Marked questions on elderly depression.

The majority of people aged 65 or older struggling to cope with moderate to severe depression go undiagnosed and untreated, warns a consensus statement issued last week by a 14-member panel of mental health clincians and researchers. This neglect persists largely because many elderly individuals and many primary-care physicians regard depression as a normal part of aging, the panel concludes.

Social and physical problems also complicate the diagnosis and treatment of depression in the elderly, notes the panel, convened by the National Institutes of Health in Bethesda, Md.

"The system of care currently provided to elderly depressed persons is inadequate, fragmented and passive," asserts panel chairman Arnold J. Friedhoff, a psychiatrist at New York University School of Medicine in New York City.

Unfortunately, the same adjectives apply to the current state of research on the nature, course and treatment of depression among the elderly, which left the panel with important unanswered questions that elicited an urgent plea for more and better studies of older adults.

Problems begin with the definition of severe or "major" depression, a diagnosis derived from symptoms seen in people between 20 and 60 years of age. Some clinicians now suspect that these symptoms - including hopelessness, loss of interest in all activities, disturbances of sleep and appetite, and dulled concentration -- may not accurately diagnose severe depression as experienced by the elderly, says panelist Kathleen R. Merikangas, a psychologist at Yale University School of Medicine.

For instance, depressed elderly people usually complain about a discrete medical illness and not depression's "classic" symptoms. In addition, depression may create an even greater risk of suicide in the elderly than in younger individuals. And unlike younger adults, elderly suicide victims usually have no history of suicide attempts or substance abuse, and often use guns or other violent means to end their lives.

Despite diagnostic uncertainties, the panel estimates that recurring bouts of severe depression afflict 3 percent of the elderly in the United States at any time, with another 15 percent sustaining "clinically significant" symptoms that fall short of full-blown depression. About one-quarter of the 1.3 million elderly living in U.S. nursing homes suffer from severe depression, the panel contends.

Antidepressant drugs known as tricyclics (which do not include the currently popular Prozac) and electroschock therapy have attracted the most scientific attention as treatments for depression in the elderly. Tricyclics ease depression -- but usually do not wipe away all symptoms -- in about 60 percent of the people over age 65 studied, the panel says. However, side effects, such as lowered blood pressure and weight gain, may cause many of those given tricyclics to stop taking the drugs, the report says.

The depressed elderly get the bulk of electroshock therapy in the United States. The treatment provides short-term relief from depression, but relapses occur frequently once a series of electroshock session ends, the panel says. Moreover, people of advanced age have an increased risk of memory problems and confusion following electroshock.

Little research exists on psychosocial treatments for elderly people with depression, such as various forms of psychotherapy and outreach programs run by senior centers and other community programs. Combinations of biological and psychological treatments have not received any study, the panel observes.

Some researchers feel the paucity of research prevents any consensus on treatment. "All the research is weak," says psychologist Linda Teri of the University of Washington School of Medicine in Seattle, who did not sit on the panel. "Psychosocial research isn't necessarily weaker than biological research."