Published: Oct. 17, 2006
Updated: May 10, 2010
Delaina Buehler didn't feel sad or blue. "It was more of a blah feeling," recalls the 68-year-old retired schoolteacher. "I had every reason in the world to be happy -- a wonderful husband, children, and grandchildren -- but I wasn't. It's not that I was unhappy. I'd just go for weeks without any interest in life and have times when I felt like I really didn't care what happened."
When her doctor diagnosed depression, Buehler was surprised. Reluctant to see a psychiatrist, she enrolled in Duke's Project IMPACT, a study testing a novel approach to depression treatment in primary care. At the same Durham clinic where she saw her primary care physician, Buehler met regularly with Carol Saur, an advanced practice nurse specializing in mental health, who in turn consulted with the program's psychiatrist.
"I didn't want to take medication," Buehler admits. "But Carol taught me that depression is a medical condition involving changes in brain chemistry, so I decided to try it. And in our meetings, so many things came out. She also helped me come up with some strategies to be more assertive when necessary. The whole experience was extremely positive and made a big difference in my life.”
Depression is a widely underrecognized and undertreated medical illness. "At best, only about a quarter of all cases of major depression are diagnosed," says David Steffens, MD, psychiatrist for Project IMPACT and head of Duke's Division of Geriatric Psychiatry. While the illness is frequently missed in people of all ages, he says several factors make depression particularly misunderstood in older adults.
"The classic symptoms of sadness, crying, and the blues tend to be present in people in their 20s and 30s," Steffens says. "But we've only recently recognized that depression generally presents in older people as loss of interest in life and the inability to experience pleasure in formerly enjoyable activities." In addition, he says, problems that may be shrugged off as "part of getting old" -- such as memory loss, difficulty concentrating, and slowing down of body movements -- may, in fact, be symptoms of depression. "When the depression is treated," Steffens says, "these problems may lessen or go away entirely."
Depression is also associated with increased disability and exacerbation of other medical conditions, which can trigger a deepening cycle of depression. "We know that the more medical problems an older person has, the greater their risk of depression," says Ranga Krishnan, MD, chairman of Duke's Department of Psychiatry.
Researchers are just beginning to unlock the complex biochemical connections between depression and other disorders. Krishnan has identified a condition called vascular depression caused by "silent strokes" deep within the emotion centers of the brain. This evidence suggests "a two-way street," he says, "with risk factors for cardiovascular disease influencing the onset of depression in otherwise mentally healthy patients."
In addition, says Krishnan, certain medical conditions can mimic depression and should be ruled out, including thyroid problems and some brain disorders such as Parkinson's disease. "It's important to treat both the depression and the medical condition," he notes. "Improving one can help the other, and vice versa." Treating depression is also critical to reduce the risk of suicide, which he says is "almost epidemic now among older adults, particularly white males."
Yet there are many barriers to effective treatment, particularly among seniors. Many still subscribe to outdated notions that depression represents a character flaw or weakness they should be able to overcome with willpower, says Linda Harpole, MD, a former assistant professor in the Department of Medicine. "The idea behind Project IMPACT is that, because of this stigma issue, older adults are more likely to come to their primary physician's office for care," says Harpole, principal investigator of the Duke portion of the multi-center, randomized clinical trial.
Project IMPACT studied more than 1,800 participants age 60 and older with major depression and/or dysthymic disorder (chronic, low-level depression) from 18 primary care clinics across the U.S., including 254 Duke patients. At each site, participants worked with a depression care manager -- generally a mental health nurse or psychologist -- in collaboration with a psychiatrist and primary care practitioner. Compared to the "usual care" patients, those in Project IMPACT experienced significantly higher rates of depression treatment, greater satisfaction with depression care, improvement in depression scores, lower rates of major depression at six months, less functional impairment, and greater quality of life.
To help identify patients with depression, Saur and her colleagues use simple screening tests. After a patient has been diagnosed, Saur, in consultation with Steffens, brings in a full arsenal of treatments -- including medication, psychotherapy, and self-help methods. "First I educate patients about depression," she says. "Then I help them identify their triggers and create strategies to handle difficult situations."
Saur also gives her patients "homework," asking them to practice self-management techniques such as deep relaxation breathing and taking at least 10 to 15 minutes a day to pursue an enjoyable activity.
Exercising for at least 30 minutes three times per week may also be part of the prescription. Indeed, studies by Duke psychologist James Blumenthal, PhD, suggest that aerobic exercise is comparable to antidepressant medication in relieving depression in the middle-aged and elderly.
As research reveals more about the causes of depression, treatment is bound to become more effective -- but no therapy can replace the simple act of identifying those who need help, according to Blumenthal. "Depression is fairly common, and it doesn't hide itself if you ask the right questions," he says. He believes the most important question is this: "Do you get enjoyment out of life?"
As Delaina Buehler says, “I'd urge anyone who's not feeling right to get this kind of help immediately. Life's too short to feel bad."