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December 4, 2006

A University of Michigan Health Minute update on important health issues.

Home for the holidays? Watch for signs of depression in older loved ones, U-M Depression Center expert advises

Late-life depression is more common than once believed, especially among those who also have heart disease, lung disease, diabetes, cancer or other major illnesses

ANN ARBOR, MI – So you’re heading home to see Mom and Dad this holiday season – or maybe Aunt Sue or Grandpa George. If you’re like many Americans, it may have been weeks, months or even years since you’ve seen them last. And as they – and you – grow older, these holiday reunions grow more special each year.


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But what if you notice that one of your older relatives isn’t quite their old self? That they’re more anxious, more irritable, less joyful or quieter than they once were? That they seem focused on talking about people who have died, or have lost interest in things that they used to enjoy – including holiday traditions and festivities?

It’s possible that these changes add up to signs of late-life depression, which may affect as many as one in seven older people. It’s especially common among those who have suffered a serious physical problem, whether it’s a heart attack, cancer, lung disease, or problems with their hips and joints.

Helen C. Kales, M.D., hears this tale many times each year, from patients who come to see her after their family members notice a serious change in their behavior at the holidays and encourage them to seek help. As a geriatric psychiatrist who specializes in helping older people cope with depression and other mental illness, Kales knows that it often takes the prompting of a family member to help an older person recognize their symptoms.

“One of the big things that happens at the holidays is that families who are coming in from out of town spot these symptoms and changes for the first time. For instance, their parent or relative isn’t taking as good care of themselves or their home as they used to,” says Kales, a member of the University of Michigan Depression Center. “It’s a myth that depression is a normal part of aging, and that you just get old and tired and sad naturally. Normal aging is not associated with depression, and late-life depression is just as treatable as any other form.”

Kales, who treats older patients with depression at the U-M Geriatrics Center and the VA Ann Arbor Healthcare System, notes that older people who have experienced mental health problems in the past, and those who have significant physical health problems that limit their lives, face the highest risk of developing late-life depression.

But even otherwise healthy elders can find themselves feeling depressed after a serious blow like the death of a spouse, sibling or close friend, or the loss of their social network when they move to an assisted living facility or to live with relatives.

All of these “triggers”, as they are called, can combine with the special pressures and interrupted routines of the holiday season to create an even greater risk of depression during the holidays. Such feelings may pass as Christmas, Hanukkah and New Year’s Day fade into memory. Or, they can lead the person to develop more serious and prolonged depression lasting weeks or months. That’s when it’s important to get help.

People in their seventies, eighties and nineties may also be less likely to recognize their increased tiredness, loss of appetite, and mood swings as signs of depression, Kales says, both because of other physical problems they have, or simply because of the era in which they grew up.

Health Minute Image“They were taught to pick themselves up by their bootstraps and not to cry when things went wrong,” she explains. “So it may be really hard for them to talk about having emotional problems or experiencing depression. They may feel like they need to be stoic and power through it.”

In other words, the generations that witnessed the Great Depression may be less likely to recognize their own depression.

Fortunately, younger people have grown up in an era when research has shown that depression is a physical illness rooted in brain chemistry and genetics, and not in personal failings or weakness. That’s why it’s so important for them to speak up to their relatives if they notice something wrong, says Kales, who is an assistant professor of psychiatry at the U-M Medical School and Director of the Geriatric Psychiatry Clinic at the VA. Sometimes, it may even be worthwhile to mention those observations to the loved one’s main doctor, who can check on things further at the next office visit.

So what can be done for an older person who develops temporary or more lasting depression? The easiest prescription, Kales says, is simply to get out of the house and connect with other people.

“That’s actually a hard thing to do, because in depression people feel unmotivated, and feel like being isolated – but it can become a vicious cycle because the more they stay in and don’t connect with others, the worse they feel,” she explains. “They need to try to get over that hump, and get out there. And what I find is that they often feel much better once they’ve done it.”

Another easy way for older people to confront those blues is to treat themselves to something they haven’t done or had in a while, like a nice dinner or a little present – especially at the holidays. And don’t forget exercise, no matter what form it takes, Kales adds. “We know that exercise causes all kinds of good hormones to be released, and for older people that can make depression lessen.”

One thing to avoid, or at least to cut back on, is alcohol. “It’s very important that older people who are feeling low should minimize their use of alcohol,” Kales cautions. “Sometimes they might use it to help them go to sleep or improve their mood, but the bottom line is that alcohol is a depressant and helps mess up their sleep.”

For those whose depression symptoms continue for weeks or months despite these measures, Kales emphasizes two things: counseling, also known as talk therapy, and medication.

Talk therapy, which can be done with the help of a psychologist, mental health social worker or psychiatrist, involves developing new ways of thinking about one’s situation – and confronting negative thoughts and moods.

Older people may conjure up a stereotype of going to a “shrink” as something that will make them recite their childhood feelings while lying on a couch -- but that’s not the way it’s done these days at all, Kales says. Counseling, whether alone or in groups, has been proven to help people get better and stave off future bouts of depression. “Even though people are getting older, you can teach an old dog new tricks,” as the saying goes, Kales explains.

When other approaches don’t do enough, older people may want to consider some of the modern antidepressants that have been introduced in the last two decades, Kales says – much better than the mental health treatments of old that they may be familiar with.

Interestingly, older people usually need to start with much lower doses of antidepressants than younger people, because of changes in their drug metabolism and use of other medications as they age. But importantly, many older people need the same final dose as younger people, so it’s important to “start low, go slow” but “don’t stop” when increasing the antidepressant medication.  Ultimately, the choice of drug, and of dose, varies from person to person, and it may take patience to find something that works. It’s best if this trial-and-error process is guided by someone experienced in treating depression, or even someone who specializes in treating older people’s depression.

The bottom line is that families need to keep their eyes and ears open for signs of depression in older relatives, especially at the holidays when they have a chance to get together and spend some time. And if someone seems to need help, don’t be afraid to speak up and reach out.

Facts about late-life depression:

  • About 15 percent of older people may be experiencing depression at any given time.
  • Depression is different from temporary “blues” or mourning for a lost loved one, in that it lasts longer, and doesn’t let up from day to day.
  • Symptoms can include anxiety, irritability, loss of pleasure in activities, feelings of hopelessness and worthlessness, and worsened physical pain.
  • Some of the symptoms of depression that are most common in younger people, such as prolonged sadness, may not be as common in older people.
  • As older people develop age-related health problems like heart disease, complications of diabetes, lung disease, joint problems and vision or hearing loss, they may start to experience symptoms of depression. In other words, their physical illness can ‘trigger’ a bout of depression.
  • Other triggers for depression include the loss of a loved one, the loss of social networks of friends and acquaintances because of a move, and even the hubbub of the holidays.  

Find more on the Web at:

U-M Depression Center: Depression in older adults

Free online self-test for depression from the U-M Depression Center

Geriatric Mental Health Foundation: Mental Wellness in Older Age depression toolkit

To find a mental health professional who specializes in diagnosing and treating older people, visit, or

Or call the national Eldercare Locator service toll-free at 1-800-677-1116 weekdays between 9 a.m. and 8 p.m. ET.


Written by Kara Gavin


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