properties and appears to be a good instrument for screening for depression in community-dwelling older adults.

5.1.3. Geriatric Depression Scale

The Geriatric Depression Scale (GDS) is a 30-item scale designed specifically for use with older adults. The scale uses a yes–no format and has well-established psychometric properties with community-dwelling older adults, outpatient and hospitalized older adults, and geriatric stroke patients. A 15-item form of the GDS yields scores that are strongly correlated with those of the long version. Overall, the GDS appears to be a useful instrument for assessing depression in older adults.

5.1.4. Zung Self-Rating Depression Scale

The Zung Self-Rating Depression Scale contains 20 items that are rated on a 4-point scale by the patient according to the amount of time he or she currently experiences the symptom. Psychometric properties with older adults are less than desirable.

5.2. Clinician Rating Scales

5.2.1. Hamilton Rating Scale for Depression

The Hamilton Rating Scale for Depression (HRSD) is used to quantify the severity of symptoms of depression and is one of the most widely used and accepted instruments for assessing depression. The standard version of the HRSD is designed to be administered by a trained clinician, and it contains 17 items rated on either a 3or 5-point scale, with the sum of all items making up the total score. The HRSD may be a useful scale for cognitively impaired patients who have difficultly with self-report instruments.

5.2.2. Geriatric Depression Rating Scale

The 35-item Geriatric Depression Rating Scale (GDRS) combines the severity rating format of the HRSD with the content of the GDS. The GDRS probably requires less experience and training to administer than the HRSD and has good psychometric properties with hospitalized, outpatient, and community-dwelling older adults.

5.3. Instruments for Assessing Depression with Coexisting Dementia

Individuals with dementia pose a particular challenge when assessing for depression due in large part to the overlap of symptoms of depression and dementia as well as the effects of cognitive impairments and memory deficits. Several instruments have been developed to address the complicated nature of assessing depression with coexisting dementia, including the Cornell Scale for Depression in Dementia (CS) and the Dementia Mood Assessment Scale (DMAS).

5.3.1. Cornell Scale for Depression in Dementia

The CS contains 19 items that assess for the severity of depression based on a 3-point scale with content similar to the that of the HRSD. Psychometric properties of the CS are adequate. The CS appears to be a useful measure for assessing severity of depressive symptoms in older adults with dementia or cognitive impairments.

5.3.2. Dementia Mood Assessment Scale

The 17-item DMAS is a brief measure of mood in patients with dementia that includes a semistructured interview and direct observation of the individual over time. The psychometric properties of the DMAS are not strong. Its advantage lies in the combination of interview and direction observation.

In summary, there are a wide range of assessment instruments available for the assessment of depression among older adults, with each having strengths and weaknesses. Although many of the instruments were developed for use with younger adults, they have proven reliable and valid with older adults with a wide range of clinical characteristics.

6. Treatment Of Late-Life Depression

Despite the availability of treatments for depressed older adults, only a few older adults utilize such treatments. Depressed older adults are most frequently first seen by a primary care physician, usually for somatic symptoms and complaints of low energy. Unfortunately, many older adults and their physicians attribute these symptoms to ‘‘normal aging’’ or a physical ailment and fail to make a mental health referral.

Although presentation and diagnostic considerations for depression appear to differ in older adults when compared to their younger counterparts, Karel and Hinrichsen’s review of the literature suggests that treatment interventions effective for younger adults are also efficacious for older adults. This section focuses on psychosocial interventions, with an emphasis on evidence-based treatments for older adult depression.

6.1. Evidence-Based Psychosocial Treatments

A number of psychosocial interventions have proven effective for treatment of older adult depression. These treatments include psychodynamic, cognitive, behavioral, cognitive–behavioral, and interpersonal therapies. Although the rationale for each form of therapy is derived from varying conceptualizations, a number of studies have demonstrated the effectiveness of each of these therapies for treatment of depressed older adults.

6.1.1. Psychodynamic Therapies

Psychodynamic therapies focus on intrapsychic conflicts that may be affecting the individual’s coping and adjustment. Emotional insight, gained through the therapeutic process, is the goal of treatment for resolution of these conflicts and establishment of more effective coping styles. In addition, this form of therapy focuses on resolution and acceptance of social and physical losses that are characteristic of old age and addresses unresolved issues from various stages of development that may be contributing to the person’s distress. Psychodynamic therapies also frequently incorporate a focus on the ‘‘self’’ and maintaining self-esteem through the trials and tribulations of the aging process.

6.1.2. Behavior Therapy

Behavior therapy relies on the premise that overt activity and mood are closely linked. In 1974, Lewinsohn, who offered one of the principal behavioral theories of depression, demonstrated that the lack of sufficient positive reinforcement from one’s environment can negatively affect one’s mood state. Zeiss and Lewinsohn adapted Lewinsohn’s behavioral approach for older adults. This form of therapy typically involves behavioral activation, scheduling of pleasant events into the person’s life, decreasing one’s participation in aversive activities, and problem solving and social skills training. In addition, ‘‘homework’’ assignments are frequently given to facilitate the achievement of clearly developed goals and skills and activate the person for change.

6.1.3. Cognitive Therapy

Cognitive therapy, as developed by Beck et al. in 1979, assumes that maladaptive and irrational cognitions are contributing to, if not causing, the depressed mood. This therapy focuses on identifying distorted or irrational thoughts and beliefs that may be contributing to the mood state. During therapy, the person is encouraged to monitor, challenge, and eventually replace negativistic and irrational thoughts with realistic, more positive ones. Practice through completion of homework assignments is integral to this form of therapy, and clients are encouraged to monitor and challenge irrational or negativistic cognitions in their daily lives once they have practiced in a therapeutic setting.

6.1.4. Cognitive–Behavior Therapy

Gallagher-Thompson and Thompson combined behavioral and cognitive therapies, which they termed cognitive–behavior therapy, for the treatment of depression in older adults. This form of therapy is based on the rationale that irrational cognitions and/or maladaptive behaviors contribute to and maintain a depressed mood state. It is assumed that negative cognitions or thoughts, especially about one’s self, future, and experiences, create a negative lens through which one sees the world. In addition, the depressed older adult is not engaging in enough positive mood-enhancing activities, which tend to exacerbate the negative cognitions. This form of therapy is generally psycho-educational, goal-directed, structured, and brief, designed to give the depressed older adult the cognitive and behavioral skills (e.g., relaxation techniques, assertiveness training, and problem-solving skills) he or she is lacking.

6.1.5. Interpersonal Psychotherapy

Finally, interpersonal psychotherapy (IPT), developed by Klerman et al. in 1984, is a time-limited form of therapy that emphasizes interpersonally relevant issues that may have preceded or resulted from depression. Specifically, this therapy stresses the importance of family relations in older adults’ lives and, as such, emphasizes the nature of important relationships and focuses on one of four potential interpersonal problems: grief, interpersonal dispute, role transition, and interpersonal deficits. Treatment strategies are then implemented to address each of these problems and reach identified treatment goals. In a review of the use of IPT with older adults, Hinrichsen found several studies that demonstrated the effectiveness of this therapy for older depressed adults.

6.1.6. Other Psychosocial Treatments

Although the previously described therapies have been well established as effective for use with older adults, a number of other therapeutic approaches are used, although little empirical evidence is available for their efficacy in this population. It should be noted, however, that simply because an intervention has not been empirically studied does not indicate that it is not useful or effective in the treatment of older adult depression. Several of these forms of treatment have been examined through preliminary studies that have rendered promising results.

6.1.6.1. Life Review Therapy

Life review therapy, a form of reminiscence therapy, encourages the older adult to reflect on his or her life and is thought to facilitate his or her progress through Erikson’s final developmental task and emerge with a sense of integrity or despair. Although it is used for the treatment of depression in older adults, some caution its use with this population because it could prove more harmful than helpful, especially for older adults for whom a life review would not be a positive experience. Researchers continue to debate the efficacy of this form of therapy.

• Group Therapy

Group therapy, especially psychoeducational group therapy, is another form of treatment for older adult depression. Group therapy captures the interpersonal or social component not seen in other forms of therapy and thus allows for older adults to share with and learn from each other while acquiring behavioral and cognitive coping skills. This form of therapy can be quite effective with depressed older adult family caregivers.

• Less Common Forms of Treatment

Less common forms of treatment for older adult depression include bibliotherapy and self-help therapy, both of which emphasize the individual’s role in treatment and overcoming depression without a great deal of intervention from a therapist. Typically, in both of these forms of therapy, the older adult is educating himself or herself through readings. In 1989, Scogin et al. conducted one of the few studies on the efficacy of bibliotherapy and found promising and generally positive results.

A number of treatments or therapies for older adult depression have been described briefly in this section. Although there are several well-established, effective treatments for depression in this population, there is a need for additional research to empirically examine some of the other less common but potentially advantageous forms of therapy. There is also a need to make treatments more available and acceptable to older adults so that when referred by physicians, depressed older adults will seek treatment.

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