Failure to Thrive

Scientists and clinicians know how to battle depression in the elderly. But without needed policy changes in the health care system, they're being held back.

For reasons no one will ever know, Moe and Estelle Spivack had no interest in living to see the year 2003. So last New Year's Eve, the elderly Florida couple asked the maintenance worker in their condominium complex to remove the bedroom window screens to let more fresh sea air into their 17th-floor room. The request must have seemed harmless enough: After all, 85-year-old Moe was grappling with emphysema and had just gotten home from the hospital. But Moe and 80-year-old Estelle, both dependent upon their walkers, had a larger plan. With the screen gone, they crawled out the open window and fell to a gruesome death--an event that shocked and horrified the Spivacks' neighbors. According to USA Today, Estelle "appears to have taken the lead, probably helping her ailing husband out the window before she went."

Later, a telltale clue as to what might have driven the Spivacks to end their lives leapt out at investigators. Like so many seniors who take their own lives, Moe Spivack was reportedly "despondent about his failing health," a state of mind that probably set the suicide in motion. Although suicide pacts among depressed seniors occur rarely, depression has been implicated in many murder-suicides and thousands of ordinary suicides every year. At a recent Senate Special Committee on Aging hearing about depression, Jane L. Pearson, chair of the National Institute of Mental Health (NIMH) Suicide Research Consortium, noted that seniors account for 18% of all suicides in the United States, although this group of people makes up only 13% of the population.

Older Americans aren't necessarily more prone to depression than those in their 20s and 30s. But because depression tends to be thought of as a natural part of aging instead of a chemical imbalance that can be corrected, it goes undiagnosed in four out of five seniors. As a result, the condition places a disproportionately heavy burden on the elderly. Left untreated, depression doesn't merely prompt suicidal thoughts. It contributes to the increased lethality of disorders that typically accompany aging, such as cardiovascular disease--an effect that arises at least in part because depressed elders tend to take poor care of themselves. This depression-driven deterioration is so common in nursing homes, says psychologist Donna Cohen of the University of South Florida, Tampa, that it even has a name: "failure to thrive" (a term normally used in reference to infants).

A long-neglected public health problem, depression has garnered considerable attention of late. A landmark 1996 Senate hearing, "Treatment of Mental Disorders in the Elderly," dramatically raised the illness's profile. Senator Harry Reid (D–NV), whose father killed himself at age 58, used the event to call for more NIMH funding to study depression treatment and suicide prevention in the elderly. And a groundbreaking 1999 Surgeon General's report on mental health called for the destigmatization of mental illness and highlighted depression as a condition that takes an "inordinate toll" on senior citizens.

During the past 10 to 15 years, physicians and policymakers have made major advances in recognizing that depression is a big problem afflicting seniors, says Ira Katz, a geriatric psychiatrist at the University of Pennsylvania in Philadelphia who testified at the 1996 Senate hearing. But that recognition is only the first step. As scientists such as Katz repeatedly emphasize, 70% of seniors who commit suicide have seen their doctor within a month of their death. Given this figure, it's clear that better clinical diagnosis and treatment of depression would provide an immense benefit.

At present, however, clinicians find themselves too busy tending to patients' other needs and demands, says Mary Whooley, a University of California, San Francisco, epidemiologist who co-authored a recent New England Journal of Medicine article on the management of depression by primary care physicians. "It's hard to make the diagnosis of depression," she says. "We have very short visits, and we need to focus on very immediate problems, like cardiac disease. Dealing with depression tends to take a back seat." But Whooley's recent research on cardiac disease and depression suggests an intimate connection between the two. In a recent paper in the Journal of the American Medical Association, Whooley and her co-authors showed that depressed patients had a harder time dealing with their heart disease and reported a lower quality of life than did those who were not depressed--even though in some cases the depressed patients had healthier hearts.

It doesn't help that many elderly patients--especially men--don't like talking about their feelings. And even when properly diagnosed with depression, seniors can have trouble continuing to take an antidepressant. Nearly half of patients receiving a prescription for antidepressants stop taking them within a month. "Tracking people downstream and making sure that effective care is really delivered" will be the next step in defeating depression, says Katz.

Although targeted research questions about depression remain--for example, why antidepressants sometimes fail to help seniors--scientists say the time has come to implement policy changes that can help mitigate the toll the disease takes on senior citizens. In particular, health care providers must institute programs to catch and treat depression in the primary care setting. Proven models already exist: With NIMH support, Katz and a team of scientists have conducted a study called the Prevention of Suicide in Primary Care Elderly: Collaborative Trial. In this study, the researchers tested the effectiveness of better initial diagnosis, patient tracking, and follow-up therapy in improving the treatment of depression. The approach increased patients' responsiveness to treatment while decreasing their propensity for suicidal thoughts.

In addition to ensuring that patients diagnosed with depression receive proper treatment, experts cite another policy fix that would help battle depression in the elderly. At present, the Medicare program reimburses 80% of patients' expenses for physical conditions such as osteoarthritis but only 50% of their expenditures for mental health care. That extra cost makes it less likely that seniors will seek treatment for depression. Eliminating this disparity might save money in the long run. "If you treat depression, the medical care cost will go up a little at the beginning," says Cohen. "But then the medical care costs decrease. So there's a cost benefit." Given the possibility that ongoing research will produce an extension in human life span during the 21st century, we'd better hope that our health care systems can adjust to help keep us all well-balanced, optimistic, and thriving--even at the oldest of ages.

Chris Mooney is a freelance writer living in Palo Alto, California. He's glad to be able to increase recognition of the depression problem by reporting on it.