Depression Without Sadness: Alternative Presentations of Depression in Late Life



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Am Fam Physician. 1999 Sep 1;60(3):820-826.

Older adults often deny feeling sad while exhibiting other characteristics of depression. Elderly patients with depression who do not present with sadness often have unexplained somatic complaints and exhibit a sense of hopelessness. Anxiety and anhedonia (a general loss of ability to feel pleasure) are also encountered frequently. Other features that may indicate underlying depression include slowness of movement and lack of interest in personal care. A screening device, such as the Center for Epidemiologic Studies—Depression Scale, Revised (CES-D-R), may identify depression in suspicious cases. When this condition is identified, treatment should generally include the use of an antidepressant medication, usually a selective serotonin reuptake inhibitor.

“When I was first aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word, ‘depression.’”

—William Styron, Darkness Visible1

Older persons may not exhibit the typical symptoms of depression, including sadness.24 Standard criteria for major depression, such as those found in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV),5  require depressed mood or loss of interest in activities that were once enjoyable, and at least four additional symptoms: appetite disturbance; sleep disturbance; fatigue; psychomotor agitation or retardation; feelings of worthlessness, sinfulness or guilt; trouble with concentration; and thoughts of death or suicidal ideation (Table 1).5  While patients who deny feeling sad, blue or depressed may still meet standard criteria for major depression as set forth in DSM-IV, this review will emphasize alternative clinical clues to depression in older persons, in whom loss of interest in activities is sometimes difficult to assess. When these clinical clues are present, the symptoms of depression should be sought (Table 1).5 Sleep disturbance, decreased appetite, weight loss, irritability, difficulty with concentration and fatigue, which are common signs of depression in older patients, will not be specifically addressed in this article.

TABLE 1

Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.


Reprinted with permission from the American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:327. Copyright 1994.

TABLE 1   Criteria for Major Depressive Episode

View Table

TABLE 1

Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.


Reprinted with permission from the American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:327. Copyright 1994.

Older persons with significant depression may have fewer symptoms than the number required by the DSM-IV criteria for major depression. In one study,6 older adults who expressed feelings of hopelessness or worthlessness, admitted to thoughts of death or suicide, and had at least two other symptoms of depression were at increased risk for functional disability, cognitive impairment, psychologic distress and death, even if they did not display symptoms such as sadness or loss of interest or pleasure in activities that were formerly enjoyed (nondysphoric depression). Depressive symptoms were associated with development of functional impairment as measured by performance tests (avoiding reliance on self-report of function) in a similar study.7  This article will focus on selected clinical clues to depression in late life (Table 2) and the implications for assessment and treatment of older primary care patients with depression.

TABLE 2

Clinical Clues to Depression in Older Adults Who Deny Sadness or Depression

Unexplained somatic complaints

Hopelessness

Helplessness

Anxiety and worries

Memory complaints with or without objective signs of cognitive impairment

Loss of feeling of pleasure (anhedonia)

Slowed movement

Irritability

Lack of interest in personal care, such as poor adherence to medical or dietary regimens

TABLE 2   Clinical Clues to Depression in Older Adults Who Deny Sadness or Depression

View Table

TABLE 2

Clinical Clues to Depression in Older Adults Who Deny Sadness or Depression

Unexplained somatic complaints

Hopelessness

Helplessness

Anxiety and worries

Memory complaints with or without objective signs of cognitive impairment

Loss of feeling of pleasure (anhedonia)

Slowed movement

Irritability

Lack of interest in personal care, such as poor adherence to medical or dietary regimens

Clinical Clues to Depression

UNEXPLAINED SOMATIC COMPLAINTS

Older patients with depression may present with somatic complaints for which a medical etiology cannot be found or that are disproportionate to the extent of medical illness. Patients who express somatic symptoms as a manifestation of depression seem to be less willing to mention psychologic symptoms to their physician.8

Somatic presentations of depression are among the most challenging situations faced by family physicians. The patient may worry that a serious illness underlies the symptoms, while the physician's concern that hidden disease might be missed is appropriate. Certainly, illnesses such as pancreatic carcinoma or hypothyroidism might cause symptoms that mimic depression. Therefore, addressing the patient's psychologic distress while appropriately evaluating the possible diagnoses is important. The evaluation should always include a careful, critical review of the medications the patient is taking. Family physicians are well-situated to consider both the mental and physical aspects of the patient's illness.

Older adults who are physically ill are especially at risk for inadequate treatment of depression.9 In the depressed patient with physical symptoms, depression may not be easy to recognize. Often, physicians attempt to find a reason for the existence of depression, rather than ascertaining whether the depression syndrome is present. Patients who meet the criteria for major depression syndrome should respond to treatment regardless of the etiology.10

Older patients may not seek help for physical or functional problems because of a sense of worthlessness or the fear of burdening others. Clinicians should resist the attitude of hopelessness that the patient may sometimes arouse in the physician. Clinical experience suggests that physicians are less likely to move from recognition to treatment of the illness in older patients than in younger patients. Since physicians, older patients and their families are usually able to find a “reason” for depression in the older person, treatment is often delayed or not pursued at all.11 Physicians may believe that a medical illness is a contraindication to treatment with antidepressants, but older patients with physical illness seem just as likely to respond to selective serotonin reuptake inhibitors (SSRIs) as older patients without physical illness.10

HOPELESSNESS

It is important to assess the psychologic component of physical illness and functional impairment when examining older patients. Hopelessness, not sadness, has been associated with suicidal ideation.12 Contrary to expectation, elderly persons who commit suicide do not have increased rates of severe or terminal illness.13,14 In some cases, however, patients falsely believed that a physical illness was severe or life-threatening and acted on this assumption. Most older adults who have a physical illness, even one as serious as cancer, are not suicidal, but patients' worries about burdening others may seem disproportionate to their degree of illness.

While thoughts of death may be developmentally normal in older persons, suicidal thoughts are not. Statements such as “what's the use?” or “I might as well be dead” should prompt a psychologic assessment of the older patient, rather than simply assurances that all is well. Older patients must be asked how they are coping with their illness, whether they feel helpless or hopeless about life, and what concerns they have about the future.

ANXIETY AND WORRIES

Worry and nervous tension (as opposed to specific anxiety syndromes, such as panic disorder) are common presentations of depression in older people. Unfortunately, many physicians tend to focus on the symptoms of anxiety and, thus, fail to consider the possibility of depression. For example, patients who have both anxiety and depressive symptoms are more likely to be given a benzodiazepine rather than treatment for depression.15,16

Older adults with depression may worry about memory loss without showing objective evidence of memory impairment in simple tests of memory. These patients should be evaluated for symptoms of depression, with careful follow-up to watch for the development of dementia.17  Patients with anxiety should be carefully assessed for symptoms of depression (Table 1)5 and, if appropriate, should be treated initially with an antidepressant. Benzodiazepines, used in the initial weeks of therapy, can treat associated anxiety. However, benzodiazepines should not be used as sole treatment since they may worsen depression and are associated with undesirable effects, such as falls, delirium and symptoms of withdrawal.

LOSS OF FEELING (ANHEDONIA)

The inability to derive pleasure from life (anhedonia) is a core symptom of depression. Patients with depression may lose their overall zest for life and the satisfaction normally derived from everyday events. Asking older patients if activities that once brought pleasure are no longer enjoyable may be helpful. While blaming restriction of activities on physical illness may be tempting, increasing evidence suggests that depression may contribute to further disability in patients with diabetes, arthritis and heart disease. Anhedonia may be expressed as no longer enjoying time spent with grandchildren or losing a sense of closeness to God. Patients who deny having suicidal thoughts may report thinking that it would be fine to fall asleep and never wake up.

SLOWED MOVEMENTS

Nonverbal clues, such as stooped posture, and slowed movement and speech, may also signal depression. Depression that is associated with vascular disease in late life is characterized by cognitive deficits and psychomotor retardation, with parallels to Parkinson's disease (involvement of subcortical brain structures).18

Risk factors for cardiovascular disease, such as hypertension, may be directly related to depression in late life; for example, the distribution of white matter and subcortical hyperintensities on magnetic resonance imaging in older persons with depression appears to be along medullary and lenticulostriate perforating arteries.19 Lesions in frontocaudate circuits may be associated with anhedonia, cognitive dysfunction and psychomotor retardation20; the syndrome is similar to depression, but without mood disturbance. Similar lesions may occur in older patients with minor depression.21

These observations emphasize the heterogeneity of the depression syndrome, providing further evidence that elderly patients may develop a form of depression that falls outside of standard criteria associated with vascular lesions in the central nervous system.

LACK OF INTEREST IN PERSONAL CARE

Physicians may become frustrated with patients who fail to follow medical or dietary therapy guidelines because of depression. Sometimes, older adults may feel unworthy of medical attention or may worry about burdening their family. Lack of interest in personal care in an older patient, including diminished concern for personal appearance, should prompt an evaluation for depression.

Implications for Assessment

Primary care physicians play a pivotal role in the evaluation and treatment of mental disturbances in older adults.22 Physicians should ask older patients about symptoms associated with depression, including sadness, but should not rely on the presence of sadness alone to diagnose depression. Asking an older patient such questions as “How are your spirits today?” may elicit a discussion about depressive symptoms and how the patient is coping with illness and other life stressors.

In older patients, cerebrovascular lesions and depressive symptoms may share a common pathologic pathway that involves depression and cognitive impairment. Older persons with depression may present in uncharacteristic ways, so that physicians may have to look beyond the patient's presenting complaint to find the depression. The patient should be evaluated for depression whenever functional impairment seems disproportionate to the extent of medical illness. It is also important to ask about thoughts of self-harm, especially in the context of bereavement and physical illness. Relatives or caregivers may be able to tell the physician about changes in the patient's functioning or may provide important clues to the diagnosis of depression.

Symptom scales, such as the Geriatric Depression Scale (30- and 15-item versions), the Beck Depression Inventory (21-item and shorter versions), the Center for Epidemiologic Studies Depression Scale (CES-D; 20 items) and other questionnaires may be useful in following the progress of patients who are receiving treatment.23,24 The CES-D-R, which is a modification of the Center for Epidemiologic Studies—Depression (CES-D), is a new instrument that corresponds with the DSM-IV criteria for depression (personal communication from William Eaton, Corey Smith and Carles Muntaner, April 22, 1999).

The CES-D-R (Figure 1) allows responses to the items that form the diagnostic criteria for major depression (Table 1)5 to be mapped so that physicians will know if the criteria for major depression are met. Specifically, a response in the most intense category (“nearly every day for two weeks”) in five of the nine symptom groups, along with either dysphoria or anhedonia, is consistent with a diagnosis of major depression.

Center for Epidemiologic Studies Depression Scale, Revised

FIGURE 1.

The Center for Epidemiologic Studies Depression Scale, Revised (CES-D-R). The items may be mapped onto the diagnostic criteria for major depression (listed in Table 1), namely, depressed mood in items 2, 4 and 6; anhedonia in items 8 and 10; appetite disturbance in items 1 and 18; sleep disturbance in items 5, 11 and 19; psychomotor agitation or retardation in items 12 and 13; fatigue in items 7 and 16; feelings of worthlessness or guilt in items 9 and 17; difficulty with concentration in items 3 and 20; and recurrent thoughts of death in items 14 and 15. When employing the CES-D-R as a scale, each item is coded from zero (“not at all or less than one day”) to 3 (“five to seven days” or “nearly every day for two weeks”). (To obtain a copy of the CES-D-R scale, visit the Johns Hopkins Web site at http://www.jhu.edu/)

View Large

Center for Epidemiologic Studies Depression Scale, Revised


FIGURE 1.

The Center for Epidemiologic Studies Depression Scale, Revised (CES-D-R). The items may be mapped onto the diagnostic criteria for major depression (listed in Table 1), namely, depressed mood in items 2, 4 and 6; anhedonia in items 8 and 10; appetite disturbance in items 1 and 18; sleep disturbance in items 5, 11 and 19; psychomotor agitation or retardation in items 12 and 13; fatigue in items 7 and 16; feelings of worthlessness or guilt in items 9 and 17; difficulty with concentration in items 3 and 20; and recurrent thoughts of death in items 14 and 15. When employing the CES-D-R as a scale, each item is coded from zero (“not at all or less than one day”) to 3 (“five to seven days” or “nearly every day for two weeks”). (To obtain a copy of the CES-D-R scale, visit the Johns Hopkins Web site at http://www.jhu.edu/)

Center for Epidemiologic Studies Depression Scale, Revised


FIGURE 1.

The Center for Epidemiologic Studies Depression Scale, Revised (CES-D-R). The items may be mapped onto the diagnostic criteria for major depression (listed in Table 1), namely, depressed mood in items 2, 4 and 6; anhedonia in items 8 and 10; appetite disturbance in items 1 and 18; sleep disturbance in items 5, 11 and 19; psychomotor agitation or retardation in items 12 and 13; fatigue in items 7 and 16; feelings of worthlessness or guilt in items 9 and 17; difficulty with concentration in items 3 and 20; and recurrent thoughts of death in items 14 and 15. When employing the CES-D-R as a scale, each item is coded from zero (“not at all or less than one day”) to 3 (“five to seven days” or “nearly every day for two weeks”). (To obtain a copy of the CES-D-R scale, visit the Johns Hopkins Web site at http://www.jhu.edu/)

The CES-D-R may also be used as a scale of depressive symptoms, much as the original CES-D has been used. Each item is coded from zero (“not at all or less than one day”) to 3 (“five to seven days” or “nearly every day for two weeks”) so that scores range from zero to 60. Scoring the CES-D-R in this way correlates with the original CES-D (personal communication from William Eaton, Corey Smith and Carles Muntaner, April 22, 1999). Based on previous work with the CES-D, a threshold of 16 or above may be considered a sign of significant depression. Depression assessment instruments may be administered by trained office staff either to assess patients or to monitor response to depression treatment.

Implications for Treatment

Three points about the treatment of depression should be emphasized.25 First, counseling has not been found to be any less effective in older patients than in younger adult patients.26 Physicians who become familiar with problem-solving or cognitive-behavioral strategies will find many useful techniques to supplement the clinical management of depression.27,28

Second, the tertiary amines amitriptyline (Elavil) and imipramine (Tofranil) should not be used to treat depression in older patients because these drugs may cause significant anticholinergic side effects. If a tricyclic antidepressant is chosen, a secondary amine, such as desipramine (Norpramin) or nortriptyline (Pamelor), is effective and associated with fewer anticholinergic side effects.

Third, whether patients are treated with psychotherapy or pharmacotherapy, if they deny or minimize feelings of sadness, the physician should rely on other features of the patient's presentation, such as level of social activity, functioning in personal care or reduction in the symptoms discussed above, to assess response. More studies of how depression presents and responds to treatment in older primary care patients are needed.29,30

The Authors

JOSEPH J. GALLO, M.D., M.P.H., is a faculty member in the Department of Family Practice and Community Medicine at the University of Pennsylvania School of Medicine, Philadelphia. Dr. Gallo received his medical degree from Pennsylvania State University College of Medicine, Hershey. He also earned a master's degree in public health from the School of Hygiene and Public Health of Johns Hopkins University, Baltimore, where he completed an NIA/NIMH fellowship in psychiatric epidemiology. He is a Brookdale Foundation National Fellow in geriatrics.

PETER V. RABINS, M.D., M.P.H., is a professor of psychiatry in the Department of Psychiatry and Behavioral Sciences of the Johns Hopkins University School of Medicine and has joint appointments in the departments of Medicine, Mental Hygiene, and Health Policy and Management. Dr. Rabins received his medical degree and a master's degree in public health from Tulane University School of Medicine, New Orleans.

Address correspondence to Joseph J. Gallo, M.D., M.P.H., Department of Family Practice and Community Medicine, University of Pennsylvania Health System, 3400 Spruce Street/2 Gates, Philadelphia, PA 19104-4283. E-mail: jjgallo@mail.med.upenn.edu. Reprints are not available from the authors.

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