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Article Excerpt
It is estimated that half of the 35 million people in the United Slates who are over the age of 65 are in need of mental health services, though fewer than 20% are actually being treated (Comer, 2004). Coexisting mental and physical problems make recognition of depression in elder persons more difficult because presenting symptoms of depression are often masked by physical problems. In addition, most elder people who have depression never seek or obtain treatment because of the commonly held myth that depression is a normal part of the aging process and that elder people cannot benefit from psychotherapy. The purpose of this article is to survey these issues as they relate to mental health counseling.
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The fields of geropsychology and geropsychiatry have developed almost entirely in the last 30 years, with fewer than 4% of clinicians working primarily with elder patients. Because so few clinicians have been trained to work specifically with elder individuals, many never receive needed mental health treatment. Of the 35 million people in the United States over the age 65, it is estimated that half are in need of mental health services but fewer than 20% actually receive treatment (Comer, 2004). In fact, depression has been found to be the most frequent psychiatric diagnosis in the elder population (Lebowitz, Pearson, Schneider, Reynolds, Alexopoulos, Bruce, Conwell, et al., 1997). An estimated 2 million elder persons have a depressive illness and another 5 million may have symptoms not fully meeting the diagnostic criteria for depressive disorder (Conwell, 2001).
One reason this population does not get appropriate treatment may be that physicians fail to notice or properly diagnose depression in their elder patients (Lin, Simon, Katzenick, & Pearson, 2001; Haley, 1999; Rost, Nutting, Smith, Werner, & Duan, 2001). For example, a survey of primary care providers found that only 33% used a standardized screening instrument specifically designed to detect depression in patients. Up to 65% of elder persons who have major depression may not have been accurately diagnosed; the consequences could be devastating considering that elders represent 19% of suicides in the United States (Conwell & Duberstein, 2001).
Accurate diagnosis of depression among elder persons is often complicated by multiple issues, not the least of which is that older adults generally do not seek mental health services on their own. Those who do generally do so at the request of others (Hinrichsen, 1999). The lessening of social connections with others who might observe increased depressive symptoms further reduces the likelihood that elder people will present for treatment for depression (Hinrichsen). Yet once properly diagnosed, treatment of depression in an elder person can be very successful (Katona, 2000). This article will therefore address the following issues of depression in the elder population: (a) symptomotology, (b) diagnosis, (c) potential causes of depression, (d) treatment, (e) the need for mental health coverage, and (f) mental health counseling issues.
SYMPTOMATOLOGY
Many symptoms of depression (e.g., thoughts of dying, fatigue, loss of libido, reduced sleep, sleeplessness) are often considered normal signs of aging (Katona, 2000). In fact, some physicians still do not consider depression as a potential diagnosis in the elder population because it mimics features of existing physical problems (Katona; Unutzer, Katon, Sullivan, & Miranda, 1999). For example, a stroke can cause many of the same symptoms as depression, as can side effects from medications for heart disease, hypertension, and arthritis (Gottfries, 2001; Unutzer, et al.) and co-occuring disorders of cancer and diabetes mellitus (Bell, 1999). Thyroid dysfunction and low estrogen levels in women can likewise complicate diagnosis of depression (Blazer, 2002). Furthermore, although memory loss is a common symptom of depression in elder people, it is often attributed instead to dementia.
Symptoms of depression in elder individuals vary but can include insomnia, hypersomnia, eating too much or too little, loss of energy, fatigue, and a general diminished ability to concentrate (Blazer, 2002). Irritability is a frequent sign of depression in elder men, as are complaints of stomach problems, palpitations, and shortness of breath (Karel, Ogland-Hand, Gatz, & Unutzer, 2002). Observable signs of depression are changes in appearance, stooped posture, social withdrawal, hostility, suspiciousness, slowed speech and movements, wringing of hands, picking of skin, pacing, and outbursts of aggression (Blazer). Five areas of functioning that are adversely affected by depression tend to exacerbate one another: (1) emotional, (2) motivational, (3) behavioral, (4) cognitive, and (5) physical aspects of an individual's life (Blazer; Karel, et ah).
Emotional Symptoms
Many individuals who experience emotional symptoms of depression report gaining little pleasure from almost any activity. Some report feeling angry, dismal, agitated, humiliated, often melancholy to the point of tears, sad, miserable, meaningless, and even anxious (Blazer, 2002). At least half the population diagnosed with major depressive disorder also have a co-ocurring anxiety disorder that can mask depressive symptoms and complicate accurate diagnosis of depression (Blazer).
Motivational Symptoms
Elder persons who are experiencing depression may lose the drive to pursue their usual activities, leading to a state that has been referred to as a "paralysis of will," also known as apathy. This motivational state can cause individuals to feel they must force themselves to eat, work, or even talk to friends (Blazer, 2002). They also may lose interest in normal...
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