Is depression a normal part of aging?  What are the risk factors, treatments and hope for the future for older adults?  Dr. Sheri Gibson, private psychotherapist and consultant, University of Colorado Colorado Springs instructor and faculty affiliate, holds a Clinical Psychology PhD with an emphasis in geropsychology from the University of Colorado Colorado Springs.  Dr. Gibson shares her years of experience and insight to better understand how mental health becomes an issue for older adults and how to find and receive support that can make the 3rd Chapter of one's life a time to look forward to.  Resources to tap into Drsherigibson.com, UCCS Aging Center, National Suicide Prevention Lifeline 1-800-273-8255.

Aging with Altitude is recorded in the Pikes Peak region with a focus on topics of aging interest across the country.  We talk about both the everyday and novel needs and approaches to age with altitude whether you’re in Ft. Lauderdale, Florida or Leadville, Colorado.  The Pikes Peak Area Agency on Aging is the producer.  Learn more at Pikes Peak Area Agency on Aging.

Transcript:

Cynthia Margiotta: Hello and thank you for listening to Aging with Altitude, a podcast series sponsored by the Pikes Peak Area Agency on Aging that aims to highlight issues and resources that affect older adults in our community.  My name is Cynthia Margiotta and I'm here with Dr. Sheri Gibson who received her PhD in clinical psychology with an emphasis in geropsychology from the University of Colorado, Colorado Springs.  She's an instructor for the Psychology Department at UCCS and a faculty affiliate with the UCCS Gerontology Center. Dr Gibson serves on the editorial board for the Journal of Elder Abuse and Neglect, is chair of the Colorado Coalition for Elder Rights and Abuse Prevention, a member of the research committee for the National Adult Protective Services Association, and board member for the Colorado Culture Change Coalition.  In addition to being an advocate for elder justice, Dr Gibson has a private psychotherapy and consultation practice which includes provision of capacity evaluations, expert testimony, consultation and training. 

 Thank you so much for being here Doctor.  

Dr. Sheri Gibson: You're so welcome. Thanks for having me, Cynthia. 

Cynthia: Today's podcast theme is on mental health and aging.  My first question, is depression a normal part of aging?  

Dr. Sheri Gibson: There is a wide belief that it is normal, but it's not correct.  You know our society has believed for a long time that, as we age it is certainly inherent in our aging process is the theme of loss.  That there are losses both at the individual level, where we lose friends in our personal circle as we age, and also losses in terms of our physical functioning, chronic health problems, maybe even loss to our home where we may need to downsize and possibly move to a different part of the country to be closer to our children or maybe move from our large home into a smaller place.  I think society has often believed that as those losses occur it would be reasonable to make the jump that depression would also accompany those losses. But, what we do know is that a lot of people, as they age, have developed coping mechanisms throughout their lifetime. Many older adults, by the time they reach that part of their life, which is what I like to call the third chapter of life, that they have learned to tolerate losses throughout their life and they have they have developed effective coping strategies. So, what we do find is that depression is not a part of normal aging process. That's a myth that really needs to be debunked in our society so that we don't associate older people with depression. 

Cynthia: How common is depression in the senior population? 

Dr. Sheri Gibson: Well, it's really interesting, it's less common among older adults compared to younger persons. However, the age of onset of depression is really important. Research has shown that the first onset of most mental health disorders occurs in childhood or adolescence, and a much smaller percentage of disorders have an onset in later life. Among older adults with mental disorders, it's clinically relevant for us to discern when a disorder began. For example, an older adult who may have suffered from lifelong depression would likely have a lengthier and more complicated treatment than an adult who developed or experienced depression in later life.  

Cynthia: Regarding depression, what are the risk factors? 

Dr. Sheri Gibson: The risk factors are multifaceted and they are influenced by cohort, socioeconomic status, culture, and gender.  At the individual level, for example a person's ability to initiate treatment or even to understand if they are experiencing depression, may be directly impacted by the mood disorder itself. It can also be further influenced by whether or not there's presence of cognitive impairment for example, or multiple chronic health disorders. Some of the risk factors that we look at are those multiple chronic health conditions such as vascular problems, diabetes mellitus, and then there are certain acute stressors of health.  Stressors such as stroke, which has been associated with depression. So we want to look at that when we look at depression as practitioners. When I say practitioners, I also mean primary care physicians. 

We tend to take a biopsychosocial approach so that we look at one of the biological risk factors, so that would be those at health conditions that I discussed. We look at the psychological risk factors, one risk factor is if the person has had lifelong depression that does increase their risk for having a depressive episode later on. We also look at psycho-socially what's going on for the individual. Have they had any changes? For example, has there been a death of somebody they are grieving? Is their home situation distressed by family discord, for example? Or, are they isolated from people? 

I would add one more circle to that Venn diagram, if you will, and that would be spirituality. Understanding a person's spiritual relationship, whether or not they are part of a faith community or if they're not. How does spirituality and religion impact a person for them to make meaning of these certain stressors in their life?  

Cynthia: Many of our older population was so involved with their churches, this created an issue for them not be able to go anymore and to not be connected to that community. So you know that also brings up the question of what is the difference between a situational depression and regular depression? 

Dr. Sheri Gibson: That's a really good question, Cynthia! Depression, as a mental health disorder, is kind of broken down into two categories. We have depression that is kind of a general diagnosis and then we have Major Depressive Disorder. Since you asked the question about depression, what we want to know as clinicians is what might be causing the depression. Oftentimes it may be situational and what that means is the person may be dealing with a chronic stressor or an acute stressor in their life and if that stressor was remedied then their mood functioning would return back to normal. Situational depression is kind of used among lay people to describe the feeling of “hey I'm just going through something right now this is situational.” However, from a clinical standpoint, we use that term to really think about is there something that, if it were resolved for the person, that they would be functioning in a normal capacity?  The important thing is to point out around situational kinds of stressors is that there's never a timeline for that situation to remedy. So the person may come in to say (I’m talking about caregivers), “I'm caring for a person who is chronically ill...” this may be wife, this may be a parent, and may even be an adult child, “... I know that if I could either get resources in or when the person does die or have to be moved into higher level of care then I will begin to feel better.” The problem is that we never have a timeline for that, and if we let depression as a disorder progress without being treated and hope that it will remedy once the situation remedies, we are often very remiss. It can lead to worse things for an older adult such as isolation or it could lead to thoughts of suicide, for example.  It could lead to early mortality because depression has been related to early mortality. It can also lead to cognitive impairment if the person is older and is functioning. Without being treated for their depression, or not being diagnosed, that can have real deleterious effects on their overall wellbeing in their course of their life. 

Cynthia: Wow, so what kind what types of treatments are the most successful for older adults? 

Dr. Sheri Gibson: What the literature tells us, and what clinical research has shown, is that really the best treatment or the treatment with the most effective outcomes, is a combination of medication and mental health treatment like counseling, for example. Older adults need to talk to their primary care physicians, or if they're seeing a psychiatrist to talk, about their mood. They can be put on a fairly safe low-dose anti-depressant.  There are some cautions with that depending on the person's health problems. If they have multiple chronic health problems that they're being treated for, it may be ill-advised that they take a medication. In that case, psychotherapy alone or counseling alone, can be very beneficial.  

There is another myth out there that older adults do not benefit from therapy and I just want to say that is completely untrue and that older adults benefit just as well, if not better compared to their younger counterparts. They are more willing to dive into some very important meaningful issues of their life. One thing that we know, as practitioners, is that sometimes treatment can last or take a little longer with older adults than with their younger counterparts. That's just because of our own aging process, we have slower processing speeds in our thinking. So, we may need to take a longer time to integrate the information that we're learning in therapy and then applying that. So sometimes the course may take a little bit longer with older adults. Psychotherapy with older adults is very successful and the highest outcomes are when you can combine a very low dose and short-term medication.  

Cynthia: This is using Erickson’s nine tasks, saying that we're looking at our past and go into some of that to help ourselves heal? 

Dr. Sheri Gibson: That's right, so we're resolving going back kind of doing a life review, is what we call that. A life review is reflecting on what's been important to me and how can I make meaning of some of the things that were hurtful in my past? What do I want to do with this chapter of my life? I always ask, whether or not the person actually talks about it. The forefront of older adults is kind of resolving this stage of development, if you will. Going back to Erikson’s stages of development, is that people are thinking of their own mortality and that time is limited. So thought of “how do I want to spend this time and what is meaningful to me? How do I want a good death?” for example. Even planning our deaths because time is limited and we're thinking about that more as we approach old age. 

Cynthia: And it's perfectly OK to be thinking about those things.  

Dr. Sheri Gibson: Absolutely, it's so healing to be thinking about that. 

Cynthia: It's a normal part of our lives. 

Dr. Sheri Gibson: Correct!  

Cynthia: Nobody gets out of this alive, that what I say. It a horrible joke, right? But it is true. 

Dr. Sheri Gibson: That is true!  

Cynthia: So, why might older adults avoid pursuing the treatment that would be helpful, especially when they're struggling emotionally so much? 

Dr. Sheri Gibson: I think that, again this is very multifaceted as I mentioned before, we see differences with older adults who are probably seventy-five and older. There may have been a little bit of stigma associated with mental health. Those who grew up with mental health problems of that cohort kept those things under wraps and they didn't talk about it. It may be an individualized kind of mantra that you just pull yourself up by your bootstraps and you don't talk about it. That it is nobody else's business and only your business and so you handle it on my own. Sometimes that problem gets so big that the person can't handle it on their own. We also know that certain personality types are less open to receiving help. Another barrier might be a socioeconomic status that's a huge barrier for access to mental health resources. If a person isn't able to drive and doesn't have a social circle of people who can take them to appointments. Or, if they are segregated in their community by virtue of their culture, their race, their socioeconomic status, they will have less information about services available to them and less access nearby. So, it really is multifaceted. 

 I think that this community in Colorado Springs has done a really good job of doing our best to reach out to people and let them know. We have to shift the way we think about provision of mental health services and going to the people rather than waiting for them to come to us. We know that all of those things can be a barrier to them seeking help.  

Cynthia: So, like being isolated for whatever reason affects all of that. 

Dr. Sheri Gibson: Correct. When we think about isolation, I think about social isolation and geographical isolation. We're missing a big population of people in rural parts of our state, for example.  

Cynthia: Another issue, changing topics, if it were, I don't want to say too much because suicide is also related to depression. Another issue for older adults suicide, can you speak to that for a bit? 

Dr. Sheri Gibson: Yeah, you bet. Well, I think it's important to note that older adults complete about 20% of all suicides. They also have the highest rate of suicide completion, compared to any other age group which is a startling statistic. Older adults tend to use more lethal forms of on completing suicide. Some major risk factors occur in later life. One of the highest of demographics of persons who complete suicide are older white males. So, aside from being an older white male, other risk factors include depression hopelessness, substance abuse, a previous suicide attempt, and widowhood, a major late life transition like physical illness, social isolation, family discord, financial strain and stressful life event. Institutionalizations, interestingly enough (I'm really referring to nursing homes), may also be a predictor of suicide although residents of nursing homes tend to use more subtle forms of self-termination to complete their suicide such as starvation. In those cases, they may not be officially labeled as suicide in nursing homes.  Unfortunately, the majority of older adults who do complete suicide were experiencing their first episode of depression, meaning that it could be readily treated.  

Another more staggering and if not more alarming statistic is that 75% of those persons were actually seen in their physician’s offices within a month prior to their suicide. This really puts on our radar on the importance of screening in primary care offices. Physicians and their nurses need to be much more diligent in asking about whether or not a person is feeling suicidal or wanting to end their life. Knowing that people have been seen by their physicians, I think really gives us an opportunity to do something different in our primary care offices. It's certainly an issue. 

 I would also say that persons who are showing signs of suicide, that we have an opportunity as friends and family and neighbors to look for certain signs. Maybe some of the signs that we would look for is if the person stopped participating in activities that they used to enjoy. For example, are they isolating from their social or familiar circles, including their faith circles? Do they make off-handed comments about ending their life or wanting to die? It's not uncommon that some older adults will say things like “I'm just tired and I'm waiting to die” or “I'm waiting for God to take me” or “it's time I should be going” … and it shouldn't stop us from asking further. “Are you wanting to end your life prematurely,” that's the way I would ask that. However, it's also not always the case that their meaning to end their life, they're just tired and they're just waiting and that's also a normal response for some people towards the end of life.  I can't stress it enough, just the simple question of asking a person “are you okay” and leaving the question open. Asking “are you okay” or making an observation like “it seems that you're feeling down or you're having the blues” or “is there anything that I can do” or “tell me about your managing these days”... Oftentimes, there's another myth that we dance around these questions with older adults and we don't want to be seem like intruders and ask those questions. But I will tell you, in my clinical practice over the years, whenever I've asked the question more than likely the person is so willing to share. Often people don't ask them those questions and they don’t want to burden others and they don't want to bring it out. So, it is our I think responsibility as friends and as family members to ask that question.  

Cynthia: They’re thinking about these things so why can't we talk to them? They may feel isolated by that conversation and think “my children don’t want to hear about this” or “my friends don't want to hear about this.” But really, we need to get involved in where they're at. 

Dr. Sheri Gibson: That's right. 

Cynthia: It helps us to grow. 

Dr. Sheri Gibson: Absolutely, and it gives us an opportunity to hear where we might be helpful to that person if we know that there are barriers to them getting the help. We have an opportunity to maybe bridge those barriers or just destroy the barriers altogether, but we don't know that if we can’t ask the question. 

Cynthia: Thank you. 

Dr. Sheri Gibson: You’re welcome. 

Cynthia: According to the CDC, in 2013, the highest suicide rate was nearly the 20% among forty-five to sixty-four year-olds.  The second highest rate, very closely related was 18.6% (his is a few years ago) occurred in people eighty-five years and older, why? 

Dr. Sheri Gibson: I think there's a couple things here. If we know that typically the highest risk factor is older men, and you think about how women tend to outlive men, also think about the gender roles of this cohort of seventy-five to eighty-five year-olds. There were gender roles in heterosexual relationships. That's what we know most about that cohort. Gender roles were that women were kind of a social outlet for the family and the men were the workers of the family. So, I think that we see this occurring when the woman of the couple has died first and so the man is left without a social network. Also, at the age of eighty, so many friends and close people have also deceased at that point.  

We also see a high percentage of older veterans who complete suicide because they're not afraid to use a firearm and most of them have firearms, so they use a more lethal means of ending their lives. 

So, I think it gets to cohort and that isolation piece. When we think about eighty-five year-olds living at home, they likely more isolated than people who are...