For most of us, the holidays are a time to gather with friends and family, celebrate, reflect on the past and plan for the future. However, for some, especially older individuals, the holidays can be a difficult time. During the holidays, older adults may feel more acutely the passing of time, the absence of parents, siblings and friends who have died, and the distance of loved ones who have moved away. Traditional reunions and rituals that were observed in the past may not be possible and in their absence, the holidays may seem devoid of meaning. This holiday season may be particularly difficult as we adjust to a world forever changed by terrorism.

It is normal to feel subdued, reflective and sad in the face of these losses and changes. But family members or friends may notice that a senior is experiencing the “blues” for a long time and that what they may have thought was simple sadness is actually a serious case of depression.

Some major factors contributing to holiday depression in the elderly are:

• Financial limitations
• Loss of independence
• Being alone or separated from loved ones
• Failing eyesight (and lessening of the ability to write or read holiday correspondence)
• Loss of mobility and/or the inability to get to religious services

Depression is not a natural part of aging.

Everyone feels sad or blue sometimes, and the stress associated with holidays may stir feelings of loss or separation. However, a person who is sad or anxious around the holidays, can, in most cases, continue to carry on with regular activities. Such feelings are generally temporary and the individual eventually returns to his or her normal mood state. However, a clinically depressed person suffers from symptoms that interfere with his or her ability to function in every day life. These symptoms include much more than feeling blue.

When clinically depressed, the affected older person may lose the will to live. These persons begin to question the value of life and may think of suicide. There are often feelings of diminished self-esteem or excessive feelings of guilt. As these symptoms develop, the older person may take to bed or not bother getting dressed in the morning.

Appetite and sleep may suffer while lethargy sets in. The person may show little interest in his or her own welfare and little interest in doing things that in the past brought pleasure.

Recognizing depression in older individuals is not always easy. It often is difficult for a depressed older person to describe how he or she is feeling. In addition, the current population of older Americans came of age at a time when depression was not understood to be a biological illness. Those who are depressed may fear being labeled “difficult” or worse, or may worry that their illness will be seen as a character weakness.

Those who are depressed, their families and friends may think that a change in temperament or behavior is simply “a passing mood,” and that the person will just “snap out of it.” Unfortunately, a person suffering from depression cannot just “get over it.” Depression is a medical illness that should be diagnosed and treated by trained professionals. Left untreated, depression may last months or even years.

If left undiagnosed and untreated, depression can:

• Lead to a loss of independence
• Aggravate symptoms of other illnesses
• Lead to premature death
• Result in suicide

When properly diagnosed and treated, however, most people recover from depression.

Facts About Depression

Following is some information about depression in the elderly and how to help those who might be suffering.

What are some of the warning signs of depression?

The most common symptoms of late-life depression include:

• Persistent sadness
• Withdrawal from regular social activities
• Slowed thinking or response
• Lack of energy or interest in things that were once enjoyable
• Excessive worry about finances or health
• Frequent tearfulness
• Feelings of worthlessness or helplessness
• Weight changes
• Pacing and fidgeting
• Changes in sleep patterns (inability to sleep or excessive sleep)
• Inability to concentrate
• Staring off into space (or at the television) for prolonged periods of time

What triggers depression in older adults?

Chronic or serious illness is the most common cause of depression in the elderly. However, the disease also can be caused by biological changes in the brain and, thus, may occur for no visibly apparent reason.

As the body and brain age, a number of bio-chemical changes begin to take place. Changes as the result of aging, medical illness or genetics may put the older adult at a greater risk for developing depression.

Among older people, medical illnesses are a common trigger for depression, and often depression will worsen the symptoms of those other illnesses. In addition, some illnesses may hide the symptoms of depression. When a depressed person is preoccupied with physical symptoms resulting from a stroke, gastrointestinal problems, heart disease, arthritis or another affliction, he or she may attribute the depressive symptoms to an existing physical illness, or may ignore the symptoms entirely. For this reason he or she may not report the depressive symptoms to a doctor, family or friends.

Is depression treatable?

Today, there are highly effective behavioral and pharmacological interventions for depression in late life. In fact, most depressed elderly people improve dramatically with treatment.

Antidepressant medications can be very effective in treating depression by beneficially affecting the level of certain neurotransmitters in the brain.

Typically, it takes 4-12 weeks of treatment with antidepressant medication to begin seeing results and medication is taken for six months to a year. It is important to take antidepressant medications in close consultation with a general practitioner or psychiatrist. Taking the wrong amount--too much or too little--or discontinuing medication too soon may compromise the effectiveness of the treatment.

Psychotherapy (talk therapy) can also play an important role in the treatment of depression. Some patients improve notably with short-term talk therapy (10-20 weeks); others may benefit from long-term therapy. Some patients find group therapy with their peers helpful as they are able to share insights with others who are going through similar experiences. It is very important that the depressed person find a therapist with whom he or she feels comfortable and who has experience with older patients.

What are some of the complications in treating depression?

The treatment of depression requires patience and perseverance from the person who is depressed as well as their family and friends. Each person has individual biological and psychological characteristics that require specialized care. Sometimes different medications must be tried for a successful recovery. This is especially true with the elderly who have other serious illnesses or who are otherwise in frail health.

What are the first steps in caring for the depressed person?

An elderly person who may be depressed should see a medical professional--a family doctor, a general psychiatrist or a psychiatrist specializing in the elderly, called a geriatric psychiatrist. A complete physical should be part of any evaluation since depression may be the result of another medical condition. If the person is reluctant to see a doctor on his or her own, friends or family can offer support by going with them.

How do you talk to someone who is depressed or blue?

Sometimes the hardest part in helping someone who is depressed or blue is finding an approach that does not contribute to him or her feeling defensive, sad, or helpless. If you are at a loss for words, you may want to consider some of the following ways to begin:

• Discuss your own varied feelings or a time in your life when you were depressed or blue. Knowing that you understand may give them the means to talk about their feelings.
• Acknowledge that the holidays can be difficult, and that the past several months have been hard on everyone. Many people don’t want to admit that life is not always as cheerful as portrayed in the media or in advertisements.
• If the older individual is not eating or has lost weight, you might start by gently asking about their appetite or why they do not seem interested in food.
• Once you have gotten past the initial awkwardness, you may be surprised to learn that your loved one will talk to you. At that point, it is up to you to listen and offer support. Too often, younger friends or family members do not want to hear some of the less than pleasant aspects--emotional and physical--of growing older. But one of the most important things you can do is listen.
• Offer specific suggestions for help and be willing to assist in implementing them. You may want to suggest that your relative or friend visit the family doctor or make an appointment with a psychiatrist. You may want to be involved in helping them select a doctor if they don't have one in mind. They may wish to make the decision on their own, but, if not, it will be a comfort to have help.

It may take more than one conversation and it may take more than one day or one week to get the individual to agree to get help. If they are struggling with depression, they may not want to hear what you have to say and may resist your suggestions. Be persistent. This is a difficult process for you and the older individual, but knowing that depression is treatable makes it easier to address.

Remember, for many older family members and friends there may be a stigma attached to asking for help and to having any discussion of depression or mental illness. Part of your role is letting them know that depression is treatable, that their lives can be better and that depression is not an inevitable part of growing old.

The Holidays After the Terrorist Attacks

Today’s senior citizens are a resilient and resourceful group, and the vast majority is managing the stress of recent events very well. However, during the holidays, the elderly and their families should be sensitive to possible delayed responses to the events of September 11 and the subsequent anthrax threats.

Over the holidays, how might older individuals respond to the recent terrorism?

In addition to feeling depressed, seniors may find themselves irritable and uninterested in previously cherished rituals or loved ones. Those traumatized by earlier life experiences may become preoccupied with unwelcome images from the past. Older émigrés who fled political terror or religious persecution in their homelands may be particularly vulnerable. Near phobic dread of travel or unwarranted worries over traveling family members can lead to isolation. These are all symptoms of anxiety and depressive disorders as well as acute and post-traumatic stress disorders.

Why might these responses be delayed?

During the holidays, we let our emotional guard down. Our psychological defenses are loosened in anticipation of the warm, secure feelings associated with the holidays. Seniors who have busied themselves and kept the terror out of mind may find that the change of pace leaves them vulnerable. The delayed response may also be triggered by seeing family members in distress. Reactions to stress are emotionally infectious.

What are signs that an older person may need help from a mental health professional?

• Suicidal thoughts are not the norm even in very old persons and their presence indicates the need for professional help.
• An escalation in the use of alcohol, pain relievers (analgesics) or sleeping pills may indicate depression.
• Seniors who seem confused, cannot concentrate or seem lost in the midst of family events may benefit from a professional assessment.
• Shedding a tear of two during the holidays is a sign of sentiment. But when crying becomes disruptive or disabling it may be a sign of depression.
• Seniors who suddenly isolate themselves are clearly having problems.

What can friends, family members and caregivers do to help?

The simple answer is to openly communicate one’s concerns. Offer to call the individual’s doctor and accompany the senior to an appointment. A conversation with the senior’s clergy can also facilitate referral to a mental health professional. Do not ask the older person to follow through without giving your support.

Nursing Home Residents

Many families rely on nursing homes to provide the consistent care their older relative needs. Holiday depression can arise--for many of the reasons previously mentioned--when individuals are in nursing homes or other long-term care situations. The holidays may be especially hard on these individuals because of the loss of their own mobility.

What kind of care can a patient receive for depression in a nursing home?

If your older family member is in a nursing home and you suspect he or she is depressed, you may want to talk with the nursing home administrator or director of nursing about the symptoms you notice. You may want to request a consultation with a physician or psychiatrist. If the individual is in frail health, you need to be especially certain that the doctor is trained in caring for the mental health of the frail elderly whose ability to tolerate treatments may be different from other elderly patients.

Remember that all patients should have access to the care they need--physical and mental--regardless of the setting. If the individual is in a nursing home and you suspect he or she is suffering from depression, insist that the nursing home help provide appropriate treatment.

What questions should I ask about mental health care in the nursing home?

• Ask whether the facility provides physical and social activities for the residents. Like all of us, elderly family members need to get exercise if they can and need to have positive interaction with friends and peers.
• Ask about the qualifications of staff professionals monitoring care, especially regarding the careful dispensing of all medications.
• Ask specifically about mental health care, including access to group therapy.
• Ask about the availability of psychiatric care through a staff or affiliated psychiatrist.