Depression in Old Age. From an uncritical viewpoint, it would be reasonable to associate old-age depression with being nothing more than a natural part of the ageing process. Burtons famous book, the Anatomy of Melancholy, contained the pessimistic wor

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Depression in Old Age: Clarifying Misconceptions

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From an uncritical viewpoint, it would be reasonable to associate old-age depression with being nothing more than a natural part of the ageing process. Burton’s famous book, the Anatomy of Melancholy, contained the pessimistic words “after seventy years, all is trouble and sorrow.” (as cited in Baldwin, 1997, p.536).  This view is often shared by the general public in their expectation of later life. As reported by Harris (1975), for contemporary Western people, life as an older person is reposted by the majority as having turned out better than expected. However as it stands, it appears that few of the “typical” features of late-life depression that derives from the commonly perceived stereotype of a depressed have withstood the rigours of modern research.

Depression is not an intrinsic part of the ageing process, but rather ageing may accentuate some clinical features of the depressive disorder and suppress others (Baldwin et al, 2002). Understanding this difference is becoming exceedingly important, as the world’s population is steadily living longer (Gottfries & Karlsson, 1997); the elderly population is expected to double in size and represent one fifth of the population of the United States by the year 2030 World Health Organisation (1999 as cited in Gottfries & Karlsson, 1997) expects elderly depression to be the leading condition associated with negative impact and disease burden by 2020. The correct and appropriate diagnosis and treatment of depression in the elderly is becoming more and more important.

Currently, depression is defined using the same Diagnostics and Statistical Manual of Mental Disorders criteria as for any age. The DSM-IV contains several categories of mood disorders, including Major Depressive Disorder and Dysthymic Disorder (American Psychiatric Association, 1994). Major depressive disorder is defined by the presence of five of nine symptoms, one of which must be pervasive dysphoria or anhedonia. The other seven symptoms include change in appetite, sleep disturbance, psychomotor retardation or agitation, fatigue, feelings of worthlessness or guilt, difficulty concentrating and recurrent thoughts of death (Qualls and Knight, 2006). The diagnosis of dysthymia requires fewer symptoms but symptoms must be present for at least two years with no symptom-free periods of 2 months or more. Other commonly used diagnostic categories include Mood Disorder due to a General Medical Condition, and Adjustment Disorder with Depressed Mood (Qualls & Knight, 2006).

It has been frequently argued in the literature (Qualls & Knight, 2006; Baldwin, 2002;) that the DSM-IV is not as accurate as they should be for diagnosing depressive illness, especially for late-late depression. Late-life depression retains the same definition in the DSM-IV, only that it the sufferer is 65 years of age or older (World Health Organisation, 2011). The variation that occurs in prevalence rates, ranging from 1%-25% (Steffens et al, 2000; Jeste et al ,1999), aids in the proposal of the notion that current diagnostical methods for depression do not capture late-life depression.  

Methodological differences are one way of determining the probable reason for this variability (Steffens et al, 2000). Much epidemiological research samples use relatively small numbers of the very elderly, thereby introducing a bias (Baldwin, 1997). Also, results seem to majorly depend on the method of measurement implemented. When strict DSM-IV criteria are applied in prevalence studies, only 1%-3% of elderly are found to have major depressive disorder (Palsson & Skoog, 1997). Other studies utilise scales as their main instrument of diagnosis. Morgan et al (1987) using a stratified sample of 1299 individuals over the age of 65 and using the Symptoms of Anxiety and Depression scale (Bedford et al, 1976), found prevalence rates of 10%. Other similar studies found similar rates of 10%-15% ( Copeland et al., 1987; Livingston et al., 1990). It is often the case that these scales do not correspond exactly to the strict diagnostic criteria of the DSM or ICD, therefore they are picking up what could be referred to as minor depressive disorder or subsyndromal depressive symptoms. As an example, in 1980, studies by Blazer and Williams found an overall prevalence rate of 14.7% but 6.5% were regarded as having dysphoric disorders secondary to health problems. Only 3.7% were deemed to have major depressive order.

         There is a growing implication from the literature that old age depression does have a different profile which the current classification systems do not take into account. It has been found that elderly people who have clinically significant depressive symptoms do not meet the rigorous diagnostic criteria for major depressive disorder (MDD) from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (Baldwin, 1997; Lavretsky and Kumar, 2002; Rollman and Reynolds, 1999; Beekman et al., 1995; Snowdon, 1990).  Kivela et al (1989) identified a dysthymic group which did not DSM III criteria for major-depression, and then showed that this group’s depression was just as severe as a comparison group with major depression.

               It could be said that the symptoms are the same yet the way they are portrayed is different. According to Baldwin (1997) there have been no studies that have found much symptomatic difference between early onset old age depression and late onset, besides the well known lower prevalence of family history link for late onset depression suffers. The symptom of reduced mood is often concealed due to the guilt that elderly people may associate with admitting bad mood (Gottfries and Karlsson, 1997, p. 26).  Georgotas (1983) argues that the tendency for old people to minimize their feelings of sadness reflects presumably a cohort of people brought up not to bother their doctors with emotional difficulties. Furthermore depression is often hidden behind somatic symptoms, which are more prominent and more willingly admitted (Gottfries and Karlsson,1997). The reason for this is that the somatisation of the disorder or because of the accentuation of symptoms of a concomitant physical illness. Baldwin (1997, p.537) gives an example of how the DSM IV diagnostic criteria may be suitable for late-life depression by noting that the actual complaint of depression is not a necessary feature in the DSM IV and that this may be especially relevant when considering elderly people. The severity of depression is also not a reliable guide, as most elderly patients who commit suicide have moderate rather that severe depression (Barraclough, 1971).

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               The literature has emphasised certain aspects of depressive illness that are thought to be more common in old age. They include a preponderance of somatic complaints, excessive hypochondriasis and greater agitation, more frequent delusions compared to young persons (Baldwin, 1997). These findings are not supported fully by empirical evidence, especially when age-related factors are held constant. Blazer et al. (1987) compared young adults with depression and elders with depression, controlling for symptoms which might fortuitously increase with age independent of depression and they found that older community subjects, characterised according to DSM criteria ...

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