Introduction
As defined by George Alexopoulos, doctor at Weill Cornell Medicine, specializing in geriatric psychiatry, geriatric or late-life depression is periods of depression in people aged 65 and above. There are two different types of depression, situational and biological. As defined by Robert Hirschfield, doctor and professor of psychiatry at Weill Cornell Psychiatry Center, and specialist in depression, situational depression is a depressive state that occurs because of traumatic changes and aspects of one’s personality. As described by Professor of Economics at the University of California, and member of the National Academy of Sciences, traumatic life events such as divorce, and disabilities have a long-term effect on someone, beyond their genetics (Easterlin, Richard A). This is specific to situational happiness. On the other hand, according to the Mayo Clinic, a non-profit organization providing clinically reviewed medical articles, biological depression is a lasting disorder with severe symptoms that hinder everyday activities and life quality (Depression (Major Depressive Disorder).). This is caused by physical changes like problems with neurotransmitters in the brain (Depression (Major Depressive Disorder).). This paper solely focuses on situational depression in seniors.
Of the 31 million elders in America, about 5 million are clinically depressed, according to researchers Richard Birrer and Sathya Vemuri, geriatrician and family physician. As a result of psychological events such as being divorced, loss of independence, social isolation, bereavement, moving homes (like nursing homes), or financial troubles, which are common in the elderly, senior citizens are more susceptible to situational depression, according to Bonnie Wiese, a certified subspecialist in geriatric psychiatry by the Royal College of Physicians and Surgeons of Canada. In addition, negative health changes, such as declining health, dementia, and other diseases are common with age. Because of this, there is a notion that depression is a normal part of aging. As a result, geriatric depression may go unnoticed or untreated. (Wiese, Bonnie). The issue with treatment is that because the fragility that comes with aging, side effects are an unwanted consequence of treatment, as described by professors of medical statistics, psychiatry, elder care, epidemiology, and health economics at the University of Nottingham. Furthermore, payments for treatments can become burdensome for patients and families, described by professors in the department of Psychiatry at the University of Michigan and professor of social work at the University of Central Florida. As a result, the debate on whether antidepressants are an ideal treatment for geriatric depression, scientifically, financially, and ethically is becoming increasingly important. This paper examines why antidepressants are not the ideal treatment for situational depression in older adults, and what treatment is ideal for these patients.
Antidepressants
According to researchers at the department of psychiatry at Oxford University, specializing in old-age psychiatry, selective serotonin reuptake inhibitors (SSRIs), are frequently prescribed antidepressants, especially with elders (Topiwala, Anya, et al). As described by researcher of psychopharmacology in depression at Oxford University, Philip J Cowen, and lead of the Computational Psychiatry Lab in the Department of Psychiatry at Oxford, Michael Browning, serotonin is a neurotransmitter in the brain that carries signals to brain cells, influencing emotional processing. SSRIs block the reabsorption of the serotonin, therefore making more accessible (“Selective Serotonin Reuptake Inhibitors (SSRIs).”). Prescriptions like vilazodone and citalopram are common SSRIs. (“Selective Serotonin Reuptake Inhibitors (SSRIs).”) However, according to Kelsey Hegarty, an academic general practitioner and health services researcher at the University of Melbourne, SSRIs are commonly prescribed to those with major depression, and situational tends to be short term and minor. As described earlier by Richard Easterlin, certain events such as divorce and disabilities have impacts on one’s happiness, uncorrelated with genetics. As described earlier by Robert Hirschfield, situational depression results from these traumatic events, in addition to others like loss of independence or bereavement. Therefore, because situational depression is not caused by genetics, but adverse events in a senior citizen’s life, antidepressants such as SSRIs are not the ideal treatment because they specifically target the brain, genetics, and not the root cause.
Side Effects
According to the Agency for Healthcare Research and Quality, a branch of the United States Department of Health and Human Services, common side effects of SSRIs in elders are weight gain and sexual dysfunction. Following this is nausea and vomiting, the biggest reasons an elder may discontinue their use of antidepressants (Choosing Antidepressants for Adults). Although these side effects are harmful, it is reported by Stanford professors Dolores Thompson, professor of research of psychiatry and behavioral science who clinically focuses on geropsychology, Erin Cassidy-Eagle, clinical associate professor in the Department of Psychiatry and Behavioral Sciences, specializing in the treatment of mental health disorders in older adults, and Laura Dunn, director of the Geriatric Psychiatry Fellowship Training Program, that small symptoms persist before antidepressants work. However, SSRIs may take 12 weeks for elder patients to respond to them. (Gallagher-Thompson, Dolores, et al). The most harm that results from antidepressants such as SSRIs is serotonin syndrome. (Choosing Antidepressants for Adults) Serotonin syndrome is caused by toxic levels of serotonin, as SSRIs increase serotonin in the brain (Choosing Antidepressants for Adults). Common symptoms of serotonin syndrome are hypertension, tachycardia, and diarrhea (Choosing Antidepressants for Adults). With other options of treatment for situational depression, patients could forgo the possibility of side effects for another effective treatment.
Patient Aversion
In a study by a group of researchers from the University of Pennsylvania, in the departments of psychiatry, and family practice and community medicine, older patients aversions to antidepressants were revealed. 42 out of the 68 participants were reluctant to utilize antidepressants (Givens, Jane L, et al.). The biggest reason that patients had for not wanting to utilize antidepressants was a fear of becoming addicted to or dependant upon the medication (Givens, Jane L, et al). Many of the participants also had reservations in believing that depression was a medical illness (Givens, Jane L, et al.). Others were concerned that antidepressants would make them unnaturally happy, or not allow them to feel natural sadness (Givens, Jane L, et al.). The last reservation elders had towards antidepressants were previous problems (Givens, Jane L, et al.). Patients had experienced negative side effects, particularly sedation, and therefore did not want to take future antidepressants. While some of these preconceived notions may not be true, it is important to note the aversions that elders have towards antidepressants, and reasons why antidepressants may not be their ideal choice. It is also, therefore, unethical to force elders who have these reservations against antidepressants, to take these medications.
Costs
Antidepressants tend to bring costs to the patient. Brand name drugs tend to cost more than generic, and costs vary between dosages. An SSRI such as Citalopram (brand name Celexa) costs $75 dollars for a 10mg daily, month supply. Other SSRIs, such as Sertraline and Paroxetine, cost $85 and $80, respectively (Choosing Antidepressants for Adults). However, this is for the generic medication. Name brands of Citalopram, Sertraline, and Paroxetine, cost $90, $90, and $95. (Choosing Antidepressants for Adults). Costs such as these may be an issue because of the fixed incomes of elderly. The average income of people 65 and older is $31,742, according to an AARP released Fact Sheet. While Social Security, for those who are eligible, gives an average benefit of $14, 229 (Bin Wu, Ke), limited incomes such as these may make it difficult to afford a steady dosage of antidepressants. Insurance, such as Medicare, can be used to lower the costs of antidepressant medications. As described by themselves, Medicare is a “federal health insurance program” typically for people 65 and over (“What's Medicare?”). However, Original Medicare, the plan that all Medicare users have, does not cover medications, as described by Tamera Jackson, a licensed Insurance and Medicare agent. In order to get coverage for prescriptions such as antidepressants, a Medicare Prescription Drug Plan must be added onto Original Medicare. (Jackson, Tamera). Along with the monthly premium for Original Medicare, a premium for this added plan must be paid for as well (Jackson, Tamera). In the end, money is being spent, and portions of the prescriptions must still be paid for. These costs may become burdensome to the patient, or not be able to be paid for in the first place, making antidepressants an un-ideal option
Therapy
Cognitive behavioral therapy (CBT), is a form of psychotherapy that deals with cognitions and behaviors that affect mental illnesses, and in this case, depression, according to professor of Health Psychology at the International Senghor University of Alexandria, psychiatrist, and specialist in psychopharmacology, Jerome Palazzo. This works because it focuses on the losses and major life events that typically occur as a patient ages. Cognitive behavioral therapy targets the meaning assigned to these events and helps patients cope and adapt to the changes in their life (Palazzo, Jerome). CBT works to help patients assess the adverse life events that commonly happen as an elder, creating a new way of thinking so that in the future, other events will not trigger depressive episodes (Palazzo, Jerome). Cognitive behavioral therapy has been studied to be effective in elders with depression, as found in a meta-analysis by researchers at the department of Clinical Psychology at VU University (Cuijpers et al.). Data further substantiates this, confirming that CBT has been researched and found to be an effective treatment for geriatric depression (Palazzolo, Jerome.). It’s also a long-term solution. In a study led by Philippe Landreville, a professor at the Laval University of Psychology and specialist in the clinical psychology of the elderly, patients with a mean age of 67 who received cognitive behavioral therapy were found to have reduced depression after 1 year. However, there are limitations to choosing CBT. Although it has been researched and found to be effective, it is the most researched form of therapy for geriatric depression and therefore has the most evidence to support its use (Cuijpers et. al). Therefore, there could be other effective psychotherapies that are not being researched as often as CBT. Because of this, these psychotherapies are not seen as valid in comparison to CBT. As a result of the effectiveness and lack of side effects, CBT is a more ideal medicine for patients, especially elders who cannot tolerate the side effects from antidepressants as well as the younger population.
Costs
Cognitive behavioral therapy isn’t an inexpensive treatment. Sessions range from $100 to $290 per 45 minute session (“Frequently Asked Questions.”). However, the cost of CBT is typically dependant upon the salary of the patient and the indirect expenses of insurance, described by Health economists and researchers at King’s College, Barbara Barrett and Hristina Petkova. This means that according to the income of the patient, the cost of CBT is adjusted. Furthermore, the Original Medicare plan covers psychiatrists, clinical psychologists, and clinical social workers (“What's Medicare?”). However, there are limitations that come with this. Choosing to pay a lower price may sacrifice the quality of the therapist. Described by the Cognitive Behavior Therapy Center, an experienced facility in Silicon Valley providing CBT, a pre-licensed therapist costs $145, which is $30 to $145 less than licensed therapists. Out-of-pocket costs must also be paid, depending on the patient, plan, and income. In addition, the Original Medicare plan requires premiums to be paid (Jackson, Tamera). Part B, the part of the original plan that covers doctors, requires a $134 or more premium (depending on income) to be paid each year (What's Medicare?”). However, paying for the Original premium only, compared to the Original and Part D that is required to cover antidepressants, is less than the Medicare costs for antidepressants. Although money must still be paid to cover cognitive behavioral therapy, it remains to be less than the money paid for antidepressants because of the coverage of Original Medicare and adjustment for income.
Conclusion
In terms of treating geriatric depression, antidepressants target neurotransmitters and parts of the brain (“Selective Serotonin Reuptake Inhibitors (SSRIs).”). However, situational depression is not caused by changes in the brain, but by traumatic events that occur as a person ages (Hirschfeld, Robert M. A.). Antidepressants can also become costly because of dosages, limited income, and lack of Medicare coverage. Elderly patients tend to have aversions to antidepressants because of the stigmas and negative experiences they've had with them. In place of antidepressants, specifically concerning situational depression, CBT should be used. It has been largely researched and found to be effective in treating geriatric depression. CBT targets the events that cause situational depression, while antidepressants target the brain. It also assists patients in changing how they think and deal with their traumatic events, lowering relapse and training them to cope with future events. Although CBT is still costly, the price is adjusted for income and covered partially by Medicare. Therefore, when evaluating side effects, costs, and the ethicality of patient aversions, CBT is the ideal treatment for seniors suffering with situational depression.