Caregiver Guide: Depression

Understanding the Problem

We all experience life changes that can lead to feeling depressed. Some people go through physical changes affecting their eyesight, hearing, or how well they can move. Others have changes in their health that are treated with many medicines. Still others have changes in their ability to think and remember.

Lifestyle changes are also common. Some older adults retire from their work and need to find new ways to fill their time or make themselves feel useful. Others move into a smaller house or apartment, or move in with family members who can help take care of their needs. Some people move into assisted living facilities or nursing homes. Finally, older persons lose friends or family members close to their own age who pass away. Studies show that as many as 25% of people who lose a family member or close friend are seriously depressed for months after the death.

It can be hard to cope with these changes, which become more common the longer we live. This is especially true when several changes occur at the same time. The emotional stress of dealing with these changes can cause many uncomfortable feelings, including depression.

Symptoms of depression

Sometimes older people are able to get over "the blues" after a short time. However, sometimes these feelings last a long time and can severely hurt their quality of life. When a person is sad, discouraged, gloomy, or feeling hopeless for several weeks or months, and when these feelings interfere with being able to manage day-to-day affairs, we say that he or she is suffering from depression. Depression can last a long time if the person does not do something to stop it.

Not everyone notices feeling sad.  Symptoms of depression may sometimes only show up as problems with appetite, sleeping, lack of energy, ability to pay attention to things, and loss of enjoyment of favorite activities. Other symptoms can be vague physical complaints such as headaches, constipation, or aches and pains in several parts of the body for which there is no medical explanation. Excess use of alcohol, especially if it is new or worse since the person has been through a significant life event, may also be a sign of depression. Sometimes a depressed person thinks about suicide as a way out of his or her problems.

Depression works like a downward spiral

The person feels down, so he or she does not put energy into solving problems. When the problems get worse, they can make the person feel worse. And so it continues. This spiral pattern must be interrupted. Some kind of change has to happen, or these feelings will become severe and will last for a long time.

Depression can also be a side effect of some medicines, or it can be caused by chemical imbalances in the body due to medical illnesses. It can also be caused by the combination of several medicines taken at the same time. When this happens, changes in medical treatments may help the depression.

It is important to remember that, although depression happens often to older adults, it should not simply be accepted. There are several treatments available to help relieve depression and most people can find relief with at least one of them, regardless of their age or situation. People may also experience depression along with medical conditions. Even when everything is being done to treat the medical conditions, additional efforts often can be made to relieve the depression as well.

Your help is valuable to a person who is feeling depressed

However, it is also important that he or she help themselves. You and the person you are caring for can work together as a team to deal with depression.

Some symptoms are a normal response to the stresses and uncertainties people have in everyday life

Don't expect to all these feelings to go away. However, as a caregiver, you can help prevent feelings of sadness or discouragement from becoming severe or continuing for long periods of time. By working with the person, you may help keep depressed feelings under control. If the symptoms become severe, you can encourage the older person to seek professional help.

If the older person is seen by a doctor, he or she may prescribe antidepressant medicine

You may need to help the older person take the medicine as directed and watch for side effects. It may take several weeks or even months before the medicine takes effect, and it may also be continued on a low dose after the depression gets better. You may have to keep watch on how the antidepressant medicine is taken for a long period of time.

The healthcare provider who is prescribing the medicine will need feedback on how the older person is responding and you might need to help here as well. It is also extremely important that they are fully aware of all the medicines that the person you care for is currently taking, regardless of the reasons why they were originally prescribed.

Preventing negative drug interactions is very important

Be sure to give all healthcare providers a list of all prescription medicines, over-the-counter medicines bought at the pharmacy, and any herbal or other alternative therapies, as well as the dosage levels and the times they should be taken.

Pay attention to your own emotional health

Living with or spending large amounts of time with a person who is depressed can be stressful and can even lead to you feeling  depressed. It is important to pay attention to your own emotional health so that you can do your best as a caregiver.

Your goals are to:

  • Work together with the older person to manage depressed feelings and thoughts
  • Keep an eye out for early symptoms of depression and help the older person manage depression before the symptoms become severe
  • Be alert to when professional help is needed and assist the older person in getting this help
  • Take care of your own emotional needs when caring for someone who is depressed

Click on each of the topics below to read more.

When To Get Professional Help

Call the healthcare provider immediately if any of the following is occurring

He or she is talking about hurting or killing him or herself

Older people successfully commit suicide more often than people in other age groups. Anyone who talks about suicide should be taken seriously. If you are not sure, ask if he or she is thinking about suicide. Your asking will not make it more likely. You will not put the idea in his or her head. If you think there is a chance of suicide, this is a problem that requires professional help. Although it may be uncomfortable for you, you should seek professional help as soon as possible.

He or she is not eating or drinking enough to sustain life

This may also be a symptom of depression and it needs to be evaluated promptly.

He or she has been depressed in the past and has had at least two of the following symptoms regularly during the past two weeks

  • Feeling sad most of the day
  • Loss of interest in almost all daily activities
  • Difficulty paying attention to what he or she is doing and trouble making decisionsA person with a history of depression is more likely to become depressed after a major life stress. Major life changes such as a family member dying, becoming disabled, developing a medical condition, or moving into a new home often trigger depression in such a person. When this happens, professional help is often required to help the person improve.

The older person is acting sad, but you have not noticed any events that could explain why

Sometimes depression may be the start of other medical problems such as thyroid disease, Alzheimer's disease, heart disease, or cancer. A healthcare provider can help look for other causes of the depression and recommend the best treatment.

You notice changes in memory, concentration, or personal care

When a person is depressed he or she may put less effort into bathing and grooming, or may become forgetful or easily distracted. Sometimes when caregivers notice these signs in older individuals, they accept them as normal signs of aging or believe they are becoming "senile." Regardless of the age of the individual, these are signs of a problem. A doctor or nurse can help determine what is causing these changes and refer you to a professional who can help.

You notice wide mood swings from periods of depression to periods of agitation and high energy

Some people who have wide, uncontrollable swings in mood may have a "manic-depressive" or bipolar illness. They cycle between being depressed with low energy and having a great deal of energy with feelings of agitation or feeling "high." In many cases, the cycles aren't connected to what is going on around them. Professional help is needed to decide if medicine could help.

The older person is in a nursing home and you notice symptoms of depression

If an older person lives in a nursing home, he or she is more likely to develop depression. Because you are close to the person and probably have known him or her for a long time, you can be helpful to the staff by pointing out changes in the older person's mood or behavior. If you notice signs of depression, discuss them with someone on the staff.

How to Get Professional Help

Getting help for depression is just like getting help for physical problems. Asking for help does not mean you are saying the older person is crazy. The problem could be caused by stress related to life changes or to medical treatments he or she is receiving. Depression could be an understandable reaction to whatever is going on in the person's life.

Some people are hesitant to ask for professional help with their emotional problems because they are embarrassed. They think that seeing a psychologist, psychiatrist, or social worker means that they are weak, strange, or unable to handle normal things that happen while "growing old." Many of the older person's generation were raised to believe this. However, being upset during life changes is normal at any age. So is getting help for being depressed.

Professionals such as social workers, clergy, psychologists, psychiatrists, and geriatricians are skilled and experienced in helping people deal with emotionally stressful experiences. They are there to help you and the older person with this kind of problem just as your family doctor and other healthcare providers are there to help with physical problems.

Ask for help from a family doctor or a doctor who is familiar with the medical treatments the older person is receiving

The healthcare provider who is familiar with the person’s other medical conditions and treatments can evaluate whether the depression is due to the disease or the treatment. If it is due to the treatment, then a change in treatment may be needed. The older person’s healthcare provider can also evaluate whether anti-depressant medicine might help and can prescribe them if necessary.

Ask a mental health professional such as a psychologist, psychiatrist, or social worker for help

Mental health providers are experienced in helping people with many types of emotional problems. They can be especially helpful when there is a history of depression and when the depression is not due to medical diseases or treatments. Certain mental health providers like geriatric psychologists and geriatric psychiatrists specialize in treating older people. These professionals may be especially helpful in meeting the special needs of an older person. Mental health providers can be very helpful when depression is a reaction to the stress of life events and life changes.

Changing depressed feelings takes time. It usually takes several sessions with a counselor or therapist before a person begins to feel better. It also takes time for medicine to work, and the provider may need to adjust the dose before the medicine is helpful.

What You Can Do To Help

Take care of your own emotional needs when caring for a person who is depressed

Family members and friends who care for an older person often experience depression themselves. Because many elderly people have a variety of needs, caregivers who are trying to attend to all these needs may feel frustrated or "burned out." When caregivers feel this way, they will not be much help to the people they are caring for.

Caregiving can be stressful. To do your best in this difficult role, you need to find ways to stay emotionally well yourself. Here are some things that you can do for your own emotional health:

Understand that it is not your fault if the person becomes depressed

You should realize that you are not responsible if the person you are caring for becomes depressed. Depression can be caused by many things, including physical changes as well as changes in a person's life. Sometimes, especially if the depression is severe, only healthcare professionals can help. You should not feel guilty if, in spite of your best efforts, the person you are caring for becomes or stays depressed. In addition to caregiving, try to find time to enjoy some of the things you once did together. If the older person is not able to do these things anymore, find something else you can enjoy together such as talking to one another, listening to music together, looking at family photographs or thinking over good times from the past.

Schedule positive experiences for yourself

Keep doing things that make you feel good. Do not become so involved in your caring responsibilities that you neglect your own emotional health. Do not feel guilty about taking care of yourself. If you become overwhelmed, you will not be able to provide care and support. You will be a better caregiver if you get regular exercise and you take time to do things that you enjoy outside of your caring responsibilities. Do this early before you become depressed yourself or your own feelings of depression become severe. This can help give you the strength to carry on.

Get the companionship you need

Being with others is as important for you as it is for the person you are caring for. Continue to do things with people you like and enjoy. This helps to prevent and manage your own "blues." If you feel yourself becoming depressed, seek out other people with whom to talk to and do things. Some people find it helpful to talk to other people about their problems. Others find it more helpful to talk about things that have nothing to do with their problems. This depends upon how you feel and the person you are talking to.

You can get professional help for yourself too, if necessary.

How to react to a person who is depressed

One thing you should not do is ignore the older person's depression. Sometimes caregivers act as if the depression is not there, either because they do not want to encourage it or because they do not want to deal with it. However, ignoring depression only makes it worse because the depressed person may feel that you do not care.

You can be of most help early, before depression becomes severe. If you ignore the early signs of depression, it is more likely to get out of hand, to seriously affect the older person's quality of life and to require professional help.

How to prevent or decrease depression

Much of the work in controlling depression has to come from the person who is depressed. This section describes several things that he or she can do to prevent or decrease depression. Your primary role is to be a team member by helping the older person learn these strategies and then by supporting and encouraging their use.

One of the most important things a caregiver can do for an elderly person is help that person find a balance between his or her problems and the enjoyable things in life. Your goal is to arrange as many pleasant, positive experiences as possible for the older person. Focus your attention on these types of activities

Increase activities that the older person does with other people

Being with people one knows and enjoys is an excellent way to take attention away from negative thoughts and feelings. It provides opportunities to think and to recognize the good things in one's life. It provides opportunities to give as well as to receive help, to share experiences and perspectives, and to get help in dealing with problems that are causing depression. Most important is that other people can express caring and love. Knowing that other people care and are available to help when needed gives strength and confidence to people who are having difficulty coping.

Three types of people can be especially helpful in preventing someone from having depression. Make a list of friends and family members using the following categories:

  • People who are sympathetic and understanding.
  • People who give good advice and who can help solve problems.
  • People who can turn attention away from problems and toward pleasant experiences.

Encourage setting reasonable goals which can be reached

Depressed people tend to set goals that are too high, and when they do not reach their goals, they become even more depressed. Setting reasonable goals may be hard for an elderly person who is experiencing new physical or mental limits. He or she might not have a realistic sense of what is possible and might need help accepting or working around limits. When you plan positive experiences, be sure that your goals are reasonable. It is better to set a low goal and do more than you expected than to set too high a goal and fail. Be creative when working around new limits. Usually, there is more than one way to solve any problem.

Support his or her efforts to control repeating, negative thoughts and to substitute positive experiences and thoughts for negative ones

The person you are caring for may you that he or she needs to do something to "break out" of depressing thoughts.  You can help by encouraging and becoming involved in activities that are helpful.

The following techniques are techniques for controlling negative thoughts:

  • Reminiscing allows the older person to recall positive thoughts and to think about how things have been with life in general.
  • Companionship helps to fill time with positive experiences instead of negative thinking.
  • "Thought stopping" to interrupt repeating negative thinking.
  • Control and limit negative thinking  by arranging a plan and time for it.
  • Paying attention to positive thoughts to push out or replace negative thinking
  • Arguing against negative thinking to show yourself how unreasonable your negative thoughts are.
  • Solving day-to-day stressful problems that can be a cause of negative thoughts.

Let the older person know when you think he or she is doing things that might lead to depression

This helps the older person to manage the depression early, before it becomes severe. Some people find it easy to use a code word or phrase that the two of you agree on to point out depressed thinking. However you do it, a gentle reminder from you to stop thinking negative thoughts and being unrealistic can help prevent the depression from becoming severe.

Carrying Out and Adjusting Your Plan

Talk this plan over with the older person

Together you should agree on what the two of you can do to manage depression. It is important to work as a team when dealing with these problems. Sometimes the feeling of being on a team in itself is helpful to a depressed person.

Use these techniques early

Look for beginning signs of depression and put your plan into action right away. Do not wait until depression is severe. The techniques discussed in this plan have helped severely depressed persons, but usually as part of professional treatment. As a caregiver, you can help most before depression becomes severe.

Plan in advance what you will do to manage depression

If you know, based on past experience, that the older person is likely to be depressed at certain times, then make plans to do things to prevent depression from building up.

Be Persistent

Even if the older person continues to feel depressed, do not give up. It is common for depressed people to feel there is no hope. You are probably preventing the depression from getting worse. Keep working cooperatively with the depressed person. If you are working together, these ideas can help.

Problems You Might Have Carrying Out Your Plan

"I don't want your help. Leave me alone."

"I can't do anything unless you agree and cooperate. But would you please read this section? We can discuss it together and agree on what you will try first. We'll start small with something that is easy to do and then check the results. If you're so depressed that you don't even want to try, you should get some professional help."

"I don't want to talk about my feelings."

"Talking about your feelings helps you to understand and to manage them. Getting help for your feelings is just like getting help for any other medical problem."

"What's the use in feeling better? I'm dying anyway."

"But you are alive now and you can have a happier life by doing some things to control your depression. We love you and we care about you and we want you to enjoy life. All of us will work with you."

Express with words or touch that you care for the person. Remind him or her that, although it seems like life is near the end, he or she is still living. Following the techniques in this section can help both of you enjoy his or her life as long as possible.

"My Dad is involved in so many treatments already. I don't want to bring this up and make him worry about one more thing."

If your dad is depressed, then he is already troubled. Your bringing it up will not make things worse. Talking about depression and doing something about it can improve other problems in addition to the depression.

Think of Other Problems You Might Have Carrying Out Your Plan

What other problems could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?

Checking on Progress

Talk regularly with the older person about his or her feelings. If you show that you are comfortable talking about feelings, the older person is more likely to let you know early on if he or she is experiencing depressive symptoms.

Watch for signs that professional help is needed.

What to do if your plan isn't working

Ask yourself if you are expecting change too fast. It usually takes time to manage depression. Look for a small improvement at first. Remember, your efforts may be successful even if they just keep depression from getting worse.

If these techniques do not seem to be helping and the older person has been feeling very depressed for several weeks, review this section to be sure you have tried all of the ideas. If so, you should encourage the older person to seek professional help. You may need to be with the older person during the visit to the psychiatrist, psychologist or doctor.

Techniques for controlling negative thoughts

Have the older person read the following techniques or read them to him or her. Encourage trying some or all of these techniques. Also, read them for yourself. Both of you can use these techniques to stop depressed feelings before they get out of control.

Reminiscing/Thinking over the past

When you start to feel down, try thinking about positive things that have happened in the past. Remembering the past helps you to positive thoughts and feelings over again. It can also help you to feel better about how life is going for you overall.

  • Tell stories. Children and young adults are often very interested in what you did in your life. Tell them stories about yourself. Simple things like what your first grade teacher looked like or where you had your first job may be interesting to them. If the children do not live nearby, type or record your stories.
  • Look at old photographs and keepsakes. Looking through photo albums and keepsakes can help jog your memory and remind you of more stories to talk about.
  • Play old music. Most people find music enjoyable, and old songs can bring back memories of good times you have had. Do be aware, however, that certain music may cause sadness and longing for a deceased family member or good friend.
  • Take a trip to a place that brings back memories. Visiting places such as the street where you once lived, the school you attended, or the place of worship you attended can also bring back memories for you. Take someone along who would like to know about these places and the meaning they had in your life.
  • Call or visit an old friend. Who can understand your past experiences better than someone who shared them with you? If you have an old friend, talk to him or her when you start to feel down. Bring up old times. Talk about something important you did together or something funny that happened.
  • Research your family history. Many people enjoy finding out about their ancestors-who they were and what they did. You can pass on this information to younger family members to carry on your family history. Most older people can remember things that happened a long time ago, even when they have trouble remembering what happened recently. Don't worry about things you can't remember; just enjoy what you can.

Companionship

Many elderly people spend a lot of time alone. Unfortunately, time alone is when negative thoughts can go around and around in your head. Therefore, try to plan doing at least one activity each day with another person. For example, try taking walks with someone, joining a support group, having a meal with a friend, or talking on the telephone. Use brainstorming techniques to think of other ways you can spend time with others. (In brainstorming you let your imagination go free and think of ideas without worrying about if they are practical. Then you go over your idea list and try to think of ways to make them practical. Finally, you select the ideas that are practical and the most helpful.

Thought stopping

One of the hardest things about depression is getting stuck in a whirlwind of negative thinking. Suddenly, depressing thoughts are going around and around in your head. It does not take long for this to make you feel bad; and then it may seem like you cannot stop. But you can!

Thought-stopping techniques help you to "snap out of it" when that whirlwind of negative thoughts first starts. If you catch it early, you can stop yourself from getting very upset. The trick is to do this when you first notice a negative thought.

When you first feel yourself in the negative-thinking whirlwind, try one of these techniques:

  • Yell "STOP" loudly in your mind. Silently scream, "STOP," pretending it is very loud. The idea is to "wake yourself up," to become aware of the danger of getting stuck in negative thoughts. You can start by going to a private place and shouting "STOP" aloud. Then gradually shift from shouting out loud to doing it only in your mind.
  • Imagine a big red STOP sign. Think of what a STOP sign looks like. Try to see it clearly. Make sure it is a red sign. Practice imagining it so that you can bring it to mind easily. Then, whenever you catch yourself starting negative thoughts, think of this sign to stop yourself.
  • Splash some water on your face. Splashing water on your face is another way to wake yourself up from the negative thinking. Pay attention to how the water makes you feel, rather than dwelling on the negative thoughts.
  • Move to a new spot. Getting up and moving to a new spot gives you a change of scenery. Use the new surroundings to help you think about other things.
  • You have to fight negative thoughts. You may need several of these techniques to control strong negative thoughts. If you're feeling depressed, you might think, "These techniques are silly. They could never work." Actually, research has shown that they can work. Give them a try.

Arranging a time and a place for negative thinking

This technique allows you to think about negative things, but puts you in control of when and where to do this thinking.

  • Find a negative-thinking "office." This can be a room, a chair, or a certain window. Make this the only place you let yourself think negative thoughts. Your "office" space can be any place you choose. This should not, however, be your bed or the seat where you have your meals. These need to be "safe zones." Once you choose your negative-thinking "office" try to think negative thoughts only in this one place.
  • Schedule a time each day to think negative thoughts. Scheduling a time to think about negative thoughts can help you take control of them. It is best not to make this time around mealtimes, just before going to sleep, or just before expecting to see people. These meal, sleeping, and visiting times should be relaxing. Also, make your negative thinking time no longer than 15 minutes and always stop at the end of 15 minutes. A timer can help you stop on time.

Attending to positive thoughts

It is impossible to think two things at once. When negative thoughts begin, start thinking about other activities that can "push out" or replace the negative thinking. Try one of these ideas:

  • Prayer. Go to a quiet place and pray. You can read and recite prayers or pray silently. Beware of letting your praying turn into time spent thinking about problems. If praying makes you uncomfortable or turns into time thinking about problems, then reading self-help or religious writings may be helpful.
  • Taking a vacation in your mind. Close your eyes and think about your favorite spot. Spend a few minutes there on a mental vacation. Relax and enjoy it.
  • When you take your mental vacation, work your imagination by thinking of as many details as possible. Use this exercise to fill your mind with pleasant details. This exercise is also helpful when you are feeling anxious and need help falling asleep:
    • What does it feel like? Is there a warm breeze? Imagine how it feels on your skin.
    • What does it sound like? Are there waves gently crashing on the beach? Are people laughing, or is music playing? Imagine it as clearly and vividly as you can.
    • What does it look like? Is the sky clear and blue? Or are you in a room? Imagine what the room looks like. Try to see it as completely as you can.
    • What does it smell like? Is it the salty smell of the ocean? Do you smell the fragrances of a garden or a big dinner? Make it as clear as you can.
    • What does it taste like? Are you drinking a nice cool drink? Feel it in your mouth and taste it.

Arguing against negative thoughts

The goal of this exercise is to make yourself see both sides of the situation. Things are not as bad as they seem when you are depressed. One way to help yourself see the other side is to actively argue against the negative thoughts.

You can fight your negative thoughts. You can challenge the accuracy of your thinking. Every situation has at least two sides to it. When people are depressed, they tend to see only the bad side. When they are not depressed, they usually think of both sides. Use this exercise to force yourself to actively take the other side. Have a debate with yourself.

  • Ask if your negative thoughts are really true? Be clear about what evidence supports these thoughts.
  • Take the other side. Argue the exact opposite. Think of every reason why your thought may not be true or may be exaggerated. Don't give up too easily. Really argue as if you were arguing with someone else.

Be as complete as possible when arguing against your negative thoughts.

Solving day-to-day problems that are causing you stress

Use a problem-solving approach for some of the day-to-day problems that are may be making your feelings of depression worse.  These may include finding ways to get around your disability, finding ways to get together with friends and family, getting to your doctor visits, and so on. Solutions to these problems may be as simple as getting a hearing aid, or arranging with the local transit system to take you to your appointment. With these problems solved, you will have more energy to put toward relieving your depression.