Late-Life Depression
This double-column opus is the work of two experts in the field who assigned 41 other scientists and clinicians to participate in what the editors describe as the first textbook devoted to a comprehensive overview of depression in the elderly. The senior author of each multiauthored chapter had to agree to write the chapter himself or herself, a requirement that boggles my mind. What were the roles of junior authors such as Harold Sackeim and Alexander Glassman? To underscore the importance of this endeavor, the editors tell us that the elderly are rapidly increasing in number. It is estimated that by the year 2030 more than 70 million Americans will be older than 65. We are also told that people older than 85 are the fastest growing group of individuals in the population and that their numbers will double in the decade. The editors state that this book is intended essentially for all clinicians and researchers interested in depression in this population.
In answer to a question not asked (why single out a disease in an age group?), we are reminded that diseases such as depression vary in many dimensions. Age and concurrent medical conditions affect the presenting symptoms, treatment, course, and prognosis of medical disorders such as emphysema, pneumonia, and immunological disorders. Psychiatric illnesses are affected in a similar manner. For example, if a first episode of depressive disorder occurs in an elderly patient, its presentation and underlying factors should cause the clinician to approach the problem somewhat differently than if it occurred in a much younger individual. The elderly patient may not complain of depressive feelings, and the diagnosis may be more dependent on the somatic concomitants of depression such as sleeping and/or eating disorders. The clinician should be particularly interested in searching for a comorbid medical illness in an elderly patient with first-episode depression. The editors tell us that 80% of those who die of suicide were suffering from depression. Therefore, in all age groups, but especially in elderly men, attention needs to be paid to the possibility of suicide.
One of the most striking and clinically significant areas of current psychosomatic research is the discovery of the association between depression and poorer outcome of physical illnesses. Depression is an independent factor for the development of ischemic heart disease, and it increases the mortality of patients with myocardial infarction, angina, and congestive heart failure. The editors tell us that “patients with depression are more likely to develop symptomatic vascular disease, and those with vascular disease are more likely to die if they are also depressed.” Because of the association of depression with poor compliance, the outcome of diabetes, renal failure, hypertension, and even cancer—all more prevalent in the elderly—are negatively affected by depression. The editors conclude that late-life depression “transcends subspecialty boundaries,” making it a matter of importance for screening in all specialties. Of interest is the association between stroke and depression: clinical and biological research shows that stroke begets depression by interfering with brain pathways and by its physical and connotative results for the patient, such as disability, loss, and shortened life expectancy.
The book is divided into four segments, each of which consists of between two and 10 chapters, a total of 29 in all. The leanest segment is Epidemiology and Burden of Illness, and the largest is Treatment. The other two sections are titled The Phenomenology and Differential Diagnosis of Late-Life Depression and The Psychobiology of Late-Life Depression. Each segment is preceded by the editors’ overview of the topic and a description of the nature of the chapters that follow. The editors wonder and perhaps worry that the table of contents may “prompt some readers to consider this book to be primarily biological, with too much emphasis on brain function and somatic therapies and not enough attention to social context, psychological theories, and psychotherapy.” This is the case because one of the principles of this volume is to present evidenced-based data. Psychological theories of depression have been based on clinical observation of a younger population and may not be applicable to the elderly. The editors argue for “a compelling need for a substantial program of rigorous research on the sociological and psychological dimensions of late-life depression and its treatment.”
The section titled Treatment is largely devoted to biological forms of therapy—antidepressants and their side effects, mood stabilizers, stimulants, antipsychotics, and ECT. There are two excellent chapters, one of which, by Charles F. Reynolds III et al., is devoted to psychotherapy. The rationale and use of cognitive behavior therapy, interpersonal therapy, and dialectical behavior therapy are discussed in some detail as well as other psychosocial interventions, such as family group workshops, supportive psychotherapy, family counseling, visiting nurse services, and bereavement groups.
This seminal volume, a comprehensive overview of the many dimensions of late-life depression, is a valuable addition to the literature in this field. The editors are to be congratulated for gathering together the leading clinicians and researchers and producing this opus maximus. It is highly recommended to those involved in clinical work as well as those in research in the diagnosis and treatment of late-life depression. It belongs in the library of psychologists, psychiatrists, and other behavioral professionals and their students.
