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Depression in the elderly is hard to treat
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Dr. William Orr heads the geriatric psychiatry department at the Minneapolis VA. He says the current mental health system is struggling to meet the treatment needs of older adults. He predicts the demand for mental health services among the elderly is only going to increase. (MPR Photo/Erin Galbally)
Mental health researchers are finding that clinical depression is more common in the elderly than once thought. Heart attacks, strokes and bypass surgery can all trigger depression, as can factors like the loss of independence and growing isolation. But diagnosing and treating depression among older adults isn't easy. Patients are often in denial, trained geriatric psychiatrists are in short supply, and steep Medicare co-pays often prevent effective treatment. Left unaddressed, the problems threaten to grow as the state's population ages.

Rochester, Minn. — It's the first snowfall of the season, and Andrew sits on his living room couch, watching as flakes coat tree branches just outside the window of his Rochester home. Andrew asked that his real name not be used in this story. He's in his 80s, and wears a red flannel shirt and blue cardigan. He has a springy white beard. As he talks his mood shifts rapidly.

"As I sit here, I don't think you would recognize that I have anything wrong. But I'll have periods of being way up on cloud nine and then I'll go way to the bottom," he says. "I call myself Oscar the Grouch, who lives in the garbage can. Maybe that's where I belong." For the past few years Andrew has been struggling with depression. At times he's contemplated suicide and he's prone to what he calls "dark thoughts."

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Image Mary Doucette

It all began when doctors detected an inoperable brain aneurysm. Andrew started to have trouble keeping his balance. Soon, the one-time star athlete was falling at an alarming rate. Around the same time his mother and brother died. The combination was too much.

Andrew's primary care physician is convinced he's clinically depressed. But Andrew's wife, who we'll call Mary, says its been difficult news to accept.

"He can't persuade himself that this is not a sign of weakness, as many times as his doctor and I have tried to emphasize that he can't help this," says Mary.

Andrew still tries to convince himself that he can move beyond the depression by sheer force of will.

"I have a wonderful wife, good friends, good things to do and I've got to keep thinking good thoughts like Lou Gehrig, I am the luckiest man on the face of the earth," Andrew reasons.

Researchers believe that in cases like Andrew's depression is caused by a change in brain's neurochemistry. Andrew grudgingly takes anti-depressants. But that's not always enough for people like Andrew. White men in his age group are considered the highest risk for successfully committing suicide. That makes some form of counseling or regular contact with doctors vitally important.

Andrew resisted visiting with a psychiatrist. Finally, as part of a compromise with his wife, he signed on with Elder Network, a program that covers six southeastern Minnesota counties and provides free peer counseling for older adults struggling with mental health issues. Andrew meets with his peer counselor every week or so to talk about his anxieties and concerns.

Mary Doucette heads Elder Network. She helped found the organization in the late 1980s. Doucette works out of a room the size of a closet crammed with awards, two computers and heaping stacks of paperwork. She says studies show mental and physical health are very much connected.

An older adult experiencing a depression and possibly needing hospitalization will not have the same sort of reimbursement at all that they would have if they were hospitalized with diabetes or hypertensive episodes.
- Mary Doucette

"Their heart disease will get worse because of their depression," explains Doucette. "It's that mind, body spirit linkage is very very real. So an older adult experiencing depression, all of his physiologic disease processes will be harder to manage."

In other words, if depression goes untreated it puts the individual at risk for more serious health problems, even death.

Close to a quarter of the program's funding comes from the state funneled through county grants. This year, the program stood to lose all of its county money because of massive budget cuts. In a twist of luck, Elder Network managed to avoid the chopping block, in part to compensate for other local mental health programs that didn't fare as well and will have to scale back their efforts.

Doucette says money is a constant concern. She worries that if Elder Network lost its funding, clients would have to begin to pay for the counseling. She say Medicare might cover some of the cost but she's afraid large co-pays might prevent many from using the service.

"There's not parity in the system so an older adult experiencing a depression and possibly needing hospitalization will not have the same sort of reimbursement at all that they would have if they were hospitalized with diabetes or hypertensive episodes," says Doucette.

There's a 50-percent co-pay under the federal Medicare program for patients receiving psychiatric services. That's more than double the co-pay for a routine doctors visit or treatment for a broken leg.

It's graduation day at Elder Network. Two women have successfully completed the three-month peer counselor course. They are about to be certified to meet with clients.

They run through a list of goals and objectives led by Elder Network employee Ramona Digre.

"We are her to discuss steps with people not take the steps for them," one of the women reads aloud.

"That's really important - very, very, very - and then if you could remember it would be very," chimes in Digre.

"That deserves a star," says another volunteer.

The women are optimistic and excited. They're among the roughly 145 counselors the programs trained over the years around southeastern Minnesota.

They're considered a vital part of the region's mental health network. Their skills are especially valued since there's a major shortage of specialists trained to tackle mental health issues particular to older adults.

According to the American Association for Geriatric Psychiatry, there are roughly 2,500 geriatric psychiatrists around the country. The Association says demand calls for twice that amount. And come the year 2011 when the bulk of the baby boomers reach age 65, the need for those specialists is expected to explode.

Geriatric psychiatrists are trained to work through the maze of complex health problems that tend to plague older adults. For instance they can determine whether chronic sleeplessness is a result of anxiety or a side affect from another mediation. And they know what warning signs to look for when depression and despondency become life threatening.

William Orr heads the geriatric psychiatry program at the Minneapolis Veterans Administration. He says it's common for older adults to be wary about entering therapy or even admitting that they have depression. But Orr predicts the Baby Boomers will respond more proactively to their health needs than their parents.

"I expect that patients mat become more proactive for themselves and have a higher expectation that they will enter their later years with a healthier lifestyle, which means that depression needs to be more fully identified and treated," he predicts. Orr says that means the mental health care system has a lot of catching up to do.

But recent federal legislation has not offered much hope for improvement. The new federal Medicare Prescription Drug Act requires high co-pays for anti-depressants. And he budget proposed by President Bush offers little to no room for increased spending on resources for older adults coping with mental health problems.

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