Aging is never easy. And the final years of life can be especially difficult, as evidenced by the fact that nearly one-third of people over the age of 65 in the United States experience depression in one of its many facets. The reasons are many: the loss of dear friends and family members, pasts that cannot be altered, presents spent too idly. Researchers also point to physical changes, such as a condition called “vascular depression,” that can contribute to low moods in seniors. Still, Dr. Michael Miller, Editor-in-Chief of the Harvard Mental Health Letter and an Assistant Professor of Psychiatry at Harvard Medical School, doesn’t believe that we should be resigned to living our senior years unhappily. There are many steps people can take, he says, to feel better. What are the signs of depression in older people, and what can be done if you or a friend or relative is suffering from it? Dr. Miller joined us on Friday, Jan. 16 for a Live Talk on what seniors can do to stay happier and healthier as they age. Read the transcript below.
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Dr. Michael C. Miller is the Editor-in-Chief of the Harvard Mental Health Letter, a publication of Harvard Medical School, and a senior editor at Intelihealth.com. He has a clinical practice at Beth Israel Deaconess Medical Center, a large teaching hospital in Boston where he has worked for 25 years. He also practices forensic psychiatry, providing consultation when psychiatric questions emerge in legal cases. After earning his undergraduate and medical degrees at Tufts University, Dr. Miller completed his medical internship, psychiatry residency and chief residency at Beth Israel Hospital in Boston. He is now an Assistant Professor of Psychiatry at Harvard Medical School as well as a teacher and supervisor of residents in the Harvard Longwood Psychiatry Residency Training Program. He has taught and lectured widely, and devotes much time to educating the public about mental health and mental illness.
Dr. Michael Miller: Hi. My name is Michael Miller and I’m a psychiatrist in what is today an extremely cold Boston. I wrote this week’s article in Newsweek on aging and depression. I’m ready to take your questions.
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New York, NY: What's the best way to approach a senior you think is suffering from depression?
Dr. Michael Miller: That is a great place to start, because recognizing the problem is at least half the battle. With some seniors, the direct approach is best – if you know the person well and think the word “depression” might be upsetting, you can use other words to describe the same thing. You seem discouraged to me. You’re not enjoying life the way you used to. How can I help? If the person responds with a resigned shrug or a refusal of help, persist gently. Primary care physicians often have an important role here. If they get some hint from family members or friends that a person may be depressed, they are more likely to recognize it and offer help.
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Hartford, CT: My father, who has been retired for several years now, doesn't seem totally depressed, but doesn't seem to have a lot of interest in the world around him. He mostly stays at home, eats meals, watches some TV, naps in the afternoon. I think he's bored, but I don't think he'd ever admit it. It just seems to me that he could be enjoying his senior years so much more. However, he's never been one to try new things. Any advice?
Dr. Michael Miller: This gives me a chance to elaborate on how to approach a senior you think might be depressed. It’s not important that he admit being depressed. There is a better than even chance that his lack of motivation and energy is a consequence of depression though. Lean on your relationship with him, if you can, and encourage him. Even a little more activity or social contact may make a big difference for him. But getting him out of the house to interact with people may be a struggle, given what you describe. His primary care physician may be able to prescribe an antidepressant. This may be a tough sell, but the potential benefits are usually much greater than any negative effects. By talking in practical terms, about enjoying life more, you can sometimes avoid the stigma attached to the words “depression” and “antidepressant.” And the medication may give him a different outlook and he may have more desire to get out into the world again.
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Boston, MA: What is the government doing, if anything, to help seniors who are struggling with depression?
Dr. Michael Miller: Well, if you ask me, I think devoting resources to helping the millions of Americans with depression is a higher priority than going to Mars. The sad thing is that resources are inadequate and may be dwindling. Seniors, who may advocate for themselves less well than younger folks, could be in the worst straights. The government though has been very good at disseminating information to the online community. The surgeon general’s office has an excellent report on mental health in the US, which you can find at www.surgeongeneral.gov. The National Institute of Mental Health also has a very informative website.
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New City, NY: I found the stats on senior suicides staggering. How does that go unnnoticed? What warning signs should one be on the lookout for?
Dr. Michael Miller: Suicide risk goes unnoticed for a few reasons. Seniors are less likely to talk about depression and particularly about self-destructive ideas. Seniors tend to be more isolated -- isolated seniors may be at the highest risk. Furthermore, seniors with medical illnesses may just stop their medical treatment as a way of commiting suicide that often goes unnoticed. It is impossible to predict who is going to commit suicide. Notice if you can any signs of giving up, but in general the best approach is to get the underlying depression treated whenever possible.
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Winston-SalemNC: I'm 58 but am already taking several drugs, including Paxil, Tegretol, lithium, Lipitor and Synthroid. I find that whenever I make the smallest change in dose or even time, I develop symptoms. How can we best get a handle on interactions and side effects on multiple drugs?
Dr. Michael Miller: There is no easy way around this problem, I'm afraid. As we age, it is more common to be on multiple medications and those medications have a tendency to interact with one another. We also react in a more pronounced way to medication side effects. The best way to approach this problem is patience. Go slowly with any medication change. Understand the possible interactions with the help of your doctor.
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Fort Worth, Texas: How can you convince the elderly that they need help for depression? These are the same people who have been telling you "Yes" and "No" all your life and they don't want to listen now. But, they are not recognizing the depression in themselves.
Dr. Michael Miller: This is a challenge -- the children becoming parents to their own parents! Many aging parents have difficulty accepting the help and advice of their middle-aged children, though many welcome it. Again, I wouldn't focus on getting them to recognize that they are depressed. It's better to help them recognize that they are suffering and that you'd like to help them suffer less.
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Hanson, Ma: Is it normal to break down almost two years after the death of a loved one, almost everytime she's thought of or reminded of?
Dr. Michael Miller: Human beings are so complicated that almost anything could be considered normal. I'm not sure which scenario you're describing. Maybe after the death of the loved one, there was not much of an emotional reaction, then 2 years later, there is a sudden breakdown. Maybe there is understandable grief after the loss, and that grief continues for years without getting better. A delayed reaction is not unheard of, but you have to spend time understanding why -- this may require the help of a professional psychotherapist. Grief that persists longer than a year or two without getting better -- that is probably depression until proven otherwise. It should be evaluated and treatment is likely to be helpful.
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Whitehouse Station, New Jersey: Should seniors consider drugs to relieve depression? Would anti-depressents interact with other drugs seniors take? Do other drugs for diabetes, high-blood pressure, arthritis cause depression?
Dr. Michael Miller: Drug treatments are very commonly used in seniors and have generally been very well tolerated. People of all ages can be reluctant to use an antidepressant -- it has a different meaning than taking a medication for your blood pressure or for a headache. But ultimately it is no different from a medical point of view. Every medication has its risk and benefits. Every medication interacts with other medications, but all this means is you should learn what you can about the interactions and look out for them, reporting any uncomfortable symptoms to your doctor.
And yes, blood pressure medications and arthritis treatments can cause depression though fortunately that happens in the minority of cases.
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North Branford CT: My father-in-law moved to Puerto Rico a year ago, since then he has been depressed and his health has deteriorated greatly. He has had a few strokes and is currently in the hospital with symptoms of kidney failure, due to diabetes. I have also noticed that sometimes he sounds distant, it's almost as if he's unsure of who I am. What tips can you give us on how to deal with this medically? Thanks!
Dr. Michael Miller: Your father-in-law has been through a number of things that could cause depression. The temptation for some is to say, well, he's been through so much, no wonder he's depressed. There's some truth to that, but he can still be helped.
A big move to a new living situation, a stroke, dementia, diabetes, kidney failure -- all of these are connected to higher rates of depression. Support and comfort will continue to be important, but don't rule out all the treatments for depression -- whatever social contact his up to may help him and an antidepressant is a relatively safe thing to try and may also make a significant difference in his mood.
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Fairlawn, NJ: What would be recommended for a 67 year old woman who feels down in the dumps around the holidays? My mom also is kind of a buzz-kill, worrying and not enjoying life so much. Is it a medicinal thing, or lifestyle?
Dr. Michael Miller: Feeling down in the dumps around the holidays is certainly not limited to seniors! This is a tough time for everyone, because expectations are so high, which leads people to feel terrifically burdened. If she has always been the person in the family taking prime responsibility for making the holidays just right, she may be ready to retire from that job.
But you hint that she has always been something of a worrier, taking less pleasure from life than average. She may have always had a low-grade problem with depression, something called "dysthymia." I'm sounding like a broken record, I know, but she may feel less anxious and take more joy in life with treatment -- an antidepressant is worth trying and if she's up for talking with someone about what burdens her, that could be very helpful too.
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New York, NY: Sometimes people have tried to lead honest, hard-working lives and then, when they should be relaxing and living with a little less stress, they find they have no money, no health insurance, no help from the society around them. How do people cope when they are older and have financial difficulties? This is one factor that leads to stress and depression in seniors
Dr. Michael Miller: You're absolutely right and I don't have a good answer. Looking back with pride on a life of hard work and accomplishment is a good thing. But the shrinking of social and financial resources cannot be ignored.
Coping depends upon a combination of personal, inner resources as well as social support. The social support is key, though, because it is very hard to cope when you're isolated and not getting encouragement from others that you respect.
Even though I've indicated that resources could be better, most communities do have some things available -- through the states' mental health or public health departments, local relgious groups or charitable organizations. If you've taken care of yourself your entire adult life, it may be difficult to turn to charitable organizations. There is no shame in asking for help, though, when you need it.
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Arlington, VA: I want to remain active in my old age, but I know that I won't be able to do all the activities I do now. What low-impact sports can you recommend for older people besides walking? And when you talk about the importance of staying active, do you mean both physically and mentally? Which is more important?
Dr. Michael Miller: Well, I'm not an expert on low-impact sports -- I'll refer you elsewhere for that. But yes, I do mean both physically and mentally. I often think about those great pianists, Horowitz, Rubenstein and Eubie Blake, who were active into their nineties -- is playing the piano a low-impact sport? Well, it does combine physical and mental elements.
So the more activity the better. The Hoffmans, the couple I talked about in the article are a great example of this. The more you can do for your body and your mind/brain the better. I'm an advocate of doing things you enjoy -- maybe we should change the old saying a little: amuse it or lose it.
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Jersey City, NJ: I'm not crazy about loading up on mood-altering drugs. Are their drug-free ways to treat depression?
Dr. Michael Miller: Absolutely -- there are drug free ways. Psychotherapy is as effective as medication for treating depression. Some think that medications work from the bottom up in the brain -- brain systems deep in your brain that control your mood are changed by medications. Psychotherapy may work from the top down, affecting your patterns of thinking, causing similar changes to those mood-regulating systems. The processes are different, but some believe the end result is similar.
But be aware of the following statistic -- medications and psychotherapy are about equally effective, but the COMBINATION of the two are clearly more effective than either alone.
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Brooklyn, NY: Can you elaborate a little on the causes and treatments for “vascular depression”?
Dr. Michael Miller: The idea is this: in "vascular depression,” blood flow is interrupted microsopically and this can cause damage to nerve cells in the front part of the brain (frontal lobe) and in the nerve circuits that control mood. This combination of factors leads to a kind of depression that looks a little different. Individuals may not even know they're depressed, because they don't think they're sad or blue. Instead they feel apathetic, their energy is low, they lose interest -- in other words they lead with all the symptoms of depression without describing a change in mood. This is often hard for families or doctors to recognize, because there is a tendency focus on the physical symptoms rather than the person's mental state.
The treatment is generally the same as the treatment for any kind of depression -- an antidepressant, increasing social contact, psychotherapy. But it is also important to treat any underlying medical condition that might be compromising the blood circulation to the brain.
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Miami, Fla: Dr. Miller, Besides the usual advice (stop smoking, work out etc), what would you say is the secret to get older with health and being happy?
Dr. Michael Miller: If I had the answer to that question, I'd be a very wealthy man! I go back to what I've written about. Be realistic, but stay as active as you can and stay as involved with people as you can. Find something meaningful to carry you through the day. These are easy things to write about, but not at all easy to do.
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Dr. Michael Miller: I see that we are out of time. Thank you for a series of excellent questions that got me thinking. And for all my fellow residents of the northeast: stay warm!
