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Bereavement, depression, and our growing geriatric population.

The population of the United States is in great flux. In the 1970s and 1980s, as the baby boomer generation grew up, the majority of citizens were young, healthy, and often acted in the role of care provider to their loved ones. Today, as that generation ages, the populace is becoming more elderly, more medically unstable, and more likely to require care from family and social institutions. This cohort is now beginning to experience other difficulties associated with aging as well. The loss of a spouse or companion can be devastating, and this can be a major turning point in these patients' lives. In fact, it is estimated that 51% of women and 14% of men will be widowed at least once after age 65. (1) When bereavement is experienced in an appropriate manner, the patient can grieve their loss, fondly reminisce about shared experiences, and eventually move on through their developmental journey. They may spend time concentrating on their grandchildren, they may become involved in a cause they believe in, or they may mentor a young person with similar interests. However, when grief is complicated, it may become sufficiently severe as to induce any number of poor outcomes. These can include delayed or prolonged grief, suicidal ideations, new onset of psychotic symptoms, or the development of a major depressive episode. (1)

In this issue, Williams (2) reviews the literature regarding the effects of bereavement and depression on recently widowed spouses. It is very obvious that bereavement often leads to depression and that both are associated with increased morbidity. In fact, patients with depression have been found to have an increased incidence of death from cardiovascular illness. (2,3) It is not clearly understood how this happens, but there are multiple theories. These theories range from depression affecting health behaviors leading to the development of heart disease to depression promoting the development of atherosclerosis. (3) Regardless of the association between cardiac illness and depression, the diagnosis and treatment of depression in the elderly will become of increasing importance as the population ages. Therefore, there must be an increase in the vigilance in which we screen for this disease.

One of the first points to consider is whether the patient's clinical presentation is a major depressive episode or simply bereavement. In those patients with a major depression, any mood symptoms are usually pervasive and unremitting. (1) Mood fluctuations are common in patients who are experiencing grief, as they often describe grief as coming at them "in waves." (1) Other symptoms more common in major depression rather than grief include excessive guilt, suicidal ideations, preoccupations with worthlessness, unremitting functional impairment, and hallucinatory experiences (other than transiently seeing or hearing the decreased). (4) This underlies the primary problem that there is often some difficulty in diagnosing depression in the geriatric population. In a recent study by Unutzer et al, (5) it was noted that late life depression is common in the primary care setting but that it was not frequently diagnosed or treated. There are many reasons for this, including the fact that the elderly themselves minimize or deny their symptoms. (6) They may become preoccupied with somatic symptoms, which may further decrease the chance of detection in the primary care setting. These may be cases of "masked" depression in which a patient focuses on physical rather than mood symptoms. (6) Symptoms of depression may also overlap with dementia or may be assumed to be a part of "normal aging." (6) All of the above are reasons that all physicians will need to have a high index of suspicion for geriatric depression, especially in cases in which there is a greatly increased risk, such as a recent loss of a loved one.

Unfortunately, the old mnemonic "SIG E CAPS" (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, and Suicide) is probably not a great choice to screen for geriatric depression, although it is better than no screen at all. However, there are a number of different scales that can be used. These include the Beck Depression Inventory, the Hamilton Depression Rating Scale, the Symptom Check List 90-Revision, and the Zung Depression Scale, among others. (4) However, these can take anywhere from 5 minutes to 20 minutes to administer and may not be viable choices in a busy primary care practice. In that case, consideration can be given to using the Beck Depression Inventory (which has a primary care and brief screen version) or the Geriatric Depression Scale, both of which are very brief and are patient self-report instruments. (3)

In summary, as physicians, we are looking at a significant increase in the number of geriatric patients seen in our practices in the very near future. As America ages, we need to be prepared so we can continue to provide the best medical care to our patients. That care includes being able to diagnose and treat depression in the geriatric population. This is especially important in those patients who are vulnerable. As our patients age, they will experience losses, such as widowhood, that will make them more likely to have depression. As noted in Williams' article, there is a significant connection between grief, depression, and cardiovascular disease. By aggressively diagnosing and treating depression, we can help decrease our patients' overall morbidity.

Accepted June 15, 2004.

Please see "Depression as Mediator Between Spousal Bereavement and Mortality from Cardiovascular Disease: Appreciating and Managing the Adverse Health Consequences of Depression in an Elderly Surviving Spouse" on page 90 of this issue.

References

1. Sadock BJ, Sadock VA: Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences Clinical Psychiatry. Philadelphia, PA, Lippincott Williams & Wilkins, 2003.

2. Williams JR. Depression as a mediator between spousal bereavement and mortality from cardiovascular disease: appreciating and managing the adverse health consequences of depression in an elderly surviving spouse. South Med J 2005;98:90-95.

3. Sayers SL. Depression and heart disease. Psychiat Ann 2004;34:282-288.

4. McDaniel JS, Brown FW, Cole SA. Assessment of depression and grief reactions in the medically ill. In Stoudemire A, Fogel BS, Greenberg DB (eds). Psychiatric Care of the Medical Patient. New York, NY, Oxford University Press, 2000, ed 2, pp 149-164.

5. Unutzer J, Simon G, Belin TR, et al. Care for depression in HMO patients aged 65 and older. J Am Geriatr Soc 2000;48:871-878.

6. Unutzer J, Small GW, Gunay I. Geriatric Medicine. In Wise MG, Rundell JR (eds). The American Psychiatric Publishing Textbook of Consultation Liaison Psychiatry: Psychiatry in the Medically Ill. Washington, D.C. American Psychiatric Publishing, Inc, ed 2, pp 853-869.

Glenn Catalano, MD

From the Department of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine, Tampa, FL.

Reprint requests to Glenn Catalano, MD, University of South Florida Psychiatry Center, 3515 East Fletcher Avenue, Tampa, FL 33613. Email: gcatalan@hsc.usf.edu
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Author:Catalano, Glenn
Publication:Southern Medical Journal
Article Type:Editorial
Geographic Code:1USA
Date:Jan 1, 2005
Words:1134
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