Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. 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 #15: Late-Life Depression

DR. RAHN BAILEY INTRO:

Welcome to the Down and Up Show on Depression is Real.Org. I'm Rahn Bailey, your guest today filling in today for Dr. Ellen Frank, the standard host. Today we're happy you're joining us and very happy to be discussing a topic of substantial interest, but maybe one that doesn't get as much attention as it should.

It's a focus on late life depression. Today our guest will be Dr. Helen Laretsky. Dr. Laretsky's a geriatric psychiatrist and associate professor in residence in the Department of Psychiatry and Biobehavioral Science at the [Unint.] Institute for Neuroscience of Human Behavior at the David Geffan School of Medicine at UCLA. Dr. Laretsky's completed a fellowship in geriatric psychiatry there at UCLA and a National Veteran's Administration Research Fellowship in neuroscience at the West Los Angeles VA Medical Center. Currently she serves on the editorial board of Aging Health, a journal that addresses the clinical challenges of aging. Welcome, Dr. Laretsky. How're you doing?

DR. LAVRETSKY:

Thank you very much.

DR. BAILEY:

We're happy to have you today. I want to kind of just open up our discussion of circumstances that you've seen and really taken care of many older adults. What really makes them more vulnerable to depression and what can you really tell our audience about this today?

DR. LAVRETSKY:

First of all, most commonly depression occurs in the context of losses, some kind of losses. It's either due to bereavement, loss of a spouse or a partner, care-giving, loss of health in their loved ones, loss of health, and financial losses, retirement placement or assisted living, loss of independence, and disability due to medical illness making them unable to do what they used to do. It could be due to pain. So all of these aggravating circumstances, including brain changes, either due to vascular disease or depletion [unint.] of chemicals in the brain associated with aging.

DR. BAILEY:

Do you think it is any harder to identify this diagnosis of clinical depression in older adults because of different presentation or there are more medical [unint.] that may complicate matters? And I always wondered, do we just as psychiatrists and clinicians in this field sometimes really miss that persons, whether they're 55, 65, or 85 or 95 and have clinical depression, that we really shouldn't just inadvertently attribute it to old age.

DR. LAVRETSKY:

Right. Stigma is a big issue of aging, primarily, because all of these losses occur, it's expected to be depressed about it. But it's not the typical sign of aging. Many are quite resilient and don't have to be depressed. It is much harder to identify, diagnose depression in older people, because of underlying medical problems such as pain, insomnia, poor appetite, cognitive impairment. And because of it, primary care physicians may miss the early stage of diagnosis and treatments, early treatment of depression. Also, some medications prescribed for medical illness, such as anti-hypertensive medications, may cause depression.

DR. BAILEY:

Back in the old days you worried about [unint.] and those agents causing and such, now I think in the cardiovascular material the discussion about whether the agents actually cause depression and/or whether patients have a predisposition to this medical co-morbidity, when they have cardiovascular illness or the like, which as one might imagine geriatric patients are probably more predisposed to based on their age, as well as the functional components of emotional disease like clinical depression.

DR. LAVRETSKY:

Yes, it's very important to screen for depression in primary care settings.

DR BAILEY:

Are there any specific health risks in addition to cardiovascular illness that you think about that older adults particularly face, especially when you're concerned in [unint.] or clinical depression.

DR. LAVRETSKY:

Certainly decreased immunity, susceptibility to infections, cancer, and increased risk of mortality. Nearly all disease categories. That is, if depression is present in association with either heart disease or stroke or hip fracture, mortality will be higher than that in the absence of depression. Also, suicide rates are much higher in people who are depressed.

DR. BAILEY:

I imagine the reality is depression may actually last longer in this patient population because of the stresses that tend to keep you in a depression and [unint.] the lack of some of the other external supports that may allow one to get up, go back to work, get active and develop some environmental cues that may help you move away from being clinically depressed or [unint.] does that actually increase the risk of death, either via suicide directly or other concerns in a person with depression who is at an older age?

DR. LAVRETSKY:

Right.

DR. BAILEY:

Do you think it increases the risk of death or [unint.]?

DR. LAVRETSKY:

It does increase the risk of death and the reasons are multiple. As I said, it decreases immunity, so they are more susceptible to all kinds of infections. They might die from infection. And immobility, isolation, not being hooked up to social support is one thing that leads to demoralization and decline, physical and mental, and faster death, basically.

DR. BAILEY:

It's interesting. I'm actually going to be on a conference here, a friend of mine from medical school is actually sponsoring it here in Houston in November, and the focus is on medical co-morbidities. For my entire career where we've seen these [unint.] conferences put on, really rarely has the primary focus been on what the nonpsychiatric, or the psychiatric Ð it's been put on by nonpsychiatrists. It's actually called cardiology for the noncardiologists. So I think that across the spectrum our PCP colleagues and other specialists as well are increasingly appreciating this co-morbidity stance. The numbers that show that it can lead to more fatalities or even in addition to that, I would imagine that these are concerns that actually modify, maybe even decrease the likelihood of getting patients to fully respond to our treatments that [unint.].

DR. LAVRETSKY:

Yeah, I've dealt with depressed stroke victims. And they just refuse to participate in rehab and therefore their outcomes of rehabilitation from stroke are much poorer in those who are depressed. Same goes for hip fractures. Rehabilitation from that doesn't go as well if people are depressed.

DR. BAILEY:

[unint.] that point, my mom had a hip replacement a few years back and, I'm a psychiatrist, I was talking about some of these issues with the orthopedic surgeon and really some of those comments came out and much of what we were seeing emotionally was probably more related to age than anything else. Although I disagreed with it, it was really kind of interesting to me that here in 2000 Ð this was [unint.] 2003, at that point, certainly in the 21st century, many doctors still think and feel that is the case, that because of age, we may accept more depression symptoms and attribute it to a normal part of aging. I imagine one of your most important roles is to get the message out that this is not normal, these are disease components, and it can be treated and can respond effectively.

DR.LAVRETSKY:

Depression is one of the most treatable conditions in the entire field of medicine, so paying attention to it and treating it early and aggressively makes most sense, to prevent any adverse outcomes due to medical illness or suicide.

DR. BAILEY:

[unint.] suicide, I think another issue for the audience is this concern regarding senior suicide and is it different? Are the particular [unint.] factors that one might see at home or [unint.] in a nursing home, are particular factors we're concerned about Ð [unint.] specifics that shown the really, the number's about 13% of persons over age 65, of the overall suicide population. Although that's their general number, they account for almost twice that amount, about one-fifth of all suicides are persons over age 65. What are your thoughts about this, and are there any parameters in place to try to limit this growing trend toward a higher rate of suicide in seniors?

DR. LAVRETSKY:

Right. There's some ethnic differences. The suicide rates are [unint.] highest among older white males over the age of 75. And one of the factors that is known is ready access to firearms, because that's the most commonly used mode of killing themselves successfully, so that's one factor. But it's not an only, an absolute factor, because in other countries with gun control, men also have higher suicide rates than women, let's say. And they do it by aggressive modes of hanging or jumping out of the high buildings. Women, however, have higher rates of suicide attempts by overdosing on pills. And in the elderly, primarily, depression is the main predictor of suicide. [unint.], victims typically see their primary care physician a month within the time prior to committing suicide. So it's very important to be alert to this and ask questions, know about social situation and their moods.

DR. BAILEY:

[unint.] I've shared that data with patients quite regularly over the years and I find people are very often somewhat surprised when they hear that old patients commit suicide, the average about 30,000 unfortunately successful suicides in the country every year. Our patients do go to see a provider. And I think you're right, what's of great note, the provider most commonly is not a psychiatrist. He is a PCP or the like. That's why I think it's essential that we speak with the [unint.] regularly, hoping that we will get the message out to our nonpsychiatrist, PCP colleagues, that they're going to be the ones that are often at the 11th hour seeing someone, really need to not miss that diagnosis.

DR. LAVRETSKY:

I have to say that men are typically reluctant to talk about their feelings, acknowledge of being depressed. They tend not to ask for help, and only come to mental health specialists when they are severely depressed. So that's one factor to be aware of.

DR. BAILEY:

Do you think older men are more likely to commit suicide than younger men?

DR. LAVRETSKY:

Yes, definitely, yes.

DR. BAILEY:

This recent Wall Street Journal we talked about, they reported that researchers and psychiatrists are all saying that a bout of depression really increases the risk of dementia later in life. Are there any thoughts about that, or can you explain the connection between depression in maybe middle-aged or younger adults and dementia in older adults?

DR. LAVERTSKY:

Yes. Depression has been an known factor for Alzheimer's Disease and both illnesses, depression and dementia, Alzheimer's Disease, share the same structural impairment in the brain, atrophy of the hippocampus in common. So hippocampus is the main structure that is involved in regulation of memory and in depression, shrinking of the hippocampus occurs due to a kind of poisonous effect of stress hormones, such as cortisol [ph.], that are elevated when people are depressed. The more they are depressed, the longer they are depressed, the higher cortisol levels are, and they produce this chronic effect on the hippocampus. And if hippocampus becomes small enough, it will cause memory impairment leading to Alzheimer's disease, so this is the link between stress hormones, depression, hippocampal atrophy and Alzheimer's disease.

DR. BAILEY:

That really kind of points out that it's a fairly multi-determinate process, seemingly with some genetic, biologic, and recent environmental factors as well. Interestingly, though, I think that for all of us in the profession, there's really a certain degree of utility I'd say, as we move towards some more organic manifestations of illness. One day, perhaps, there'll be something we can use for [unint.] actually, look at on a film and show to a patient. [unint.] probably ties us, increasingly, in psychiatry, [unint.] there is a medicine or there's some organic findings or laboratory. People want to know what is it to have these, what are the organic components of these so-called functional psychiatric illnesses, like the question of dementia.

DR. LAVRETSKY:

Hippocampal atrophy is one finding, consistent finding, that can be found on CT Scan or MRI. But usually in a research facility, not in the clinical setting.

DR. BAILEY:

Right, we haven't gotten to that point yet. Many of the higher level items that we engage in have not historically been used as routine lab in psychiatry, a) because they were not always tied to clinical ramifications of illness, and/or b) the cost was and remains [unint.] extreme. [unint.] part of the consideration has been the treatment. The treatment differences are not substantial, whether you get lab or not, really kind of argues against getting labs, especially when they are involved [unint.] let alone somewhat expensive.

DR. LAVRETSKY:

I deal with a situation when I have to distinguish between Alzheimer's Disease and depression in the elderly. And brain scans, [unint.] or MRI become very handy. It can help differentiate in difficult cases. To diagnose Alzheimer's Disease versus dementia, er, depression.

DR. BAILEY:

I want to reference this June 25th recent article in the Archives of the Journal of Medicine, showing that older men and women who take SSRIs, or the selective serotonin [unint.], Prozac or Paxil or Lexipro, Zoloft, or [unint.], may be at increased risk of bone loss, [unint.] osteoporosis. Other experts believe that depression itself may actually affect bone loss. Do you have any thoughts or reactions to that, or do you think that the issues are [unint.] concurrently, or are they not really tied together?

DR. LAVRETSKY:

It could be that both circumstances are true. When depressed patients tend not to exercise, they're withdrawn, immobile, lose weight Ð that leads to bone loss. Also, nutrition, metabolism are usually abnormal in depression and lead to the lack of calcium intake, increased inflammation in the body, also leading to bone loss. In very old people, appetite depressants can cause confusion and falls, leading to bone fractures. But this new study brings up an interesting point, that SSRIs specifically could be associated with bone loss on bone-mineral density CT scans. What is interesting about it is that they compared SSRI users to those who took tricyclic antidepressants, and the [unint.] on bone scans was found only in the SSRIs, those who took SSRIs, not tricyclic antidepressants. I have to understand it better, because the antidepressants are not that different on their effects on serotonin, so further studies should clarify this point.

DR. BAILEY:

Any other thoughts regarding how best we should leave with our audience [unint.] managing depression in older adults, any closing comment?

DR. LAVRETSKY:

Well, it's important to bring up, if people are depressed, it's important to announce this to somebody, whether it's physician, mental health professional, clergyman, anybody who would help them develop some networks, a support network, alternative care. One question could be enough for physicians, whether patients feel depressed, sad, demoralized, and that one question would identify a diagnosis of depression, or at least screen for it. [unint.] inquire about suicidal ideations in patients' relatives who are depressed and it's important to pursue treatment aggressively, using either medications or counseling. Group therapy have [sic] been very important for isolated older adults. Exercise has been repeatedly found to be very useful for depression. And especially some meditative mind-body approaches such as Yoga or Tai-Chi meditation. Acupuncture also might be helpful. And there's not a single prescription for everybody. So individual preferences are very important. They might be different, but it's important to pursue [unint.] symptoms, whatever it takes, because then the function and the quality of life will improve.

DR. BAILEY:

I'd agree. Any current research that you're aware of, or that your group at UCLA is conducting on depression in the elderly, that we should be particularly aware of, or any new items coming down the pipeline pretty soon?

DR. LAVRETSKY:

Right. The studies that we conduct here involve neuro-imaging, trying to understand structural changes of the brain in geriatric depression, atrophy, frontal atrophy, and we're trying to distinguish correlates of depression versus apathy, which is another important syndrome, when people are not interested but not necessarily sad or depressed. For that reasons, I use [unint.] or [unint.] to speed up and enhance response in geriatric depression to improve response, but also improve cognition, and that's an ongoing study. I'm always using Tai-Chi to improve response to standard antidepressants, and those who don't respond to standard antidepressants. I'm using also SSRIs to improve resilience in care-givers, dementia caregivers with a lot of stress in their lives and depression, and I'm getting very early positive results of improved coping and resilience to stress. So it's very important to [unint.] in seeking help everywhere you can, trying [unint.] Especially for physicians, therapists, clergy, peer support and you can do a lot of yourself by just doing the exercise, pursuing healthy diet, stress reduction and finding satisfying hobbies, positive emotions, good sleep. Those are the best medicines for you that you can do by yourself.

DR. BAILEY:

Outstanding. I'd agree. I clearly think that your work is pretty impressive and I think that this type of discussion really shines a lot on an area that needs more attention. I think by the year 2050, or even before that, a third of Americans will probably fall into this category that has historically been considered old [inint.] age, certainly past age 60, will likely be retired, but are living longer lives [unint.] more [unint.] and more fruitful and more productive lives as well.

DR. LAVRETSKY:

I agree.

DR. BAILEY:

Dr. Laretsky, I want to thank you so much. Nice to meet you. Great to [unint.] I want to read some of your work. Thanks for taking time out of your schedule to talk with us today. I'd agree. I think depression at any age is very real, can be very severe, very impairing. I think it's essential that all of us, those of us on the clinical side as well as families and friends, could understand that depression is not simply a moral concern or weakness. It is a normal part of aging. It's a biological disorder that requires professional care and treatment. I think that that's what our elderly population really deserves, especially because so many of them are very vulnerable, really need for us to pay more attention to both their physical and psychiatric and mental health needs. Thank you very much for being with us today. I look forward to work with you again in the future. Have a good day.