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Dealing with the winter blues in older people
For many older people, the winter months are dark and lonely, particularly because of Christmas and New Year. For many, these seasonal events are a time of happiness and family reunion. The festivities offer a blaze of light that throws the darkness of winter into stark contrast. For some people, however, it is a time when their own misery and isolation are emphasized by surrounding good cheer. Isolation is felt strongly and lonely old people are many times more likely to be depressed during the winter months than those who are not lonely. Vulnerable patients There is also a strong relationship between depression and disability, handicap, and deficits in social support. Additionally, hazardous weather conditions and the increased risks of falls can lead to people becoming more housebound than usual and increasingly isolated and lonely. Some of these factors are not amenable to intervention but some, including isolation, handicap, and depression itself can be managed effectively. Those who are caring for people with long-standing health problems such as Alzheimer's disease are also vulnerable to depression and may find the winter months to be a difficult time. They may not be able to go to family gatherings or, if they are able to go, may be stressed by trying to manage a partner who cannot cope with a change in routine. Extra support may be needed during the winter months, but this is the very time that day services and other sources of support tend to shut down. Diagnosing depression Overall, depression sufficiently severe to interfere with daily life affects around 12 per cent of older people. Perhaps 3 per cent meet the criteria for a categorical diagnosis of depressive episode. To meet these, the syndrome must have been present for at least two weeks. Depressed mood is not essential. The diagnosis can be made on the presence of two out of three of the following symptoms:
These may be combined with a variety of other symptoms such as:
At least four of these symptoms are necessary for a formal diagnosis. Diagnosis is notoriously difficult to make in older people. Often co-existing physical illness masks the psychiatric diagnosis for both doctor and patient. Sometimes patients are reluctant to accept that some of their physical symptoms may be due to, or exacerbated by, depressed mood and insist on a physical diagnosis. This is based on a misconception associated with the stigma surrounding mental-health problems. Older people are likely to see such problems as a sign of weakness. The risks of depression Depression is associated with an increased risk of suicide but persistent depression is also linked with an increased general mortality, mostly from cardiovascular disease. It tends to be under-diagnosed and under-treated. This is particularly problematic in higher-risk groups such as those:
Treatment Pharmacological treatment is effective, even in people with co-existing medical illness. Ideally, treatment should be multi-faceted with attention given to social isolation and psychological interventions such as cognitive behavioural therapy. The latter has proven effectiveness in old as well as young people, although it may be harder to access. Isolation and handicap can be tackled by active social intervention. This requires sensitive casework from social services and sometimes from mental-health services. Care should be sensitive to the preferences and personality of the patient. Old-age psychiatry services should be called in early if there are difficulties in diagnosis, if the patient is at risk from suicide or self neglect, or if treatment in primary care is not working. Pharmacological treatment is easier and safer using modern drugs rather than the old tricyclics. The wide range of treatments now available makes it easier to choose an antidepressant that suits the patient and where a therapeutic dose can be quickly and safely attained. Treatment must be at an adequate dose and must often be continued for a month to six weeks before definite response is seen. When patients respond to antidepressant therapy, they need to continue on therapy for at least six months to a year – probably longer if this is not their first episode of depression. When appropriate, treatment should generally be discontinued slowly with careful observation for relapse or recurrence of the depression. Some patients may need to remain on long-term prophylactic therapy. The risk of suicide must always be considered and old-age psychiatry services can help where diagnosis or risk assessment is difficult, when treatment is unsuccessful, or if the risk to the patient is perceived to be high. Specialist old-age psychiatry services can provide intensive community support, day assessment and treatment, and inpatient care for the most severe cases. They also have expertise in the use of combination treatments, including lithium augmentation. In psychotic depression, combination of antipsychotics, often olanzapine with antidepressants, and the use of ECT should be considered. However, this is generally the province of the specialist team. Final thoughts This winter brighten someone's life. Consider isolated, disabled patients and those who are caring for others with disabling illness. Consider those who are inpatients on acute wards, or residents in care homes. Consider repeated attenders at the surgery with seemingly trivial complaints. They are all at higher than average risk of being depressed. Consider using a screening instrument such as the Geriatric Depression Scale in high-risk groups. If you find depressive illness, treat it with psychosocial and pharmacological interventions. You might not only lighten the burden of illness, you may save a life. John Wattis is Professor, Ageing and Mental Health Research Group, University of Huddersfield, Huddersfield Further reading Curran S, Wattis J, Lynch S (Eds). Practical Management of Depression in Older People. 2001; Arnold, Londo |