Despite stereotypical notions that many older people are depressed, in fact, relatively few are. Epidemiological studies have found consistently that rates of depression in older adults are lower than in younger adults. Among community residing older people, studies have found that the one year prevalence rate of Major Depressive Disorder (MDD) ranges from 1 – 5%. (Blazer, 2003). Lifetime rates of MDD are also lower among older adults compared with younger adults despite the fact that they have lived longer. However, one year rates of MDD are much higher among older adults with health problems. Rates of MDD are 5-10% among older people seeking outpatient health care, over 10% in hospital settings, and from 12 – 20% in long term care (Blazer, 2003). Dysthymic disorder (now called Persistent Depressive Disorder in the DSM-V) is evident in less than 2% of community residing older people. Rates of subsyndromal depression are much higher with the one year prevalence ranging from 8-16%. Nonetheless, rates of depressive symptoms are equal to or smaller than younger adults. Despite the many challenges of later life, resilience is evident in older people.
For the minority of older people who are depressed, the consequences can be serious. Subsyndromal symptoms of depression increase risk for onset of MDD. The functional consequences of depression for older people include increased risk for physical disability and onset or exacerbation of physical health problems (Lenze et al., 2001). Older people – specifically older white men – are at much higher risk of suicide than younger adults. The rate of suicide for all people in the U.S. is 12.4 (per 100,000) whereas for older people it is 21.0 (McIntosh, Santos, Hubbard, & Overholser, 1994).
Life and interpersonal stresses increase risk for depression in both younger and older adults (Hinrichsen & Emery, 2005). Medical illness, life transitions, interpersonal/marital difficulties and other stressors increase risk for depression. Depression in one member of a marital dyad can negatively affect the relationship – a relationship on which the depressed person may depend on support during the depressive episode (Hinrichsen, Adelstein, & McMeniman, 2004). Depression can be “contagious” within older marital dyads – if one spouse is depressed, the other member is at increased risk of later becoming depressed (Tower & Kasl, 1995).
Depression is underdiagnosed and undertreated in older people. Primary care physicians can play a critical role in the initial screening of depression. The PHQ-9 (which contains the symptoms tied to MDD) is increasingly being used in medical primary care settings to identify patients who have clinically significant depressive symptoms and who could then be treated or referred for treatment (Kroenke, Spitzer, & Williams, 2001). Other commonly used assessment instruments include the Beck Depression Inventory, Second Edition (Beck, Steer, & Brown, 1996) and the Geriatric Depression Scale (Yesavage et al., 1983). The symptoms of MDD in older adults are similar to those of younger adults although older people may evidence more apathy, excessive physical complaints, anxious rumination, and greater irritability than younger people (Karel, Ogland-Hand, & Gatz, 2002).
Depression can be treated successfully with both psychotropic medication and psychotherapies in older people (Scogin & Shah, 2012). A number of evidence based psychotherapies have been studied in older adults including behavior therapy, cognitive-behavioral therapy, problem solving therapy, psychodynamic psychotherapy, reminiscence therapy, and interpersonal psychotherapy. Some of these therapies have been found to treat successfully an “acute” episode of depression and also decrease the likelihood the older person will have another episode. Despite the efficacy of these treatments, many clinicians do not use them or only use them in an informal way. Of note is the fact that the U.S. Department of Veterans Affairs healthcare system – which serves a sizeable number of older adults — has made a substantial effort to formally disseminate evidence-based treatments to VA clinicians for Veterans with depression and other mental disorders (Karlin et al., 2012).
Written by Gregory A. Hinrichsen, Ph.D., Icahn School of Medicine at Mount Sinai
GENERAL DEPRESSION IN LATER LIFE
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Bernick, L., & Reid, J. (2005). Suicide Prevention Among Older Adults. Symposium presented at the SPRC Regions III and V Conference, Pittsburgh, Pennsylvania. Powerpoint slides available here.
Blazer, D.G. (2003). Depression in late life: Review and commentary. Journals of Gerontology: Medical Sciences, 58A, 249-265.
Blazer, D.G. (2003). Depression in late life: Review and commentary. Journals of Gerontology: Medical Sciences, 58A, 249-265.
Bryant, C., Jackson, H., & Ames, D. (2009). Depression and anxiety in medically unwell older adults: Prevalence and short-term course. International Psychogeriatrics, 21(4), 754-763. doi:10.1017/S1041610209009399
Bryant, C., Jackson, H., & Ames, D. (2009). Depression and anxiety in medically unwell older adults: Prevalence and short-term course. International Psychogeriatrics, 21(4), 754-763. doi:10.1017/S1041610209009399
Chávez-Korell, S., Delgado Rendón, A., Beer, J., Rodriguez, N., Garr, A. D., Pine, C. A., Farías, R., Larson, L., & Malcolm, E. (2012). Improving access and reducing barriers to depression treatment for Latino elders: Un nuevo amanecer (A new dawn). Professional Psychology: Research and Practice, 43(3), 217-226 https://doi.org/10.1037/a0026695
Chávez-Korell, S., Delgado Rendón, A., Beer, J., Rodriguez, N., Garr, A. D., Pine, C. A., Farías, R., Larson, L., & Malcolm, E. (2012). Improving access and reducing barriers to depression treatment for Latino elders: Un nuevo amanecer (A new dawn). Professional Psychology: Research and Practice, 43(3), 217-226 https://doi.org/10.1037/a0026695
Chiraboga, D.A., Yee, B., Jang, Y. (2005). Minority and cultural issues in late-life depression. Clinical Psychology: Science and Practice, 12 , 358-363.
Chiraboga, D.A., Yee, B., Jang, Y. (2005). Minority and cultural issues in late-life depression. Clinical Psychology: Science and Practice, 12 , 358-363.
Fiske, A. E., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual Review of Clinical Psychology, 5 , 363-389.
Fiske, A. E., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annual Review of Clinical Psychology, 5 , 363-389.
Gum, A. M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the National Comorbidity Survey?Replication. American Journal of Geriatric Psychiatry, 17, 769-781.
Gum, A. M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the National Comorbidity Survey: Replication. American Journal of Geriatric Psychiatry, 17, 769-781.
Hinrichsen, G.A., & Emery, E.E. (2005). Interpersonal factors and late-life depression. Clinical Psychology: Science and Practice, 12, 264-275.
Hinrichsen, G.A., & Emery, E.E. (2005). Interpersonal factors and late-life depression. Clinical Psychology: Science and Practice, 12, 264-275.
Hinrichsen, G.A., Adelstein, L., & McMeniman, M. (2004). Expressed emotion in family members of depressed older adults. Aging and Mental Health: An International Journal, 8, 343-351.
Hinrichsen, G.A., Adelstein, L., & McMeniman, M. (2004). Expressed emotion in family members of depressed older adults. Aging and Mental Health: An International Journal, 8, 343-351.
Hyer, L., Carpenter, B., Bishman, D., Wu, H. (2005). Depression in long term care. Clinical Psychology: Science and Practice, 12 , 280-299.
Hyer, L., Carpenter, B., Bishman, D., Wu, H. (2005). Depression in long term care. Clinical Psychology: Science and Practice, 12 , 280-299.
Jacobson, N. C., & Newman, M. G. (2017). Anxiety and depression as bidirectional risk factors for one another: A meta-analysis of longitudinal studies. Psychological bulletin, 143(11), 1155.
Jacobson, N. C., & Newman, M. G. (2017). Anxiety and depression as bidirectional risk factors for one another: A meta-analysis of longitudinal studies. Psychological bulletin, 143(11), 1155.
Laidlaw, K., & Knight, B. (2008). Handbook of emotional disorders in later life: Assessment and treatment . New York, NY US: Oxford University Press.
Laidlaw, K., & Knight, B. (2008). Handbook of emotional disorders in later life: Assessment and treatment . New York, NY US: Oxford University Press.
Lenze, E.J., Rogers, J.C., Martire, L.M., Mulsant, B.H., Rollman, B.L., Dew, M.A….Reynolds, C.F. (2001). The association of late-life depression and anxiety with physical disability: A review of the literature and prospectus for future research. American Journal of Geriatric Psychiatry, 9, 113-134.
Lenze, E.J., Rogers, J.C., Martire, L.M., Mulsant, B.H., Rollman, B.L., Dew, M.A….Reynolds, C.F. (2001). The association of late-life depression and anxiety with physical disability: A review of the literature and prospectus for future research. American Journal of Geriatric Psychiatry, 9, 113-134.
McIntosh, J.L., Santos, J.F., Hubbard, R.W., & Overholser, J.C. (1994). Elder suicide: Research, theory, and treatment. Washington, DC: American Psychological Association.
McIntosh, J.L., Santos, J.F., Hubbard, R.W., & Overholser, J.C. (1994). Elder suicide: Research, theory, and treatment. Washington, DC: American Psychological Association.
National Institute of Mental Health. (2021). Older adults and depression. Retrieved from: https://www.nimh.nih.gov/health/publications/older-adults-and-depression/
National Institute of Mental Health. (2021). Older adults and depression. Retrieved from: https://www.nimh.nih.gov/health/publications/older-adults-and-depression/
Pachana, N. A., Laidlaw, K., & Knight, B. G. (Eds.). (2010). Casebook of clinical geropsychology: International perspectives on practice . New York: Oxford University Press.
Pachana, N. A., Laidlaw, K., & Knight, B. G. (Eds.). (2010). Casebook of clinical geropsychology: International perspectives on practice . New York: Oxford University Press.
Qualls, S.H., & Knight, B.G. (2006). Psychotherapy for depression in older adults . [Wiley Series in Clinical Geropsychology]. Hoboken, N.J.: John Wiley & Sons.
Qualls, S.H., & Knight, B.G. (2006). Psychotherapy for depression in older adults . [Wiley Series in Clinical Geropsychology]. Hoboken, N.J.: John Wiley & Sons.
SAMHSA: Treatment of Depression in Older Adults Evidence-Based Practices (EBP) KIT: http://store.samhsa.gov/product/Treatment-of-Depression-in-Older-Adults-Evidence-Based-Practices-EBP-KIT/SMA11-4631CD-DVD
SAMSHA: Treatment of Depression in Older Adults Evidence-Based Practices (EBP) KIT: http://store.samhsa.gov/product/Treatment-of-Depression-in-Older-Adults-Evidence-Based-Practices-EBP-KIT/SMA11-4631CD-DVD
Scott, K. M., Von Korff, M., Alonso, J., Angermeyer, M., Bromet, E. J., Bruffaerts, R., … & Williams, D. (2008). Age patterns in the prevalence of DSM-IV depressive/anxiety disorders with and without physical co-morbidity. Psychological Medicine, 38(11), 1659.
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Segal, D. L., Qualls, S. H., & Smyer, M. A. (2018). Aging and mental health (3rd edition). Wiley/Blackwell.
Tower, R.B., & Kasl, S.V. (1995). Depressive symptoms across older spouses and the moderating effect of marital closeness. Psychology and Aging, 10, 625-638.
Tower, R.B., & Kasl, S.V. (1995). Depressive symptoms across older spouses and the moderating effect of marital closeness. Psychology and Aging, 10, 625-638.
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Zisberg, A. (2017). Anxiety and depression in older patients: the role of culture and acculturation. International journal for equity in health, 16(1), 1-10.
Zisberg, A. (2017). Anxiety and depression in older patients: the role of culture and acculturation. International journal for equity in health, 16(1), 1-10.
ASSESSMENT OF DEPRESSION IN LATER LIFE
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: Validity of a brief depression screening measure. Journal of General Internal Medicine, 16, 606-613.
Kroenke, K., Spitzer, R.L., & Williams, J.B. (2001). The PHQ-9: Validity of a brief depression screening measure. Journal of General Internal Medicine, 16, 606-613.
Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.
Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.
Storandt, M. & Vendenbos, G. R. (Eds). (1999). Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician’s Guide . Washington, DC: American Psychological Association.
Storandt, M. & Vendenbos, G. R. (Eds). (1999). Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician’s Guide . Washington, DC: American Psychological Association.
Yesavage, J.A. Brink, T.A., Rose, T.L., Lum, O, Huang, V….Leirer, V.O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.
Yesavage, J.A. Brink, T.A., Rose, T.L., Lum, O, Huang, V….Leirer, V.O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.
Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.
Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.
MEASURES OF DEPRESSION
Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.
The most commonly used, validated measures of depression in both clinical and research settings with older adults are in the public domain (i.e., free):
- Geriatric Depression Scale, 15 item (GDS-15), now with iPhone app!
- Patient Health Questionnaire-9 (PHQ-9)
- Center for Epidemiological Studies – Depression Scale
PSYCHOTHERAPY FOR DEPRESSION IN LATER LIFE
Cognitive Behavioral Therapy
Steffen, Ann M., Larry W. Thompson, and Dolores Gallagher-Thompson, Treating Later-Life Depression: A Cognitive-Behavioral Therapy Approach, Clinician Guide, 2 edn (New York, 2021; online edn, Oxford Academic, 1 Nov. 2021), https://doi.org/10.1093/med-psych/9780190068431.001.0001
Steffen, Ann M., Larry W. Thompson, and Dolores Gallagher-Thompson, Treating Later-Life Depression: A Cognitive-Behavioral Therapy Approach, Clinician Guide, 2 edn (New York, 2021; online edn, Oxford Academic, 1 Nov. 2021), https://doi.org/10.1093/med-psych/9780190068431.001.0001
Thompson, L. W., Dick-Siskin, L., Coon, D. W., Powers, D., & Gallagher-Thompson, D. (2009). Treating late life depression: A cognitive-behavioral therapy approach, workbook (Client Workbook). Oxford: Oxford University.
Thompson, L. W., Dick-Siskin, L., Coon, D. W., Powers, D., & Gallagher-Thompson, D. (2009). Treating late life depression: A cognitive-behavioral therapy approach, workbook (Client Workbook). Oxford: Oxford University.
Paukert, A.L., Phillips, L., Cully, J.A., Loboprabhu, S.M., Lomax, J.W., & Stanley, M.A. (2009). Integration of religion into cognitive behavioral therapy for geriatric anxiety and depression. Journal of Psychiatric Practice, 15(2):103-112. PMID: 19339844
Paukert, A.L., Phillips, L., Cully, J.A., Loboprabhu, S.M., Lomax, J.W., & Stanley, M.A. (2009). Integration of religion into cognitive behavioral therapy for geriatric anxiety and depression. Journal of Psychiatric Practice, 15(2):103-112. PMID: 19339844
Gallagher-Thompson, D. G. Steffen, A. M., & Thompson, L. W. (2008). Handbook of behavioral and cognitive therapies with older adults . New York: Springer.
Gallagher-Thompson, D. G. Steffen, A. M., & Thompson, L. W. (2008). Handbook of behavioral and cognitive therapies with older adults . New York: Springer.
Gallagher-Thompson, D. & Thompson, L. W. (2009). Treating late life depression: A cognitive-behavioral therapy approach, therapist guide . Oxford: Oxford University.
Gallagher-Thompson, D. & Thompson, L. W. (2009). Treating late life depression: A cognitive-behavioral therapy approach, therapist guide . Oxford: Oxford University.
Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice, 16 , 394-407.
Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice, 16 , 394-407.
Beck, A. T., Rush, A. J., Shaw, B. F., Emery, G. (1987). Cognitive therapies of depression . New York, NY: The Guilford Press.
Beck, A. T., Rush, A. J., Shaw, B. F., Emery, G. (1987). Cognitive therapies of depression . New York, NY: The Guilford Press.
Interpersonal Psychotherapy for Depression
Hinrichsen, G.A. (2010). Sexual orientation issues in the context of interpersonal psychotherapy for late life depression. In N. Pachana, K. Laidlaw, and B. Knight (Eds.), Casebook of clinical geropsychology: International perspectives on practice. New York: Oxford University Press.
Hinrichsen, G.A. (2010). Sexual orientation issues in the context of interpersonal psychotherapy for late life depression. In N. Pachana, K. Laidlaw, and B. Knight (Eds.), Casebook of clinical geropsychology: International perspectives on practice. New York: Oxford University Press.
Hinrichsen, G.A., & Clougherty, K.F. (2006). Interpersonal psychotherapy for depressed older adults . Washington, DC: American Psychological Association.
Hinrichsen, G.A., & Clougherty, K.F. (2006). Interpersonal psychotherapy for depressed older adults . Washington, DC: American Psychological Association.
Hinrichsen, G.A., (2008). Interpersonal psychotherapy for late life depression: Current status and new applications. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 26 . 263-275. doi: 10.1007/s10942-008-0086-5
Hinrichsen, G.A., (2008). Interpersonal psychotherapy for late life depression: Current status and new applications. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 26 . 263-275. doi: 10.1007/s10942-008-0086-5
American Psychological Association (Producer). (2007). Interpersonal Psychotherapy for Older Adults with Depression . [DVD]. http://www.apa.org/pubs/videos/4310796.aspx
American Psychological Association (Producer). (2007). Interpersonal Psychotherapy for Older Adults with Depression . [DVD]. http://www.apa.org/pubs/videos/4310796.aspx
Problem-Solving Therapy for Depression in Later Life
Choi, N. G., Hegel, M. T., Marti, C. N., Marinucci, M. L., Sirrianni, L., & Bruce, M. L. (2014). Telehealth problem-solving therapy for depressed low-income homebound older adults. The American Journal of Geriatric Psychiatry, 22(3), 263-271
Choi, N. G., Hegel, M. T., Marti, C. N., Marinucci, M. L., Sirrianni, L., & Bruce, M. L. (2014). Telehealth problem-solving therapy for depressed low-income homebound older adults. The American Journal of Geriatric Psychiatry, 22(3), 263-271
Areán, P.A., Raue, P., Mackin, S., Kanellopoulos, D., McCulloch, C., & Alexopoulos, G.S. (2010). Problem-Solving Therapy and Supportive Therapy in Older Adults With Major Depression and Executive Dysfunction. The American Journal of Psychiatry, 167(11), 1391–1398.
Areán, P.A., Raue, P., Mackin, S., Kanellopoulos, D., McCulloch, C., & Alexopoulos, G.S. (2010). Problem-Solving Therapy and Supportive Therapy in Older Adults With Major Depression and Executive Dysfunction. The American Journal of Psychiatry, 167(11), 1391–1398.
Alexopoulos, G.S., Raue, P., & Areán, P. (2003). Problem-Solving Therapy Versus Supportive Therapy in Geriatric Major Depression With Executive Dysfunction. The American Journal of Geriatric Psychiatry, 11[1], 46–52.
Alexopoulos, G.S., Raue, P., & Areán, P. (2003). Problem-Solving Therapy Versus Supportive Therapy in Geriatric Major Depression With Executive Dysfunction. The American Journal of Geriatric Psychiatry, 11[1], 46–52.
Arean, P., Hegel, M., Vannoy, S., Fan, M., & Unuzter, J. (2008). Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48, 311-323. doi:10.1093/geront/48.3.311
Arean, P., Hegel, M., Vannoy, S., Fan, M., & Unuzter, J. (2008). Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48, 311-323. doi:10.1093/geront/48.3.311
Psychodynamic Therapy for Depression in Later Life
Evans, S. (2004). Talking over the years: A handbook of psychodynamic psychotherapy with older people . New York, NY: Brunner-Routledge.
Evans, S. (2004). Talking over the years: A handbook of psychodynamic psychotherapy with older people . New York, NY: Brunner-Routledge.