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Mental Health and Depression

Questions I and My Family Should Ask?

Do you feel your mood is low?
Do you feel a lack of connection with caregivers?
Does your mood prevent you from engaging in activities and hobbies you usually enjoy?
Do you have low motivation to manage or follow treatment for other health conditions?
Are you satisfied with your life?
Do you often feel bored?
Do you often feel helpless?
Do you prefer staying at home rather than going out and trying new activities?
Do you feel worthless?
Are you happy most of the time?
Do you feel you have memory problems?
Do you feel happy to be alive?
Do you feel energetic?
Do you feel your situation is hopeless?
Do you feel most people are better than you?

What actions should I take after reviewing this section?

Always speak with your doctor. They can guide you, screen for depression, diagnose, and treat it.
If they cannot, they can refer you to a specialist, such as a geriatric psychiatry clinic.
Remember that older adults are at increased risk of depression, and you are not alone.
Family doctors often know you better than other physicians and can provide significant support regarding your mental health.
It is important to have a primary care doctor you trust.
Studies show that physical exercise can improve depression in older adults.
The exact reason is not fully understood, but it may be due to several factors such as weight loss, feeling better, increased activity, and social interaction.
Depression is complex, so always discuss options to find what is best for you.
You can choose non-pharmacological options, medications, or a combination of both. Studies show that combining both yields better results.

What does feeling depressed mean?

Depression is an abnormal mental health condition.
It is a cluster of symptoms that include low mood and loss of interest.
It affects performance by causing distress and is more than just feeling sad.
Depression affects about 5–10% of adults over 65.
It increases by 30% in hospitalized older adults.
It increases by 40% in those with stroke, heart disease, or cancer.

Why is depression a risk?

Depression is the fourth leading cause of disease worldwide and causes long-term disability.
It is the most common mental health condition among older adults.
Depression also increases the risk of cognitive decline such as dementia, mortality, and heart disease.
Diagnosing depression in older adults is challenging due to atypical presentation compared to younger adults.
Unfortunately, depression is often undiagnosed in primary care and frequently left untreated.
Depression arises from multiple factors that develop differently in older adults.
It results from changes in brain chemistry, environment, genetics, and social stressors.

What are the symptoms of depression, and how do they appear?

Depressed mood and loss of interest in life and activities are the primary symptoms. Symptoms can appear over weeks to months.
Other symptoms include:
Reduced activity
Feelings of worthlessness
Feelings of guilt
Suicidal thoughts or intentions
Changes in sleep (increase or decrease)
Changes in appetite (increase or decrease)
Weight changes (gain or loss)
Thoughts about death or suicide

How does depression differ in older adults?

Depression in older adults differs from that in middle-aged adults.
Older adults may experience additional symptoms such as memory impairment and cognitive difficulties.
Physical symptoms resulting from mood changes, such as chest or stomach pain, are more common in older adults.
Older adults often deny feeling down, and may also show less interest and lower self-esteem.
Depression is often underdiagnosed in older adults due to atypical symptoms.
Depression can occur secondary to cognitive decline such as dementia or anxiety.
It causes low mood and loss of interest.
Older adults may experience symptoms not seen in younger adults, such as low self-esteem, reduced cognition and physical complaints.

What is the difference between depression and grief?

Grief is the intense sadness and sorrow resulting from a stressful or distressing event.
An example is the grief following the death of a loved one.
Grief may have symptoms that resemble depression, but it is not the same.
Grief is a natural response and usually resolves on its own.
Depression is not a normal response and requires diagnosis and treatment.
The main differences between grief and depression are that individuals experiencing grief:
Those grieving have lost something, whereas those depressed may not have a specific loss.
Grieving individuals focus on the loss, depressed individuals focus on themselves.
Grieving individuals prefer closeness with others, depressed individuals often prefer isolation.
Grief involves mixed emotions, depression focuses on persistent low mood.
Grief involves guilt about the loss, depression involves generalized guilt.
Grief generally preserves self-esteem; depression often diminishes it.
Grieving may involve thoughts of death to join the deceased, while depression involves thoughts of death due to low self-worth.

How is depression screened and diagnosed?

Depression is diagnosed clinically by reviewing the history of symptoms and signs.
Blood tests and brain imaging may be performed to rule out other causes.
Many studies recommend annual depression screening for older adults.
During a doctor visit, answering screening questions is essential for evaluation.
Common tools include the Geriatric Depression Scale; a score of 5 or higher suggests possible depression but requires further assessment.
Screening should be administered by a trained physician for accurate results.
Grief can increase depression risk, but grief alone does not require treatment—depression does.

Why is depression difficult to diagnose in older adults?

Other illnesses may mimic depression (e.g., low activity, poor appetite, sleep changes, memory changes).
Medication side effects may mimic depressive symptoms.
Limited time in clinical visits may restrict mental health evaluation.
Social perceptions of mental health from the patient, family or caregiver can influence recognition.

What increases the risk of depression in older adults?

Aging
Female gender
Social isolation
Grief
Low social support
Chronic illnesses
Social circumstances
Retirement or unemployment
Unexplained pain
Poor sleep
Functional impairment
Alcohol abuse
Family history of mental illness

Is suicide related to depression?

Yes, depression is a major risk factor for suicide.
Suicide is the intentional ending of one’s life.
Older adults attempt suicide less frequently than younger adults, but attempts are more likely to succeed.
Older men have higher suicide rates compared to women and younger adults.
Most older adult suicides occur during the first depressive episode.
Depression in older adults is more complex due to atypical symptom presentation.
Multiple risk factors contribute to depression.
Depression increases suicide risk and requires treatment.

Can depression increase the risk of cognitive decline like dementia?

Yes, late-life depression is linked to dementia.
Studies show the risk is approximately twice as high compared to those without depression.
This is complicated because dementia itself can cause depression.
Refer to the Cognition and Dementia section for more details.

What about other types of depression?

Depression is a broad term.
The type discussed here is Major Depressive Disorder.
Other types not discussed include: minor depression, post-stroke depression, and depression secondary to dementia.
Mood changes can also result from medical conditions, e.g., low thyroid or steroid levels.
Some studies show depression can increase cognitive decline risk.
Dementia can also contribute to depression.

Is there treatment for depression?

Yes, there are well-studied treatment options.
Treatments include talk therapy, medications, or a combination.
Cognitive Behavioral Therapy (CBT) is a non-pharmacological talk therapy involving sessions with a trained mental health professional.
Studies show CBT is effective for mild-to-moderate depression and comparable to medications.
Antidepressant medications are also available.
The two most common classes are Selective Serotonin Reuptake Inhibitors (SSRIs) and Tricyclic Antidepressants (TCAs).
Examples of SSRIs: Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline.
Examples of TCAs: Amitriptyline, Clomipramine, Desipramine, Imipramine, Nortriptyline.
SSRIs are preferred first-line in older adults because they are generally better tolerated.
TCAs have more side effects and may be harmful to older adults.
TCAs can cause low blood pressure, confusion, and increased fall risk.
Discuss these options with your doctor to determine what is safest and most effective for you.
Remember, depression is complex, and each person is different.
Never start or stop treatment without consulting your doctor.
Everyone should start with non-pharmacological approaches; some may require medication as adjunct therapy.

What are the side effects of these medications?

SSRIs may cause nausea, stomach upset, short-term anxiety, appetite loss, and weight loss.
TCAs may cause drowsiness, constipation, low blood pressure, irregular heartbeats, confusion, and increased fall risk.
SSRIs are generally better tolerated in older adults compared to TCAs.
Overdose risks are also lower with SSRIs than TCAs.
Depression treatment can be divided into talk therapy (like CBT) and medication (antidepressants).
Discuss treatment options with your doctor to find the most suitable plan.
Never start or stop treatment without consulting your doctor.

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