Late-Life Depression: Triggered By Age…Or Ageism?

No one knows for certain what causes depression or what role it is meant to play in the evolution of humankind. Most current theories propose it is the result of the interaction of factors as varied as epigenetics, trauma, illness, stress, loss, guilt, regret, isolation, side effects from medications, and even hearing problems. We do know that many times depression is the result of external events, but just as often it is believed to be the result of internal factors such as negative self-talk or a generally pessimistic worldview.

It’s normal to feel sad when bad things happen. But when you can’t bounce back and the feelings of sadness, lethargy or anger begin to affect how you get along with friends and family, it becomes a real problem.

One tell-tale sign that you are depressed is that when time passes and the situation improves, you don’t feel better.

According to a 2015 study by the National Institute of Mental Health, 6.7 percent of American adults 18+ annually experience at least one episode of symptoms sufficient to warrant a diagnosis of Major Depressive Disorder. That figure is projected to be more than doubled for older adults. The founder of the Weill Cornell Institute of Geriatric Psychiatry, Dr. George Alexopoulos, predicts that 15 percent of the population over sixty-five will develop clinical depression and that more than two-thirds of those will remain undiagnosed and untreated. The thing to remember is that depression is one form of mental illness that can be fatal because it may lead to suicide, especially among seniors. According to the New York Times (8/7/13), elderly white men have the highest rate of suicide with 29 per 100,000 over all, and more than 47 per 100,000 among those over age 85. Dr. Martha Bruce, PhD, also of Weill Cornell, says this alarming figure is “partly a result of so much stigma about mental illness and partly a result of ageism.”

Ageism is only now being recognized as a significant contributing factor in late-life depression. One reason for this new awareness of age discrimination may be that the Baby Boomers who created our youth-obsessed culture are now entering their sixties and surprised to find traditional assumptions about old age at odds with their values and lifestyles.  Ageism remains the last socially accepted form of prejudice. Older adults continue to be portrayed as frail, inflexible, and a burden on society. These attitudes are instilled in us when we are young and are further reinforced by the media and society as we grow. What’s even worse is that we tend to internalize these socially constructed biases without questioning them.

Studies have shown a definite link between age discrimination and depression.  If you believe the stereotypes, the instant you turn 65 you are suddenly “old and in the way.” These unfounded characterizations have a corrosive effect on our self-esteem and tend to make us withdraw from activities that are not “age-appropriate.” If you add this sense of marginalization to the loss of identity, loss of youth, loss of career, loss of independence, and loss of friends or loved ones you experience as you age, you have a surefire recipe for depression. In fact, loneliness, and the depression it causes, have been cited in a recent study by the Alzheimer’s Association (2015) as a major factor in cognitive decline.

There are several reasons why depression in older adults often goes untreated. The state of the medical profession is one. There is a severe shortage of doctors trained in geriatric medicine, especially in psychiatry. General practitioners rarely take the time to screen for depression or anxiety during routine check-ups. If an older person complains of feeling down or not enjoying life, the doctor is likely to say something like, “Well at your age, what do you expect?”  If your doctors pass off your symptoms as a function of age, call them on it. Depression is not a normal part of aging. And hopefully in the near future ageism won’t be either.

This article originally appeared in the Charlottesville Daily Progress on September 14, 2017

Mindfulness Training: A Proven Brain Changer

As I was researching material for an upcoming workshop, I came across an article by Dr. Frank Sommers who is the author of “Lose Weight, Stop Stress and Make Better Love” (Amazon.com / Caversham Booksellers). The article appears in The Sexual and Relationship Therapy Journal’s special edition on Mindfulness (ed. By L. Brotto and M. Barker).  In the abstract for the piece, Dr. Sommers says, “Increasing evidence is accumulating on the real benefits of mindfulness training. It is also emerging as a core, effective component of modern sex therapy practice.” He notes that neuro-endocrine and neuro-imagery studies he’s observed provide evidence that a treatment called Visually Enhanced Psycho-Sexual Therapy is effective in treating sexual dysfunctions in a number of cases. He discusses applying two basic mindfulness principles, which he terms, “Present Centered” and “Process Absorbed,” as a way of “training the autonomic nervous system, and the integrative and sensory components of the central nervous system.”  He sums up by saying that the “graduates” of his 10–15 session practice program “learn to become mindful not only in their loving and love-making behavior, but also generalize this way of being in the world in their daily lives.”

Dr. Sommers’ findings echo what many therapists I talk to are discovering: that using mindfulness techniques in tandem with evidence-based therapies such as CBT and REBT in treating sexual dysfunction not only changes behavior but actually alters brain structure and chemistry in a way that makes those changes more lasting. When you become more mindful about the sources of your pleasure, it encourages the brain to set up a positive feedback mechanism that motivates us to recreate that pleasure we’re feeling now in the future. As a result of becoming more mindful of where our pleasures come from, we can almost assure a consistent increase in the amount of pleasure we will experience.  This pleasure, according to Dr. Sommers, will encourage our nervous systems to become more tuned to pleasant experiences and (one hopes) make us more resilient and resistant to negative thoughts and mood disorders.

How Resilient Are We?

A therapist working with older adults looks at how people react to loss and realizes that in the end most of us do a pretty good job of coping.

While providing crisis counseling to people who suffered significant losses in the aftermath of Hurricane Sandy, I began to wonder what the natural response is to losing someone (or something) we hold dear, especially among the older adults I work with.

First off, it’s well known that all of us face a mounting number of losses as we get older– Parents and friends pass away, careers end, bodies wear down, and our minds sometimes aren’t as sharp as they once were. How we respond to those losses varies depending on a number of factors.  A socially (and clinically) accepted response to a significant loss is profound sadness.  But how long that sadness lasts and how it affects the way we function on a daily basis reveals a lot.  First a few quick definitions: Bereavement is the state of having suffered a loss. Grief refers to how a person deals with loss. Mourning has to do with society’s rituals surrounding the loss, such as funerals and burial rites.

The Handbook of Assessment in Clinical Gerontology edited by Peter A. Lichtenberg, cites a longitudinal study by Zisook, Paulus, Shuchter and Judd of how prevalent depressive disorders are after the loss of a loved one.  The results showed that 20 percent of the participants met the criteria for major depressive disorder two months after the loss.  After 13 months, that figure fell to 12 percent. After 25 months, it dropped even further to only 6 percent.  At the same time, during all three periods, the study showed that nearly half the participants displayed no symptoms of depression, major or otherwise. These people coped.  They may have been very sad, but they processed the loss and moved on.

How did they do it?  My guess is that they had positive social supports that gave them a time to grieve and at the same time signaled them when it was proper to stop grieving.  Furthermore, since having depressive symptoms or other problems prior to a traumatic loss is a prime indicator of whether or not a person will become depressed when a loss occurs, it’s safe to assume the resilient ones were not prone to rumination, negative self-talk, or delusions that God was somehow punishing them. Studies have shown that in most cases half of us will bounce back from a significant loss after about two months, about a third of us will have trouble adjusting but eventually let the loss go, and the remaining 20 percent will continue to suffer for a while.  In the end, the number of people who have the most difficulty getting better is approximately equal to the number of people in the general population who are already at risk for mood disorders.

Bereavement is a normal reaction to loss.  Depression is not. Statistics show that in most cases paying attention to others, maintaining a healthy lifestyle, staying mentally active and keeping a positive outlook will provide the resiliency we need when we lose someone or something we hold dear.

In Defense Of Pleasure

As a therapist in New York working with older adults, it seems that just about every psychological issue has its roots in a lack of feeling safe, included or trusted. Generally people develop severe mental illness when accidents of heredity or persistent trauma are added to that equation. Sexual abuse can be the most crippling. Parental abandonment is right up there, too. Healing in traumatic situations like these requires much more than the “pain relief” pills provide. Instead, I believe it requires the proactive introduction of pleasure into the individual’s life. This pleasure is not just for fun. It is to attempt to see if pleasure can be learned and applied to the affairs of daily living. It is also an attempt to see if the endocrine system can reverse the physical damage caused by long-term stress or trauma.

What would happen if a program of treatment included increased human touch, along with social engagement, personal validation, and group activities instead of pharmacological interventions? Of course, there will always be those who require medication, but we should only provide pharmaceuticals when a caring environment and efforts of a healing community have failed. I want to see if having masseuses, therapists, sex surrogates, nutritionists and personal trainers working as something of a “personal crisis team” can help older adults improve their sense of well-being.

The reason I mention all this is that, too often, as people get older, their opportunities for pleasure diminish. Older adults deserve to feel good and that includes having physical intimacy with others or themselves. The fact that people who are uncomfortable with sexual activity–whether adult children, institutional caregivers or administrators–restrict older adults’ opportunity for privacy, intimacy and pleasurable activity is both ageist and contemptible.

As you can probably guess by now, I’m a big believer in talk therapy in general and the therapeutic value of human touch in particular. I won’t go into the research comparing the act of hugging favorably with drugs for reported relief from distress. But I believe we should treat pain and distress by finding ways to increase the amount of pleasure a person is experiencing rather than simply trying to reduce their pain.

Motivational Interviewing: It’s All About Creating Change

Motivational Interviewing is a directive counseling style that is all about creating change. It works on modifying clients’ behavior by helping them explore and resolve their ambivalence. Using empathy, encouraging self-motivation, and diffusing resistance, the counselor helps clients develop their coping skills. The goal is to enable people to realize the discrepancy between behavior that helps them meet their personal goals and behavior that doesn’t.  Motivation for change occurs “when people see the gap between where they are and where they want to be.”

The technique has become the therapy of choice for many addiction counselors and, when combined with education, harm-reduction approaches, social support and (occasionally) Cognitive Behavioral Therapy, it has been proven effective in many cases, especially in the area of relapse prevention.

Motivational Interviewing is based on Abraham Maslow’s Hierarchy of Needs and his concepts of “self-actualization” and “self-transcendence.” Maslow’s theory is that at the most basic level we need food, water, sex, sleep and oxygen.  After taking care of those needs, we turn our attention to finding shelter and safety.  When those needs are satisfied, we look to meet our social needs—things like love, belonging, friendship, and intimacy. After that, we are driven to satisfy our need to think well of ourselves and strive to build self-esteem, achieve things, gain courage and confidence, and obtain the respect of others.

Once you have secured these needs in your life, then you are in position to begin to think about reaching the “apex” which is self-actualization. Self Actualization is the state where your needs for order, creativity, problem solving, are met and you realize your fullest potential. Self-Actualization was the apex of the hierarchy. At least until Maslow added the need for “Self-Transcendence.” In the Self Transcendence area, your spiritual needs are met. These needs are beyond and outside the self and are usually concerned with feeling a part of you will live on after you’re gone. People in this stage are concerned with issues such as success of their offspring and leaving a legacy.

Maslow believed that society’s full focus should not be on creating people who can work and fight, but instead on creating people who are self-actualized.  If people have their needs met at that level, he reasoned, then everything else would take care of itself.

With Maslow’s theory in mind and Motivational Interviewing techniques in hand, the therapeutic possibilities outside addiction counseling are interesting. It helped one member of a couple I worked with recently understand why she was upset with her partner and how to create change when she was certain it was impossible.

For teenagers who feel forced into therapy by their parents, it is an effective tool for building a therapeutic alliance under difficult circumstances. I have also seen MI break therapeutic logjams in cognitive-behavioral treatment for depression and anxiety. I also encourage parents to acquaint themselves with Motivational Interviewing. It can come in handy when your teenager begins acting out or shutting you down.

For those who want more information,  “Eight Stages In Learning Motivational Interviewing,” an article by Miller and Moyers in the Journal of Teaching in the Addictions is a good resource. Also Monty Roberts’ instruction manual, “OASAS Training of New Trainers and Supervisors.”