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What is depression and when should I be concerned?

What is depression and when should I be concerned?
Hello again. This is Brian Lawlor talking about depression, and when you should be concerned about it. Everyone can experience low mood at times, feeling sad and down. But this isn’t necessarily depression. Experiencing a short-lived low feeling or sadness can be a normal reaction to stress, or circumstances, and usually passes off and doesn’t persist. This is not depression. Depression is an illness and is where there is persistent and sufficient low mood for at least a two-week period that it interferes with your quality of life and your day-to-day function. When someone is clinically depressed, they’re feeling down most of the day, most days, for at least two weeks. And there is a definite loss of interest, pleasure, and enjoyment in life.
Sometimes, when a person is depressed, they can feel that life has very little meaning, and they have no hope for the future. This can even extend to feeling that life is not worth living, and thinking that they would be better off dead, and even having thoughts of suicide. Older people who become depressed can experience poor sleep, decreased appetite, and low energy levels. Others can experience a lot of anxiety. When depression interferes with functioning, or causes suicidal feelings or hopelessness, it’s time to do something about it and seek help from your GP. Treatment of depression can take the form of psychological input, or sometimes medication. The important message is that depression is very treatable once you seek help.
Now, what causes depression in older people? Oftentimes, there’s not one single explanation. However, in older people, there’s often a triggering event, like a bereavement, a physical illness, or some other major life stressor. For some people, it can be actually a succession of stressful events that occur together. For others, particularly if they have a history of depression, or indeed a family history of depression, they can develop depression in the absence of a stressful life event. So what can you do about depression, if you actually get it? Your natural inclination will be to withdraw and stop seeing your friends, because of how you feel, and because of associated anxiety. However, it’s best to try and keep up your social connections.
Maintain a good diet, even if you don’t feel hungry. Physical exercise is good for your mood. Exercise that raises the heart beat, so-called aerobic exercise, causes the release of natural brain chemical messengers that actually can have antidepressant effects. Talking therapy that focuses on solutions to life’s stresses, and mindfulness-related cognitive behavioural therapy, where you try and correct distorted and negative thoughts, can certainly help people with mild to moderate levels of depression. Mindfulness involves getting you to stay in the moment, to focus on what you are actually experiencing in your body, as opposed to being overwhelmed by negative and anxious thoughts. For more severe levels of depression, antidepressant medication may be necessary, in addition to talking therapy.
It’s also important to exclude medical causes of depression, such as thyroid disease, vitamin deficiencies, and rarely, some forms of cancer. So blood tests are often done as part of your doctor’s evaluation of depression.
While physical illnesses can trigger depression in older people, there are a number of conditions that are particularly associated with the development of depression.
These are having a stroke, Parkinson’s disease and Alzheimer’s disease. This may be because these particular conditions have a direct effect on how the brain functions. When depression occurs in the context of these illnesses, it’s important to treat the depression. A successful alleviation of the depression will improve the quality of life of the person who has this condition.
But remember, stressful life events don’t always result in depression, even if they cause a transient lowering of mood. As you get older, you can experience physical health issues and losses. Friends, family members can become ill and even die. These stressful events sometimes can be associated with low mood. So how can you distinguish between low mood or anxiety related to these events, and a true depression? Usually, when it’s an adjustment, the low mood doesn’t last all day, or occur every day, and the person can cheer up in company. Sometimes, however, just like with grief and sadness after the loss of a loved one, a person’s mood can transition from a reaction or an adjustment to a full-blown depression.
While there’s no specific treatment needed for the adjustment to loss or grief, if this moves into this pervasive low mood, with loss of pleasure, interest and function, this is actually a depression and would warrant treatment and intervention. Sometimes, older people– and this occurs more often in older men than in older women– can drink too much. Excessive alcohol intake can either cause depression, or because depression is associated with anxiety, the older person can drink more and more to try and alleviate the anxiety or depression. But the alcohol actually can have the opposite effect, and increase the level of depression.
If someone is depressed, it’s important to think about alcohol intake, as alcohol could be a contributing factor. And for sure, you have to take it out of the equation. What’s a safe level of alcohol in older people? It’s usually less than in younger people, and probably no more than one drink a day. We now believe that it’s also important to address less severe forms of depression, and low grade depressive symptoms, because if left unheeded, they can develop into a full blown depression. In these situations, exercise, social and behavioural activation– by this, I mean keeping socially active involved with people and activities– may actually prevent depression from occurring.
And finally, we now know that depression may be a risk factor for the future development of dementia in later life. So just like addressing high blood pressure and high cholesterol in midlife may reduce your risk of dementia, it’s also important to look after your mood, as it may be a way to protect your brain health as you get older, and potentially could decrease your risk of developing dementia. And now, how about a question? How would you distinguish between grief and depression?

Whether someone becomes depressed can be influenced significantly by the level of social support that they have and also the degree of loneliness that they experience. For example, when someone is bereaved, if they are experiencing a high level of loneliness and are socially isolated, that person is more likely to become clinically depressed than someone who has plenty of supports and is not lonely.

The graph below is from our research with community-dwelling older people. It shows the effect of loneliness and social support on the number of people who become depressed. What you see here in the graph is:

  • On the yellow line are the people who have a lower level of support.
  • One the blue line there are people with a higher level of support.
  • The degree of loneliness goes from left to right.

You will notice two important things:

  1. If you have more support (blue line), there is less depression.
  2. You can also see the striking effect of loneliness on the numbers that get depression. In effect, the higher the degree of loneliness, the more depression, whether or not you have social supports.

Here are some strategies for combating depression in your daily life:

  1. Exercise: Aerobic exercise, where you get your heart beat up, is good for you because it releases chemical messengers that can lift your mood state. People often exercise in the company of others (e.g. walk with others or meet people in the gym) and this social connection can also have a positive effect on your mood.
  2. Keep connected: You might feel like withdrawing, but try to do the opposite as it can help maintain or improve your mood.
  3. Challenge those negative thoughts: If you have a negative thought, challenge it to see if it’s logical; don’t just accept it as true. Sometimes, people get negative thoughts about their life, their past or future, and these thoughts cause them to feel more depressed or get stuck in a depression. For example, you may feel like you’re a failure or that you have let someone down even though it’s not true. Don’t just accept this thought or idea as true or push it away. Dwelling on it or accepting a thought when it’s not true can make you feel worse. Acknowledge the thought and the feeling by challenging your assumptions.
  4. Problem solve and look for solutions: When you’re depressed, sometimes it’s hard to be positive and figure out solutions. It can help to make a list of your problems and then put a possible solution beside each problem. When you do this, your problems may not seem so insurmountable.
  5. Just talk about it: Don’t be afraid to let you friends and family know how you feel. Their support and encouragement can be of great benefit in dealing with depression. Likewise, there are tremendous benefits in helping others.
  6. Don’t be afraid to talk to your General Practitioner or see a mental health professional: Seek help beyond friends and family if you’re really feeling stuck.
  • As an example, not everyone who has a bereavement develops depression. What can you do to decrease your risk of developing depression after a person that you are very close to moves away or dies?
  • How would you distinguish between grief and depression?

Brian Lawlor is Professor of Old Age Psychiatry at Trinity College Dublin.

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