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Everyone feels sad from time to time. However, depression is more than just a case of the blues. It can cause long-term sadness that steals the happiness from life. Depression can also interfere with the ability to function socially or to be productive. It can even lead to suicide. This is why depression needs to be recognized, taken seriously, and treated appropriately.

• Types of Depression
• Major (clinical) depression
• Depression associated with dementia
• Depression associated with physical illness
• Depression associated with bereavement
• Psychotic depression
• Minor (sub-clinical) depression
• Seasonal depression
• Bipolar disorder
• Diagnosis and Evaluation
• Treatment
• Psychotherapy
• Drugs
• Response to drug treatment
• Drugs for bipolar disease
• Electroconvulsive (electroshock) therapy

There are several different types of depression. They differ in character, time of onset, severity, and duration.

Major depression is also called clinical depression. It is one of the most serious forms of depressive illness, and it can be associated with many debilitating symptoms, including the following:

• Depressed mood
• Loss of interest or pleasure
• Significant weight change or change in appetite
• Sleep problems (ie, insomnia or too much sleep)
• Restlessness, agitation, or slowing of movements
• Decreased energy or increased fatigue
• Feelings of worthlessness or excessive guilt
• Decreased ability to think or concentrate
• Recurrent thoughts of death or suicide

People suffering from major depression often have many of these symptoms, but depressed mood and loss of interest or pleasure are the most prominent. At least one of these two symptoms must be present and last for at least two weeks for a diagnosis of major depression to be made.

Thoughts of suicide associated with major depression are especially important, given the increased risk of suicide with older age. People aged 65 and older are less than 13% of the population, but account for 25% of suicides. Research suggests that as many as 75% of older adults who commit suicide are suffering from depression.

National surveys suggest that only 1%—2% of older women and less than 1% of older men have major depression that meets the above definition. In fact, statistics suggest that the chances of experiencing the onset of major depression actually decrease after age 65. However, older adults are less likely to recognize and report depression, so it may be more common than reported in surveys. In addition, major depression among older adults is much more common in certain settings, such as in nursing homes, hospitals, and psychiatric clinics.

In about 30%—50% of cases, depression in older adults is the continuation of a problem that began earlier in life. Major depression is a disease that often comes back in both younger and older adults. Without treatment, up to one third of depressed individuals stay depressed for a long time, and another third recover only partially, leaving them with lingering disability and on-going problems. People who suffer their first episode of depression in later life take longer to recover. Depression that begins in later life is often associated with chronic medical illness, disability, or mental or social stress. However, usually no cause can be identified for any particular episode of depression in later life.

Depression associated with dementia: Frequently, major depression may accompany disorders that result in dementia, such as multiple strokes, Alzheimer’s disease, or Parkinson’s disease (see also Delirium and Dementia). In fact, approximately 20% of people with early Alzheimer’s disease also have major depression. Major depression may be the initial symptom in these disorders, or it may develop well after the onset of dementia.

Distinguishing between depression and dementia can be difficult. Many common symptoms of depression, including decreased ability to concentrate, indecisiveness, and lack of motivation, are also seen in dementia. Dementia may also have symptoms that imitate depression, including loss of interest and problems sleeping. In addition, an older person with depression may have memory loss and be unable to complete basic tests of mental function.

Depression associated with physical illness: The diagnosis of major depression in older adults is often complicated by physical illness. Many older adults have illnesses such as cancer or heart disease that, understandably, make them feel sad, lonely, or depressed. People with serious medical illness may even be preoccupied with thoughts about death or feel worthless because of disability associated with their illness. However, these feelings are related to their illness and are not truly major depression. It can be difficult to distinguish one from the other in practice.

There is a strong link between major depression and increased risk of dying from heart disease. Major depression after a heart attack, heart failure, or heart-bypass surgery increases the risk of dying from these disorders.

Symptoms of depression can also be caused or worsened by prescription medications. Drugs for high blood pressure cause this problem most frequently. In addition, corticosteroids, hormones (eg, estrogens), and sedatives can sometimes lead to depression. Medicines used to treat Parkinson’s disease can also result in depression or manic symptoms.

Alcohol abuse can also cause depressed mood (see Substance Abuse). This should be considered in any older adult who develops a shake or tremor, bleeding in the skin, heartburn, bleeding from the intestines, or symptoms of alcohol withdrawal (eg, sweating, or increased temperature, heart rate, or blood pressure).

Depression associated with bereavement: Bereavement is common among older adults as they face the loss of friends and loved ones. Feelings of sadness, sleeping problems, and decreased appetite are common but generally go away naturally within a few months. Loss of a loved one may also generate temporary thoughts of joining the deceased, which is normal. However, some older adults develop major depression within 2 years of a loss. Major depression after a loss is often characterized by preoccupations with guilt or suicide. It may also contribute to a decrease in abilities to take care of oneself and function.

People with psychotic depression have irrational beliefs, or delusions, or they may see or hear things that are not there, or hallucinations, in addition to major depression (see also Delirium and Dementia). These delusions often focus around fears of a serious physical or medical condition such as cancer, even when the person does not have such an illness. Sometimes a person may become paranoid or convinced that someone is out to harm him or her. These delusions usually happen late in the course of illness, after a significant period of depression. Psychotic depression is most common toward the end of life.

About 15% of older adults have symptoms of depression that are not severe enough to be diagnosed as major depression. Although this "minor" or subclinical depression is less severe than major depression, it can still have serious consequences. Subclinical depression has been linked to increased visits to the doctor, problems with function or health, decreased social activity, and early death.

People with seasonal depression (also called seasonal affective disorder) often report a pattern of depression during a distinct 2-month period of the year, usually the winter. This pattern generally repeats itself over for at least 3 years. Although not uncommon in older adults, seasonal depression is more common in younger adults.

Bipolar disorder has sometimes been referred to as manic-depressive disorder. This disease involves episodes of major depression that alternate with so-called "manic" episodes (ie, mania). Mania is usually associated with a distinct period of elevated mood that lasts for a week or longer. Other symptoms that may be seen during this time include inflated self-esteem, feelings of grandiosity, increased sexual desire, increased activity, and decreased need for sleep. The person may be easily distracted, talk much more than usual, spend a lot of money, be hyperactive, and have thoughts or ideas race through his or her mind. Grandiose or paranoid delusions may also be present.

Manic episodes are less common in older adults than in younger ones. Older adults may also experience a different type of mania, in which irritability and agitation are more common than euphoria or exhilaration. Talking a lot with ideas that tend to go off on tangents is still common, but thought disturbances and racing ideas are less marked than in younger adults. Increased sexual desires and grandiosity may still be seen in older adults but are less prominent than in younger people.

Older adults often do not recognize or report symptoms of depression. So, healthcare providers typically ask routine questions about your mood to see if you may be suffering from depression or other disorders of the mind (see Health Assessment). Try to answer these "screening" questions as accurately as possible. Your healthcare provider is not trying to pry, only to look after your well-being.

It is important for your healthcare provider to know about any changes from your normal mood or personality. However, sometimes we are not always the best judge of changes in ourselves. Usually, bringing along a family member or caregiver who knows you and your normal mood can be helpful. Close relatives may also be able to answer questions about family history of depression.

Other medical problems can appear like major depression. For example, stroke, congestive heart failure, and cancer can mimic major depression and can cause weight loss, sleeping problems, problems with concentrating, and low energy. People with Parkinson’s disease may have a number of symptoms that suggest depression, including lack of facial expression, slowed body movement, lack of spontaneity, and decreased energy and motivation. Changes in body chemistry (eg, low potassium) can also cause mood changes as well as disturbances in sleep, appetite, concentration, and energy. Measuring thyroid levels is especially important, because older adults with thyroid problems may have a loss of interest and diminished energy that can look like depression. Other diseases that can look like depression include nutritional deficiencies (eg, vitamin B₁₂ deficiency) and some types of infection.

Depression needs to be differentiated from other mental disorders, such as dementia. A number of neurological or psychological tests are available that can help clarify this picture (see also Delirium and Dementia). Sometimes, your primary healthcare provider will need to refer you to a psychiatrist, neurologist, or other specialist for more sophisticated testing or treatment.

The course of treatment for major depression generally has three parts:

Psychotherapy, or talk therapy, involves counseling that helps people cope with depression and reinforces a positive outlook. This has been proved to be very safe and effective for many people with depression. Several psychotherapy techniques can be effective, including the following (explained below in more detail):

• problem-solving therapy
• cognitive-behavioral therapy
• interpersonal psychotherapy.

In problem-solving therapy, the therapist helps people identify practical life difficulties that are causing distress. The therapist also provides guidance to help find solutions to these problems. In general, treatment programs run 6—8 visits that are 1 or 2 weeks apart.

Cognitive and interpersonal psychotherapy programs also typically run for a specified time but are less highly structured. They may include daily or weekly activity schedules and assignments that are designed to help the person develop more abilities to adapt to their situation. Negative statements such as "My life is not worth living," which are symptoms of depression, are challenged, and the depressed person is encouraged to adopt new ways of viewing life.

Interpersonal psychotherapy has shown promise for treating minor depression, especially for people who are depressed after the death of a close friend or relative. Psychotherapy can also help caregivers of older adults, who may develop minor or major depression (see Psychological and Social Issues).

Psychotherapy is often combined with antidepressant drugs. In many cases, this combination has resulted in a longer time free of depression after recovery from acute episodes of depression. Psychotherapy combined with antidepressant medication is usually recommended for people who have severe or suicidal depression. Most people with suicidal depression are referred to a psychiatrist.

People who have major or minor depression usually respond to antidepressant drugs. Many categories of drugs can be used to treat depression, including selective serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors, among others. The choice of drug depends on a person’s medical condition, the side effects associated with the drug, and the potential for interactions with other medications. The SSRIs are currently the most commonly used class of antidepressant drugs.

The side effects associated with antidepressant therapy depends on the drug chosen. Possible side effects include nausea, diarrhea, constipation, dry mouth, vision problems, decreased sexual desire, blood chemistry problems, blood thinning, sleepiness, and low blood pressure. Often, drugs with specific side effects are selected on purpose, as part of the treatment. For example, if insomnia is part of the depression, the physician may prescribe an antidepressant drug that causes sleepiness as a side effect (eg, trazodone).

All of the antidepressant drugs stay in the body for days to weeks, and tend to accumulate over time. If kidney and liver function is decreased, elimination time may be even longer. Over time, this accumulation within the body could possibly lead to an overdose. This is why treatment usually begins with a low dose, which is increased slowly and carefully until the desired effect is seen. Blood is usually checked at regular intervals to monitor drug levels or liver and kidney function. Drug treatment should also be stopped gradually to avoid withdrawal symptoms (eg, light headedness, insomnia, headache, and nausea) associated with some medications.

Response to drug treatment: For antidepressant drugs to be effective, they must be taken every day for several weeks. Approximately half of adults with major depression respond well to drug treatment within 6 weeks. An additional 15% to 25% only begin to respond during the first 6 weeks, but continue to improve if treatment is continued for another 4—6 weeks. A noticeable improvement within the first 2 weeks of treatment is probably the best predictor of successful recovery using the initial medication. If there is no response, a different drug may be tried, or an additional drug may be added to the current treatment.

Drugs for bipolar disease: Lithium carbonate is the most commonly used drug for manic episodes. It usually takes 1-2 weeks of treatment before the drug takes effect. Treatment is usually started at a very low dose, because lithium is eliminated from the body slowly in older adults. In addition, many common drugs can slow the elimination of lithium, including ibuprofen and some diuretics (ie, "water pills"). Lithium can cause neurologic side effects in older adults at dosages that are well tolerated in young adults but may be very troublesome in older adults. Side effects include tremor, diarrhea, and muscle spasms.

Other drugs used to treat mania include certain antiseizure (eg, valproic acid) and antipsychotic medications. Depending on the medication, side effects can include skin rashes or problems with the blood or various organs.

Electroshock therapy brings to mind scary images for many people. However, electroshock is often highly effective in treating both major depression and mania. Success rates exceed 70% in older adults. Electroshock is especially useful when other treatments (eg, drugs) have not worked or when the depression may have life-threatening consequences. For example, electroshock is the first choice of treatment for people at serious risk of suicide or life-threatening malnutrition due to depression. Malnutrition is most common in people with psychotic depression who develop paranoid delusions directed at their food or caregivers, and refuse to take food or medications offered by their caregivers.

Electroshock therapy is done under general anesthesia to ensure that it is painless. Electroshock therapy is safe for people with most kinds of heart disease or stroke, given proper medication. However, a recent heart attack or stroke increases the risk of complications. Electroshock therapy should not be done in people who have unstable heart problems or increased pressure in the brain from something like a brain tumor.

The most common side effect of electroshock therapy is amnesia. Some people are not able to remember events that happened immediately before the therapy. They may also have problems initially learning new information, but this problem improves rapidly after treatment is completed. Some people fear that electroshock therapy may cause long-term memory loss. However, research has not shown this to be the case; in fact, in some cases, memory has improved.