Personal contact, medicines ease depression in elderly; Emotional complexities complicate treatment


BOSTON -- The 92-year-old woman was sitting in her wheelchair, talking with her psychiatrist at the Hebrew Rehabilitation Center for Aged, when the phone she carries in a black canvas bag rang. She unzipped the bag and greeted her niece on the line: "Hello, Myrna. I'm in a meeting now. Can I call you back?"

The psychiatrist, Dr. Eran Metzger, smiled. A year ago, the woman was so depressed that she had not only lost interest in talking to anyone, but she had stopped eating. Not long after he started her on an anti-depressant, her mood began to improve. The ringing telephone, he said, was as good an indication as any that she was again engaged in life.

The woman, a former business executive, had suffered grief that might seem to define old age: the deaths of her husband and her five sisters; the loss of her vision and her ability to walk; then, the death of her only child, a son.

"To tell you the truth, I didn't want to live," she recalled.

The woman was one of the luckier older Americans who suffer from what doctors call major depression, a condition in which the brain chemistry is altered.

Her home for the aged had a geriatric specialist on staff, Metzger, who could recognize her symptoms and not confuse them with old age itself. Most nursing homes and residences for the aged do not.

Just as medicine is more able than ever to treat depression, experts worry that the nation's health care system is not prepared to deal with a surge in cases as baby boomers approach old age -- eventually doubling the population 65 and older -- and encounter the chronic diseases and losses that can make a person vulnerable to depression.

But the growing treatment of depression among the old also raises questions about the quality of the last stage of life and its emotional complexities -- the mingling of grief at the loss of a spouse, for example, with the anticipation of seeing a grandchild -- that younger people, who mostly fear old age and disability, find difficult to understand.

Doctors say there is no question that depression can be safely treated, but they also debate where sadness ends and depression begins and what realistic expectations for the final years are.

Poets and philosophers have always spoken of the despair -- "the tragic sense of life," the Spanish philosopher Miguel de Unamuno called it -- that the very old experience as their days dwindle. Some experts on aging worry that modern medicine may end up trivializing that despair, trying to medicate away the deep sadness that comes with losses.

"Some despair is inevitable as you recognize that time is short, that you don't have the opportunity to work out a different life," said Rose Dobrof, 74, the Brookdale Center on Aging's professor of gerontology at Hunter College.

"What too often happens is that because the family doctor doesn't have time to talk, he prescribes medication," Dobrof said. "It's the easiest thing to do. What people need are human connections." People, she said, need to talk, to doctors, clergy and social workers, and to family and friends.

At the same time, Dobrof said, medication -- particularly newer anti-depressants like Zoloft, Paxil and Prozac that have fewer side effects than older ones -- is needed to ease depression in many cases.

Medication undoubtedly played a major role in the recovery of the 92-year-old woman (many old people talk freely, even eagerly, about their ailments, but depression is not considered a subject for open discussion; the woman, like other patients interviewed for this article, did not want to be identified).

The woman had attended weekly group therapy sessions, Metzger said, but until she began taking anti-depressants she could only sit by helplessly and cry. Now she joins in.

But Metzger said her recovery was also helped by a psychiatric nurse, Phyllis Cronin, who recognized the woman's isolation and made an effort to form a close relationship with her.

The goal of treatment, Metzger said, was not to erase her sadness, nor to transform her into a different person. "We're not trying to make everyone conform to our stereotypes of aging," he said. Most of the cases he treats, he said, are people with major depression, a condition that can inhibit recovery from disease and strokes and increase pain.

Though the woman no longer talks of wanting to die, Metzger said, she still cries over her son, and she still gets angry about living in an institution. He is mindful of how she put it the other day: "The doctor and the medicine help you, but the pain in your heart will live forever."

For most of this century, to the extent that doctors thought about depression and the elderly at all, it was to say that depression among the elderly was understandable, even to be expected. But geriatric psychiatrists and other experts see no reason that the old and infirm should not find some fulfillment in life.

In her book "Another Country -- Navigating the Emotional Terrain of Our Elders" (Riverhead, 1999), Mary Pipher explored the psychological growth that many old people experience as they decline. "There is an amazing calculus," she wrote. "Anyone who isn't an idiot becomes a philosopher."

It is important, experts say, that younger people not impose their fears and stereotypes about old age on the old.

"These people find new relationships and new interests," said Dr. Ira Katz, director of geriatric psychiatry at the University of Pennsylvania School of Medicine. "I truly believe that even in a nursing home, even in someone with heart failure, even with disabling arthritis, with Parkinsonism, with any number of disabling conditions, it really is possible to have pleasure in life and to have a meaningful life if only one isn't depressed."

Even as Katz and other geriatric psychiatrists report that increasing numbers of people are recovering from depression with the help of new medications, experts say the great majority of depressed older Americans are not getting adequate treatment.

The health care system, they say, has not trained physicians to look for depression in older people; managed care gives doctors little time to explore what can be a difficult diagnosis (geriatric psychiatrists often talk with a patient for an hour before prescribing anything), and the newer anti-depressant medications are expensive and require follow-up.

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