CHAPTER 14 Depression and suicide in older people

FRAMEWORK

This chapter examines the issues of depression and suicide in older people. The definition of what constitutes depression in older people is discussed and the difficulty in gathering prevalence data is identified. Obtaining a clear diagnosis is often difficult and can become clouded by issues of loss and grief. The importance of distinguishing depression from confusion, medication effects and delirium is raised and the ongoing issue of demoralisation through adversity is of concern. Risk assessment undertaken by a well-trained health care worker should be done routinely when an older person presents with health problems. The use of antidepressant medication must be monitored well and initial doses are usually lower with increasing amounts given according to reactions. The authors discuss suicide in older people, the spectrum of suicidal behaviours, and the risk factors, with management issues described. Early recognition and treatment of depression is seen as the important preventative intervention for suicide. [RN, SG]

Introduction

Depression and suicide are two closely linked and pertinent issues for older people. Depression is the leading mental illness to affect older people and it is the major risk factor for suicide. In Australia and other developed countries, older men have one of the highest rates for suicide. This chapter examines recent developments in the management of depression and suicide in older people and discusses some of the more controversial aspects of this topic.

Although there are quite a number of different types of depression recognised in nosologies such as the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR) of the American Psychiatric Association (2000), the archetypal depressive illness is the one referred to as ‘major depression’. It is this type of clinically significant depression that will be emphasised in this chapter. However, it is worth noting that chronic low-grade depression is referred to as dysthymia and depressive reactions to adverse life events that do not meet diagnostic criteria for major depression are referred to as ‘adjustment disorders with depressed mood’. However, major depression remains major depression regardless of whether it has occurred in the context of an adverse life event.

The prevalence of major depression in older people is the subject of some dispute (O’Connor 2006). In particular, there is a debate about whether its prevalence actually declines with age as indicated by large-scale epidemiological studies. Many of these studies systematically excluded people who were not living at home at the time of the survey. So older people in hostels, nursing homes and hospitals were generally not counted. We know that the prevalence of depression in these settings is much higher than in the general community, so it is likely that population studies that are based on doorknock surveys have systematically underestimated the number of older people with depression. In addition, the survey instruments commonly used to generate diagnoses of depression, such as the Diagnostic Interview Schedule (DIS) or the Composite International Diagnostic Interview (CIDI), usually exclude symptoms that might be due to general medical conditions. This is not such a problem in young and middle-aged populations, but in older people may have the effect of under-counting symptoms of depression, as older people have a much higher prevalence of general medical problems.

The Australian National Survey of Mental Health and Wellbeing of Adults (McLennan 1998) found that less than 1% of men and less than 2% of women aged 65 years and over living in the community met diagnostic criteria for a depressive disorder. However, this survey did not include older people in residential aged care settings and it is now well established that between 6% and 18% of older people living in aged hostels and nursing homes are suffering from a depressive disorder. The prevalence of depression in older people receiving domiciliary nursing care and in older hospital inpatients is reported to be even higher. In a US study (Steffens et al 2000) that surveyed community and institutionalised older people in Cache County, Utah, the point prevalence of major depression was 2.7% in men and 4.4% in women and the estimated lifetime prevalence of depression was 9.6% in men and 20.4% in women.

Clinical features

Depression in older people may present in several different ways and it is important to appreciate that many depressed older people will deny feeling depressed, even when asked directly. A diagnosis of depression is made by a trained clinician on the basis of the symptoms and signs exhibited by the patient and in the absence of alternative explanations for those symptoms and signs. An appropriate work-up for a first episode of depression in an older person includes detailed history-taking from the patient, mental state examination, physical examination, laboratory tests and, where relevant, a brain scan. In many cases it is also appropriate to obtain further history from an informant, such as a family member or a friend. This is particularly important if the older person is thought to have cognitive impairment.

Many depressed older people will deny feeling depressed, even when asked directly.

By definition, major depression is characterised by either depressed or irritable mood, or by a loss of interest and pleasure in usual activities, or by both. In addition, patients have a number of other symptoms that involve their thought content, neurovegetative function, or behaviour. Thought content symptoms include thoughts of guilt or hopelessness and thoughts of suicide. Neurovegetative symptoms include abnormalities of sleep, appetite and energy. Behavioural symptoms include psychomotor agitation or retardation. Crying tends to be uncommon in major depression although displays of exaggerated distress in relation to the vicissitudes of life or exaggerated sadness in relation to real or perceived evils of the world are common. Some older depressed people adopt a type of importuning behaviour that might lead the clinician to the incorrect conclusion that the patient has serious personality difficulties. Some older people experience and report the distress associated with their depression in the form of somatic symptoms such as headache, dizziness, chest pain, or shortness of breath. It is not uncommon for older depressed people to display socially sanctioned smiles when engaged in interviews with health workers. Such superficial smiling has given rise to the term ‘smiling depressive’.

Some people experience a single episode of depression and make a complete recovery whereas others experience a remitting and relapsing course. In later life it is useful to divide depression according to the age of onset of the first episode. Most depression has its onset in young and middle-aged people and such individuals often go on to experience further episodes in later life. However, some older people experience their first episode of depression in later life. This late onset depression is often a harbinger of cognitive decline and later dementia, or occurs in the context of a general medical problem or one of the other vicissitudes of later life.

Late onset depression is often a harbinger of cognitive decline and later dementia.

Differential diagnosis

It is important to avoid the tendency to reduce most human misery to the notion of ‘depression’ and, in so doing, to fail to appreciate that there are many things that may superficially resemble depression but require a different interpretation and response.

Avoid the tendency to reduce most human misery to the notion of ‘depression’.

In older people it is particularly important to distinguish depression from grief and demoralisation (Clarke & Kissane 2002). Grief is a normal human response to loss and is a very common experience among older people (Byrne & Raphael 1997). Symptoms of grief include crying, thoughts about the deceased, insomnia, a sense of presence of the deceased, hallucinations of the deceased and thoughts of death. Although the manifestations of grief vary considerably between cultures, grief tends to come in waves, the so-called ‘pangs’ of grief, and generally settles spontaneously with the passage of time and without treatment. Grief may be pathologically severe or prolonged in cases where the death was traumatic or unexpected or in cases where the attachment was ambivalent. Grief counselling may be warranted in such cases. In Western culture, at least, grief is associated with considerable tearfulness whereas depression is often associated with an inability to cry. One implication of this is that it is important to allow people to grieve in their own culturally appropriate way and to avoid medicalising a common, normal phenomenon. However, in a minority of cases grief is complicated by depression and this depression requires treatment in the usual manner. Depression complicating grief may be associated with pervasive anhedonia or the development of suicidal intent.

Demoralisation is a common consequence of adversity, particularly where this is prolonged. Many older people with chronic medical conditions or chronic disability following acute medical conditions such as heart attack or stroke develop demoralisation. This is not the same as depression. Treatment of demoralisation requires a different approach (see Clarke & Kissane 2002).

It is also important to distinguish depression from delirium, dementia and sedative drug-induced states. Delirium is a clinical chameleon and often mimics depression. Dementia is frequently complicated by depression and often preceded by depression. Drug-induced sedation in older people often leads to psychomotor slowing that can be confused with depression.

It is also important to distinguish depression from delirium, dementia and sedative drug-induced states.

Emotionalism (pathological crying or laughing) associated with stroke and other manifestations of cerebrovascular disease, including subcortical vascular damage, can sometimes be mistaken for depression. Assessment in the context of stroke can be challenging and often calls for expert opinion. Curiously, both emotionalism and depression respond to treatment with antidepressant medication.

Parkinson’s disease is often associated with a paucity of movement (bradykinesia) and with a reduction in facial expression. These clinical features can easily be mistaken for depression. However, Parkinson’s disease is also commonly associated with depression.

Other assessment issues

Given the high rate of suicide associated with depression it is essential that all older people with depression have a risk assessment undertaken by a well-trained health worker. This is discussed in detail in the second half of this chapter. Some older people with depression stop eating and drinking and this can be dangerous, particularly if they live in a socially isolated situation or if they live in a harsh climate.

About 10% of people with severe depression develop psychotic symptoms including delusions and hallucinations. Often these psychotic symptoms are mood-congruent and take on depressive themes. Common themes include those of guilt, poverty and hypochondriasis.

Psychological treatments

The main evidence-based psychological treatments used in depression are cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT). Although most clinical trials of CBT and IPT have been conducted in young and middle-aged people, there is a growing body of evidence that suggests that these treatments are also effective in older people (Laidlaw et al 2003). In the oldest of the old it is necessary to modify the application of the standard techniques used in these treatments. For instance, it is often necessary to increase the number of sessions and decrease the homework requirements. Sensory impairment (vision and hearing) and cognitive impairment are both significant challenges to psychological treatment. Although CBT and IPT have traditionally been administered by clinical psychologists or psychiatrists, they can be administered by trained therapists from any disciplinary background.

A recent systematic review has suggested that behaviour therapy (BT) might be as effective as CBT in the treatment of depression (Ekers et al 2008). If this is confirmed, it is likely to be very important for the management of depression in older people. Pleasant events scheduling, physical activity, exposure techniques, and other BT interventions are often easier to implement in older people than formal CBT.

A recent systematic review has suggested that behaviour therapy (BT) might be as effective as CBT in the treatment of depression.