Awareness builds change is the official slogan of National Depression Screening Day, held annually on the Thursday of the first full week in October, to raise awareness of screening for depression and related mood and anxiety disorders. This year, our expert colleagues seek to bring awareness to depression screening practices and older adult mental health needs.
“It can be tricky. Older adults are still somewhat stigmatized about depression and less likely to disclose it,” said David Mischoulon, M.D., Director of MGH’s Depression Clinical and Research Program.
A negative stigma associated with seeking mental health help is still prevalent in the older adult population. Feyza Marouf, M.D., a psychiatrist at MGH’s Department of Psychiatry, agrees that this is a barrier that clinicians are working to overcome.
“There is a background of stoicism and a general reluctance to take medications, with older adults feeling they should muscle through the depression and anxiety,” Dr. Marouf said. “There’s a sense that, ‘I’m supposed to be strong and asking for help is weakness,’ with mental health that we don’t see with physical symptoms.”
Screening Tools
If depression is left untreated, symptoms could worsen and even lead to suicide. It is crucial for health care providers to recognize red flags.
“Older adults might feel helpless as a symptom of depression,” explained Alexis Freedberg, M.D., Psychiatrist-in-Charge of the Cognitive Neuropsychiatry Unit at McLean Hospital. “It can also develop into fixed false beliefs, such as their insides not working, not being able to swallow, and a risk for suicide. Classic warning signs are older adults giving away all of their belongings or thinking they’re a burden to those around them.”
According to Dr. Marouf, older adults are less likely to readily admit to their primary care doctor they are feeling depressed. Because older adults are poor self-evaluators, they may need to rely on family members or caregivers observing behavioral changes..
“Children may present with irritable moods; young and middle-aged adults often present with standard Diagnostic and Statistical Manual of Mental Disorders symptoms; but older adults are more likely to see somatization of depression symptoms than younger and middle aged adults,” Dr. Mischoulon said.
While irritability can be a red flag, depression doesn’t always look like sadness in older adults.
“Older adults experience physical symptoms more intensely when they’re depressed,” Dr. Freedberg explained. “When you have someone with a lot of pain that isn’t medically explained, and the experience of pain is taking over their lives, that may be a symptom of geriatric depression.”
Depression screening is therefore vitally important to take action before the patient’s health and outcomes get worse.
“One option is the Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS), which is a widely-used tool,” Dr. Mischoulon said. “For the clinician looking for an unobtrusive method, these are great tools.
“These screenings are to capture who is depressed and what might otherwise go unnoticed. Depression might slip under the radar. If the clinician sees something worrisome, they should decide on appropriate intervention or referral.”
Because depression presents atypically in older adults, Dr. Marouf said, the Cornell Scale for Depression in Dementia has proven to be a useful screening tool.
“Depression and dementia have a very complicated relationship,” Dr. Freedberg said. “Depression can make the symptoms of dementia worse, and vice versa. When you can’t think clearly and you’re stuck in your depressed thoughts, you might appear as if you’re forgetting things and can’t do things for yourself. The phenomenon of pseudodementia makes it difficult to distinguish between the two, but diagnosis can come down to how long symptoms have been around.”
Because symptoms of cognitive decline and dementia in older adults can overlap with depression, Dr. Mischoulon warned, clinicians should be mindful of dementia in older patients before diagnosing depression.
“I would encourage all clinicians who suspect depression in their older adult patients to take action on it,” he said. “We’ve done studies that depression is picked up in the PCP setting, but they may not take action because they’re not sure or they’re inadequately trained. My advice is the clinician should make a referral to a psychiatrist. Otherwise, a patient can go on without treatment and if depression isn’t treated early, the outcome is worse.”
Prescribing Treatment
Older adults are more sensitive to the side effects of medication and they are more likely to stop using their medications, Dr. Marouf said, if the side effects become too much to tolerate.
“The body changes as we age, and we are much more sensitive to drug–receptor interactions,” she explained. “Gastrointestinal effects emerge. Stimulating antidepressants may cause agitation. In the initial period of a new medication, it may make them feel anxious and restless.”
Furthermore, because medication may initially be prescribed at too high of a dosage, older adults are less likely to continue taking it into the recommended 12-16-week period, and a determination can’t be made if it would’ve been an effective medication.
“We sometimes like to say, ‘Start low, go slow,’ with prescribing medication for older adult patients,” Dr. Marouf said. “On the other end, sometimes prescribed antidepressants are left at ineffectively small dosages indefinitely because clinicians aren’t paying enough attention. Tolerability is a much greater issue with older adults. There must be a careful selection of the first choice of dosage in any prescribed medication.”
National Depression Screening Day underscores the importance of psychoeducation. “Psychotherapy and medications are more efficacious than treatment alone,” Dr. Marouf said. “But there are fewer geriatric psychologists and insurance coverage is more favorable for psychopharmacology than psychotherapy. It’s tough on patients seeking to access care.”
Learn more and access additional resources around older adults and depression on the National Institute of Mental Health website.