In Another Land

A brief overview of the statistics on depression and suicide in older adults, with information on depression treatments and suicide prevention (2003).

How common is suicide among older adults?

Older Americans are disproportionately likely to die by suicide.

Although they comprise only 12 percent of the U.S. population, people age 65 and older accounted for 16 percent of suicide deaths in 2004.1
14.3 of every 100,000 people age 65 and older died by suicide in 2004, higher than the rate of about 11 per 100,000 in the general population. 1
Non-Hispanic white men age 85 and older were most likely to die by suicide. They had a rate of 49.8 suicide deaths per 100,000 persons in that age group.1

What role does depression play?

Depression, one of the conditions most commonly associated with suicide in older adults,2 is a widely under-recognized and undertreated medical illness. Studies show that many older adults who die by suicide — up to 75 percent — visited a physician within a month before death.3 These findings point to the urgency of improving detection and treatment of depression to reduce suicide risk among older adults.

The risk of depression in the elderly increases with other illnesses and when ability to function becomes limited. Estimates of major depression in older people living in the community range from less than 1 percent to about 5 percent, but rises to 13.5 percent in those who require home healthcare and to 11.5 percent in elderly hospital patients.4
An estimated 5 million have subsyndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder.5,6
Subsyndromal depression is especially common among older persons and is associated with an increased risk of developing major depression.7
Isn’t depression just part of aging?

Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary “blue” moods are normal. Persistent depression that interferes significantly with ability to function is not.

Health professionals may mistakenly think that persistent depression is an acceptable response to other serious illnesses and the social and financial hardships that often accompany aging - an attitude often shared by older people themselves.8,9 This contributes to low rates of diagnosis and treatment in older adults.

Depression can and should be treated when it occurs at the same time as other medical illnesses. Untreated depression can delay recovery or worsen the outcome of these other illnesses.

What are the treatments for depression in older adults?

Antidepressant medications or psychotherapy, or a combination of the two, can be effective treatments for late-life depression.

Medications

Antidepressant medications affect brain chemicals called neurotransmitters. For example, medications called SSRIs (selective serotonin reuptake inhibitors) affect the neurotransmitter serotonin. Different medications may affect different neurotransmitters.

Some older adults may find that newer antidepressant medications, including SSRIs, have fewer side effects than older medications, which include tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs).10 However, others may find that these older medications work well for them.

It’s important to be aware that there are several medications for depression, that different medications work for different people, and that it takes four to eight weeks for the medications to work. If one medication doesn’t help, research shows that a different antidepressant might.11

Also, older adults experiencing depression for the first time should talk to their doctors about continuing medication even if their symptoms have disappeared with treatment. Studies showed that patients age 70 and older who became symptom-free and continued to take their medication for two more years were 60 percent less likely to relapse than those who discontinued their medications.12

Psychotherapy

In psychotherapy, people interact with a specially trained health professional to deal with depression, thoughts of suicide, and other problems. Research shows that certain types of psychotherapy are effective treatments for late-life depression.9

For many older adults, especially those who are in good physical health, combining psychotherapy with antidepressant medication appears to provide the most benefit. A study showed that about 80 percent of older adults with depression recovered with this kind of combined treatment 13 and had lower recurrence rates than with psychotherapy or medication alone.14

Another study of depressed older adults with physical illnesses and problems with memory and thinking showed that combined treatment was no more effective than medication alone.12 Research can help further determine which older adults appear to be most likely to benefit from a combination of medication and psychotherapy or from either treatment alone.

Are some ethnic/racial groups at higher risk of suicide?

For every 100,000 people age 65 and older in each of the ethnic/racial groups below, the following number died by suicide in 2004:

Non-Hispanic Whites — 15.8 per 100,000
Asian and Pacific Islanders — 10.6 per 100,000
Hispanics — 7.9 per 100,000
Non-Hispanic Blacks — 5.0 per 100,000

What research is being done?

NIMH-funded researchers designed a program for health-care clinics, to improve recognition and treatment of depression and suicidal symptoms in elderly patients. A recent study of the program showed that it reduced thoughts of suicide and that major depression improved.15

Examples of other ongoing or recently completed NIMH-funded studies on topics related to depression and suicide in older adults include:

overcoming barriers to treatment for depression
improving adherence to treatment
the relationship between other medical illnesses and depression
physical function and depression
depression treatment for depressed older adults in homecare
treatment services for depression
death rates of depressed older adults, compared to others
depression treatment for low-income older adults
depression treatment for caregivers of older adults

Ask yourself…

…if you feel:

nervous
empty
worthless
that you don’t enjoy things you used to
restless
irritable
unloved
that life isn’t worth living
…or if you are:

sleeping more or less than usual
eating more or less than usual
These may be symptoms of depression, a treatable illness. Talk to your doctor.

Other symptoms that may signal depression, but may also be signs of other serious illnesses, should be checked by a doctor, whatever the cause. They include:

being very tired and sluggish
frequent headaches
frequent stomachaches
chronic pain

REFERENCES

1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2005) [accessed January 31 2007]. Available from URL: www.cdc.gov/ncipc/wisqars.

2. Conwell Y, Brent D. Suicide and aging. I: patterns of psychiatric diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.

3. Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide and Life Threatening Behavior, 2001; 31(Suppl): 32-47.

4. Hybels CF and Blazer DG. Epidemiology of late-life mental disorders. Clinics in Geriatric Medicine, 19(Nov. 2003):663-696.

5. Narrow WE. One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Unpublished table.

6. Alexopoulos GS. Mood disorders. In: Sadock BJ, Sadock VA, eds. Comprehensive Textbook of Psychiatry, 7th Edition, Vol. 2. Baltimore: Williams and Wilkins, 2000.

7. Horwath E, Johnson J, Klerman GL, Weissman MM. Depressive symptoms as relative and attributable risk factors for first-onset major depression. Archives of General Psychiatry, 1992; 49(10): 817-23.

8. Depression Guideline Panel. Depression in primary care: volume 1. Detection and diagnosis. Clinical practice guideline, number 5. AHCPR Publication No. 93-0550. Rockville, MD: Agency for Health Care, Policy and Research, 1993.

9. Lebowitz BD, Pearson JL, Schneider LS, Reynolds III CF, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life. Consensus statement update. Journal of the American Medical Association, 1997; 278(14): 1186-90.

10. Reynolds III CF, Lebowitz BD. What are the best treatments for depression in old age? The Harvard Mental Health Letter, 1999; 15(12): 8.

11. Madhukar H. Trivedi H, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush AK, for the STAR*D Study Team. Medication Augmentation after the Failure of SSRIs for Depression. New England Journal of Medicine, Volume 354:1243-1252. 2006.

12. Reynolds III CF, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ. Maintenance treatment of major depression in old age. New England Journal of Medicine. Mar 16;354(11):1130-8. 2006.

13. Little JT, Reynolds III CF, Dew MA, Frank E, Begley AE, Miller MD, Cornes C, Mazumdar S, Perel JM, Kupfer DJ. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 1998; 155(8): 1035-8.

14. Reynolds III CF, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA, Stack JA, Pollock BG, Kupfer DJ. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 1999; 281(1): 39-45.

15. Bruce ML, Ten Have TR, Reynolds III CF, Katz II, Schulberg HC, Mulsant BH, Brown GK, McAvay GJ, Pearson JL, Alexopoulos GS. Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients: A Randomized Controlled Trial. Journal of the American Medical Association, 2004;291:1081-1091.

NIH Publication No. 4593
Revised April 2007

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I've waited on purpose to get to Bible Reading in the matter of living with depression, with good reason: That's normally the first "advice" you get from church people, as if Bible reading (and prayer, for that matter) will cure depression. To be brutally honest, Bible reading won't cure clinical depression. (But you've discovered that, right?) Neither was it ever intended as a cure for a medical condition.

Having said that, Bible reading - as part of your daily spiritual life - is crucial to living with depression. Millions of people struggling with depression have found great solace and spiritual encouragement in the Bible, especially in the psalms of David. In this age of technological marvels the Bible is still God's preferred method of reaching our hearts, principally (in my opinion) because it's written down black on white. You don't have to battle with some sort of "revelation", trying to figure out if it's really from God. You don't have to ask some intermediate's to discern God's will. You don't have to try and disentangle a preacher or author's own ideas from Scriptural truth. Just read it, and let God's Holy Spirit work with it in your life.

The greatest problem with Bible reading, if you're suffering from depression, is usually on two fronts.

Firstly, you very often don't feel like it, right? Let me tell you a little secret: "Non-depressed" people mostly don't feel like it either! It calls for discipline: View it as of the same importance as taking your medication, and after an initial period it will become part of your routine - and that's not a bad routine! A drowning man hanging on to a tree trunk in the midst of raging waters doesn't have to know why the tree would keep him afloat, but he needs to hold on! You need the Word, so hang on to it, even if it's just a few verses at a time.

Secondly, more importantly, it feels like everything else to a depressed person: Meaningless. Not doing anything. Many people say that they read the Bible, but nothing "sticks", it has no effect on you - just like water running through a mesh sieve with BIG holes!

Well, let me give you two ways of looking at this.

The first comes from an old missionary, who once said that the Word is just like that water running through the sieve: It does not fill up the sieve, but it is still cleaning it! Likewise, you may not even remember what you've read, but the Word "running" through your mind DOES have an effect, even if you don't notice it. Just keep on reading, and eventually you'll begin to discover changes that might surprise you.

The second illustration comes from the Rev Rex Mathie, a former principal of the Baptist Theological College in Johannesburg. In a class students once asked him how he would bring the gospel to someone who doesn't believe in the Bible.

"Well," he said, "I'll start with Romans 3 verse 23 and then Romans 6 verse 23..."

"But he doesn't believe in the Bible!" the students interrupted him.

"Oh. Well, in that case, I'll start with Romans 3 verse 23..."

"No!" the students said. "It won't work. The guy doesn't believe in the Bible!"

Dr Mathie smiled at them and said: "Gentlemen, I'm just placing little land mines in his mind, and sooner or later the Holy Spirit is going to step on them."

I think you get the picture! When you really need it, the Word that you've read and "not remembered" (consciously) will be there for God to bring to remembrance, and He'll use it to carry you through.

So start reading the Bible. Put the Bible somewhere close at hand where it's sort of "in your way". Start with the New Testament, the book of Matthew, chapter 1. Just read, don't try some fancy study or meditation. Just read as far as you can, put in a marker, come back later/tomorrow, read further. When you're through Matthew, get into Mark. Then Luke... When you're through the New Testament, tackle the Old Testament. Then go through the New Testament again. Just read.

As you read, you'll find (surprise!) some words sticking in your mind. Think about it. Apply to your life as and when possible. But even if everything just runs through, keep on reading. God has made a promise, and He's bound by His character to fulfill it:

As the rain and the snow comes down from heaven,
and do not return to it without watering the earth
and making it bud and flourish,
so that it yield seed fro the sower and bread for the eater,
so it my word that goes out from my mouth:
it will not return to me empty,
but will accomplish what I desire
and achieve the purpose for which I sent it.
[Isaiah 55: 10 & 11]

We can get all theological and argue about what His purpose might be, but what can't be argued about is that His word will NOT return to Him without achieving something!

So start reading!

Well, my mielies are finally ready for the table. The tomatoes are as tasty as only homegrown can be, not to mention the radish. The beans are more than we can handle.

So my little garden is doing well, especially with the lots of rain we're getting in Gauteng these days. Unfortunately, as my fellows in distress will know, there's a downside to the weather: It tends to make depression go a bit deeper, so you have to fight it a little harder. (Less light, less time to be outdoors, and apparently the changes in atmospheric pressure also plays a role.)

But life goes on - maybe with less smiling, more effort, but God is still good and He still takes care of those who rely on Him.

I've found that my depression is constantly forcing me back to God, because at the end He is really all you have. Suffering from depression makes you so much more aware of that: family can be as supportive as possible, you could do everything in your power to cope, but sometimes only God can see you through. And that's OK: God doesn't mind - He's the one who invites you to come. Right through the Bible we are encouraged to bring everything to Him.

I've learned one lesson from the book of Job: to be honest with God. Society demands that you to put on your best face, smile through your teeth, and carry on with daily life, but God does not expect that from us. Be real. Tell Him how you feel. In everyday language: forget the churchy cliches and say it like it is. If you can't be honest with God, where in the universe can you be? Read the end of Job and see what God says about Job's friends who were so "theologically correct".

There's many Biblical precedents for calling a spade a spade: King David (who I suspect suffered from depression) gets quite honest in his psalms. Jeremiah cries out to God as he sees Jerusalem in ruins. Habakkuk queries God when he sees destruction approaching his nation. Elijah runs away and hosts a pity party on God's mountain. Yet all of them gets help and support from God.

Hold on to God. As seasons change, and people come and go, He remains the one place of safety. Forget the macho I-can-do-it-by-myself attitude - it's not impressing God, and I think our macho is quite wimpy against Him!

Accept His helping hand. We need it.

I try to write this blog positively, trying to offer hope and encouragement, but I'm afraid some visitors might get the idea that I have it really easy... Not at all! Let me set the record straight!

I battle, every day, with the same things that make depression such a lonely hell for those suffering from it. I also get angry, in general and also towards God, when I think what life could be like without this ball and chain around my life. I also wonder if all the fighting is really worth anything...

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Allow me to tell you what got me started with this blog.

Last year a dear Christian woman suffering from severe depression committed suicide. I attended the funeral, and it was actually a beautiful funeral - people were shocked, many cried, but it was a Christ-oriented funeral: She was honoured as a Christian woman whose legacy won't be forgotten, and her husband gave a moving description of her battle with depression, ending with a call to all present not to take depression lightly, to get help, to take it seriously. And then someone else took the microphone and said: "And beware of negative thoughts. Negative thoughts cause depression..." It was like a kick in the most sensitive place, and it represented the very essence of religious misinformation/abuse about this disorder.

That was the day I decided to start a blog,

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Like John Lennon sang: "And so this is Christmas/What have you done?" Most of us suffering from depression will probably say "I survived the silly season".

Well, to be honest, some parts of it was just surviving for me, but by the grace of God this was actually a good Christmas/New Year for me. Our offices were closed, so I spent the time at home, doing some gardening, and laying a bit of paving in a corner of the backyard - only about 4m x 3m, but it kept me busy! I cleaned the ground, pushed in lots of wheelbarrows full of sand to level the surface, then laid the bricks, then did a concrete retainer around it, filled up between the bricks with more sand - and now we have a very nice place to sit & relax!

I lost some weight (sweating it out!), got a bit of a tan, and generally pushed up my levels of feel-good chemicals, but don't get me wrong: Mr Depression is still stalking me, but I feel better than I've felt in a long time. I suppose now the trick will be to continue being active...

Anyway, this is just a quick update to say I'm back. From next week I'll try to write some serious posts here, at least one a week again.

To all visitors to In Another Land: May 2009 be a good year for you. In the midst of your struggles with this dark enemy called depression, may you experience the presence and comfort of God.

...and sometimes it's not!

It took me a long time to learn this lesson. I expected that the more I worked at managing my depression, the easier it would get - it didn't!

Taking medication kind of smoothes out the mood swings associated with depression, but it does not take it away. Sometimes you feel quite OK, sometimes under the weather, sometimes depressed, sometimes in deepest darkness, and that's just the way it is. I learned to manage my lifestyle, my habits, my thought patterns, but every now and then I still take a big dive.

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Is it really necessary to say this?

Absolutely! One of the greatest temptations for anyone with depression/bipolar disorder is to start reasoning something like "I'm feeling good, I'm exercising, I'm eating well, let's cut this #%^&$@#$ pills!"

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No, I'm not joking! And, no, veggies won't cure your depression. But it might just help.

A healthy diet is beneficial for you in all kinds of ways, and recent research are showing that diet deficiencies can aggravate depression, sometimes quite dramatically. I'm not going to list all the studies, but I'd like to give you the essence of what I've learned so far.

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I grew up on a farm at a time when baboons were so plentiful that they regularly trashed crops and whatever they could get hold of. In response farmers used to shoot them on sight, trying to protect their lands, and in the process greatly decimated the local baboon populations.

Because they were so agile, a lot of the shots ended up just wounding baboons, who would then run away. Sometimes they would survive, but if they had abdominal wounds, a really gross sequel would play itself out somewhere in the hills. The wounded baboon would run until it felt safe, sit down and start inspecting its wounds. Being inquisitive, they would start pulling at some piece of protruding intestine, and keep on pulling, literally pulling out their own insides.

Really gross, I agree, but with any chronic disease or disorder we humans tend to do exactly the same.

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