Text Overview of Video
Professor Nicola Lautenschlager
It is important to discriminate, when we use the term “depression,” between the term how we use it often in everyday life, “Oh I feel depressed today,” and depression as a medical condition. In the latter scenario, depression is a mental health problem, and is an illness and, obviously, is a very important illness to treat, because if not recognised and treated, it can come along with very severe health outcomes. It is one of the most common mental health conditions, and it is actually also one of the most common health conditions, full stop. Current estimations of how common depression is globally, estimate that roughly, at any given time, 350 million people suffer from depression globally. When it comes to using depression as a term in our everyday language, we often describe with that [word] just having a bad day, and sometimes it can also mean feeling stressed. We all can have symptoms of depression. Let’s say we go through a very difficult phase in our life. We have adverse life circumstances, without actually fulfilling the criteria to experience full-blown depression as a medical condition. What are the essential criteria or essential symptoms of depression as an illness? Obviously, most important is the symptom of feeling down or having a low mood. That’s usually considered central in a depressive episode, for example, but it has to be more than that. Usually it has to be around for a certain duration of weeks. It has to be severe enough that it impacts on the person’s daily life. For example, it impacts on their work or impacts on their family life. There are other important symptoms like having poor sleep, or having changed appetite, having changed energy levels, and the interesting thing about depression is that it can go either way. You have people who are more fatigued and sleep more, and have no energy, and find it very difficult to get out of bed and do things. But then you can also have people who have more an agitated depression, meaning they’re restless, they can’t sleep, they are overactive, they’re reactive, but all the activities they might do might not be very meaningful, because they can’t concentrate.
The challenge with depression is that it can come with various forms of presentation, and therefore can be missed, for example, in general practice, especially if it presents in an unusual form. One interesting question is, “Does depression look different in a younger person versus an older person?” What’s important to understand is that the core symptoms of depression are the same in young and old. But research tells us that in old age there are certain symptoms which are more prominent, when it comes to depression, than in younger people. I’ll give you an example. Older people with depression tend to feel more somatic symptoms and these are usually the complaints or the concerns they communicate to their general practitioner. So they have headaches or they have problems with their stomach or their bowels. They might have pain in their chest or they feel they have weak muscles. So we have to be mindful, working in the health field, or also just as family members, that when an older person has many changing and various health complaints, somatic health complaints, that what could be behind it is a depression, especially if the general practitioner investigating can’t find any causes for these complaints. That’s different to younger people. Since younger people tend to experience more the mental health side of depression, with having a low mood and feeling irritable, for example.
Another important fact to be aware of, is that older generations of people tend to associate a bigger stigma with having a mental health condition such as depression, and therefore are much more reluctant to talk about it, because they often interpret that as a failure of who they are, and it might be a sign of weakness, or weakness of character. It is rarer in older people for them to talk about their mental health, even to their loved ones, than on average it is in younger people. There is also an interesting gender bias. So, not surprisingly, looking at western societies, men find it harder to talk about their mental health than women, and there is also a geographical difference, that people living in rural communities find it harder to talk about their mental health compared to people living in cities.
One important point when it comes to depression in older people is, to try to investigate “Why is the person experiencing depression in the first place?” This is particularly important if it is an older person who never had a depressive episode before in their life. We call that having late onset depression for the first time in their life. The reason why this is important is, that there are different health or medical conditions which might be causing the symptoms of depression. It could be just a depressive episode for various reasons, and these reasons could be changing of the body, physiologically, due to ageing, additionally with chronic health issues, additionally through changes to their life circumstances, but it also could be a symptom of emerging biological changes to the brain, due to cognitive decline or emerging dementia. We do know that there is a certain percentage of people who develop, later on, dementia, such as Alzheimer's disease, where the first symptom was actually change to their mood with developing depression, and research has shown that can be several years before there is any onset of clear cognitive changes.
It is important not to scare people who have late onset depression, because that might not be the case for them. What the recommendation is for clinicians is, if a person develops late onset depression, to assess their memory, and even after they have recovered from the depression, to see them on a regular basis and to continue to assess their memory, just to have an eye on it. Because usually, if it would be due to underlying dementia processes, eventually you would be able to measure the cognitive decline. To give you an idea, most studies statistically estimate that a person with late onset depression has roughly a twofold risk of developing cognitive decline, compared to an older person who doesn’t experience late onset depression.
How common is that, that an older person with depression also has problems with their cognition? Studies estimate between 40% to 60% of older people who experience depression have, at the same time, problems with their cognition. Very often it is around being able to concentrate and pay attention, which is typical for depression, but this is a much higher percentage than in younger people. Sometimes one comes across a term called “pseudo dementia” especially in the older literature which tries to describe these changes to cognition, while depression is present, and it’s called “pseudo” because very often when the person has recovered from their depressive symptoms, also their cognition returns to normal again.