The elderly experience depression differently, expert says

PITTSBURGH, Pa. — Geriatric psychiatrist Charles Reynolds III has for decades been one of the nation’s leading scholars and clinicians focused on depression and other mental disorders affecting the older population.

Earlier this year, Reynolds, a University of Pittsburgh distinguished professor of psychiatry and the university’s medical center endowed professor in geriatric psychiatry, was winding down a career that began at Western Psychiatric Institute & Clinic in 1974.

Reynolds has focused his voluminous research on sleep disorders and suicide as well as depression, among various mental health issues that can impact the elderly differently from the younger population. An interview with him on those and related topics appears below. (The interview has been edited for brevity and clarity.)

How is depression different for older people from younger adults?

It’s a bit more complicated. There’s the concurrence of other medical disorders; co-prescriptions of lots of other medications; the presence often of some degree of cognitive impairment. Those often pose challenges to a clinician who is treating an older adult with depression. There’s also psychosocial issues that pose challenges, be they unwanted retirement, bereavement, conflicts with family members or social isolation.

Is there still a stigma among older adults that has them avoiding mental health specialists?

It’s still an issue, but it’s changing and getting better. Increasingly, people are willing to accept help for depression, particularly if that can be offered in the general medical sector.

Part of your focus has been on preventing depression to avoid the need to treat it. What’s the key to prevention?

It’s relatively straightforward for older adults who have relatively mild symptoms. We teach people better coping skills, better problem-solving skills and better sleep habits, and we encourage healthier lifestyles with more physical activities and better diets. Better self-care helps reduce the risk of depression in older adults, maybe by 20 to 25 percent over a one-to-two-year period. That’s a very meaningful figure in terms of the public health burden averted and the dollars saved.

You mention better sleep habits. How does the chance of achieving good sleep change as we age?

The brain’s ability to generate sleep decreases by the time people get into their 60s and 70s. Sleep becomes more fragmented, there are more frequent awakenings at night and the ability to get into the deepest level of sleep decreases. The good news is we can help by fairly simple behavioral interventions that obviate the need for sleeping pills or antidepressants. We try to avoid sleeping pills because they can cause a lot of mischief — things such as falls and cognitive impairment and sleep apnea.

What kind of simple interventions can help eliminate the need for pills then?

One key thing is to decrease time in bed to maybe seven hours a night. Many older adults spend an increasing amount of time in bed and thereby destroy their sleep. If you reduce the time in bed to maybe 7 or 7 1⁄2 hours out of 24, your sleep drive is preserved so you get deeper and more continuous sleep. The other important thing is to keep as regular as possible in the time when you go to bed and when you get up in the morning. If we stabilize the schedule, we help the brain’s clock that determines the time of sleep and time of wakefulness. That can be a problem after losing a spouse who might have been an important source of social cues and time cues, which can be a factor in an irregular sleep and wake schedule.

Outliving not just a spouse but many family and friends is common for people with successful longevity. How much of depression gets tied in with grief over those losses?

If you look across the life cycle, including old age, about 75 percent of people who experience attachment bereavement — the loss of a spouse or parent or child — are able to adapt, to accept the loss and move on. Somewhere around 20 to 30 percent develop mental health complications including depression, with a variety of anxiety disorders including post-traumatic stress and substance abuse. Somewhere around 7 to 8 percent who experience the loss of a loved one develop a severe reaction — complicated grief — which often concurs with clinical depression. It’s not the same thing as depression and benefits from a special type of counseling.

But if grieving is a necessary stage to go through, when does it actually become a problem?

If you see evidence of suicidal feelings or agitation, that’s a tipoff. And if it’s been six months or longer and someone is still having these intense feelings of yearning or longing, still feeling that their world has turned upside down, that’s a tipoff that something is amiss.

How would someone show that?

It may be someone expressing a strong wish to rejoin the partner who passed away, or endorsing feelings that “Life has no purpose anymore. I’d be better off dead than continuing.”

And the proper steps then would be what?

I would start with the primary care physician, who can evaluate whether depression or anxiety is part of the problem and can provide supportive care or medication. They may have access to social workers or others with expertise in mental health and grief, who can provide counseling that can be helpful to seniors to free up some energy for life going forward.