Do you have elderly relatives who struggle with loneliness or depression? Are you concerned and unsure of what can be done to help the elderly in our communities who might be suffering in silence and would benefit from psychological assistance?

Depression is not a problem that only affects young people. Older adults often suffer from depression in late life, known as late-life depression (LLD). Depression is an intractable problem, but it can be treated. When it occurs in the elderly, there are considerations to take into account that are different from young people, specifically in aspects of lifestyle, social, cultural, and available options for treatment.

LLD is depression that ensues among people 65 years and above without a prior history of depression. It is characterised as the affective form of sadness that arises as a reaction to different circumstances, including losing a family member, lack of success in attaining dreams, or dissatisfaction in relationships (Sekhon et al., 2023) and is one of the most common mental disorders among older adults (Zhao et al., 2023). The prevalence of LLD in Singapore is approximately 5.5% (Well-Being of the Singapore Elderly (WiSE) – IMH | Institute of Mental Health, 2021).

There are four main types of treatment for LLD. These are pharmacological, collaborative care, lifestyle and psychological.

Pharmacological interventions for LLD include primarily selective serotonin reuptake inhibitors (SSRIs) and tricyclics. They do not differ from interventions for depression in younger adults (Wassink-Vossen et al., 2022). SSRIs work by increasing the availability of serotonin in the brain. Serotonin is a neurotransmitter that regulates mood, sleep, appetite, and other bodily functions. By blocking the reuptake (reabsorption) of serotonin by neurons, SSRIs increase serotonin levels in the synaptic cleft, leading to improved mood and alleviating depressive symptoms. Tricyclics, on the other hand, work by inhibiting serotonin and norepinephrine reuptake, two neurotransmitters involved in mood regulation.

Collaborative care interventions refer to the combination of multiple types of intervention applied together to achieve a holistic therapeutic approach (Unützer et al., 2023). A study by Unützer et al. (2002) evaluated the effectiveness of a collaborative care intervention for late-life depression, which included antidepressant treatment and psychotherapy (problem-solving treatment) provided by a multidisciplinary team. The study found that collaborative care intervention resulted in significantly better clinical outcomes, including higher rates of depression treatment and remission, compared to usual care.

Lifestyle interventions include nutrition, sleep, and exercise to implement healthy lifestyle habits (Aguilar-Latorre et al., 2022).

Psychological interventions, such as cognitive behavioural therapy (CBT), aim to produce a personal change, lead to functional results through a relationship and optimisation of personal resources (Ricou et al., 2019). CBT achieves this by targeting and modifying unhelpful thought patterns and beliefs while equipping clients with coping strategies like cognitive restructuring, problem-solving skills, and stress management techniques. The trusting therapist-client bond is crucial in guiding the practice of CBT skills effectively. (Fenn & Byrne, 2013). Overall, CBT facilitates positive change by leveraging the therapeutic alliance to build resilience and self-management abilities.

Myriad sociocultural factors often differ between young and old-aged individuals that could contribute to the risk of developing depression (Fiske et al., 2009), as well as the types of interventions that are likely to succeed (Wassink-Vossen et al., 2022). These may include reduced personal capacity to complete activities of typical daily life, as the elderly often face multiple chronic health conditions, which can contribute to depression and make it more challenging to manage. In addition, older adults are more prone to social isolation and loneliness due to the loss of loved ones and retirement, which can exacerbate depressive symptoms (Fiske et al., 2009).

LLD is underdiagnosed and inadequately treated due to misunderstandings as part of the ageing process (Ji et al., 2023). It also becomes challenging to differentiate it from dementia, as both these diagnoses have co-occurring manifestation profiles, primarily when depression influences cognition and is presented as ‘pseudodementia’ (Sekhon et al., 2023).

By 2035, around one-third of our population will be 65 or older, so the prevalence of LLD is expected to rise (Diniz & Teixeira, 2019). This leaves our country particularly vulnerable to the challenges of LLD.

Depression in the elderly is a unique and challenging phenomenon that needs careful consideration of social and cultural factors in treatment. In Singapore, research and healthcare provision is improving in terms of understanding the extent of the problem and how to address it in our communities. This is relevant to our rapidly ageing population and expected future rising rates of disease, mortality, and depression. It is crucial that we do more to address this urgent challenge in our society.

 

Written By:

Andrea Seo

Murdoch University

 

References

Aguilar-Latorre, A., Pérez Algorta, G., Navarro-Guzmán, C., Serrano-Ripoll, M. J., & Oliván-Blázquez, B. (2022). Effectiveness of a lifestyle modification programme in the treatment of depression symptoms in primary care. Frontiers in Medicine, 9, 954644. https://doi.org/10.3389/FMED.2022.954644 

Diniz, B. S., & Teixeira, A. L. (2019). Advances in the neurobiology of late-life depression. Neurobiology of Depression: Road to Novel Therapeutics, 441–449. https://doi.org/10.1016/B978-0-12-813333-0.00038-X 

Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioural therapy. InnovAiT: Education and Inspiration for General Practice, 6(9), 579–585. https://doi.org/10.1177/1755738012471029

Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in Older Adults. Annual Review of Clinical Psychology, 5(1), 363–389. https://doi.org/10.1146/ANNUREV.CLINPSY.032408.153621 

Ji, M., Sun, Y., Zhou, J., Li, X., Wei, H., & Wang, Z. (2023). Comparative effectiveness and acceptability of psychotherapies for late-life depression: A systematic review and network meta-analysis. Journal of Affective Disorders, 323, 409–416. https://doi.org/10.1016/J.JAD.2022.11.089 

Ricou, M., Marina, S., Vieira, P. M., Duarte, I., Sampaio, I., Regalado, J., & Canário, C. (2019). Psychological intervention at a primary health care center: Predictors of success. BMC Family Practice, 20(1), 1–8. https://doi.org/10.1186/s12875-019-1005-9 

Sekhon, S., Patel, J., & Sapra, A. (2023). Late-Life Depression. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK551507/ 

Unützer, J., Katon, W., Callahan, C. M., Williams, Jr, J. W., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. & for the IMPACT Investigators. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836–2845. https://doi.org/10.1001/JAMA.288.22.2836 

Unützer, J., Vredevoogd, M. A., Hoeft, T. J., James, K., Hinton, L., Rath, L., Chen, S., Greene, M., Hulst, D., Jones, F., Nau, C., Rentas, K. G., Vierra, W., & Langston, C. A. (in press). Improving Care for Late-Life Depression Through Partnerships With Community-Based Organizations: Results From the Care Partners Project. The American Journal of Geriatric Psychiatry. https://doi.org/10.1016/J.JAGP.2023.12.006 

Wassink-Vossen, S., Oude Voshaar, R. C., Naarding, P., & Collard, R. M. (2022). Effectiveness of late‐life depression interventions on functional limitations: A systematic review. International Journal of Mental Health Nursing, 31(4), 823. https://doi.org/10.1111/INM.12982 

Well-being of the Singapore Elderly (WiSE) – IMH | Institute of Mental Health. (n.d.). Www.imh.com.sg. https://www.imh.com.sg/Research/Research-Programmes/Pages/Well-being-of-the-Singapore-Elderly-WiSE.aspx

Zhao, Y., Wu, X., Tang, M., Shi, L., Gong, S., Mei, X., Zhao, Z., He, J., Huang, L., & Cui, W. (2023). Late-life depression: Epidemiology, phenotype, pathogenesis and treatment before and during the COVID-19 pandemic. Frontiers in Psychiatry, 14, 1017203. https://doi.org/10.3389/FPSYT.2023.1017203