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Saturday, 13 February 2010

GRAY MATTERS: Depression

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.


For those of us along the East Coast, flooded by weeks of rain and buried by five feet of snow since December, this surely is our winter of discontent, or worse. Add to that the state of the economy and the stock market, and as I warned during the approaching winter after 9/11 2001, older people need to be very aware of the danger of depression.

That desire to crawl under the covers and hibernate can be more than the winter blues. I know; I had a brush with depression only because of a fall and a bump on the noggin, which laid me low for a few days and nagged at my thoughts: “Why wasn’t I bouncing back faster? Will I regain my strength?

When last I wrote about depression, an unprecedented surgeon general’s report on mental health in 2000 pointed out that depression, in one form or another “is strikingly prevalent among older people,” too often accompanied by alcohol or drug dependence. But many older people tried to ignore their symptoms as simply a sign of age.

Coincidentally, just after my fall, Ilaina Edison, a vice-president and researcher for the superb Visiting Nurse Service of New York, the nation’s leading home health care provider, told me that ten to 20 percent of older people seen by primary care physicians “have critically significant depression.”

Moreover, many of these physicians, not specializing in geriatrics, don’t diagnose or they under-treat depression. Edison wants home health care nurses, who know their patients best, to be able to diagnose a case of depression before it takes root.

In one of her papers, Edison says that depression “places a significant burden on the health system” and impedes a patient’s ability to comply with medical treatment. The classic symptoms – sad, empty, hopeless feelings, trouble concentrating, a lack of energy, trouble sleeping, a loss of interest in what you like to do, and even vague or passing thoughts of suicide – can complicate getting better from even a routine illness.

The surgeon general’s report noted that there is no need for older people to put up with depression and risk their health further because there are modern and relatively safe drugs, among other treatments. And since the report, Medicare has led the way in recognizing and paying closer to parity for the treatment of mental as well as physical illness.

However, Medicare has been slower in understanding how its regulations can become a barrier to home health care for depression which, in a sense, is the front lines for the discovery and treatment of depression. Says Edison, ”Mental health status is not being addressed by hospitals when discharging a patient, even if he or she is taking an antidepressant.”

When I was discharged from a fine hospital after my fall, a doctor prescribed home health care for my physical problems, including physical therapy. But no one asked after my emotional well-being.

“Another barrier,” said Edison, “is the way Medicare reimburses for depression and mental health services in home health care.” Medicare has been demanding a positive diagnosis before it will pay. But if a home health care nurse discovers a patient’s depression, mild or severe, during a visit for other purposes, reimbursement may be complicated.

Thus she believes Medicare should allow and train the visiting nurse practitioners to diagnose depression and help guide a patient’s treatment with guidance from a psychiatrist.

Medicare Part A helps pay for inpatient mental health care; Part B covers outpatient visits to mental professionals, subject to the yearly deductible ($155). For a visit with a doctor to diagnose your problem, Medicare pays 80 percent of the cost. But to get treatments, such as psychotherapy, the patient now pays 45 percent and that will decline to the parity of 20 percent in 2014.

But to return to the surgeon general’s report, it recommended getting help from modern drugs that can treat and even prevent anxiety and depression. And if you feel you need something, a pre-emptive strike to get you through the winter, consult with your physician but be very careful about what you choose.

The surgeon general reported that certain widely used anti-anxiety drugs, called benzodiazepines – Ativan, Lorazepam, Librium, Valium, Xanax – are immediately effective but have been misused by many older people because they are chemically addictive over time, which means the more you take, the more you need. Some Medicare Part D drug plans are not required to provide these drugs.

These drugs are often over-prescribed and withdrawal from these drugs is likely to be difficult and could be dangerous. Similarly, sedatives and sleeping pills such as barbiturates, including Butisol, Nembutal and Seconal are highly addictive.

Less dangerous or addictive, although they take longer to work, are the anti-depressants including the granddaddy, Prozac, along with Zoloft and Paxil and other newer compounds such as Celexa, which are purged more quickly from the body and present fewer problems for older adults. These are a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), which can prevent mild depression from getting worse.

Other new anti-depressants (SNRIs), including Cymbalta, are being advertised for more serious problems.

However, all these drugs may produce unpleasant side effects and dependency. Your physician can fit the drug to your needs – if you need drugs at all. A pet that you can care for where you live, or perhaps a trip this winter to somewhere sunny could give you the lift you need.

What we’ve been calling the winter blahs has been given an appropriate name, SAD, for Seasonally Affective Disorder. And if you use a computer (which can be a great help in keeping you mentally fit (I play freecell or spider solitaire to check on my mind.), you can find sources for special lamps and lighting which, according to many legitimate-sounding claims, helps brighten those dark days.

You may want to visit the Medicare website and search for “mental health care and Medicare.” To learn more about the services of the Visiting Nurse Service of New York, visit their website.

Write to saulfriedman@comcast.net.


Posted by Ronni Bennett at 02:30 AM | Permalink | Email this post

Comments

Saul,

Thank you for your always "spot-on" commentary. My husband and I took the time to read this piece from The Atlantic last night. It's a bit off topic for your piece, today, but it has longer-range implications. Hope you take time to have a look because your thoughts are valued by all of us. There are four sections and it's very meaty.

http://www.theatlantic.com/doc/201003/jobless-america-future

I have three of the symptoms of depression; inability to sleep, trouble concentrating and the beginning of loss of interest in things I like to do.

It never once occurred to me that these are symptoms of depression because I do not feel depressed. I just chalked it up to being old and partially disabled.

Thanks for a wake-up call. If I begin to show other symptoms I will talk to my doctor. I believe the computer has kept me from being depressed and hope it continues to do so.

Thank you for pointing out this important issue. I have a couple of thoughts to share.

There is a prevalent notion that it's relatively easy to get off the antidepressants such as Prozac, Paxil, et al. Google it; it's not necessarily so. And it's also possible to take the same dosage of benzodiazapenes for years without needing to increase the dosage.

See http://www.newsweek.com/id/232781 for another, and very controversial, view arguing that there is no scientific evidence that antidepressants work.

Dear Saul - You just hit my nail on the head...and sorry about your fall...I am 66 and have been depressed for more than 13 years...it become debilitating psych. after my beloved Mother died at age 83 from heart disease. She was the lifeline that helped me cope with world and suddenly I had to "grow up." Despite a good husband - I needed the drugs and became addicted to casino visits where I blew away our life savings. It seems that the computer and the games etc. help but now I have once again brought us to the verge of bankruptcy. I don't know why I am writing this but I need to get it out and maybe I can begin to understand me. I take zoloft each day and it helps a little. I have seen the Psych. doctors but they don't help me...I know I need to talk to myself and try and keep my mind sharp. Thank you for letting me vent. Refuah Shlaymah from your fall.


Saul,

I'm happy that you are here to help Ronni take a little time to herself. She needs that time now that her life plans are changing.

Your posts are always very interesting and usually deal with subjects that appeal to us Elders.

I am not depressed because I have my computer friends like Darlene to "Talk" to every day. If not for her and a few others, it's possible I would need help with depression,too.

Thanks for being here,Saul, and keeping us informed on matters like this that we may wonder about but never get the answers to without your help.

I read some time ago that depression could be a reactive condition that we may have inherited (genetically speaking) from our cave man/woman ancestors. In those early days when man was limited in his arsenal (sticks & stones, fire & bones) to stave off the attacks of marauding predators, sometimes the only defense was to lie silently until the danger had passed. Also, when our distant ancestors were in a weakened state due to wounds and disease they would rest quietly until they recovered. So, we might say that clinical depression could be a reaction to trauma or stress.

Saul, I too have suffered from depression but through therapy both group and solo the incidences are getting fewer and less intense - i.e. I no longer want to take myself out. I am confident that it will pass. I attribute prozac in conjunction with therapy for saving my life and am thankfully drug free today. I also believe, just my opinion, that there are serious underlying issues to depression usually rooted in childhood.
Depression can be a defence mechanism. At least it was in my case and in the case of many depressives I know.
XO
WWW
PS And glad you are feeling better.

I have used antidepressants in conjunction with counseling with good results in the past. While the dark winters contribute to feeling isolated with oneself and one's demons these things do exist in other times of the year when it is easier to become distracted from them. I think it is always wise to consider counseling with medication.

As an aside to mary jamison and the question as to whether they really work at all: I used them and they worked so well on anxiety that I forgot to smoke cigarettes at first while on them. This later lead to me using a similar antidepressant to assist me in quitting smoking and I've been smoke fee for 12 years. I'd say that they work especially well for people who just need a steady hand up onto their feet to recenter themselves through a blue period and with counseling for chronic troubles.

Thank you, Saul, for bringing up this often misunderstood option to get us through a difficult time.

As a retired psychotherapist, I was really glad to see this topic covered today, Saul, and thank you for your personal story, too. I'm very interested in TGB reader comments about the efficacy of antidepressants (re: Newsweek article by Sharon Begley cited by Mary Jamison, above). I researched and blogged on the article recently, and the statistics offered by Kirsch, on which the article is based. His methodology hasn't always been appreciated by academics and practitioners in this country...so he's based in England, now.

The one note Begley does strike soundly in Newsweek is in pointing out that treatment for depression is greatly enhanced by combining medications with the appropriate talk therapy. The mistake I think Kirsch makes is to seem to imply that one methodology (talk) is good and the other (meds) is not.

Medicare has lost a lot of good providers for psychotherapy by dropping the rates they pay. I wonder if research like Kirsch's will have an effect on the types of treatment Medicare is willing to pay for adequately.

Great post about a serious problem.

I wasn't even close to being a senior when SAD hit me hard. Living here in the Pacific Northwest the winters can get really gloomy for lack of sunshine. I purchased one of the light boxes, an Apollo Bright Lite III, back in 1997. It has withstood the test of time and is currently helping me with a painting project. I highly recommend light therapy. Oh, and I also take Prozac. My doctor mentioned that the dose might need to be increased (he said that is common in older patients) but it's been some years and I'm doing fine with the original script. Prozac has made me a much less intense person!

A postscript:

After leaving my other comment I Googled the Apollo light box to see if it is still in production. Yes, and it is in a sixth generation. The Brite Lite 6 can be purchased at Amazon at a 24% discount - details HERE.

Nance: Thanks so much for your post - I visited your blog and read your article and can only say, Thanks again.

Try perking up after days of overcast weather here in Seattle and being an oldie of nearly 90 as well.

A friend loaned me her daylight light system. I hope it works.
Adding S.A.D. (Seasonal Affective Disorder) to aging and arthritis is a tough combination. I have found that if I plan something interesting to accomplish each night before retiring that it helps. The next day I wake up with what I am going to accomplish in my mind.

Getting a massage, going to the library, practicing a skit to present to groups about Corporate Personhood,
going to Arthritis Swim Class, exercising every day, cooking something interesting every day, keeping indoor plants, emailing my friends,
practicing my violin, staying involved in all my political and other groups ---you name it, it all helps to keep in the world.

I act in non-profit videos on Credit Card Revolt, go on the comedy stage with a young improv friend, write articles for the local papers, dance anytime I get the chance and play for
the local sing-along. You name it,
I will try it and keep active doing it.

I remember being a child of 7, watching my grandmother from afar. She was shrouded in darkness, voluntarily hidden and shriveled in a corner. You'd need an ax to cut through the gloom. Today, I'm the same age as she was then. I've inherited a lot from her. I'm "artsy" on the one hand, and at the same time brazenly logical and analytical on the other. All from Grandma. I love to cook, I love the piano (can't play to save my life - but I love it anyway) - all from Grandma. But unlike grandma, I don't huddle in a corner - and I don't shroud myself in black. Also unlike Grandma, I am blessed to have been prescribed an anti-depressant that works for me.

Those of us in the "Gray Group" - the After Fifty Generation, are blessed to have available to us pharmaceutical wonders unknown not only to our grandparents - but perhaps in many cases, to our parents. I say a prayer every night for the good health of those researchers who peel away at the onion of mental anguish.

Now, if only we could peel away at the onion of mental anguish's social stigma.

Thanks for a great article. I've gone through many different antidepressants and each helped at the time, though they tend to 'wear off' (or something). Tiny note that may help someone: Effexor XR constipated me horribly; switching to Pristiq was a godsend. Don't settle for one pill if it's not working for you!!

I especially liked the comments that lauded keeping busy every day. I take an aerobics swim class 3x a week and volunteer at the local Humane Society 5x a week. The love you share comes back, and helps greatly! Very best wishes to those who struggle with bi-polar disorder and depression!

Bi-polar disorder and depression is a strong and growing reality in this mixed up society. I believe that Seniors (50 Plus) can change this trend if they become more productive, creative and useful in Society as compared to having a negative attitude, feeling hopeless and pursuing only more entitlements.

Joe Wasylyk
Seniorpreneur

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