Clinical Depression in Later Life - Research Paper Example

Dерrеssiоn in Lаtеr Lifе - Соnfliсting еvidеnсе suggеsts that аdults in lаtеr lifе аrе аt inсrеаsеd risk оf dерrеssiоn. Rеviеw thе litеrаturе аnd drаw а соnсlusiоn аbоut thе ехtеnt tо whiсh оldеr аdults аrе аt аn inсrеаsеd risk оf сliniсаl dерrеssiоn or dерrеssive symptomology Contents Introduction, page 1 Thesis, page 3 Justification, page 3 Method , page 4 Literature Review, page 4 Future Practice, page 10 Conclusion , page 11 References, page 13 Introduction Depression is a very prevalent global human illness. The National Institute of Mental Health claim that at any one time 10% of people are clinically depressed. Horgan ( 2013) claims that it affects as large a proportion as 20% of Australians , whereas SANE Australia gives a figure of 6% so that the statistics and the situation is not clear cut. This essay will consider why there is such a discrepancy in the figures given, as well as the implications for such uncertainty. The term ‘depression’ is used in a number of different ways to cover a range of symptoms and degrees of the condition. Depression, as well as a medical condition, can mean a transient state of low mood, a common human experience at some point in life, whether or not the cause can be defined. However the same term is also used for a serious psychiatric disorder. Major depression has severe symptoms that interfere with the victim’s ability to do the ordinary things of life, as well as getting some enjoyment out of activities they once enjoyed. . Some people will experience only one such episode within their life, but more often someone will experience multiple episodes. Wells (2013 describes it as a ‘chronic state interspersed with high and low periods.’ In some cases what is experienced is dysthymia. This involves having depressive symptoms that last for two years or more, but are which are usually less severe than those of a major depressive illness. Minor depression in some form can be a natural response to life events, usually relatively short term, though in other cases it is based upon factors such as genetics and biology, and affects not just how a person feels about life’s situations, but also how they feel about themselves, their own feelings of self-worth and value which can be quite negative. This genetic link includes differences in brain chemistry from that found in non-depressive people. Depression is found to be more common at certain times of life (Australian Government, undated). According to this report generally the medical profession divide depression into three grades; melancholia, severe depression with psychiatric symptoms and mild to severe depression without psychiatric symptoms. There are many sub-types of depression such as post-natal depression; anxiety, anaclitic depression found among infants separated from parents for prolonged periods ( Behave Net 2013) and seasonal affective disorder. Another possible cause could be a reaction to certain medications such as beta blockers and steroids ( Neel, 2012) which are commonly prescribed for older people. The American National Institute of Mental Health ( 2013) also describes how older people can suffer from ischemia , that is restricted blood flow as older blood vessels may stiffen and slow blood from flowing normally to reach the organs including the brain. This can lead to vascular depression in older people with no previous family history of depression. This condition also increases the person’s risk of other circulatory diseases such as stroke and heart disease, as well as perhaps affecting their cognitive abilities. Major symptoms of depression would include such things as loss of interest in activities which were previously enjoyed; excessive sleep or its opposite, insomnia; loss of energy; thoughts of suicide and low self-worth and an inability to concentrate. Environmental and social issues such as family illness; bereavement and relationship breakdown can be factors. Depression can also be associated with physical illness. According to Colombia Psychiatry ( 2013) each individual patient has his or her own unique mixture of the symptoms of depression and medical conditions. Smith, Robinson and Segal (2013) add to this list of possible factors the fear of death, social isolation and a reduced sense of purpose, which are more common in older people than in other age groups. According to a 1997 survey by the National Survey of Mental Health and Well Being (Cited by Australian Government, page 50, undated) depression tends to occur less often in later life among both men and women in Australia. According to Goldney and Harrison ( 1997) rates of suicide , which is of course closely associated with severe depression, are actually lower in older people than they once were. On the other hand, according to Health (2013) depression is twice as common among older people than it is in adults in general at a rate of 20%, yet only half of these get any treatment at all, and fewer than 3% of them will be referred to a mental health specialist. So the real picture is not clear. How does Health arrive at these figures if they claim that only half of those older people with depression get treatment? Where are such estimates coming from and are what are they based upon? Has there been empirical research? The answers are unclear from reading such reports. If it is really the case that only 50% of those with depression are receiving treatment , and even fewer are receiving specialist help , this has implications when one considers that anti-depressant treatment alone is less likely to be successful than if the medication is taken alongside counselling and support. Thesis Older adults may or may not be more at risk of developing depression than earlier in life. Justification If it can be shown that depression is more likely in older people, or is less likely to be diagnosed, then physicians are more likely to consider it as a possible diagnosis and so spot symptoms earlier, and then provide suitable treatment at an earlier stage of the condition, including both medications, advice and referral to other forms of support such as counselling. Method This topic will be considered using a literature review. Search terms will include such things as depression, depressive illness, older people and depression, age associated depression, diagnosing depression, research into depression in older people. This will be done with particular relationship to the current situation in Australia and topicality. Research papers both quantitative and qualiative will be considered , but so too will be reports and guidelines from various organisations, including government bodies. The findings will be considered and analysed with regard to its possible effect upon future planning, practice and provision. Literature Review According to the Royal College of Psychiatrists (2013) later life can bring with it a number of reasons for depression. They list such things as stopping work; having less money; health problems and the death of a partner or friends. They point out though that in less than one in six case of depression among older people is it severe enough to be noticed by others. The condition nevertheless consists of a range of symptoms which can interfere with normal activities. This therefore points to a major degree of under diagnosis, and so it follows that there will also be under optimum levels of treatment are being offered. Yet depression is a condition that usually responds very well to adequate treatment ( National Institute of Mental Health, 2013). The Royal College of Psychiatrists ( 2013) point out that older people may only consider physical matters as being real illnesses, and so not inclined to go and see a doctor about their depression, perhaps assuming that it is a normal; part of the aging process. It must be asked how do they arrive at these figures if the people are not going to their doctors, or at least not going saying that they were depressed. From what is said it could perhaps be that fewer people in old age have depression then can sometimes be assumed. Yet Fitz, Wetherall and Gatz ( 2009) point out that in half of diagnosed cases among older people this is their first episode. According to the American National Alliance on Mental Illness ( 2013) 21% of those over 65 will experience depression. It is most often closely linked with circumstances such as dependency and disability, but according to Fiske, Wetherall and Gatz ( 2009) the condition is most often brought on by a combination of social, genetic factors, stress, and cognitive diathesis, that is a higher than usual tendency to have cognitive problems. It causes distress not only for the depressed person, but also their family and carers. The article goes on say that depression in elderly people is often untreated because it is so often seen as being a normal part of the aging process. In other cases the symptoms of depression are seen as possible signs of dementia or such conditions as Alzheimer’s disease, Parkinson’s disease and thyroid disturbance among others. People don’t want up face up to having these conditions and so don’t consult the medical profession. Also people may see depression as a character flaw rather than an illness. They could also be aware of perceived social stigmas against mental illness, an d so could also be reluctant to explain their feelings to another, and are much more likely to seek medical help for a physical condition than a mental illness. On the other hand the person may not realize that their physical difficulties are signs of a depressive illness. They may also be relatively socially isolated and so there is no one to notice their condition, or to encourage them to seek help. With regard to this social isolation a report from Suicide Prevention Australia (2008) makes a distinction between physical remoteness and isolation. Remoteness it says can mean not geographical distance, but a lack of access to such things as information, good communications and other resources, as well as a sense of social isolation. They point to reports (Suicide Prevention Australia, 2008, page 3) such as that from Page and Frager (2002) which claims that within Australia rural suicides occur at a higher rate than urban one. Also described are such things as guilt experienced because of financial experiences, and increased vulnerability. Again though there is a problem in coming up with near accurate figures, and it is believed by the authors of this report that many deaths reported as accidents, are in fact suicides. Even if medical help is sought, the diagnosis of depression can be hard to come to, as some symptoms such as fatigue, loss of appetite loss and insomnia can be seen as a normal part of the aging process. Despite this, according to Thomas, (2010) depression is the most common mental illness diagnosed among older people and is the second most common single underlying cause for people consulting their general practitioners among those 70 years old and older. Even those who do seek medical help may not continue with treatment for a number of reasons. They may for instance find that the response they expect and need takes longer than they anticipate, because they have not been told that anti-depressants can take from six to eight weeks to produce a noticeable effect ( The Royal College of Psychiatrists, 2013). Also they may not be adequately linked up to other supportive mechanisms. There needs therefore to be :- Improved coordination and collaboration by existing services , as well as the resourcing of additional services remains central to provision of seamless pathways to care. ( Suicide Prevention Australia, 2008, page 3 ). In the same report though (Suicide Prevention Australia, 2008, page 5) the closure of services, not just health services, but also such things as banking, government offices and public transport services in remoter communities is mentioned, citing Wainer and Chesters, ( 2000, page 143). There is also the matter of possible side effects from anti-depression medication among those who do seek help. Some people may find for instance that they become anxious in the first few days of treatment, and others may find that they are nauseated. Sleepiness can also be a problem as can having a dry mouth. Another problem is that taking anti-depressants can cause a lowering of the body’s sodium levels which then results in feeling of weakness and debility ( Royal College of Psychiatrists, 2013). There is also an increase in the risk of such things as stroke and other circulatory conditions. Any or all of these reasons may mean that the person fails to continue treatment. Another problem is that many older people are already taking regular medication and this is just one more set of tablets to remember to take. Draper ( 1995, page 1153) concluded that the choice of medication for older people should depend upon their ability to tolerate the drug offered. This lack of treatment can have negative consequences for physical illnesses. Depression in later life increases the risk for both medical illness and for cognitive decline, and so affects mortality, even in cases which are non-suicidal, although , within the United States, depression is the highest risk factor for suicide among the older people in the population , especially so among white males. Fiske, Wetherall, and Gatz ( 2009) state that the number of suicides among older depressive people is on the decrease, but they are still at a higher level than that found among younger adults. Also suicide is commonest among men who are divorced and widowed, and of course the older one is the more likely this is to be the case. There is also the fact that the average life span is rising, a world -wide phenomenon ( Boseley, 2012), a statement backed up by the Specialist Mental Health Services for Older People, NSW, ( 2005) . This will mean presumably a greater number of older depressives, even if the proportions remain the same as at present. Murray, quoted by Boseley ( 2012) said that :- We're finding that very few people are walking around with perfect health and that, as people age, they accumulate health conditions. This would of course include a range of mental health issues, including depression. It is a future situation which requires very careful pre-planning, as set out by groups such as Specialist Mental Health Services for Older People, NSW, ( 2005). As long ago as 1997 Beekman et al considered this increasing utilisation of available services by the rising numbers of the elderly with mild or moderate depression which is accompanied by physical symptoms. The group concluded that even mild depression leads to an increased use of non-mental health services, and this is accompanied by underuse of more appropriate services. The authors describe a lack of consensus on issues of definition and the criteria for accurate diagnosis (Cheung and Snowdon, 1990. It seems that major depression may be relatively rare among the aged, while other pervasive depressive are more common ( Beekman et al 1995). Despite this apparent scarcity of major depression among this age group significantly the vast majority of depressive suicide victims have consulted a doctor recently. In 20% of cases they had actually seen a doctor on the day they die. Were they diagnosed and sent away with a prescription, with the doctor knowing that any anti-depressive medication takes some weeks to have any effect? Also, despite this supposed rarity, recent Australian research into the human genome ( National Institute of Mental Health , August 2013) has concluded that between 17 and 28% of a predisposition to mental illness can be linked to a genetic variation and a 9% link between schizophrenia and depression. The American National Alliance on Mental Illness,( 2013) list a number of symptoms found in older people with depression :- memory problems , confusion , insomnia, social withdrawal, loss of appetite with accompanied weight loss. They may have vague aches and pains and show signs of irritability. They may also be deluded and have hallucinations. Some of these symptoms will be found in all those with depression, but others are specific to older patients. According to The Foundation for Older People ( 2013) depression in older people can include memory problems, but that those experiencing such symptoms may fear that they are experiencing dementia , and this situation requires careful analysis by medical staff in order that the most appropriate treatment and support is offered. However there may be such a fear of the diagnosis of dementia and a loss of independence that doctors are avoided. Draper discussed the possibility of such a mis-diagnosis in 1999 in his paper concerned with dementia and depression. He claims that :- Depression causes excess disability among patients with dementia, and this additional disability can be reversed with successful treatment of the depression. Thomas ( 2010) states that the elderly often do not complain of having low moods, but tend instead to experience physical symptoms. Their depression is often linked to anxiety as well as forgetfulness and confusion among older depressives. Overall health is defined by both physical and mental levels and perceptions of wellness, so it is important that older adults, and medical staff who treat them, take their mental health seriously. These differences in perception about the condition means that depression in older people needs to be assessed in a rather different way to that used for other age groups. This has been recognised since the 1980s. There is for instance a special Children’s Scale for Depression ( Miksad, 2005) and a Geriatric Scale for Depression based upon a series of questions. ( Yesavage et al, 1983). Yet twelve years later in 1995 Bonin-Guilliame were still saying that depression among older people was often going undetected because of the non-existence of specific tests. This they say was particularly a problem among those who might be suffering from dementia. Thomas ( 2010) does point out however that, although the symptoms may be somewhat different, older patients, like younger ones, will respond to treatment , both to medication and to support, especially when these are combined. The other side of this is that older people are perhaps more likely than younger ones to be grieving. This is a normal part of life and death, and grieving may be an appropriate response to a loss, and is not the same as depression. Treating this as depression may lead someone onto a long term medication regime they don’t need, although of course they may well benefit from other support, or short term medications. There are other barriers to effective treatment. The Australian National Aging Research Institute (2009, page 6 ) mentions a lack of availability to services in rural areas of Australia away from the larger conurbations, which can lead to higher levels of suicide. They state that, according to a 2007 National Survey of Health and Wellbeing, older people were much less likely to use mental health services than those of other age groups. They also describe a lack of adequate research into the efficacy of psychological help in instances of depression in older people. The report goes on to mention barriers to effective treatment ( page 18) which include a widespread stigma towards the mentally ill (O’Conner, Rosewarne and Bruce, 2001), the reluctance of health care workers to become involved, and a lack of understanding about mental illness in general , which is described as ‘poor mental health literacy’( Farrer, Leach et al, 2008), a point also mentioned by Suicide Prevention Australia ( 2008, page 4) who were particularly referring to those in socially isolated rural Australia. As well as barriers there are of course aids to diagnosis such as the Canberra Interview for the Aged, described in 1992 ( Acta Psychiatrica Scandanavia ) as :- An efficient tool for clinical and epidemiological research on dementia and depression among elderly people, where close adherence to international criteria is required. There are even on line tests one can take, which might at least lead someone to consider going to seek medical help for their condition. Future Practice Smith, Robinson and Segal (2013) point out that in many cases depression in older adults is due to the circumstances and situations in which they find themselves. It therefore follows that the situation must be dealt with if the depression is to be lifted. Treatment is therefore about more than just handing out prescriptions for pills, but also about offering support and where possible working towards viable solutions. Groups such as those specifically for the bereaved, the depressed, and those for older people in general, can all offer support, but can also provide the means for volunteers to give their help to others in a variety of ways, everything from simply offering a friendly smile to specific advice. There are web sites and telephone services such Lifeline( 2013) as aimed in particular at reducing the number of suicides in Australia by offering one to one counselling via telephone. There is also help available for the relatives and friends of those with depression ( Reachout.com ( 2013), enabling them to better deal with , and to support, their depressed relatives and friends by giving facts, advice, training and support. If the depressed person is anxious about finances they can be put in touch with someone who can offer useful analysis of their situation and advice. If they are lonely they can be encouraged to get out every day, even if only for half an hour. Depression does often respond to medical treatment, but it can be clearly shown that the individual outcome is usually better for those people who have adequate access to social services and to family and friends who can help them stay active and engaged. Groups such as SANE Australia ( 2013) are working with depressed people, but also with health care workers and the government so as to bring about greater knowledge and understanding, both by those affected by depression and those who seek to help and support them. Their aim is to offer an increased level of support, and to improve the services which are already in place. They offer a free call service available countrywide which means they can offer a listening ear, but also advice and referrals. The patients can be told about clubs or volunteer opportunities and also be better integrated into family occasions. There may be peer based support groups for the bereaved, the divorced and so on. There are of course also lots of interest groups covering everything from creative writing, jazz and local history. All of these are resources to be utilised. Conclusion Having considered the available literature on this topic it still seems difficult to conclusively give figures or percentages as to the numbers or proportion of older people who suffer from depression. What is clear however is that, although older people do suffer from depression, they not only experience this in a rather different way to younger people, it being much more likely to present as a physical problem, or be linked to one. Also they may have different attitudes to such conditions, blaming themselves for having a weak personality, rather than seeing it as an illness which anyone might have. This has obvious implications for health care staff and educators , including groups who work specifically with older people and who produce health care leaflets, and of course general practitioners who are likely to be the first port of call when illness, physical or mental, presents. They need perhaps to consider asking some probing questions when an older person presents with vague complaints of feeling unwell. There also needs to be some education available aimed specifically at older people, in the form of leaflets or short courses, or talks arranged by groups such as The Foundation for Older People (2013) at such places as luncheon clubs, so that older people can see that it is alright to admit that they have symptoms of depression, and also that help is readily available. The Foundation states ( 2013) :- Good health is more than just fixing problems as they occur. It is about living a life full of physical enjoyment and mental stimulation and the independence which gives us all a sense of wellness and strength. Older people need to know that this can be the norm and a real possibility for the majority. This means that older citizens also need to know such things as that depression is not a normal component of older life, and that although one particular antidepressant may have been tried and found wanting, then other medications may well suit them better, as do other forms of help and support. There are positive outcomes and they are accessible, but only if the person seeks help and the condition is properly diagnosed and treated. References Acta Psychiatrica Scandanavia, (1992), The Canberra Interview for the Elderly: a new field instrument for the diagnosis of dementia and depression by ICD-10 and DSM-III-R. ,Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1543033 Australian Government, Chapter 2, Profile of Depression in Australia, (undated), Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/8E0E3BC67E3962AFCA25712B0080235F/$File/nhpa2.pdf Beekman, A., Deeg,D., Bramm, A., Smit, J. and Van Tilburg, W., (1997), Consequences of major or minor depression in later life: a study of disability, well-being and service utilisation, Psychological Medicine, 27, pages 1397- 1409, Beekman, A., Deeg ,D., van Tilburg, T., Smit, J., Hoojer, C., and Tilburg, W. , (1995), Major and minor depression in later life: a study in prevalence and risk factors, Journal of Affective Disorders 36, pages 65-75, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8988267 Behave Net,( 2013) , Anaclitic Depression, Retrieved from http://behavenet.com/anaclitic-depression Bonin-Guilliame,S, Clemant ,J., Chassain.A. and Leger, J., (1985), Psychometric evaluation of depression in the elderly subject: which instruments? What are the future perspectives?, L’Encéphale, 21 (1) pages 25 – 34, Boseley, S., (13th December 2012), Life expectancy around world shows dramatic rise, study shows, The Guardian, Retrieved from http://www.theguardian.com/society/2012/dec/13/life-expectancy-world-rise Cheung, F., & Snowden, L., (1990), Community mental health and ethnic minority populations. Community Mental Health Journal, 26, pages 277-291 Draper, B., (1999), The Diagnosis and Treatment of Depression in Dementia, Practical Geriatrics, Volume 50 , Number 9. page 1151-1153 Farrer,L., Leach, L., Griffiths, K.,Christenson, H. and Jorm, A., (2008), Age differences in mental health literacy, BMC Public Health , Retrieved from http://www.biomedcentral.com/1471-2458/8/125/ Fitz ,A. , Wetherall , J. and Gatz , M.( 2009) Depression in Older Adults, Annual Review of Clinical Psychology, 5 pages 363-389, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852580/ Goldney, R. and Harrison, J.,( May 1998) Suicide in the elderly : some good news, Australian Journal of Aging, Volume 17 , issue 2, pages 54-104, Health, ( 2013) Myths and Facts About Depression in the Elderly, Retrieved from http://www.health.com/health/condition-article/0,,20188647,00.html Horgan, D., (2013), Depression, anxiety, crying, tired: we understand !, Professional Counselling, Retrieved from http://www.depression.com.au/ Lifeline, (2013), Retrieved from http://www.lifeline.org.au/ Miksad, J.,( 2005), Children’s Depression Scale, Retrieved from http://www.clintools.com/victims/resources/assessment/affect/cds.html National Aging Research Institute, (2009), Depression in older age: a scoping report National Alliance on Mental Illness,(2013) Depression in Older Persons Fact Sheet , Retrieved from http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=7515 National Institute of Mental Health,( August 2013), Schizophrenia, bipolar disorder share the most common genetic variation, Retrieved from http://www.nimh.nih.gov/news/science-news/2013/new-data-reveal-extent-of-genetic-overlap-b. National Institute on Mental Health, (2013), Older Adults and Depression, Retrieved from http://www.nimh.nih.gov/health/publications/older-adults-and-depression/index.shtml Neel, A.( February 2012), 10 Types of Medications That Can Make You Feel Depressed, AARP, Retrieved from http://www.aarp.org/health/drugs-supplements/info-02-2012/medications-that-can-cause-depression.html O’Conner, D., Rosewarne, R. and Bruce, A., (2001), Depression in primary care 2 : General practitioners recognition of major depression in elderly patients, International Psychogeriatrics 13, pages 364- 373 Page, A. and Frager, L., (2002) , Suicide in Australian Farming 1988-1997, Australian and New Zealand Journal of Psychiatry, 36 (1) pages 81-85 Reachout .com, (2013), Retrieved from http://au.reachout.com/ Royal College of Psychiatrists, (2013), Depression in Older Adults, Retrieved from http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/depression/depressioninolderadults.aspx SANE Australia , (2013) Retrieved from http://www.sane.org/sane-media/media-professionals/about-sane Smith, M., Robinson, L. and Segal, J. ,( 2013), Depression in older adults and the elderly, Helpguide.org, Retrieved from http://www.helpguide.org/mental/depression_elderly.htm Specialist Mental Health Services for Older People, NSW, (2005), Retrieved from http://www.health.nsw.gov.au/policies/gl/2006/GL2006_013.html Suicide Prevention Australia , (2008) Responding to Suicide in Rural Australia, Retrieved from http://suicidepreventionaust.org/wp-content/uploads/2012/01/SPA-Suicide-in-Rural-Australia.pdf The Foundation for Older People, (2013), Retrieved from http://www.ach.org.au/foundation-for-older-australians Thomas, A.,( 2010) Depression in the elderly, Retrieved from http://www.netdoctor.co.uk/diseases/depression/depressionintheelderly_000602.htm Wainer , J. and Chesters, J., (2000), Rural health, neither romanticism nor despair, Australian Journal of Rural Medicine, 8(3) pages 141- 147. Wells, T., (2013), Planning ahead to deal with depression, Retrieved from http://carlwellstherapist.com/planning-ahead-to-deal-with-depression/ Yesavage, J., Brink, T., Rose, T., Lum, O., Huang, V., Adey, M. and Lierer, V., (1983), Development and validation of a geriatric depression screening scale: a preliminary report, Journal of Psychiatric Research, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7183759 Read More