Updated January 29, 2024
Depression
What this section covers:
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Self-assessment for depression
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Depression is a medical condition with recognizable symptoms
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Untreated depression can change a person’s life
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Depression can be treated
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Key points
Self-assessment for depression
Maybe you’ve come to this website because you wonder whether you or your loved one might be depressed. Let’s take a minute to look at an example of a brief depression self-assessment for seniors.
The Brief Depression Screen is one of many types of depression assessments. These eight questions focus on the psychological symptoms of depression. If you or your loved one answered “yes” to more than one of these questions, depression may be an issue.
Physical Symptoms of Depression
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Some elders who develop depression show it by a decline in function. They may develop the inability to walk or to do things they’ve always been able to do, like using the telephone.
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Others might lose their appetite, saying that food doesn’t taste good anymore. Weight loss becomes obvious when clothes start to sag, or the face looks drawn.
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Constipation is frequent among untreated elders with depression.
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Many elders with depression have sleep problems, either insomnia or sleeping way too much.
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Energy can be much lower than usual, with the depressed elder getting tired after a brief period of activity.
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New reports of pain or worsened pain are common.
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An observer might note that the elder sighs frequently or seems unable to make eye contact with others.
Psychological Symptoms of Depression
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The opposite of depression is not happiness; the opposite of depression is vitality.
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Another term for vitality is “zest for living.”
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The depression symptoms included in the Brief Depression Screen shown above are psychological symptoms. These include apathy, loss of interest, low motivation, hopelessness, helplessness, feelings of worthlessness, guilty feelings, and low self-esteem.
Emotional Symptoms of Depression
These symptoms are easily detected, and often are the ones that alert others that a depression is brewing. They include sadness, crying -- especially crying that is hard to stop -- and excessive anxiety and agitation.
What about Grief?
Grief is a normal reaction to loss, with symptoms in many cases resembling those of depression. For some individuals, the symptoms can be extremely severe and persistent. Grief counseling is a very effective way to help the individual deal with unbearable grief. Generally, medications are not used to treat grief unless the individual also suffers from depression alongside the grief reaction. In these cases, and particularly when symptoms last a very long time (more than one year), several types of treatment might be used, including medications and hospitalization.
Interpersonal Symptoms of Depression
Often, these are first noticed by the depressed patient’s partner. The patient may become extremely irritable and negative, and it may seem like they’ve had a change in their normal personality.
Impatience is a common problem; these
individuals may have no ability to tolerate delay.
Withdrawal from social activities and neglect of personal grooming may be seen.
Cognitive Symptoms of Depression
The depressed individual may have trouble paying attention, and may become absent-minded and forgetful. Some depressed individuals develop what is called “a sense of a foreshortened future,” which means they have the idea that they don’t have long to live. An alarming number think obsessively about death or suicide.
At this point, maybe you’re thinking that many people you know have at least some of these symptoms. And that may certainly be true, particularly since the Covid-19 pandemic arrived and changed everyday life to such an extent. In addition, there are different variants of depression: chronic, low-level depression (dysthymia) and bipolar depression, with mood upswings as well as downswings. The latter is covered in another section. Often, individuals will have a temporary period of distress in response to life events, both large and small.
So, does everyone with depression have to be treated? Probably not. Depression becomes a disorder when symptoms pass a threshold (red line below), causing serious distress for the individual, or when they interfere with normal or usual functioning. The disorder requires treatment.
Many people have the idea that a depressed person should be able to pull herself up by the bootstraps, to snap out of it. This is not a reasonable expectation, particularly if the depression is severe, because the brain is not functioning normally, and the brain is the very organ responsible for pulling herself out of it.
Brain scans (SPECT and PET) like those shown above reveal low blood flow and reduced metabolism in specific brain areas (white circles) in people who are depressed. When depression is treated, blood flow and metabolism go back towards normal. In addition, blood levels of cortisol — the stress hormone — are often elevated in depression, and this is harmful to many organ systems, including the brain. Other brain chemicals — called neurotransmitters — become unbalanced in depression, as well. Norepinephrine (noradrenaline) levels may be increased or decreased, whereas serotonin and dopamine levels may be decreased. These chemical imbalances underlie the symptoms of depression that we’ve talked about.
The quality and amount of sleep a person has may be seriously affected by depression, and depression may be worsened by poor sleep. The graph below shows the pattern of sleep in a normal person at the top, and the pattern in a depressed patient below.
The normal subject has a regular pattern of slow wave sleep alternating with REM (dream) sleep. Slow wave sleep spans all four levels (1=light sleep to 4=deep sleep). The depressed patient wakes up more often, has less deep (restorative) sleep, goes into REM (dream) sleep more quickly when going to sleep, and lacks the usual alternating pattern of deep and REM sleep. These changes may have significant effects on daytime function.
If you think about the symptoms of depression that we’ve talked about, you may begin to see how all these factors — physical, psychological, and interpersonal — are interrelated. Physical symptoms can have negative effects on interpersonal and psychological functions, and so on, setting up a vicious cycle that can end up sustaining itself, as shown in the next diagram.
Here are some other sobering facts:
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Depression --- especially major (serious) depression -- increases the risk of heart attack as well as death after heart attack.
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Depression increases the risk of stroke, and untreated depression makes physical rehabilitation after stroke very difficult.
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Although most elders who attempt suicide do not have a known mental health diagnosis, it is clear that the presence of depression increases the risk of suicide. Moreover, elderly individuals are more likely than younger individuals to use lethal means, such as firearms or hanging.
Depression is eminently treatable.
The Clinic Evaluation
If you were to come to the clinic for a depression evaluation, you would be asked questions about your symptoms, your personal and family history of mental health issues, and your medical history. Medical problems that can look like clinical depression include conditions such as anemia, hypothyroidism, low Vitamin B12 or folate levels, and vascular disease of the brain. To exclude these possibilities, laboratory tests would be performed before a treatment plan was developed.
Lab tests would include the following:
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Complete blood count (CBC)
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Thyroid screening test (TSH)
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Vitamin B12 level
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Folate level
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Head CT/MRI
Treatment of Depression
The next step would be a talk between you (and your family, if you choose) and the clinician to decide which types of treatment to use, and where treatment will take place. These decisions will consider the severity of your depression and whether you have suicidal thoughts or feelings.
TREATMENT OPTIONS
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Psychotherapy
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Group Therapy/Support Groups
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Changes in Lifestyle
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Bright Light Therapy
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Antidepressant Medications
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Transcranial Magnetic Stimulation
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Electroconvulsive Therapy
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Deep Brain Stimulation
Psychotherapy
For mild to moderate depression, where the potential for suicide is low, individual psychotherapy may be the preferred treatment. This mode of treatment influences brain chemistry, metabolism, and blood flow in the same way that medications do. The effects may not be as rapid, but are likely to be more persistent, and the side effects are usually minimal.
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Interpersonal therapy (IPT) focuses on problematic ways of relating to other people.
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Cognitive behavioral therapy (CBT) helps correct negative thinking.
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Problem- solving therapy deals with everyday problems that cause or sustain depressed mood.
Group Therapy and Support Groups
Group therapy involves a therapist who guides group discussions so that patients can learn from one another. Group therapy creates a safe space to talk without criticism, and maintains confidentiality. The goal is to help patients change.
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Support groups may not include a therapist, but help to connect people with shared issues, such as loss or disability. These groups are usually no-cost. The goal is to help patients cope. At times, these groups function well and are helpful to members. At other times, support groups have difficulty with dominating members, bad group dynamics, and lack of confidentiality, and as there is no leader, these problems may be difficult to resolve.
Changes in Lifestyle
More than half of people who are depressed find that depression improves with regular aerobic exercise.
Any diet that is good for your heart is also good
for your brain.
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The Mediterranean diet is a good example.
More information about the Mediterranean Diet can be found in the section on Brain Fitness.
Although this one may be difficult in Covid-19 times, anything you can do to increase social interaction will have beneficial effects on mood.
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Social interaction has also been noted to increase the growth of dendrites, which are a part of the nerve cell that makes contact with other nerve cells. Beneficial cognitive effects are well established.
Many elders report that meditation and prayer help with depression.
Find a pet to play with! After a positive interaction with a dog, humans show increases in “feel good” brain chemicals such as endorphins, dopamine, oxytocin, and prolactin. Also decreased cortisol levels.
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Dogs show the same positive effects.
Bright Light Therapy
It has long been known that using so-called bright lights is helpful for seasonal mood disorder. It turns out that these types of lights can be used for non-seasonal depression, too.
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These are specialty lights used once daily in the morning. One system offers lights of 10,000 lux that are to be used for 30 minutes. Bright lights may be particularly useful for elders who are homebound.
Antidepressant Medications
Numerous antidepressant drugs are now FDA-approved for the treatment of depression, although not all are recommended for use in elders. In general, older drugs such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been replaced by safer and more selective ones. Drugs commonly used fall into the following classes:
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Serotonin-selective reuptake inhibitors (SSRIs)
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Serotonin-norepinephrine reuptake inhibitors (SNRIs)
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N-methyl D-aspartate (NMDA) Antagonists
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Serotonin modulators
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Atypical antidepressants
Serotonin-selective reuptake inhibitors (SSRIs)
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Citalopram (Celexa)*
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Escitalopram (Lexapro)*
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Fluoxetine (Prozac)
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Fluvoxamine (Luvox)
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Paroxetine (Paxil)
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Sertraline (Zoloft)*
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*Preferred drugs for elderly patients
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Note that only the first brand name for each of these SSRIs is given in parentheses. Many other branded drugs are marketed, and to figure out which drug is in the bottle, look at the generic name (e.g., citalopram).
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Drugs in this class treat depression as well as many anxiety disorders by increasing the amount and activity of the brain chemical serotonin. All are effective, but the drugs differ in terms of side effects and cost. They are commonly used because they are relatively safe drugs, and side effects are manageable. The SSRIs may not be quite as effective as other drug classes for severe depression. Drug interactions are possible, particularly since these drugs can inhibit enzymes involved in the metabolism of other drugs. Make sure that your clinician knows exactly what other medications you take.
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
This class includes the following drugs:
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Desvenlafaxine (Pristiq)
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Duloxetine (Cymbalta)
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Levomilnacipran (Fetzima)
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Venlafaxine (Effexor)
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The SNRIs affect both serotonin and norepinephrine neurotransmitters, so could be expected to be more effective in treating severe depression. They induce rapid changes in brain chemistry. They are also used as add-on treatments for pain syndromes. For many individuals, discontinuation of these drugs can be difficult; this should be done under the supervision of a clinician.
NMDA Antagonists
This class includes the following drugs:
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Ketamine (Ketalar)
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Esketamine (Spravato)
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Bupropion + dextromethorphan (Auvelity)
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Ketamine has been used for years as an anesthetic agent, and more recently, has been observed to have rapid antidepressant effects when given intravenously. Clinics have been established worldwide where the drug is administered under medical supervision.
A nasal spray form of ketamine (esketamine or Spravato) was approved by the FDA in 2019 for patients who have tried two or more antidepressants without significant improvement. Nasal ketamine is also given only at certified treatment centers, which may be limited in number in more rural communities. Patients are cautioned that pre-existing high blood pressure, heart disease, glaucoma, or history of stroke may disqualify them from treatment. Esketamine must be taken along with another oral antidepressant medication; the idea is to use it to “jump start” antidepressant therapy.
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The newly approved combination drug bupropion/dextromethorphan combines the NMDA receptor antagonist dextromethorphan with bupropion, a norepinephrine/dopamine reuptake inhibitor. This is the first oral drug on the market with the NMDA antagonist mechanism, offering a rapid onset of action. It is discussed further below.
Serotonin Modulators
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Nefazodone (Serzone)
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Trazodone (Desyrel)
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Vilazodone (Vibryd)
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Vortioxetine (Trintellix)
This class of antidepressants comprises two older drugs – trazodone and nefazodone – and two newly developed drugs – vilazodone and vortioxetine. In general, these modulators enhance serotonin activity by stimulating specific receptors on the post-synaptic neuron and inhibiting serotonin reuptake into the pre-synaptic neuron (like the SSRIs and SNRIs). Trazodone has limited use as an antidepressant, but is sometimes still used to treat insomnia. Nefazodone has been withdrawn from most markets because of liver toxicity.
Vilazodone carries a lower risk of adverse effects on sexual function, less heart toxicity, and less weight gain than other antidepressants. It can be used in older patients, and is thought to work more quickly than some of the older antidepressants.
Vortioxetine may be unique among antidepressants in its favorable effects on cognition, so there is a great deal of interest in this drug for the treatment of elderly patients. It is more easily tolerated than SNRI drugs.
Atypical Antidepressants
This class of drugs includes the following:
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Bupropion (Wellbutrin)
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Bupropion + dextromethorphan (Auvelity)
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Mirtazapine (Remeron)
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Bupropion is a reuptake inhibitor of both norepinephrine and dopamine. It is activating, and is not associated with significant weight gain. It has few drug interactions. The three forms of bupropion (IR, SR, and XL) differ in how often the drug must be taken:
As mentioned above, the combination drug Auvelity combines the NMDA receptor antagonist dextromethorphan with bupropion, a norepinephrine/dopamine reuptake inhibitor. Both components increase norepinephrine activity and bind to nicotinic receptors. This is the first oral drug on the market with the NMDA antagonist mechanism. At this writing, Auvelity has not been adequately studied in the geriatric population. Dosage adjustment is required for patients with renal impairment.
Although mirtazapine affects both serotonin and norepinephrine, it works by a different mechanism than the SSRIs and SNRIs. In addition, this drug has antihistamine effects at low doses (3.75 to 7.5 mg), so it causes sedation and stimulates appetite when it is first initiated at low dose. When the dose is increased, the antihistamine effects decrease as the serotonin/norepinephrine effects emerge to treat depression. An orally disintegrating form is available for those unable to swallow tablets.
Antidepressants not recommended for Elders
Older drugs that are no longer often used in the U.S. include the tricyclic antidepressants (TCAs) amitriptyline, doxepin, imipramine, nortriptyline, and desipramine. These drugs have serious side effects, including heart rhythm problems, drop in blood pressure upon standing, constipation, and other adverse effects. They are very dangerous in overdose, and have significant interactions with other drugs. TCAs are not recommended for elderly individuals. The one exception is a very low dose of doxepin used for insomnia.
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Another class of drugs little used today is that of the monoamine oxidase inhibitors (MAOIs), which include isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate). These drugs have serious side effects such as hypotension, and require the patient to avoid a number of foods. These non-selective MAOIs are not recommended for elderly individuals at any dose.
Transcranial Magnetic Stimulation (TMS)
TMS involves the application of a magnetic field to the scalp, which affects underlying brain structures. TMS comes in several forms, including repetitive TMS and deep TMS. The protocol for depression commonly requires multiple brief sessions held every weekday for 4-6 weeks. Side effects are usually minor. The most serious side effect is seizure, which can be prevented or mitigated by proper precautions. The newest form of TMS – intermittent theta- burst stimulation – has reduced the duration of repetitive TMS sessions from 30 minutes to 3 minutes.
Electroconvulsive Therapy (ECT)
ECT is the single most effective treatment for resistant depression. It has an undeserved reputation for barbarity based on early depictions of its methods. It is now performed in medical facilities such as same-day surgery suites with appropriate monitoring to ensure safety. Response to ECT is rapid. It is followed up with an oral antidepressant.
Deep Brain Stimulation (DBS)
This procedure involves the surgical implantation of a pacemaker-like device in the chest, with a connection to targeted brain areas. It is FDA-approved for Parkinson’s disease and related disorders. At this writing, at least one company (Abbott) has been granted a Breakthrough Device Designation for depression. DBS could prove to be a life-saving treatment for depression resistant to other treatments.
Key Points
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Depression is a medical condition with recognizable symptoms — physical, psychological, emotional, interpersonal, and cognitive.
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Depression involves changes in brain chemistry and increases in stress hormone levels. Sleep is often affected. Depression increases the risk of heart attack, stroke, and suicide.
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Untreated depression can change a person’s life.
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Depression is readily treated, and a wide range of treatment options are available, as detailed in this section.