The 98-year old lady, let’s say, Mrs.X, walked into my clinic with her grandson one Monday afternoon. She looked frail, had not been eating or sleeping well and had become more and more withdrawn.
Her grandson complained that she hardly smiled or talked anymore. She had ‘changed’ over the last six months. She had a nice house where she lived alone with help but had lots of family living close by who were always in or out. She had lived like this for the past 18 years since her husband died but had never been like this before. She had a chest infection about 6 months ago and since then had ‘never been herself’.
A full history and examination revealed that she was suffering from a severe depressive episode but her memory and other cognitive functions were remarkably intact. She was only sent to me by her observant GP after two courses of antidepressants didn’t work. We started her on a second-generation antidepressant and asked her to see me again in two weeks’ time.
Some obvious questions playing through many people’s minds on listening to this story – wasn’t this ‘just another old, lonely person’ who had become socially isolated? Wasn’t I medicalising her old age and social problems?
India has one of the highest prevalence rates of elderly depression amongst large developing economies. The rates however vary significantly depending on the population studied with community-based studies showing rates of 9%-62% and clinic-based data returning higher rates of between 42%-72%. Coupled with the fact that India has the second largest elderly population in the world, it’s scary how deficient the infrastructure is for such a large morbid population.
Mrs X came back to clinic a couple of weeks’ later. She was marginally more interactive but her symptoms were pretty much there. I introduced her to our therapist and double checked that all her blood tests and physical examination was normal. I increased the dose of her second line antidepressant.
Geriatric depression, as depression in older adults is often referred to, has multifactorial etiology which typically includes a multiple environmental risk factors including social isolation, dependence, lower levels of spirituality, lack of a hobby and lack of exercising. Additional risk factors include bereavement, complicated grief, sleep disturbance, real or perceived disability and previous episodes of depression. It appears to be more common in women, the physically unwell, economically poor and the unmarried, widowed or divorced.
Geriatric Depression doesn’t always present in a classical way with many presenting with more anxiety and irritability and some with more somatic symptoms like muscle weakness, pain etc. A good thorough history, full mental state and physical examinations and investigations and use of rating scales such as the Geriatric Depression rating scale can be crucial in not only making the diagnosis but also ruling out other physical health causes that can mimic depression.
Whilst its prudent in the elderly age group to ‘start low and go slow’ with pharmacological treatments and the maximum doses of medication that the elderly can tolerate are sometime lower, sub-therapeutic treatment can also lead to a poorer prognosis in the appropriately diagnosed elderly depression. Using the latest evidence-based protocols for both pharmacological and nonpharmacological treatments (CBT, music and activity therapy, yoga and pranayam) is essential in ensuring the best prognosis for the patient.
Mrs X was back again in clinic. Her depression scores still showed her symptoms to still be severe with only marginal improvements in the previous couple of weeks. We decided to increase the medication again and then review. She had one supportive session with the therapist but it was felt that she was not ready of Cognitive Behavioural Therapy yet.
Whilst our protagonist’s GP was remarkably well informed – to first detect the depression and then to try her on two first line antidepressants (Selective Serotonin Reuptake Inhibitors), this is remarkably rare. Most geriatric depression goes undiagnosed or untreated/partially treated due to a lack of trained specialists and poor awareness amongst other doctors regarding geriatric depression – both its detection and treatment. There is also a degree of therapeutic nihilism where it’s felt that not much can be done to help this depression in old age. So a greater degree of training and awareness if required, right from medical school, postgraduate training in medicine and psychiatry as well as CME programmes to ensure greater awareness and optimism for treating this specialist population.
Mrs X came to the clinic a few more times. She had minimally responded to treatment. We admitted her to the hospital, started her on the therapeutic protocol for treatment for treatment – resistant depression. This could have been done at home as well but given her physical health risks as well as the fact that she lived alone we decided to initiate treatment in hospital. She was stabilised on treatment and then discharged home with regular outpatient monitoring, Cognitive Behavioural therapy, and home support. She made a full recovery from her depression and I received a card from her and her family on her 100th birthday.
Dr Amit Malik is a Psychiatrist with sub-specialist qualifications in psychological health of Older Adults. He is also the founder of InnerHour, a psychological wellness platform that provides high quality psychological support and therapies. Alongside his MBBS and his post-graduate and super specialist qualifications in psychiatry from the UK, Amit also has an MBA from London Business School.
Sandeep, M. Nidhi; (2015). Depression in elderly: A review of Indian research. Journal of geriatric mental health.
Martin, D. Nandini; (2003) Risk Factors for Depression Among Elderly Community Subjects: A Systematic Review and Meta-Analysis. American Journal of Psychiatry.
Anne, B. Martha,A. George, P. Deborah, R. Patrick, F. Steven, M. Barnett; (2001) Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older Outpatients With Depression. American Journal of Psychiatry.