Older Adults: Depression and Suicide
Facts
Major depression, a significant predictor of suicide in elderly Americans, is a widely
underrecognized and undertreated medical illness. According to one study, many older
adults who commit suicide have visited their primary care physician very close to the time
of the suicide: 20 percent on the same day, 40 percent within one week, and 70 percent
within one month of the suicide. These findings point to the urgency of enhancing both
the detection and the adequate treatment of depression as a means of reducing the risk of
suicide among the elderly.
Older Americans are disproportionately likely to commit suicide. Comprising only 13
percent of the U.S. population, individuals ages 65 and older account for 20 percent of
all suicide deaths, with white males being particularly vulnerable. The highest rate is
for white men ages 85 and older: 65.3 deaths per 100,000 persons in 1996 (the most recent
year for which statistics are available), about 6 times the national U.S. rate of 10.8 per
100,000.
More than 2 million of the 34 million Americans age 65 and older suffer from some form
of depression. In contrast to the normal emotional experiences of sadness, grief, loss, or
passing mood states, major depression is extreme and persistent and can interfere
significantly with an individual's ability to function. Less severe forms of depression
are also common among the elderly and are associated with an increased risk of developing
major depression. Depression, however, is not a normal part of aging.
Both doctors and patients may have difficulty recognizing the signs of depression. In
an effort to improve recognition of the illness and promote discussion about depression
during medical visits, the National Institute of Mental Health (NIMH) has developed this
cue card for older adults. (See sidebar.)
Research and Treatment
Modern brain imaging technologies are revealing that in depression, neural circuits
responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to
function properly, and that critical neurotransmitters--chemicals used by nerve cells to
communicate--are out of balance. Genetics research indicates that vulnerability to
depression results from the influence of multiple genes acting together with environmental
factors. Studies of brain chemistry and of mechanisms of action of antidepressant
medications continue to inform the development of new and better treatments.
Antidepressant medications are widely used effective treatments for depression.
Existing antidepressant drugs are known to influence the functioning of certain
neurotransmitters in the brain, primarily serotonin and norepinephrine, known as
monoamines. Older medications--tricyclic antidepressants (TCAs) and monoamine oxidase
inhibitors (MAOIs)--affect the activity of both of these neurotransmitters simultaneously.
Their disadvantage is that they can be difficult to tolerate due to side effects or, in
the case of MAOIs, dietary and medication restrictions. Newer medications, such as the
selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older
drugs, making it easier for patients including older adults to adhere to treatment. Both
generations of medications are effective in relieving depression, although some people
will respond to one type of drug, but not another.
Psychotherapy is also an effective treatment for depression. Certain types of
psychotherapy, cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), are
particularly useful. More than 80 percent of people with depression improve when they
receive appropriate treatment with medication, psychotherapy, or the combination.
In fact, recent research has shown that a combination of psychotherapy and
antidepressant medication is extremely effective for reducing recurrence of depression
among older adults. Those who received both interpersonal therapy and the antidepressant
drug nortriptyline (a TCA) were much less likely to experience recurrence over a
three-year period than those who received medication only or therapy only.
Studies are in progress on the efficacy of SSRIs and short-term specific
psychotherapies for older persons. Findings from these studies will provide important data
regarding the clinical course and treatment of late-life depression. Further study will be
needed to determine the role of hormonal factors in the development of depression, and to
find out whether hormone replacement therapy with estrogens or androgens is of benefit in
the treatment of depression in the elderly.
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