But I'm Too Old To Be Depressed (or Anxious)
by James W. Jefferson, M.D.| Geriatric Times |  |
September/October 2000 | |
Vol. I | |
Issue 3 |
A review by A.F. Jorm, Ph.D., D.Sc., from the Psychiatric Epidemiology Research Centre at Australian National University, suggests there may be something to look forward to as one ages: namely, a reduced risk of anxiety and depression. He did not come to this conclusion easily, for at first glance, the general population surveys he evaluated revealed no consistent pattern across studies for age differences in the occurrence of anxiety, depression or distress (Jorm, 2000). Since risk factors such as gender, marital status, income and education level may not be distributed evenly across age groups, controlling for them gave a clearer view of the effects of age itself. When this was done, most studies did find a decreased risk for anxiety and depression with age.
Before becoming enamored with the joys of growing old, ask yourself, could sampling biases account for these results? For example, are depressed and anxious people more likely to die before reaching old age? There does appear to be an association between depression and an increased risk of death (Wulsin et al., 1999). Wulsin and colleagues concluded that the studies linking depression to early death are poorly controlled, but suggest that depression substantially increases the risk of death, especially death by unnatural causes and cardiovascular disease. Whether this is also likely for anxiety is less clear, but there is suggestive evidence supporting increased early mortality from at least some of the anxiety disorders (Harris et al., 1998).
Causal associations may be difficult to establish because studies may not control for poor physical health as the true risk factor for early mortality, with anxiety and depression merely riding along as secondary manifestations. Be that as it may, the overall mortality rate in young people is quite low and, therefore, unlikely to have a major impact as a sampling bias.
The other potential bias Jorm considered was the exclusion of institutionalized elderly from most general population surveys. The prevalence of depression in nursing homes does appear to be higher than in the community (whether this is also true for anxiety is unclear). He points out that the percent of young-old in nursing homes is relatively low and unlikely to have a major biasing impact, although this may not be the case with the older elderly.
Finally, this apparent decreased risk of anxiety and depression with aging could actually be a cohort effect. Could the youth of today have been inoculated with "depressinogens" or "anxietyogens" at a higher rate than the youth of yesteryear and thus be at greater risk for developing these disorders? Only long-long term longitudinal studies will be able to accurately address this question.
All in all, it does seem that we can look forward to less anxiety and depression in our golden years-assuming we carefully control our risk factors and selection biases. But as clinicians, rather than consumers, do we really care? In outpatient and inpatient settings, there is no shortage of anxiety and depression in older adults. In a way, this is fortunate, since these conditions have a good likelihood of responding to treatment and, without them, geriatricians would spend most of their time struggling with the relentless progression of the dementing disorders.
It is well-established that anxiety disorders coexist commonly with major depressive disorder in the non-geriatric adult population (Pini et al., 1997). A retrospective study from the University of Pittsburgh suggested that this might not be the case with late-life depression (Mulsant et al., 1996). Comprehensive evaluation of 336 outpatients and inpatients with major depression found a considerable amount of associated severe anxiety, but less than 5% of the patients actually met diagnostic criteria for a lifetime or current diagnosis of panic disorder, obsessive-compulsive disorder, social phobia or simple phobia. Because of diagnostic criteria difficulties (symptom overlap), generalized anxiety disorder (GAD) was not assessed in the depressed patients. So the good news was less anxiety disorder comorbidity in the depressed elderly, but the bad news was that when comorbidity did exist, treatment response was impaired: there was greater benzodiazepine use and a 50% longer time to respond to antidepressant treatment.
A more recent report from researchers at the University of Pittsburgh suggests that the comprehensive evaluation done in the above-mentioned study may not have been comprehensive enough (Lenze et al., 2000). While both studies used the same structured interview, the second study, which was prospective, also incorporated the services of an anxiety disorders specialist. The outcome was quite different. Among 182 depressed patients (mean age 71.4 years), 35% had at least one lifetime anxiety disorder diagnosis and 23% had a current anxiety disorder diagnosis. In addition, 27.5% had symptoms consistent with current GAD (which was not diagnosed formally because the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID] excludes this diagnosis in the presence of major depression because of symptom overlap). All in all, it was not good to have a coexisting anxiety disorder (poorer social function and more somatic symptoms) or symptoms of generalized anxiety disorder (more severe depressive symptoms and greater suicidality).
"Seek, and ye shall find" should be the motto of this research group, whose concerted efforts uncovered substantial comorbidity of anxiety disorders in elderly patients with major depression. They stated: "This should serve as an object lesson to clinicians and clinical researchers, regarding the need to focus on comorbid disorders in order to have adequate sensitivity to find them" (Lenze et al., 2000).
This might be a bit demoralizing to the average clinician who sees 10 to 30 patients per day when they realize that it took a cadre of geriatric mood and anxiety disorders specialists using structured clinical interviews to uncover this otherwise hidden psychopathology. On the other hand, knowing that anxiety disorders coexist commonly with major depression in the elderly should stimulate a search that has a reasonable likelihood of being at least somewhat productive. That, in turn, can lead only to a more gratifying therapeutic outcome.
Clinician-leave no diagnostic stone unturned.
Dr. Jefferson is distinguished senior scientist at the Madison Institute of Medicine and clinical professor of psychiatry at the University of Wisconsin Medical School.
References
Harris EC, Barraclough B (1998), Excess mortality of mental disorder. Br J Psychiatry 173:11-53.
Jorm AF (2000), Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the adult life span. Psychol Med 30(1):11-22.
Lenze EJ, Mulsant BH, Shear MK et al. (2000), Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry 157(5):722-728.
Mulsant BH, Reynolds CF 3rd, Shear MK et al. (1996), Comorbid anxiety disorders in late-life depression. Anxiety 2(5):242-247.
Pini S, Cassano GB, Simonini E et al. (1997), Prevalence of anxiety disorders comorbidity in bipolar depression, unipolar depression and dysthymia. J Affect Disord 42(2-3):145-153.
Wulsin LR, Vaillant GE, Wells VE (1999), A systematic review of the mortality of depression. Psychosom Med 61(1):6-17.