Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Each week our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #36: Seniors and Depression

DR. REEF KARIM:
Welcome to the Down and Up Show on Depression is Real.org, I'm your guest host Dr. Reef Karim (ph.), psychiatrist, addiction specialist and (unint.). Today we are speaking with Dr. Gary Kennedy the Director of Geriatric Psychiatry at the Montifore (ph.) Medical Center in New York.

Dr. Kennedy specializes in Alzheimer's disease, depression, psycho-pharmacology and psychosomatic medicine. He's also on the board of directors of the Geriatric Mental Health Foundation. Dr. Kennedy, thank you for taking the time to speak with us today.

DR. GARY KENNEDY:
Thank you for asking.

DR. REEF KARIM:
Well you've got quite the resume there, I mean, Alzheimer's, depression, psycho-pharm, psychosomatic medicine. How many adults over the age of 65 suffer from depression each year?

DR. GARY KENNEDY:
Well of course it varies by the definition of depression. If we talk about a few symptoms of depression, enough that they would be considered clinically significant, maybe 15 percent of people over 65 who live in the community have those symptoms. However if we're looking at a depressive disorder where people have several symptoms of depression and they've lasted at least for two weeks, most everyday for two weeks, then the figures come down to a low of maybe two percent for older adults who are physically healthy to something between seven and nine percent for the average older person who may have two or three additional illnesses.

DR. REEF KARIM:
But there are some people over the age of 65 that will attempt suicide or try to commit suicide because they're so impaired in regards to their mental health.

Do you know what the suicide rate is among adults over age 65?

DR. GARY KENNEDY:
Well the most recent data available come out of 2004 and what's interesting is the highest rates are observed in older white males 65 and over, the rate for older white males is 31 deaths per 100,000. If you look across the total population of all ages, it's 14 deaths per 100,000 due to suicide.

And of note, for all the suicides that occur to person that are 65 and older, four-fifths, 80 percent are older white males. If you were to look at the suicides among older African-American women, the rates are so low that they're probably not even reliable. The other fact that one needs to keep in mind, is that for every suicide that occurs in late life, there are three or four older adults that died probably from severe self-neglect or not taking lifesaving medications.

So the rates of suicide are probably much less, reported rates rather, are probably much less then the actual rates. And you're right, we think that depression is most often, that mental illness is associated with suicide in late life. But it's clear that not every person who's taken their lives had a depressive disorder.

DR. REEF KARIM:
Okay, symptoms of depression in the elderly sometimes are thought of as part of aging, you know, there are some people that feel like their grandparents, well they're just they're just bummed out cause they're old. What should be done so symptoms of depression are more easily recognized as as a real biological, neuro-chemical condition?

DR. GARY KENNEDY:
Well first of all it's important to recognize that ascribing symptoms, whether it's mental or physical, simply to aging is by and large prejudice, it's called ageism. Depression is not a normal part of aging. Now certainly physically and intellectually we slow down when we get older.

But that slowing down process is typically associated with other accommodations on the older person so that they maintain a fair degree of independence even if they have physical problems. So my main message would be don't discount sadness or apathy in an older person to age.

That's one of the other problems is that people largely are unaware that one of the major symptoms of depression is simply apathy.

DR. REEF KARIM:
Right.

DR. GARY KENNEDY:
The way I like to characterize this is I'll ask my older patients what was it like for you the last holiday? How was it when the grandchildren were over? And for older adults who don't light up and talk about the joy they experienced in their family with their grandchildren, I always wonder is that the apathy of depression?

Now of course that's a generalization, there are certain families where good relations do not survive. But that's one of the components that one needs to be aware of with a depression late life, is that apathy maybe more common then depression.

DR. REEF KARIM:
And and you make a really great point that you know, we may slow down as we get older, but but the older part of our population, they're very wise. They have a they have a lot to offer society and just labeling them as well, they're aging that's why they are the way they are, really isn't (inaud.).

DR. REEF KARIM:
I agree, I agree entirely.

DR. GARY KENNEDY:
Older adults can be distressed about you know medications that they're taking and changing their their biochemistry, sometimes more then then younger adults. Adding an anti-depressant to their regimen worries some of them.

DR. REEF KARIM:
What would you tell a patient who's worried about taking an anti-depressant in addition to the other medications that they take and patients that older people that may refuse to treat their depression?

DR. GARY KENNEDY:
Well first of all the the point to be made is depression in older persons and young persons is eminently treatable.

DR. REEF KARIM:
Yeah.

DR. GARY KENNEDY:
And in fact depression may make the benefits of your heart medicines, your diabetes medicine, your blood pressure medicine less effective. So treating depression may make the other conditions much better because depression has a direct physiological effect on all those other conditions. I would also suggest that the anti-depressants we have presently can be safely prescribed, even safely prescribed in the routine doses used in younger persons, for older persons as well.

So yes I'm would not disagree with the older person that if they're taking a number of medications, we need to be cautious when we add one more. But I would hate for the depression to rob them of their independence or make their other conditions worse. And by focusing on the issue of independence for the older person, by focusing on their other physical conditions and how depression makes that worse, I think it makes it makes a more compelling argument for why we need the anti-depressant medication.

Now having said that, there are some older adults that would much prefer to have talk therapy and psychotherapy works as well for older persons with depression as it does for younger persons. We have a number of studies using interpersonal psychotherapy, cognitive behavioral therapy, even problem-solving therapy, that older adults are particularly good at engaging in.

So if they want to forego medications, psychotherapy can be effective. It may take a little bit longer to be effective, but we have options.

DR. REEF KARIM:
And when we talk about co-morbidities, you know, we talk about a lot of people will go to the hospital and have problems with heart disease or diabetes as you mentioned or other physical ailments and not realize the the combination of being depressed clinically and having that condition can worsen the condition, worsen the ability of the medication from working.

Overall you have more physical compromising your health as well as mental health (unint.), many people don't see that.

DR. GARY KENNEDY:
I think that's exactly right. And there are some physical conditions that predispose you to developing depression, stroke us one of those. Fully 40 percent of people who've had a stroke will have a depressive episode in the in the insuring six months. And in some instances for those individuals, if they have a few symptoms of depression, you might go ahead and suggest, let's start an anti-depressant to see if we can't prevent this becoming a full-blown major depressive disorder.

DR. REEF KARIM:
How much less of the medication would you give someone who's older because you're worried about the (unint.)? Would you would you definitely give them a decreased dose of the anti-depressant?

DR. GARY KENNEDY:
This is what the most recent data suggests and that's that you need to get older person the physician needs to prescribe the same level for an older person with depression as they would for a younger person. The difficulty is you just need to start low and go slow.

That's the usual mantra about prescribing for an older person. But it's a it's not correct to say we should wait for four weeks, 12 weeks to see if the medication's effective. For most persons that are going to respond to the first medication offered them, once they get into the therapeutic range, which is the standard dose for young or old then they should have some improvement.

If for two weeks under standard therapeutic range of the medication the person experiences no improvement, then the medication is probably the wrong pill for them and they should either be switched or have a medication added to that. So the way I typically talk about the treatment of depression with medication for older persons, is start slow, with a lower dose, but don't give up.

Get up to that regular dose and that could be as soon as 10 days. Typically I'll start a person on the lowest possible dose available. I'll ask them to increase that maybe in three days after they've after I spoke with them on the phone and they're not having any difficulties with it.

And then somewhere around 10 days, I'd like to be getting them up into the standard range for the medication.

DR. REEF KARIM:
Now you you specialize in Alzheimer's disease. Can you discuss any neurological relationships between Alzheimer's disease, depression, dementia and depression you know, anything along those lines?

DR. GARY KENNEDY:
Well it's a complicated relationship I would characterize it this way. Untreated depression shrinks the same areas in the brain that Alzheimer's does, the point being the hippocample (ph.) area of the brain which is where working memory, the kind of memory that you and I are using right now to carry on our conversation.

Both depression and Alzheimer's disease can shrink that area. When the depression is treated, it looks like that shrinkage can be reversed and anti-depression medications actually help the hippocampus regenerate new neurons. Now Alzheimer's disease kills the neurons off, depression prevents the regeneration of neurons.

So that's part of the intimate relationship between the two illnesses. We think that depression may predispose a person to Alzheimer's disease, especially if it's untreated depression. We know that Alzheimer's disease in and of itself either because of anatomical changes in the brain or neuro-chemical alterations, can also be associated with a major depressive disorder that follows the onset of Alzheimer's disease.

And major depression in the context of Alzheimer's disease can be treated with medication. So there's this back and forth relationship. Depression may also be the first sign of Alzheimer's disease so that before the person has major memory problems, they start to have problems with mood and interests.

So there's this three-way relationship.

DR. REEF KARIM:
Oh okay, so if you're depressed and you have and you have some working memory problems and you treat that depression, there's a better chance you may hold off if you were, you know, pre-determined to get Alzheimer's disease, by treating that depression as opposed to not treating it?

DR. GARY KENNEDY:
Exactly, I mean there there's no advantage to not treating the depression, under no circumstances is the depression should be left untreated. I would even argue that even patients that are on palliative care units, whose life expectancy is obviously expected to be shortened, their depression should be treated whether medi with medication or psychotherapy.

Again because the medications work faster and most of us trained to believe they did.

DR. REEF KARIM:
Yeah, do other physical illnesses of older adults affect their mental health treatment? Give us some examples.

DR. GARY KENNEDY:
Well one of the sad examples is with older adults who become wheelchair bound or have physical disability, it's harder simply for them to get into their appointments. There are some mental health providers, myself and some of those that we train who actually make house calls so that for disabled older persons, they can receive mental health care.

But that's not widely available. Medicare will pay for that but it's not necessarily widely available. Certainly as you've mentioned, Alzheimer's disease can impair the person's capacity to participate in psychotherapy The more medications a person takes obviously the more likely that you're going to have a problem with anti-depressant when you add it.

The way I like to characterize it is as you add medications you multiply side effects. But if you note, none of that has to do with a person's age, all has to do with other conditions or with physical disability that prevents them from engaging in the kind of activities that we think minimize depression.

DR. REEF KARIM:
(Unint.) the Depression is Real Campaign seeks to diminish the stigma that surrounds depression. In your work, because you work with seniors and geriatric individuals, have you encountered an additional stigma that surrounds late life depression? And and then what can we do to help seniors acknowledge and manage their depression?

DR. GARY KENNEDY:
Well I think you're right. The present population of older adults were brought up before the introduction of the safe anti-depressants, the Prozac family. They were brought up when psychotherapy was thought to be psychoanalysis and I'm not criticizing psychoanalysis, I'm saying that there are now therapies that are much briefer and targeted on depression.

So older adults are less likely then younger person to not feel stigmatized by receiving mental health services. So you're right, age can sometimes be an obstacle to the person receiving the services, but as I mentioned earlier, my focus is always on working with the older adult's independence.

And independence means a lot of different things to different people. But focusing on that I think makes it easier for the older person to accept the care. I'll also tell family members when they have a an older parent or older relative that they're concerned about, that they should offer to go with the person to see the physician.

The mental health provider is happy to talk with the family, older adults most often want their family to sit in for part of the session, not all of it. And I think when a family says, listen I'll go with you, I'll help you get this started, I think that has a major impact.

DR. REEF KARIM:
What does the Geriatric Mental Health Foundation do to raise awareness about depression in seniors?

DR. GARY KENNEDY:
Well we've been involved in a number of things. Part we've published brochures on healthy aging, on how to beat depression, how to beat the holiday blues substance abuse and alcohol problems in older adults, those are available on our web site for the Geriatric Mental Health Foundation.

We also are engaged in a campaign that we've piloted social awareness and social marketing techniques in Baltimore, Nashville to try and determine what's the best venue to get the message about the treatability to depression across to older persons and to the community at large.

There's also a web site called tretmenthelps.org, treatmenthelps.org which older adults can access and find out more about how to provide how to find a provider in their area, questions about medications. There's a for the off the web site there's also a toll-free telephone number that they can initially get advice about it.

So what we're trying to do is to mobilize the public at large, to get services expanded, to increase training, to advance the science of treatment of depression in late life. And this really needs to be, I think, a global campaign similar to what Depression is Real Coalition is interested in.

But our focus is on the older adults because we're worried that they get left behind.

DR. REEF KARIM:
And with the with the baby boomers all getting older, this is much more more (unint.) population.

DR. GARY KENNEDY:
Oh I think so and I think the I think the baby boomers have got the message. For one thing, Alzheimer's disease, they know that it's near epidemic proportions, so I think the support for better mental health care in late life is there. We just need to see it enacted in policy.

DR. REEF KARIM:
Any closing thoughts or advice to add?

DR. GARY KENNEDY:
No, I think we covered it.

DR. REEF KARIM:
Yeah, I think we did a good job. Alright, thank you for speaking with us today Dr. Kennedy, your work is essential to improving the lives of (unint.) adults who currently face or will face depression in the future.

DR. GARY KENNEDY:
It was a pleasure and thank you for asking.

DR. REEF KARIM:
Okay, join us next week for another segment of the Down and Up Show on Depression is Real.org. I'm Dr. Reef Karim.

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