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CHAPTER 11

Depression

LESLIE HASCHE and NANCY MORROW-HOWELL

EPRESSION IS WIDELY

recognized as having deleterious effects on a per-

son’s quality of life (Spitzer et al., 1995), as being a leading worldwide

cause of disability (C. J. Murray & Lopez, 1996), and as being one of the

costliest conditions to society in terms of health care dollars (Thorpe, Florence,

& Joski, 2004). Furthermore, clinically significant depression (i.e., major depres-

sion, dysthymia, and minor depression) in older adults is associated with several

negative outcomes, such as increased disability (Penninx et al., 1998), decreased

quality of life, and shortened life span (Penninx et al., 2001). Older adults with

depression exhibit poorer outcomes on other medical conditions, such as dia-

betes and heart disease, due to how depression decreases a person’s ability to

adhere to medication regimens, to diet recommendations, and to other recom-

mended health behaviors (Katon, 1996). Specifically, depression increases risk of

overall mortality, even when controlling for other health conditions, lifestyle fac-

tors, and demographics (Adamson, Price, Breeze, Bulpitt, & Fletcher, 2005;

Unützer, Patrick, Marmon, Simon, & Katon, 2002), and depression is a leading

risk factor for suicide in late life (Lebowitz et al., 1997). With this knowledge, de-

pression should be seen as a public health concern for the nation’s older adults

and their families.

Therefore, evidence-based depression treatments are a pressing gerontologi-

cal concern not only as a mental health need, but also due to the overlapping im-

pact of depression on quality of life, disability, health outcomes, and mortality.

Unfortunately, depression is often undetected and inadequately treated, espe-

cially in older adults (Charney et al., 2003), where depression is sometimes mis-

perceived as a part of normal aging. Depression in late life is often narrowly

attributed to the other developmental life events that coincide with old age, such

as loss of social support, retirement, and medical illness. However, as this review

of the literature shows, other biological, psychological, and social factors are as-

sociated with depression, and these factors go above and beyond the normal pro-

cess of aging.

With the knowledge that depression leads to multiple negative outcomes for

older adults, and that depression is not an acceptable or normal part of the aging

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process, it is necessary to learn how to detect and adequately intervene with de-

pressed older adults. Effective depression interventions are available and sup-

ported by evidence—so now the challenge is to connect the knowledge and

resources with the older adults in need. This chapter reviews the current knowl-

edge of how and why older adults are experiencing depression, presents evidence-

based interventions for depression that stretch across the continuum of services,

and provides specific recommendations for treatment guidelines, policy initia-

tives, and research agendas.

DEFINING CLINICALLY SIGNIFICANT DEPRESSION

Over the past 2 decades, a wealth of literature has expanded our understanding

of how older adults experience depression. The definition of late-life depression

has several variations depending on clinical purpose and on specificity in sub-

type (Blazer, 2003). It is further complicated due to the lack of a clear test to de-

termine if someone is depressed. The determination of a depression diagnosis

does not come from blood work or an X-ray, like other medical diagnoses. To de-

termine diagnosis, it is necessary to consider specific symptom profiles, duration

of symptoms, and the standard nomenclature for mental disorders.

Depression is classified as an affective disorder and often subcategorized as

major depression, Dysthymic Disorder, and subthreshold depression, which is

also known as subsyndromal or minor depression. These overarching classifica-

tions can be specified (a) by precipitating events or causes such as bereavement or

vascular depression, (b) by symptom profile such as psychotic depression and

melancholic depression, and (c) by course, which includes late-onset versus early-

onset depression. Early onset refers to an older adult who has experienced a de-

pressive episode at a previous time in the life course; late onset refers to an older

adult who is experiencing his or her first episode of depression (Devanand et al.,

2002). Overall, major depression, dysthymia, and subthreshold depression have

established measurements that have been the basis for most of the literature, re-

search studies, treatment guidelines, and practice reimbursement; therefore,

these categories are the predominant forms of classifying depression. The sub-

types are used to provide more specific descriptions of the symptoms, causes,

and appropriate treatment options.

AJOR

EPRESSIVE

ISORDER

Major Depressive Disorder constitutes a formal diagnosis in the fourth edition of

the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psy-

chiatric Association, 1994). It has no age specifications and includes a combina-

tion of symptoms that persist for almost every day, most of the day, for at least 2

weeks. A person must exhibit one or both of the two cardinal symptoms. The first

symptom is experiencing a low mood or dysphoria, which can also be referred to

as sad, blue, gloomy, or depressed. The second cardinal symptom is anhedonia,

which is defined as a loss of interest in activities that the older adult typically

would have found pleasurable. Activities are broadly defined to include work, in-

terpersonal relationships, hobbies, sexual activity, and other individualized defi-

nitions of “activities of interest.” The person must also exhibit four or more of the

Depression 271

following symptoms: feelings of worthlessness or inappropriate guilt, diminished

ability to concentrate or make decisions, fatigue, psychomotor agitation or retar-

dation, difficulty sleeping or sleeping too much, significant increase or decrease

in appetite or weight, and recurrent thoughts of death or suicidal ideations. In as-

sessing for these symptoms it is often recommended to ask about “change in be-

havior” to distinguish between perpetual difficulties and episodic difficulties

that are due to the depression (Blazer, 1993).

YSTHYMIA

Dysthymic Disorder is also defined by the DSM-IV and has a similar symptom

list. Dysthymia is distinct from major depression; it is less severe as individuals

are not required to meet the criterion of four symptoms. However, dysthymia is

persistent, lasting 2 years or longer. The symptom profile of dysthymia often in-

cludes more long-standing difficulties with self-esteem or hopelessness. It can

also include poor appetite or overeating, difficulties with low energy or fatigue,

and poor concentration. The other diagnostic criteria for both major depression

and dysthymia is that the symptoms must interfere significantly with the per-

son’s functioning and must not be caused by another comorbid condition or sub-

stance use. Both dysthymia and major depression can also be further specified

by the course of the illness (i.e., partial remission, full remission, chronic, single

episode).

UBTHRESHOLD

EPRESSION

The third type, subthreshold depression, may be identified according to the DSM-

IV appendix on minor depression or according to several different depression

scales. The main description is that it consists of three to four DSM-IV symptoms

for depression, but not enough to meet diagnostic criteria; thus the person is expe-

riencing a less severe version of depression. This category has generated a wealth

of research by gerontologists who assert that even though subthreshold depression

in older adults does not meet DSM-IV criteria, it does have similar negative out-

comes and responds similarly to depression treatments (Chopra et al., 2005; Hy-

bels, Blazer, & Pieper, 2001). Even though the literature supports the use of this

definition, it has rarely been applied to treatment settings because most insurance

providers do not provide coverage for the care of subthreshold depression.

Overall, these definitions are adequate in describing what is known as “clini-

cally significant depression”; however, they fail to sufficiently describe the etiol-

ogy of the depression. Furthermore, important sociological criticisms of the

diagnostic criteria exist. The first concern is with the social construction of spe-

cific disorders, in that what is considered a disorder is subjective and defined by

time, context, and culture (Aneshensal & Phelan, 1999). A second criticism, com-

ing primarily from gerontologists, is that due to the diagnostic criteria’s strong in-

fluences on the service delivery system, the system is biased against older adults

because older adults more often fall into the category of subthreshold depression.

A leading argument is that older adults vary in their symptoms in comparison to

younger adults, thus they do not fit the DSM-IV criteria for major depression or

dysthymia (Chopra et al., 2005). Older adults with depression may report more

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somatic complaints, such as problems with fatigue, insomnia, weight loss, and

withdrawal, instead of clearly describing problems with low mood (Lyness et al.,

1996; McAvay, Raue, Brown, & Bruce, 2005). This masking of sadness with com-

plaints of aches, pains, and other physical symptoms may lead to decreased de-

tection of the depression (Kirmayer, Robbins, Dworkind, & Yaffe, 1993).

This variance in symptom presentation is confounded by the fact that several

of the depressive symptoms can be symptoms of other medical conditions or even

assumed to be the natural process of aging. Examples include changes in sleeping

patterns, changes in appetite, fatigue, changes in concentration, and even

thoughts of death. With the variation in symptoms and the overlapping of symp-

toms with comorbid conditions, the nomenclature for depression diagnoses can

fail to account for the broad range of symptom presentation by older adults

(Areán & Ayalon, 2005).

Evidence-based geriatric psychiatry guidelines recommend that when comor-

bid medical or substance abuse conditions are present, differential diagnosis is

needed, as is individualized treatment, to address both the issues of depression

and the co-occurring disorders (Shanmugham, Karp, Drayer, Reynolds, & Alex-

opoulos, 2005). In fact, on discharge from inpatient psychiatry care for depres-

sion, Morrow-Howell, Proctor, Rubin, and Thompson (2000) have documented

that older adults present with multiple aftercare needs across medical, psychi-

atric, and psychosocial realms. In a study of depressed elderly patients dis-

charged home from acute psychiatric care, medical comorbidity was associated

with greater functional impairment and increased medical and psychiatric ser-

vice needs (Proctor et al., 2003). Disease-specific differences are reported to

occur in the rates of remission for depressed geriatric patients receiving usual

care, but when patients were provided a depression care manager and algorithm-

based care, the association between medical comorbidity and treatment out-

comes was insignificant (Bogner et al., 2005). Therefore, as will be discussed later

in screening for depression, a practitioner working with older adults needs to be

alert to the variety of symptom profiles, the availability of specific screens for

older adults, and the need for clinical exploration of the overlapping symptoms

related to other conditions.

EPIDEMIOLOGY OF DEPRESSION AND SUICIDE

Depression is a primary concern for older adults because it is one of the most com-

mon mental health problems affecting later life. Approximately 8% to 16% of com-

munity-dwelling older adults experience clinically significant depression

(Beekman, Copeland, & Prince, 1999; Blazer, Burchett, Service, & George, 1991),

and rates of major depression range from 1% to 4% (Beekman et al., 1995). Another

reason to review the epidemiology of late-life depression is that prevalence rates

vary by subpopulations of older adults. For example, older adults hospitalized for

medical and surgical services have rates of major depression of 10% to 12%, and

23% for significant depressive symptoms (Koenig, Meador, Cohen, & Blazer, 1988).

For older adults who visit a primary care provider, rates of major depression are

estimated to be between 5% and 10% (Schulberg et al., 1998). Other settings that

have increased comorbid medical and functional impairments have even higher

rates of depression. Among older adults receiving public community long-term

care services, 26% experience clinically significant depression and 6% meet crite-

ria for current major depression (Morrow-Howell et al., 2005). In long-term care

Depression 273

institutions the estimated rate of major depression is 12% and the rate for clini-

cally significant depression is 35% (Parmelee, Katz, & Lawton, 1989).

Another subpopulation has high rates of depression that is not linked to med-

ical and physical issues, but to life circumstances. Caregivers range in age, but al-

most half of all caregivers are above the age of 50, and older adults are more likely

to provide long-term care (i.e., over 10 years of care) than other age groups (Na-

tional Alliance for Caregivers & American Association of Retired Persons, 2004).

Caregiving responsibilities are associated with higher levels of depression, with

reported rates up to 31% of caregivers with clinically significant depression (Dew

et al., 2004; Toseland, McCallion, Smith, & Banks, 2004). Spousal caregivers had

higher rates of depression than other familial caregivers (Schulz, O’Brien, Book-

wala, & Fleissner, 1995). The caregiver subpopulation breaks away from the other

subpopulations, which are based on medical settings rather than role. This group

provides insight into the variety of social and psychological risk factors that are

associated with late-life depression, along with the known biological risk factors.

Risk factors include female sex, lack of social support, disability, previous depres-

sion, and negative life events, such as death of a spouse (Cole, 2005; Schoevers

et al., 2000).

As mentioned earlier, one reason to be concerned with the rates of depression

in older adults is because depression is a leading indicator of suicide risk. Accord-

ing to the Centers for Disease Control (2006), 5,393 Americans over age 65 com-

mitted suicide in 2001. Risk of suicide increases with age, and older adults have

the highest rate of suicide of any age group. Along with increasing age, male sex,

and Caucasian ethnicity, other risk factors for late-life suicide include depressive

symptoms, perceived poor health status, unmarried status, and lack of social sup-

port (Turvey et al., 2002). Unlike in younger age groups, a prior suicide attempt is

not as indicative of risk because older adults have a ratio of attempts to completed

suicides of approximately 41; whereas, estimates for the U.S. population as a

whole range between 81 and 201 (Pearson & Brown, 2000). Given the rates of de-

pression and suicide in older adults, it is alarming to learn about the unmet needs

of this population in detection and treatment.

With the available knowledge of the prevalence of depression and suicide in

older adults, it is disconcerting that most late-life depression remains undetected

and is inadequately treated. It has been widely reported that only about half of

the population meeting diagnostic criteria receive any sort of treatment from

either the specialty mental health sector, primary care setting, or other human

services (Reiger et al., 1993). This trend in unmet mental health care needs per-

sists with older adults, who are much less likely to seek specialty mental health

care. Only 14% of depressed older adults receives antidepressant treatment and

50% never complete mental health referrals (Callahan, Hui, Nienaber, & Musick,

1994).

The primary care setting is the predominant provider for mental health care to

older adults, and there is still persistent disparity in the recognition and treat-

ment of late-life depression in this setting. Older adults are less likely than young

or middle-aged adults to perceive a need for mental health care, obtain specialty

mental health care, or even to receive referrals from primary care physicians for

mental health specialty care (Klap, Tschantz Unroe, & Unützer, 2003). For those

older adults who do receive depression treatment in the primary care setting, the

rates of detection and receiving adequate treatment are below average for pri-

mary care patients (Katon, Von Korff, Lin, Bush, & Ormel, 1992; Simon, 2002;

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Simon et al., 1995). In general, older adults are less likely to be screened for alco-

hol, drug, and mental disorders, including depression, than young and middle-

aged adults in the primary care setting (Edlund, Unützer, & Wells, 2004).

Approximately 58% of older adults who commit suicide saw their primary care

physician in the prior month (Luoma, Martin, & Pearson, 2002).

Some of the factors proposed to contribute to the inadequate detection of late-

life depression include stigma and competing demands. The surgeon general’s re-

port on mental health identified how problems of stigma contribute to the

avoidance of discussing depression in the patient-provider interaction (U.S. De-

partment of Health and Human Services, 1999). Stigma is hypothesized to specif-

ically influence provider behavior toward late-life depression (Schwenk, 2002).

The competing demands on the primary care provider to address other, multiple

physical problems may also overshadow the detection of depression in the time-

limited provider encounters (Klinkman, 1997). Fortunately, several interventions

and research initiatives are demonstrating methods for improving the detection

and care provided in primary care settings for older adults by addressing the

issue of stigma, competing demands, and fiscal and time constraints. These mul-

tifaceted interventions are reviewed later; first we must clarify the current state

of knowledge on the causes of depression so that we have a theoretical basis for

the recommended treatment approaches.

ETIOLOGY

The three dominant theories for explaining the causes of depression are biologi-

cal, cognitive, and behavioral. Rather than having a single cause, there appears to

be a variety of genetic, neuropathological, and psychosocial factors that may

work separately or together to cause depression (Drevets & Todd, 1997). Each of

these theories contributes to the general understanding of depression, to promi-

nent treatment models, and to the specific recommendations to address late-life

depression.

IOLOGICAL

HEORY

Literature increasingly recognizes that depression in late life is associated with

brain abnormalities and may be related to genetic susceptibility (Blazer, 2003).

For example, depression may be related to the production, supply, or level of ac-

tivity of specific neurotransmitters. Medical illnesses, head injuries, heredity,

and medications may all impact the regular functioning of neurotransmitters. Re-

searchers have identified specific neurotransmitters related to depression, such

as monoamine neurotransmitters that act as mood regulators and peptide neuro-

transmitters that act on pain reduction and pleasure (Blazer, 2003). Serotonin ac-

tivity, which also is a brain chemical impacting mood, has been demonstrated to

significantly differ for depressed elderly patients compared to elderly controls or

older adults with Alzheimer’s disease (Nemeroff et al., 1988).

Two other factors have strengthened the possibility of biological causation.

First, empirical findings support that some medical illnesses directly cause a

major depressive episode. Farber and Black (1997) describe illnesses that cause

“secondary depression,” such as Parkinson’s disease, stroke, dementing disor-

ders, cardiovascular disease, and multiple sclerosis. Such illnesses have direct

Depression 275

physiological effects on the brain, so it is not surprising that damage to the brain

could cause mood disturbances. Second, widespread evidence demonstrates the

effectiveness of pharmacological treatments for depression (Charney et al., 2003).

Understanding how the antidepressants affect neurotransmitter functioning

leads to theories of how brain functions are related to moderating mood. Finally,

most biological theories are based on associations; therefore, the issue of causal-

ity is not fully determined. Depression in late life does not occur solely to those

who are sick nor to all of those who are sick with a specific illness. Therefore,

other factors should be identified to understand who out of the healthy people or

people with medical conditions is more susceptible to depression.

OGNITIVE

HEORY

Complementing the biological theories, two psychologically based theories have

remained prominent in the literature discussion. Aaron Beck developed cognitive

theory to explain how negative distortions in the thought process cause depres-

sion (Beck, Rush, Shaw, & Emery, 1979). Examples of negative distortions are un-

realistic expectations, overgeneralizations, overreactions, and personalization.

For example, the same negative life event may occur to two people, yet only one

person develops depression. According to Beck, it is this person’s negative

thought reactions to the event that cause the depression, whereas the other per-

son’s undistorted thought process protects him or her from experiencing depres-

sion. This internal interpretation of the event explains the causes of depression

(Thase & Beck, 1993). Research findings have supported this theory: Older adults

with major depression perceived greater negative impact of life events than older

adults with dysthymia or older adults in a healthy control group (Devenand, Kim,

Kaykina, Paykin, & Sackeim, 2002).

EHAVIOR

HEORY

The other prominent psychological theory explaining depression in older adults

draws from the behavioral response of learned helplessness, where initiating any

action in a perpetually stressful environment leads to expecting only minimal

change in outcomes (Blazer, 2003). The total number of negative life events and

daily hassles has been associated with late-life depression through a meta-analysis

(Kraaij, Arensman, & Spinhoven, 2002). The behavior concept of positive reinforce-

ment has also been applied to older adult depression. Lewinsohn and MacPhillamy

(1974) used empirical findings to demonstrate that depressed people engage in

fewer behaviors than do nondepressed people. In particular, depressed people en-

gage in less pleasant (positively reinforcing) behaviors, which results in a feedback

loop of declines in mood and decreases in pleasant behaviors. Complicating this

theory is that a person’s change in activity level is rarely seen as the sole cause of

depression, yet change in activity level is a symptom of depression, which con-

founds the question of causality even more.

OCIAL

HEORIES

Limited evidence-based literature articulates social causes of depression, yet a

few initial findings are important to consider. Broadening the scope beyond the

individual biological and psychological factors, it is necessary to consider a

prominent sociological perspective on aging and recent exploratory qualitative