The Rochester Review, University of Rochester, Rochester, New York, USA

Depression and the 'Golden Years'

They Don't Have to Go Together, Assures a Rochester Psychiatrist

By Kathy Quinn Thomas

Seven women and three men, their ages ranging from just-past-baby-boomer to just-this-side-of-frail, stand together in a corner of a cavernous gym. The group of 10 waits to begin a tai chi class, one of many classes that the City of Rochester's Danforth Recreation Center offers for senior citizens.

The folks in the class gossip and giggle; they know each other well. Euchre tournaments, line-dancing classes, wellness fairs, restaurants with early-bird specials, and bus trips to Atlantic City--if it's scheduled, they show up. Somewhere between dance moves and cholesterol screenings, they talk, becoming their own de facto support group.

The Danforth Center uses its seniors programs as an outreach effort, to make sure that as local elders age, they continue to receive the medical and social services they need. "We don't worry about these folks," the Danforth program manager says of the tai chi 10. "They're here, doing things and enjoying themselves. If they get sick, they know enough to ask for what they need.

"The ones we worry about are the lonely ones, the ones who give up, the ones who don't come. We don't know how to get to them."

This center is one of many such across the country that are attempting to keep our nation's seniors happy and emotionally healthy. But they can't reach everyone; too many are slipping through the cracks.

And that's a tragedy, declares Eric Caine, a Rochester psychiatrist who has made it his business to worry about those lonely seniors who just give up. The Medical Center's newly named John F. Romano Professor of Psychiatry and chair of the department, Caine is a nationally recognized expert in late-life depression and other issues that affect the elderly. (Recognized even by the feds: As the leading authority on the subject at hand, he was called last year to testify before a special Senate committee investigating causes of suicide among our aging population. A little further down the experts chain, he was named one of the 327 best mental health experts in the country by none other than Good Housekeeping magazine.)

Depression, with its concomitant withdrawal from society, is not a natural part of the aging process, Caine emphasizes. But a personal loss, that of a spouse, family member, or friend--the kind of loss that becomes more common as we go along in life--can trigger a depressive episode.

Signs of Depression "Depression in the elderly is highly treatable, but it can too easily go undiagnosed -- and then patients don't get the help that they so desperately need," says Dr. Eric Caine, chair of the Medical Center's Department of Psychiatry. Some of the signs of clinical depression to look out for are these: Changes in eating or sleeping habits Unexplained fatigue or physical pains Apathy toward job, family, hobbies, and social activities Difficulty concentrating and being decisive Frequent crying spells Inability to feel good about oneself; loss of interest in personal appearance Remember, advises Caine, depression is not a normal response to growing old. Like other illnesses, it requires medical attention--and sooner rather than later.

"Most people experience personal losses or illnesses in later life. But only some become depressed. What makes them different?" he asks. "How can we recognize them and treat their problems before they become devastatingly serious?"

Caine's office in the Medical Center is bright and sunny, with light oak furnishings, colorful paintings, and a Christmas cactus still cheerfully blooming in the spring sunshine. An antique bust sits by the cactus, a phrenologist's guide to the various sections of the head and scalp. (Nineteenth-century phrenologists claimed to identify personality traits by looking at the bumps and depressions on the skull: "I never knew I had an inventive talent until phrenology told me so. I was a stranger to myself until then!" said Thomas Alva Edison.)

The research in Caine's department--which includes 90 faculty and nearly 400 nursing and other staff--goes light years, of course, past bumps on the head. The investigators here look at all facets of depression in the elderly, from the emotional to the physical. They search for clues to unlock its mysteries and to find ways to intervene before it becomes an unendurable pain.

"We all agree that youthful suicide is a tragedy," Caine says. "But so is the incidence of suicide among older adults. It's extraordinarily high compared to younger people. The rate goes up like a rocket as age increases."

The mustachioed Caine wears a denim- blue shirt and a flowered tie, casually draping himself on the chair behind his desk as he talks about what he sees as a growing national problem.

"What we're trying to find out here at Rochester is what is different about depression in the elderly. If we can get a handle on that, we can find ways to interrupt its cycle before it becomes life threatening."

From 1980 through 1992, the suicide rate among those 65 and over increased by 9 percent, he says, with a 35 percent increase in those between 80 and 84. The suicide rate among elderly white males over 85 is six times that of the general population--"a significant public-health concern," Caine declares. "And the baby boomers are getting older; longevity is increasing. The problem isn't going to go away."

Primary care physicians may recognize and treat only 40 to 50 percent of their patients who suffer clinically significant mood disorders, Caine says. "Among the many physical illnesses and the social and economic problems of the elderly, depression can easily go undetected--or if recognized, untreated. Health care providers often don't see the symptoms, or they may consider them part of another illness, or perhaps the patient doesn't even report them.

"Sadly, some people, patients and physicians alike, see depression as a natural or expected part of growing older. It's a prejudice, really."

Moreover, of the depressed seniors who move on to suicide, 70 percent had seen a doctor within the last month of their lives--40 percent within the last week--and their depression, or the depth of it, had still gone unrecognized.

What separates from their fellows those older adults who decide to take their own lives?

Among those trying to find out is Yeates Conwell, associate professor of psychiatry and nationally known expert on suicide. As head of the department's Laboratory for Suicide Studies, Conwell is one of several researchers who are investigating the multiple contributing causes of elderly suicide.

Working with the local medical examiner, Conwell and colleagues have done "psychological autopsies" on people who have committed suicide, comparing younger and older victims. By talking to surviving spouses, relatives, and friends, the team has put together posthumous profiles of their subjects.

"One surprise is that suicide among the elderly is not a right-to-die issue," Caine says. The victims Conwell studied were generally not trying to escape unbearable pain from cancer or other illnesses. Most of them rather were suffering from clinical depression that came on in later life. The depression, often combined with an existing medical condition, acted as a blurry lens, so that their perception of events was hazy and skewed. "They were just not seeing straight."

To illustrate, Caine cites the case of a 78-year-old widower who (unsuccessfully) shot himself in the chest, assuming, from the presence of blood in his stool, a recurrence of his colon cancer. Described as a "conservative, emotionally constricted man," the would-be suicide hadn't sought the treatment for his symptoms that might have put his mind at ease: Surviving the gunshot wound, he was diagnosed with a case of hemorrhoids and was found to be otherwise in good health.

The emotional constriction displayed by this patient turns out to be fairly common among seniors who end their own lives. Paul Duberstein, an assistant professor in the department, has been looking at personality traits shared by elderly suicides. "What Paul has been finding," Caine says, "is that suicide victims tend to be less flexible, more stoic, less able to deal with changes. All their lives they have been able to plug along that way, but as they are increasingly troubled by their diseases, they just can't adapt as well as others with the same problems.

"Adaptability in late life is a very critical issue," he points out.

Other researchers in the department are equally busy, Caine says, and he can (and does) rattle off project information on each as fluently as though he himself were as deeply involved in its intricacies as the actual investigator.

He talks of the work of Jan Moynihan, a specialist in psychoneuroimmunology (the study of the link between the central nervous system and the immune system, in which Rochester researchers are pioneering; see Rochester Review, Spring-Summer 1997). Teaming up with Duberstein, Moynihan is looking into how emotional and social factors affect illness and depression--specifically, through a study of women diagnosed with breast cancer, to see what traits and behaviors may affect immune responses and different outcomes of the disease.

"And Larry Seidlitz, a research assistant professor here, is another one looking at emotions," Caine goes on. "He has people wear a pager that beeps at unpredictable intervals. Then he has them record their emotions at that particular moment. He's charting how people with depression are affected at the different times. That way he gets a more accurate reading of the intensity and duration of symptoms than he would from responses to a questionnaire that simply asks, 'Do you feel sad?'"

Preliminary results indicate that, in general, even depressed people aren't necessarily depressed all the time--patients frequently experience more variable emotions than those typically associated with the disorder.

Yet another researcher, Jeffrey Lyness, assistant professor of psychiatry, has studied hospitalized seniors to see how depression and their physical disorders interact to affect their overall function. Lyness also is testing a theory that cerebral vascular disease is a component of depression. "Everybody is hot for this theory," Caine says. "Everyone wants it to turn out that there's a clear biological cause for depression."

"Jeff is now doing his research in primary care offices," Caine adds. "He finds there an entire range of depressive conditions, from mild but disabling to very severe. Less than half of them are treated. Patients often don't share their burdens --sometimes they just don't label themselves 'depressed.' The docs are increasingly pressed to see more patients every hour. How can anyone take time to listen or ask a question under these conditions?"

Depression can have severe effects on thinking and remembering. Rochester geriatric psychologist Deborah King, a well-known authority in her field, has done a series of decade-long studies that underscores these effects, Caine says. "Her work also distinguishes depression from Alzheimer's, separating out the symptoms of one from the symptoms of the other--not an unimportant finding, since for most patients, depression, unlike Alzheimer's, can be treated if not completely cured."

Sitting back in his chair, the department chief sums up: "So, here at Rochester we're looking at issues of personality and emotion. We're looking at the cerebral and vascular. And we're looking at the various risk factors that give genesis to depression.

"All these elements," he says, "can work together or separately. But it is clear that amelioration of depression must begin in the primary care physicians' offices, not in the psychiatric services.

"Depression is treatable, through varying combinations of medications and psychotherapy. But the elderly too often don't come to us until it is very late. Their symptoms need to be recognized long before they reach that stage, long before they become unendurable."

What advice would Dr. Caine give for an emotionally healthy old age? "Keep active," he urges. "I look at people who have retired and are finding great satisfaction in their lives. They haven't simply retired to nothing, to a vacuum. Instead, they engage in meaningful work of some kind. It doesn't have to be paid work, but it has to be something--art, volunteer work, hiking, whatever.

"When you center yourself around your job, then, no matter what the job is, its loss will be a painful experience. You have to find something to replace it."

What about his own job? Does he find dealing with depression, well, depressing?

I had a friend who worked with children suffering from cancer. What she was doing would have blown me away. I couldn't have borne it. But then she would say to me, 'I don't know how you do what you do. Don't you ever get depressed yourself?'

"But I don't. I love it. In this field, you can make such a difference. It really is upbeat. Why, you can turn someone's whole life around. And that's uplifting."