Spirituality, depression, and the elderly.

The burden of depression will undoubtedly increase among the elderly. The increased burden of depression will be manifested by at least two factors: the increase in the absolute number of older people as the baby-boom generation enters later life, and the heavier burden of depression carried by the baby-boom generation compared with older cohorts. Some have connected the increased frequency of depression among younger cohorts in part with an increased secularity in Western society, a secularity that may lead to a greater sense of loss of meaning. (1)

Of all the psychiatric disorders, the depressive disorders have been most closely correlated with the core spiritual task of finding meaning. Later life was, for the psalmist, a time of particular spiritual challenge. "Do not cast me off in the time of old age; forsake me not when my strength is spent" (Psalm 71: 9). For the writer of Ecclesiastes, later life was destined to be accompanied by misery, with death the only escape: "Remember also your creator in the days of your youth, before the evil [old] days come" (Ecclesiastes 12:1). Why? One must find meaning if one is to meet the challenges of aging. The Psalmist suggests that meaning can be found in a purpose yet to be fulfilled. "Do not forsake me, till I proclaim thy might" (Psalm 71:18). The writer of Ecclesiastes never finds such meaning.

Eric Erikson picks up, in part, this theme as he describes the last stage of adult development (integration versus despair). (2) Integrating one's experiences, telling one's life story as a cohesive whole, is necessary to tie up the loose ends of one's life and making peace with one's past. If an integrated story cannot be told, then the natural outcome is despair. In other words, finding a meaning in one's life at the end of life is critical to avoiding a prolonged and terminal dark night of the soul.

Yet we do not know if these hypothetical views of the developmental tasks of late life hold up to empirical study. Most investigators have found that participation in organized religion has been more strongly associated with an absence of depression than is intrinsic religiosity or non-organized religion in older adults. (3) Identification with and participation in a religious group may be of more importance to emotional well being than a sense of having found meaning. Yet intrinsic religiosity consists of many parameters. For example, a study of 118 Jewish seniors is informative. Spirituality was not correlated with loneliness or depression. On the other hand, having a sense of meaning or purpose in life was inversely correlated with depression and loneliness. (4) A group from the United Kingdom found a negative correlation between overall spiritual well-being (especially the existential effect) and depression among cancer patients treated in a hospice facility. However, no correlation was found between religious well-being (such as strength of religious belief) and depression.

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Late life depression is therefore viewed by some as emotional suffering that is especially open to spiritual interventions given that it derives in part from a failed search for meaning. (5) From that perspective, only through spiritual exercises such as prayer, study, and meditation, can meaning be found and symptoms alleviated. Modem psychiatry, in contrast, views more severe depressive disorders as originating primarily from brain pathophysiological changes. Spiritual concerns, from that view, are epiphenomena that will be alleviated by appropriate biomedical interventions. Of course the truth lies somewhere between and includes many other origins, such as social and psychological factors. Nevertheless the dichotomy between the biologic and the spiritual mutes frank discussions across disciplines. These views need not be competitive but in fact may be complementary. An older person who suffers from a severe episode of major depression that responds to a biologic intervention, such as a medication, often finds integration of the depressive episode into her sense of self difficult. Both the caring physician and the religious counselor must work to help such people through relief of suffering as well as understanding of suffering.

References

1. Blazer DG. The Age of Melancholy. New York, Routledge, 2005.

2. Erikson E, Kivnick H. Vital Involvement in Old Age. London, Norton, 1986.

3. Koenig HG, McCullough M, Larson D. Handbook of Religion and Health. New York, Oxford University Press, 2001.

4. Springer M, Newman A, Weaver A, et al. Spirituality, depression, and loneliness among Jewish seniors residing in New York City. J Pastoral Care Counsel 2003;57:305-318.

5. Yalom I. Existential Psychotherapy. New York, Basic Books, 1980.

In every community, there is work to be done. In every nation, there are
wounds to heal. In every heart, there is the power to do it.
--Marianne Williamson

Dan G. Blazer, MD, PhD

From the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 

Reprint requests to Dan G. Blazer, MD, PhD, Box 3003, Duke University Medical Center, Durham, NC 27710. Email: [e-mail]