Depression: more than the blues

Imagine a world of blackness, where just getting out of bed every day is a struggle. Imagine having no pleasure. No anticipation. No joy. It’s a world Mary knows all too well. She first entered it just over 20 years ago at the age of 60. Her youngest son was about to get married, and she had been feeling down. Then one day, feeling blue turned into a black cloud: full-blown depression.

“I didn’t care if I lived,” says Mary, who asked that her real name not be used. “I didn’t care about anything. I didn’t want anything in life.”

The Saskatoon retiree got over that first bout of depression but she would be plunged back into the blackness twice more over the next couple of decades.

Today, Mary is once again enjoying life and keeping the darkness at bay with the help of medication, therapy and a very supportive family.

Her story isn’t that unusual. Depression is the most common of mental disorders, but it’s also one of the most misunderstood. While getting the blues or feeling sadness or grief is all a normal part of life, depression is not. Sad or grieving people can carry on with their normal activities. But when the sadness and empty feelis interfere with everyday life for a prolonged period of time, it becomes a disease.

“When people begin to have suicidal ideas, decreased appetite, sleep disturbance, less energy or interest in life, we become concerned about a depressive illness,” says Dr. Nathan Herrmann, head of the geriatric psychiatry division at the University of Toronto.

The many faces of depression
Depression can take many forms, ranging from a relatively mild condition called dysthymic disorder to severe and debilitating chronic depression. Some people may  have depressive episodes, a period of time (usually less than two weeks) where symptoms of depression develop and then disappear. Others may suffer from chronic depression, struggling against the condition the rest of their lives.

The cause of depression isn’t entirely known, but it seems to be a combination of chemical, genetic and environmental factors. The brain produces chemicals called neurotransmitters, a key one being serotonin, which is involved in processing thoughts and emotions. If serotonin levels are out of balance, depression can result.

Genetics plays a role as well, with some studies showing that children of parents with depression are three times more likely to experience depression as those children with non-depressed parents.

And environmental factors, such as stress (death of a family member, long-term illness), behaviours (alcohol or drug dependency) and even taking certain medications, may trigger depressive episodes.

Older people actually suffer less from depression
But the good news for 50-plus Canadians is depression is not a normal part of aging. In fact, older people are at less risk of serious depression than younger ones. Overall, 20 per cent of Canadian women and about 10 per cent of men are likely to suffer some form of depression during their lives. Among those 65 or older, only 10 to 15 per cent get the disease, and cases of major depression among older people in the community may be as low as one per cent.

“Maybe older people cope a bit better with life’s circumstances,” says Dr. Lilian Thorpe, a Saskatoon therapist and vice-president of the Canadian Academy of Geriatric Psychiatry. Older people have lived through the Great Depression and a world war and “they are really tough people.”

When it does hit seniors, depression can really be devastating
But while seniors are at reduced risk, when they do suffer from depression, it can hit hard. For example, seniors with depression are more likely to commit suicide. White men over age 65 have a suicide rate five times the general population. And researchers say depression in older people isn’t recognized or treated in a timely manner. “The statistics suggest family physicians are not alert enough,” says Herrmann.

When depression happens in later life, it may be a relapse of an earlier bout of the illness. It’s not uncommon for someone with severe clinical depression to suffer through it three or four times.

But when depression strikes for the first time in later years, it’s often triggered by another illness, especially Parkinson’s disease, Alzheimer’s disease, stroke, heart disease and cancer. That may explain why rates of depression in nursing homes can be as high as 50 per cent.

Fortunately, depression is a very treatable disorder. Antidepressant drugs are effective in up to 80 per cent of cases. While there are dozens available – and new ones coming out all the time – most fall into three broad categories:

Selective serotonin re-uptake inhibitors (SSRI)
SSRIs first appeared in the late 1980s. Prozac is the best known. They keep higher levels of serotonin available to the brain. They have fewer side effects than earlier drugs. Still, many people experience stomach upset, headaches, sleep disturbance and sexual problems.

Tricyclic antidepressants (TCA)
The second category of antidepressant drugs, TCAs first appeared in the 1950s and are still widely used. They may cause irregular heartbeat, dry mouth, blurred vision and constipation.

Monoamine oxidase inhibitors (MAOI)
MAOIs are generally used only when other drugs don’t work because patients taking these drugs have to avoid many common foods.

These drugs work best when accompanied by therapy sessions. One of the most effective is called cognitive therapy, where a therapist helps the patient recognize and change negative thought patterns that can lead to a depressed mood.

“With depression, it’s easy to jump to very negative conclusions,” says Dr. Zindel Segal, a professor in the psychiatry department at the University of Toronto.

Therapy sessions may also include behavioural therapy, which teaches patients to examine behaviour patterns and avoid those that can lead to depressed feelings. 

Some herbal remedies show promise, but most have never been properly evaluated. The exception is St. John’s wort. Large studies have shown it to be effective for mild depression.

But whatever drugs or supplements you’re taking, make sure your doctor knows. Some medications interact badly with antidepressants.

Exercise and a social network are effective cures
Little work has been done on the prevention of depression, but some studies indicate regular exercise is important. In fact, there’s evidence that, for mild depression, exercise can be as effective as drugs. A strong social network is also vital. Research shows that older people who are active in church groups or clubs are less likely to get depressed.

If a member of your family becomes depressed, your support is important.
Make sure they see a doctor and reassure them it’s treatable.
• Learn about depression and encourage them to talk about it.
• Try to keep them doing the activities they used to enjoy.
• Encourage them to eat regular meals and get exercise.
• Discourage the use of alcohol. It’s a depressant and can make things worse.
• Spend time with them. “Human contact is a huge factor,” says Dr. David Conn, head of psychiatry at the Baycrest Centre for Geriatric Care in Toronto.

The importance of family support cannot be overlooked
Mary knows the importance of having strong family support. To help her cope with a depressive episode, her grandson moved in with her.

Now, a granddaughter is staying with her while attending university. Mary says that their companionship has helped boost her mood. “It helps a lot to have other people around,” she says. “I don’t get down.”

Mary also has some advice for others facing depression: don’t accept it as a part of life. “You don’t have to suffer,” she says. “You need help and you should go out and get it.”