Depression and Suicide in Older Adults - Term Paper Example

Depression and Suicide in Older Adults This paper examines the occurrence of depression and suicide in older adults and what can be done tolessen these problems in individuals that are part of the older population. While many people might assume that adolescence is the most difficult time for these problems, older adults actually have higher rates of both depression and suicide – much higher than may be expected or assumed. In order to study this problem thoroughly, the rationale behind the research will be addressed, along with a discussion of the integration and synthesis of previous research. Depression is not just sadness that fades with time. It is determined by a strict set of criteria as outlined in the second edition of the Diagnostic and Statistical Manual of Mental Disorders. Recognizng depression can be tricky because depressive symptoms manifest themselves differently in older people than they do in younger people. Health care workers need to be alert to the signs and symptoms of depression because untreated depression represents the greatest risk factor for suicide among older adults. Introduction and Rationale Many people may believe that depression in older adults is simply a normal event that most people go through at one time or another; and that there is no real reason to be alarmed. It might be thought that these individuals should accept sad feelings and disinterest in life as a typical part of growing older. Nevertheless, depression is a very real disorder, and not just one that comes with age. Depressed individuals often cannot just ‘snap out of’ the problems they are facing. All too often, older adults end up taking their own lives when their depression becomes too painful for them and remains untreated (Brent, et al, 1997). Older adults have the highest rate of suicide in the United States, with over half of all suicides occurring in adult men, aged 25-65. Moreover, suicide rates steadily increase with age (Heisel, 2004). The rate of suicide among people 65 years and older is 50% higher than the national average. A senior citizen in the United States commits suicide every 90 minutes. Clearly, this is a problem that must not be ignored, particularly among older adults who are disproportionately impacted. Although older adults currently make up only 13% of the population, they suffer 19% of all suicide deaths. Persons who are 65 years and older have the highest suicide rates of any age group, and 84% of those who commit suicide are men. Population experts estimate that by 2030, older adults will comprise about 20% of the population, or about 75 million people. Thus, the problem of suicide, if left unaddressed, can be expected to increase. Heisel (2004) states, “There is a pressing need to identify vulnerability and protective factors associated with late-life suicidal ideation and behavior in order to inform assessment and treatment considerations with seniors at risk of suicide” (p. 50). Anyone working with older adults must be aware of the scope of the problem and the potential ways to help. It is important, therefore, to evaluate ways to reduce the risks posed by depression in older adults, particularly the risk of suicide. With that goal in mind, this paper will examine the prevalence of depression among older adults, diagnosis, treatment, and risk factors for suicide. It will briefly examine depression’s long history. Also, the literature dealing with various approaches to treatment of depression will be reviewed. Ultimately, this paper will thoroughly explore the question of why older adults choose to take their own lives. Diagnosis of Disorder Virtually everyone is sad from time to time, and this is generally not a cause for alarm. In many cases, a temporary negative change in mood is brought on by some specific loss, and corrects itself within a reasonable period of time. Losses late in life tend to become more common. For example, as people get older, they will likely know more people that have died.. Although older adults may experience many painful losses, they will not necessarily develop symptoms of depression. Their sadness often heals with time. People who are temporarily sad do not actually have a mental disorder; and they do not need medication or other treatment (Horwitz & Wakefield, 2005). For those older adults who have depressive symptoms, however, medications and other treatments are vital to ensure that they feel better and can enjoy their lives once again. The first step is to make an accurate diagnosis Depression has been recognized as a disorder for more than 2500 years. Hippocrates, the father of medicine, wrote, “If fear or distress last for a long time it is melancholia” (Horwitz & Wakefield, 2005). A hundred years later, Aristotle added to the definition: “We are often in a condition of feeling grief without being able to ascribe any cause to it; such feelings occur to a slight degree in everyone, but those who are thoroughly possessed by them acquire them as a permanent part of their nature” (Horwitz & Wakefield, 2005). Thus, a key distinction for more than two millennia was between states of sadness “without cause” and similar symptoms that arise from actual losses. “Without cause” referred to the absence of life events commonly associated with feelings of sadness, such as death of a spouse or economic failure. This distinction persisted into the 20th Century, when Freud observed that mourning and melancholia include dejection, loss of interest one’s world, inability to feel pleasure, inactivity, and “an extreme and inexplicable…decline in self-esteem beyond the normal self-recriminations after a loss” (p. 41). Beginning early in the 20th Century, psychiatry developed a classification system defining depressive disorder in the 1918 Statistical Manual for the Use of Hospitals for Mental Diseases. It stated, “Here are to be classified those cases which show depression in reaction to obvious external causes which might naturally produce sadness, such as bereavement, sickness and financial and other worries. The reaction, of a more marked degree and of longer duration than normal sadness, may be looked upon as pathological” (p. 42). The Statistical Manual was supplanted by the Diagnostic and Statistical Manual of Mental Disorders—DSM-I (1952) and DSM-II (1968)—which emphasized psychoanalytic concepts. The DSM-II, for example, defined depressive neurosis as “manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession” (p. 43). “Normal” sadness was associated with real loss, while disorder existed if the intensity or duration of the symptoms could not be explained by a triggering event. DSM-III, published in 1980, abandoned the distinction between normal sadness and depressive disorder. Horwitz & Wakfield (2005) argue that because psychiatrists had to use their personal judgment with each patient, their diagnosis was unreliable. Psychiatry at that time had split into factions. Behaviorists, for example, argued that all behavior is the result of learning, and there are no mental disorders in the medical sense. Psychoanalysis was waning as an influence in psychiatry -- its assumptions challenged and diagnoses under attack. Psychiatrist Thomas Szasz and sociologist Thomas Scheff charged that psychiatric diagnosis was a way to label socially undesirable behavior. In their view the behavior was not really medically disordered, and diagnosis using medical terminology was simply a way to give psychiatrists the ability to influence social (or anti-social) behavior. DSM-III brought basic changes in psychiatric diagnosis in order to meet these challenges. Lists of observable symptoms were compiled to form diagnostic criteria for improved reliability. References to causes of depression (internal conflict or defense against anxiety, for example) were dropped. Diagnostic criteria were intended to be theory-neutral. That is, no particular theory was to be pre-supposed. The criteria were descriptive and not etiological. This enabled research to accumulate across theories. “Rival approaches were allowed to compete on a flat conceptual playing field” (p. 47). A weakness of this approach was lack of attention to a triggering event (because DSM-III was supposed to be theory-neutral, and neutral as to how the disorder was caused). Psychotropic medications were believed to work regardless of cause. Thus, consideration of the context of the symptoms was eliminated. Without any exploration of context and meaning, it is difficult to tell if a person is suffering from intense normal sadness or from a depressive disorder. In addition, as Pollock & Weksler (2000) point out, depressive symptoms can be triggered by an underlying biological cause or from factors such as medication side effects. The current DSM-IV definition of depression requires that five symptoms out of a list of nine must be present for a period of at least two weeks. They are (1) depressed mood; (2) diminished interest or pleasure in activities; (3) weight gain or loss or change in appetite; (4) insomnia or hypersomnia (excessive sleep); (5) psychomotor agitation or retardation (slowing down); (6) fatigue or loss of energy; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate or indecisiveness; and (9) recurrent thought of death or suicidal ideation or suicide attempt” (Stanard, 2000). In addition to these symptoms, a depressed mood or loss of interest or pleasure must be also be found in the patient, regardless of any other symptoms (Stanard, 2000), and the symptoms must cause clinically significant distress or cause impairment of function. None of this applies to bereavement, however, because an intense grief reaction to loss of a loved one is normal and often lasts more than two months. Bereavement is not considered a truly depressive disorder unless it lasts more than two months or includes serious symptoms such as functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation (Horwitz & Wakefield, 2005). Dr. Bruce Pollock (2000), a geriatric mental health specialist and award winning independent scientist from the National Institute of Mental Health, points out that older adults exhibit depressive symptoms differently than young people. “Depressed older persons typically do not report feelings of ‘sadness.’ Rather they present with loss of pleasure, irritability, social withdrawal, hypochondriasis, and somatic symptoms. Somatic symptoms of late-life depression typically include insomnia, loss of appetite, and lack of energy” (p. 67). Because older adults often have chronic illnesses, it can be difficult to separate depressive symptoms from the person’s physical condition. A disturbing fact is that about 20% of persons over 65 who commit suicide visited a physician within 24 hours of the act! 40% visited within a week of killing themselves, and 75% were seen by a doctor during the month before. This implies that their doctors missed the diagnosis of depression. An accurate history is essential and should include assessment of cognitive function. Finkel (2003) states, “depressed older patients are more likely than depressed younger patients to present with coexisting cognitive impairment. Moreover, memory complaints made by patients who are concerned about Alzheimer’s disease are more characteristic of underlying depression than dementia” (p. 51). Attention to the time-course of symptoms in connection with functioning is also needed (Pollack, 2000). Collateral information from family members and caregivers may be very useful as well. Some family physicians are using mental health questionnaires with patients they suspect may be depressed. Once a person has been identified and diagnosed as having a depressive disorder, then the questionnaires can also be used to evaluate the effect of therapy and can provide useful prognostic information (Thibault & Steiner, 2004). When a patient says, “I want to die,” or “I’ve lived long enough and God should take me,” his or her comments should be taken very seriously. A comment like that doesn’t necessarily mean the person is contemplating suicide. He or she may simply be expressing an internal search for meaning in life. But depression should nevertheless be ruled out by directly exploring whether the person is experiencing a severe lack of pleasure, and whether there are other signs or symptoms that indicate a death wish or a major depressive disorder (Sherman, 2002). Pollock & Weksler (2000) note a lack of research on mild depression in older adults, which is surprising considering its prevalence. They state that nearly 20% of “community-dwelling older patients exhibit clinically significant depressive symptoms” although only 3% meet the strict criteria for major depression (p. 67). Moreover, functional disability strongly influences depression. About 15 to 25% of residents in nursing homes, for example, suffer from major depression, while 30 to 50% suffer from minor depression. Some researchers estimate that a quarter of older adults with chronic illnesses like heart disease, vascular changes, and arthritis are also depressed. Several medicines commonly prescribed for older adults with chronic illness—such as lipid-soluble beta blockers, corticosteroids, and benzodiazepines—can cause depression (Pollock & Weksler, 2000). Treatment for Depression The first important options for treatment are the psychodynamic approaches. Psychodynamic approaches, or psychosocial approaches, generally translate in lay terms to counseling or therapy of some kind. This can be conducted in a group or individually, depending on which method the therapist determines will be more effective. Lewinsohn et al (1999) conducted research, which shows that older adults dealing with depression may find this kind of intervention very effective in alleviating their depression. Psychotherapy is especially useful in patients with mild depression who are not taking medicine. Even in cases of more severe depression, Pollock & Weksler (2000) point out that psychotherapy can “improve treatment adherence and reduce dropout rates” (p. 69). Older adults can use psychotherapy to solve specific problems in a goal-directed manner. A study that was conducted by the National Institute of Mental Health (NIMH) in 1997 indicated that older adults suffering from depression and being treated by therapists using cognitive techniques had a 65% remission rate and responded to treatment much more rapidly than older adults who received support and concern from their families only, rather than professional intervention (Brent, et al, 1997). This does not mean, however, that family concern or intervention in the life of a troubled individual has no merit. Even those who did not have one-on-one counseling or therapy found that there was improvement when they were involved in a program of family therapy and coping skills. Not only did depressive symptoms show a decrease, but there was also significant improvement in problem-solving skills, interacting with family and friends, coping, goal setting, and overall social functioning in general (Mufson, et al, 1999). Behavioral approaches are another significant way that older adults with depression can be helped. These approaches focus on problem-solving skills, increased activities that bring enjoyment, assertiveness and social skills, the ability to make friends, and role modeling (Lewinsohn & Clarke, 1999). These behavioral areas are very important when a person is learning how to manage his or her depression. Appropriate behavior can often be learned, or re-learned, for those that have dealt with depression for some time and are now struggling to come out of it. Biological approaches are now the most common for treating moderate to severe depression in older adults. According to Pollock and Weksler (2000), “Pharacotherapy is indicated when significant depressive symptoms have been persistent for at least two weeks and interfere with normal functioning” (p. 67). Because depressive episodes often become more frequent with increasing age, medicine must be selected that will prevent relapse as well as treat the acute symptoms. Selective serotonin reuptake inhibitors (SSRIs) are more easily tolerated in older adults than tricyclic antidepressants. Thus, the initial therapy for older patients will often be SSRIs such as Celexa, Paxil, Zoloft, or Prozac. Patients must be carefully monitored, especially in the initial phase of therapy because the medications can sometimes make things worse at first. Some medications for depression and anxiety carry a risk of suicide when people initially start or stop the medication. Despite some recent concerns that have been voiced about many of the medications on the market, they are still very popular with doctors and patients alike. Many side effects are not found to be severe enough to stop recommending them for older adults. Instead, warnings are placed on the bottles and they are still marketed. Whether this is right or wrong is not a subject for discussion here. It is enough to note that medication is still one of the most popular options for the treatment of depression in older adults. The most widely used drugs are the SSRIs such as Prozac and Paxil (Renaud et al, 1999). These seem to work best in older adults, have the lowest side effects, and are easy to use. They also carry a very low risk of death if they are taken in too large a dose either accidentally or deliberately. This does not mean that these are entirely safe for all older people, or that all depressed older adults should be on medication. However, it does indicate that many of these drugs can generally be safely taken by most older adults without much fear of painful side effects or dangerous behaviors that could harm them (Pollock & Weksler, 2000). Suicide The most serious consequence of not recognizing and treating depression in older adults is this group’s higher rate of suicide (Pollock & Weksler, 2000). Moreover, determining why older adults commit suicide continues to be a dilemma faced by many individuals in the helping professions. Perhaps older adults commit suicide because they are often depressed. But arguably other reasons might also explain why many of these older adults choose to take their own lives, reasons that may be complex and not easily articulated. According to some researchers, intolerable psychological pain is often the stimulus for suicidal tendencies, while a perceived lack of meaning may lead to despair, according to Viktor Frankl (Heisel, 2004). Frankl showed that a sense of meaning and purpose promotes survival and an orientation towards life, rather than death. In Nazi prison camps, for example, many who survived were those who had something important they wanted—in fact needed—to do. In other words, they sensed that their lives still had purpose and meaning. On the other hand, those who believed life had lost its meaning ultimately perished. Heisel (2004) finds that Frankl’s ideas about meaning are very applicable to older adults, depression, and the problem of suicide. A person who has something important to accomplish generally does not contemplate committing suicide. Similarly, Heisel points out that no one commits suicide without entertaining the idea of suicide first. He looked at potential cognitive vulnerability factors for suicide ideation among older adults, and linked thoughts of suicide in late life “with decreased cognitive functioning, global and social forms of hopelessness, and an impaired recognition of meaning or purpose in life” (p. 50). As for who commits suicide, older adult men are four times more likely than older women to complete suicide, but women are twice as likely as men to attempt it. Among older adults, at least 5% have depression, which may lead to suicide if it goes untreated (Shaffer, et al, 1996). Hybels, et al. (2006) believe the percentage of older adults with major depression is closer to 10% and have deduced from longitudinal studies of older adults with major depression that “a significant proportion of patients do not fully recover” (p. 22). Older adults with depressive symptoms are more likely to seek help from a primary care physician than from a mental health professional. This often leads to partial remissions, but with residual symptoms that predict a relapse. These patients are at a higher risk for suicide (Hybels, et al, 2006). When intervention is needed, there are several specific things that should be done. These include (1) ensuring that there is a clinical interview with the older adult in question, (2) observing the behavior of the person, (3) getting other information from significant others in the persons life such as family, friends, and others that might know the older adult, (4) assessing risk factors and support levels that the person has, and (5) assessing the suicidal intent and reasons for living exhibited by the individual (Stanard, 2000). When all of these things are evaluated together, they help to create a much clearer picture of whether the older adult is depressed and suicidal, and whether treatment is necessary. Risk Factors for Suicide in Older Adults Depression is the greatest risk factor for late-life suicide, according to a report in Geriatrics in which depression is said to remain improperly diagnosed and insufficiently treated in older adults (Bruce, et al., 2004). Heisel (2004) argues that there are many people who believe suicide in late life is a rational response to painful old age. This attitude reflects the false belief that aging inevitably means poor health, disabilities, indignities, and “a host of physical, psychological and social insults…” (p. 51). Such ideas are linked to a deep-seated dread of growing old and dying and could represent a risk factor for suicide. Risk factors for older adult suicide are many and various (Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989). When older adults have been exposed to suicide early in life, they often have a stronger risk of committing that act themselves. One might assume that exposure to a suicide early in life would so frighten a person that it would stop him/her from ever doing such a thing; but it appears instead that children exposed suicide become preoccupied with trying to understand it. This reaction usually diminishes to some extent as a person gets older, but for some people that interest never goes away, and eventually manifests itself in suicidal tendencies (Rubenstein, et al, 1989). Another risk factor for suicide is the lack of a sense of belonging. Suicide rates among older adults are highest for those who are divorced and widowed—three times higher for divorced men and twice as high for divorced and widowed women. A feeling of belonging in at least one group (family or friends, for example) helps to insulate older adults from some of the pain they might otherwise feel, and thus helps in many cases to avoid depression and suicide (Hagerty & Williams, 1999; Morano, Cisler, & Lemerond, 1993). This is an especially important concern because older adults who feel isolated can struggle with depression far more often than older people who have good support systems with friends and family, or who are engaged in activities that keep them busy and give them a strong sense of purpose (Hagerty & Williams, 1999). Suicide might be prevented among many older adults if family, friends, and others paid attention to them and noted the effects of changes in their lives. Stressful events that persist, or those that continue to escalate, can put older adults at a higher risk for depression (Rueter, et al, 1999). To be sure, having stress in one’s life is not the only thing that can cause depression. Such factors as family history of mental illness, a broken home, poverty, or a past history of child abuse or neglect, to name just a few, can also lead to depression. Family history, rather than family structure, seems to be much more indicative of the level of risk of depression and suicide among older adults (Wannan & Fombonne, 1998). Depression that is combined with anxiety should prompt physicians and other helping professionals to screen older patients for thoughts of death and suicide, according to a study conducted by Primary Care Research in Substance Abuse and Mental Health for the Elderly. They found that 60.9% of patients with coexisting depression and anxiety reported suicidal ideation or thoughts of death. Moreover, older adults may experience poor quality of life due to illness and may progress to suicidal ideation with the occurrence of another adverse medical event (Patients with Depression and Anxiety Might Be Contemplating Suicide, Geriatrics, 2002). Conclusion Research findings are often useful when the research has been conducted properly, but this kind of study will not provide all of the answers. While it is unlikely that all older adult suicides will be prevented, arguably many of them could be prevented if health care professionals, social workers, family, and who interact with older adults were able to recognize the signs and respond appropriately. Those who intentionally or unintentionally ignore depression in an older adult will not help that person to minimize the risk of suicide. Friends and others who have frequent contact with an older adult should be mindful of the problems facing many of these individuals. The research findings contained here are not novel to psychiatry and related fields, but deals primarily with information that has been collected from other studies. Nevertheless, this information is valuable for those who lack an understanding of the importance of this topic and the seriousness of depression in among older adults. The research discussed here serves as a reminder of problems many older people are facing today – problems that family and friends of older people may overlook because the possibility of suicide may not occur to them. Unfortunately, suicide can affect anyone, even when the known risk factors are not present. A lack of risk factors for depression or suicide does not mean that it cannot happen, just as a lack of risk factors for heart disease is no guarantee that one will not have a heart attack. It is less likely, but that does not make it impossible. Sad, apathetic, joyless behavior that lasts for a long period of time is not normal for anyone, despite that some may perceive it as a passing phase. Older adults with health problems, losses, and countless other problems should not be depressed for long periods of time. When they exhibit depressive symptoms for more than two weeks, they should be examined by a mental health professional to ensure the proper diagnosis is made. Some practitioners may not be aware of how serious this problem actually is in the older adult population. They may not be knowledgeable about the magnitude of depression in older adults. These practitioners will benefit the most from the information presented here, as they gain a new understanding of the problems faced by older adults. The number of individuals in this age group who are showing signs of depression and committing suicide is rising. Family and friends are understandably shocked when a person commits suicide, and they often fault themselves for missing the warning signs. Most people do not have expansive knowledge of the danger for older adults who become depressed. It is, therefore, important to raise awareness of the problem. Rising rates of late-life suicide could be a fruitful focus for future research. There will likely always be work to be done on this issue, as older adults will continue to face different pressures and societal changes. Older adults who manage, through sound support systems and other means, to avoid these risks as they age should be studied in order to determine the role support plays relative to other variables in lifting their spirits following adversity and in preventing suicidal tendencies. Perhaps research will help society learn how to provide a support system to older adults who do not have one, and thus, reduce or eliminate their risk for depression and suicide. References Brent, D. A., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., Iyengar, S., & Johnson, B. A. (1997). A clinical psychotherapy trial for depression in the elderly comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 54, 877-885. Bruce, M. L., Ten Have, T. R., Reynolds, C. F. et al (2004). Physician involvement plays role in reduction of suicide in aged persons. Geriatrics (May) 59(5), 48. Centers for Disease Control and Prevention, (2000). Suicide in the United States. Atlanta, GA: National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ncipc/factsheets/suifacts.htm Clarke, G. N., Rohde, P., Lewinsohn, P. M., Hops, H., & Seeley, J. R. (1999). Cognifitve behavioral treatment of depression in adolescents: Efficacy of acute group treatment and booster sessions. Journal of the Academy of Adolescent Psychiatry, 38, 272-279. Finkel, S. I. (2003). Depression in the very old: Differences in presentation and approach to treatment: A case example. Geriatrics (Mar.), 58(3), 48, 51-52. Hagerty, B. M. & Williams, R. A. (1999). The effects of sense of belonging, social support, conflict, and loneliness on depression. Nursing Research, 48, 215-219. Heisel, M. J. (2004). Suicide ideation in the elderly. Psychiatric Times (March 1), 50. Horwitz, A. V. & Wakefield, J. C. (2005). The age of depression. The Pubic Interest (Winter), 58(1), 39-58. Hybels, C. F., Blazer, D. G., & Steffens, D. C. (2006). 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