DEPRESSION: Understanding the Disease
Winston Churchill, war hero and statesman, called it “the black dog.” He famously recorded his bouts with depression, which, even though acknowledged, caused him great suffering. It wouldn’t be likely to go unnoticed in a larger-than-life figure—nor could anyone accuse him of weakness for being “blue.” When depression occurs, however, in the elderly and the chronically ill, it is often judged to be the natural and expected result of their condition or stage of life—something the person just ought to bear. Not so, say the experts.
“Depression, essentially, is a disease which causes people to give up hope,” says Dr. Andrew Elmore, psychotherapist and assistant clinical professor of psychiatry at Mount Sinai School of Medicine in New York City. “It inhibits and limits a person’s activities, mentally and physically,” he says. And that, according to Elmore interferes with what makes life worth living. “For the layperson or caregiver,” Elmore says, “it is important that they get around the common assumptions about illness and aging and begin to sort through the stereotypes associated with depression.”
Not All Depressions Are Alike
For starters, it helps to know that there are different kinds of depression, that they have a wide range of causes and that people’s symptoms vary greatly. Men and women, for instance, exhibit somewhat different symptoms when they are depressed. And although more women than men become depressed within their lifetimes, depression in men can be a silent killer with the suicide rate among white men being the highest as a result of the illness. All depression or suspected depression must be taken seriously.
As a caregiver, you may be caring for someone who, upon reflection, has been sad or unhappy throughout his or her lifetime from what you suspect is depression. Called chronic depression, it can last for years, sometimes with occasional episodes of worsening symptoms. In contrast, major depression is deeper and more disabling and its onset may be tied to a troubling situation or a life event or change.
Other types of depression include manic or bipolar depression in which a person cycles uncontrollably between a high or excessively happy state and a depressed, angry and despondent state and seasonal affective disorder in which symptoms of depression occur predictably at the same time each year, usually at the beginning of the fall or winter season and taper off as spring and summer approach.
While it is useful to understand generally what forms depression can take, Dr. Elmore says, “When you first become concerned about depression, discussions about specific subtypes of depression are perhaps less important than getting a person to treatment.”
Is It Depression?
According to Dr. Robert E. Hales, MD, MBA, a number of the criteria for diagnosing depression, such as sleep disorders or lack of concentration or energy are already present in seniors and the chronically ill. Hales, the Joe P. Tupin professor and chair, Department of Psychiatry and Behavioral Science at the University of California, Davis School of Medicine, says, “You determine whether it is depression by focusing on the clear hallmarks of depression itself.” Hales and his colleagues rely on a mnemonic device, the acronym “D, SIG, E, CAPS” to reliably separate the symptoms of depression from the symptoms of illness.
When It’s All in the Family
Caregivers, particularly when caring for a family member with depression, will likely have had a lifetime of exposure to the disease whether they are aware of it or not. How can they begin to sort out whether or not their loved one is, in fact, depressed, when it may have been part of a family secret, a matter of family denial or dismissed or overlooked?
Dr. Hales says, “First of all, caregiver children are at high risk for depression.” He suggests they keep an eye on their own emotional well-being by running down the list of symptoms for themselves. As for determining whether their loved one is possibly in need of help for depression, he suggests that first, they get another person’s opinion. “Ask a friend, your spouse—preferably someone who did not have a parent or family member with depression. You want another, more impartial observer.” Then, Hales says, “Take some time to observe others. Pick people of the same gender, age and general circumstances as your loved one and see if there’s a difference.”
Getting Help
The first step in getting help is to speak with the person you suspect is depressed. If they seem unaware or unable to determine or admit whether they are depressed or overly sad, both Drs. Elmore and Hales advise starting with a conversation with the person’s primary care physician. Elmore says, “By starting there, you’ll get a full read of the primary care physician’s ability and willingness to deal with the question of depression.” He adds, “Be prepared to give examples of the change you’ve noticed and try to keep an open mind. If you feel your observations aren’t being taken seriously, ask for a referral to a mental health practitioner.”
Elmore and Hales agree that a determination has to be made with a person’s primary care physician as to what medications the person is currently taking. Depression is a side affect not only of many chronic illnesses, but of many commonly prescribed medications. This possibility needs to be eliminated. Particularly in these groups of patients, Dr. Elmore says he tries to avoid adding any additional medication as the first strategy. He suggests trying focused therapy and adding exercise. “It helps,” he says, “to expose them, within the limits of their illness and physical abilities, to novel stimulation and physical activity…. Engage the person for whom you’re caring—take them out more for fresh air, exercise—go to the movies.” Further, he says, “anything that gives a person some control over their environment is uplifting.”
Dr. Hales is also cautious about what medications, supplements or even herbal remedies a patient may already be taking since prescribing medication for depression is oftentimes necessary. He notes that recent studies have shown that while medication is good and talk therapy can be beneficial the best results are shown from the combination of medication and talk therapy. “I feel confident that I can tell my patients that medication will help them,” Hales says. “When the patient’s mood lifts as a result of anti-depressant medication, when they begin to feel more joy, then I can suggest that we use those gains and begin to get a handle on their lives and their futures.” Dr. Hales adds, “Seniors do better with cognitive forms of therapy—those that emphasize a practical, here and now approach, rather than analytical forms that dwell too much on the distant past.”
The key for caregivers dealing with depression? Dr. Elmore tells them: “Cultivate a sensitivity to sadness—for your own sake, and the sake of the person you care for.” He continues, “don’t accept a change in the person that appears to you to be a steady, downward drift…. Put yourself in your loved one’s shoes, ask the questions you’d want asked and get that person the same kind of care that you’d want for yourself.”