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Harvard Reviews of Health News

Senior Mental Health, a Growing Concern

About 1 in 5 older U.S. adults has a mental illness or substance abuse problem, a new report says. The numbers will only climb as baby boomers get older. And that may create problems with access to care, the report predicts. The United States does not have enough health workers trained for the special needs of older adults, the report says. The Institute of Medicine, an independent group of experts, released the report. It says that 5.6 million to 8 million people 65 and older have mental health or substance abuse problems. Baby boomers have higher rates of illegal drug use than earlier groups. So they may have greater needs for substance abuse treatment. Mental health problems in older adults may be harder to diagnose and more complicated to treat, the report says. Long-term medical conditions can mask depression symptoms. Drugs for other illnesses also may affect mood. Older adults also may need lower doses of medicines. This can increase the risk of abuse with pain medicines. The Institute called for better training of health workers who treat older adults. The Associated Press wrote about the report July 10.

What Is the Doctor's Reaction?

Recognizing and treating mental health and substance abuse problems in the elderly pose special challenges. About 20% of people over 65 are dealing with one or both of these issues.

Depression is especially common. People over age 65 are just as likely to develop it as younger folks. At any given time, about 15% of people over 65 have significant symptoms of depression. About 3% have major depression.

More women than men are depressed at all ages. But later in life the ratio comes closer to 50-50.

The symptoms are similar in old age and in youth:

  • Fatigue

  • Appetite loss

  • Insomnia

  • Difficulty concentrating

  • Loss of interest in life or the ability to enjoy it

  • Sadness

  • Feeling empty and hopeless

  • Wishing for death

  • Thinking about suicide

But in people over 65, many of these symptoms are often just attributed to "getting older and slowing down." Or they are considered "natural" because the person has a long-term (chronic) condition and can't be as active as before.

Depression symptoms also can be similar to those of early dementia. For example, someone may be forgetful or have trouble concentrating. Depression can go untreated if symptoms are attributed to the wrong diagnosis.

Substance abuse in the elderly is a growing problem. We don't have good estimates of substance abuse in older people. With people living longer, more seniors than ever have chronic pain. Narcotics may be their only answer to pain relief. This blurs the line between need and abuse.

What Changes Can I Make Now?

If you have any symptoms of depression, or a loved one does, seek advice from a health professional. There is no test for depression. Sometimes the best approach is a trial of therapy.

For mild depression, talk therapy and antidepressant drugs are both good options. Severe depression requires drug treatment.

In general, the first choice of drugs is one of the SSRIs (selective serotonin reuptake inhibitors). These drugs tend to have fewer side effects than older drugs and are less likely to interact with other medicines.

The SSRIs most often recommended for older people include:

  • Citalopram (Celexa)

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

Doses of these drugs for older people should be one-half of the usual starting doses used in younger people.

Elderly people with depression appear to respond to antidepressant drugs about as well as younger people. But they sometimes improve more slowly. Similar to younger people, they also might not respond to the first SSRI used. About half of the time, a switch to a different SSRI is needed.

What Can I Expect Looking to the Future?

The report from the Institute of Medicine surely is a wake-up call. We need more awareness of mental health and substance abuse problems in older folks. We also need improved access to treatment. How this will be addressed is unclear.

Author: Howard LeWine, M.D.
Date Last Reviewed: 7/11/2012
Date Last Modified: 7/11/2012