Depression, Morbidity, and Suicide Risk
Why is it so important to assess the risk for depression in a senior with insomnia who may not feel comfortable with the subject or who feels stigmatized by self-reporting a depressed mood? As mentioned earlier, a depressive disorder is among the most common causes for sleep disturbances in the elderly. Furthermore, depression is one of the most common psychiatric disorders among the elderly, with clinically significant depressive symptoms appearing in 30% of institutionalized seniors and in 8% to 15% of community-dwelling elderly. It has been shown that patients with any medical diagnosis were twice as likely to develop depression than were patients without a medical diagnosis. Depression increases mortality in hospitalized patients, increases medical morbidity, worsens the outcomes of medical disorders, increases the perception of poor health and the use of medical services, and increases the economic burden on the health care system.
It must not be overlooked that depression is the psychiatric disorder most likely to raise the risk of successful suicide in the elderly (TABLE 3). Statistics reveal that suicide rates in the United States are highest in people 70 and older. Suicide in white men is 45% more common in those ages 65 to 69 than in those ages 15 to 19. It is about 85% more common in those ages 70 to 74 and greater than three and one half times more common in men older than 85 than in men in the 15-to-19 age group. While suicide attempts are rarer in older people than in younger people, they are more lethal as a result of more careful planning, more lethal self-destructive acts, and fewer indications of the intent. Younger patients are more likely to seek or respond to suicide interventions than are the elderly. Although mood disorders are more prevalent in women than men across the spectrum of age, successful suicide is disproportionately higher in males, especially in elderly men.
Diagnostic Questioning and the Geriatric Depression Scale (GDS)
Unless specific questions are asked, depression may go unrecognized, as it is well known that as many as 70% of seniors who commit suicide were seen by their primary care physicians within the last few weeks of their lives. Presentation of depression in the elderly varies as compared with that in the younger population. Rather than psychological complaints, somatic complaints often predominate in the clinical scenario. Although older patients often do not report a dysphoric mood, apathy and withdrawal are common. Loss of self-esteem is prominent, and guilt is less common. The inability to concentrate, with a resultant impairment of memory and other cognitive functions, is commonly seen. In addition to a review of systems, health care practitioners can question elderly patients regarding: sleep disturbance, appetite changes, trouble concentrating, lack of energy, and loss of interest. Whenever possible, in addition to ongoing primary care, referral for consultation with an experienced geriatric psychiatrist and/or psychologist is helpful in diagnosing and managing depressive disorders.
Senior care pharmacists may find the Geriatric Depression Scale (GDS) helpful in identifying depressed geriatric patients for referral for a full evaluation. The GDS may also be used subsequently by the pharmacist as an outcomes measure of antidepressant therapy in the management of depression.