Indiana University       Research & Creative Activity      September 2001 • Volume XXIV, Number 2

The most important treatment
for depression among the elderly
may be simply

Paying Attention

by Julie Sturgeon

Folks consider Carl Burkhart a classic. The 95-year-old Beech Grove, Ind., native raised two children, served in Europe in World War II, then retired from both the post office and a cab company. He and his wife celebrated 70 years of marriage before she died two weeks short of their anniversary in 1996. Burkhart refused to allow grief to overwhelm his life: He spent the winter in Florida, continued to drive elderly friends to church services, polished his joke collection, and bought a pool table to place in the living room of his two-bedroom home.

But when chronic back pain landed him in the hospital, Burkhart begged doctors to “slip him a little black pill.” He consulted his minister about suicide consequences. He prayed aloud to die while health professionals assured the family these responses were expected for his age. At wit’s end, his daughter appealed to Burkhart’s primary care provider, who glanced at the shuffling old man staring at the floor and immediately wrote a prescription for an antidepressant.

Sara Horton-Deutsch, right, counsels older adults at the Indiana University Hospital on the IUPUI campus. Photo Julie Sturgeon.

Sara Horton-Deutsch hopes to see this ending with all elderly patients she works with weekly at the IU Hospital. An associate professor in the School of Nursing at Indiana University–Purdue University Indianapolis, Horton-Deutsch’s responsibilities include practice, education, and research related to mental health and aging. Her doctoral study for geropsychiatric nursing at Rush University in Chicago was one of the first to delve into elderly suicides and depression. In her research, she found that, of the elderly suicides she examined, 78 percent revealed a diagnosable depression that went unchecked and untreated.

“The latest research continues to show that primary-care providers are not skilled in talking about and treating mental illnesses of older adults,” Horton-Deutsch says. “That’s a tremendous problem because most older adults want to receive health care from their family doctor, not a psychiatrist.”

That preference looms large when you factor in the latest census figures, which put the over-55 crowd among America’s fastest growth demographics with 56 million members. Currently, Horton-Deutsch says, between 10 to 20 percent of these older adults experience mild to moderate depression. A calculator quickly shows our society could face more than 11 million elderly depression cases in its future. “It would be an epidemic,” Horton-Deutsch says.

This demographic prospect fuels Horton-Deutsch’s drive to establish the right support systems for older patients within the medical profession, including geropsychiatric nurses in primary care practices and parity in insurance payments for mental and physical ailments. It’s a fight she unconsciously adopted in childhood, when her mother worked as a director of nursing for a long-term care facility. On school vacation days, Horton-Deutsch would work puzzles with the residents and assist the activities director. During her undergraduate studies at the University of Evansville, she worked as a nursing assistant in a nursing home and befriended an older woman who lived in her apartment building.

"We have more knowledge than ever before, yet we still lack basic human connectedness."

“We’ve become less of a society where families live closely together,” Horton-Deutsch says. “I always hope that for every older adult I support, someone reciprocates with my relatives halfway across the country.”

And that’s the crux of Horton-Deutsch’s research experience: victory over elderly depression lies in the old-fashioned concept of paying attention. “There’s a real gap between what we know and what we do in this country,” she says. For instance, theorists and the rest of us agree that having meaning in our lives and contributing in some way to our world is important. These yearnings peak at latter stages in life, yet our culture strips this generation of its roles and social status at a time when older people are experiencing unavoidable declines in health and losses of loved ones.

Horton-Deutsch notes that 25 percent of older adults with chronic illnesses such as heart disease, stroke, cancer, arthritis, and Parkinson’s disease experience depression, and 10 to 20 percent of widows and widowers develop a significant depression during the first year of bereavement. Older adults typically manifest depression through somatic complaints: sleeplessness, digestion problems, or aches and pains. “They don’t typically say, ‘I’m depressed,’” Horton-Deutsch says. “They’re often elusive. Depression in older adults takes time to identify and treat.”

No one knows how the baby boomer generation’s emphasis on emotional openness will affect future depression diagnoses, but Horton-Deutsch points to a range of factors as reasons elderly depression won’t vanish in this century: Patients, for instance, will be living longer with chronic medical conditions. Providers are often reluctant to talk to patients about mental illness. Time pressures and the restrictions on reimbursement policies will continue.

Social factors—scattered families, a decreased sense of community, and an increase in family breakups—also play a significant role. Destructive conflict at work or at home often leads to mental health woes such as depression or substance abuse. In her ongoing research, a qualitative study, Horton-Deutsch is exploring “impossible situations” in which communication breaks down between people.

“Impossible situations are those where no matter what you try when relating to another, nothing works,” she says. “It’s when two people reach a total impasse.” Her goal is to study the basic social processes and dynamics in these “impossible” human interactions and how such breakdowns of communication might be prevented or avoided.

“It’s amazing to me that we have more knowledge than ever before, yet we still lack basic human connectedness,” says Horton-Deutsch. “One more computer application won’t fix some of the problems we have in our society.” However, she does point out some keys to help family members identify depression. First, scrap your agenda in favor of just listening.

“Everybody has a specific question for older adults: ‘Can you pay your electric bill? Any cardiac symptoms? Who came over last night?’ When we do that we’re not open to what’s on their minds,” Horton-Deutsch explains.

Second, avoid closed-ended questions. “Would you like to go out to eat today?” often elicits a quiet refusal. “Grab your coat; I want to show you something” builds a foundation for better dialogues and relationships. If you observe disturbing signs, such as sadness, loss of interest, difficulty concentrating, irritability, or excessive crying, ask directly about what you see. Encourage the older adult to seek medical treatment. Better yet, offer to take him or her to a primary care provider or a mental health professional.

As a member of the state’s Mental Health and Aging Coalition, Horton-Deutsch is working with others to develop a mental health guide for older Hoosiers and their families. The coalition is also planning six continuing education programs that will take place throughout Indiana in 2002. These programs aim to help primary care providers identify and treat depression and other mental illnesses in the elderly.

“Often health-care providers say, ‘Well it’s an understandable depression.’ But just because we understand it doesn’t mean we shouldn’t treat it,” Horton-Deutsch emphasizes. “Once we get past the barriers—older adults’ self-imposed stigmas and our stereotyped views of aging—depression is extremely treatable.”

Just ask Carl Burkhart, who now eagerly anticipates the birth of his first great-grandchild.

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