Major depression is a relatively common disorder which affects well over IO million people in the United States per year. This mood disorder is particularly prevalent in elderly populations, in 1992 the ECA study reported that 15% of community residents over 65 years of age have depression,⁽¹⁾ while other studies have indicated that up to 60% of the population over age 60 have depressive symptoms.⁽²⁾ Furthermore, the elderly account for 25% of US suicides per year,⁽³⁾ a disproportionate and disturbingly high number which speaks to the importance of treating depression in the geriatric population. The case study presented here illustrates some of these issues which surround the morbidity of depression in the elderly population.

"Ms. Oldrid" is a 68 year old Caucasian female who admitted herself to th e hospital seeking treatment for depression. The patient presents as a thin, frail, elderly woman who requires assistance to walk and be seated. Currently she reports depressed mood, anhedonia, decreased appetite, fatigue, decreased concentration, and decreased memory. Occasionally she experiences panic attacks, in which she feels extremely anxious and fearful of dying. She associates the onset of her depression with the death of her son 10 years ago. Since this time, the symptoms of her depression have been variable in intensity, and have for the most part been controllable by medications (SSRI's). Two months ago her husband passed away, and concomitantly her depressive symptoms have markedly increased in intensity to the point where she now spends most of her day in bed, and feels that only electro-convulsive therapy will help her. Associated medical conditions include a cardiac arrhythmiaa for which she has an implanted defibrillator. She smokes ½ pack of filter cigarettes per day, does not drink or use any other drugs, and denies any other medical condition or history of illness. Although she ruminated extensively on the deaths of her husband and her son, and on the perception that electro-convulsive therapy may pose a danger to her own life, she denies any thoughts of suicide. She does seem preoccupied with her own mortality, however, as several times during the interview she adamantly stated that she "cannot die with this defibrillator," a striking statement from someone who appeared quite frail and debilitated.

Ms. Oldrid spoke clearly and coherently, however during the interview she was markedly irritable and at times openly hostile to the interviewer. With regards to cognitive function and intelligence, the patient was alert and oriented to person, place and time, and her long term memory appeared intact. However, when asked specific questions to test her short term memory (i.e., remember and recall three specific words), she became extremely hostile and demanded that the interviewer not ask such questions, because she "knows" that she cannot answer them. Likewise, when asked to spell "WORLD" backwards she refused to try. It was difficult therefore to assess her concentration ability and determine whether her concentration was truly impaired or whether the patient was simply uncooperative.

Given her history and presentation, the differential diagnosis includes the axis I conditions: major depression, dementia, and anxiety disorder. Her heart arrhythmia and implanted defibrillator would be listed under axis III, and on axis IV, there is the influence of bereavement and deaths in her family, as well as loss of social support. Her most likely diagnosis is major depression. This disorder is diagnosed when 5 or more of the following criteria are met nearly every day for at least 2 weeks: depressed mood or anhedonia (this is mandatory), changes in sleep, changes in appetite with resultant changes in body weight, fatigue, feelings of guilt or worthlessness, indecisiveness or decreased ability to concentrate, suicidal thoughts or preoccupation with death, and psychomotor agitation or retardation. This patient clearly fulfills these criteria, as she exhibits or reports changes in appetite, anhedonia, depression, decreased concentration, psychomotor retardation, hypersomnia, and possibly preoccupation with death.

The case of Ms. Oldrid is particularly interesting in the context of the Eriksonian theory of development. According to this theory, Ms. Oldrid's son died during the "generativity versus self-absorption" stage in her development. This stage is marked by the desire to contribute to the next generation and to pass on one's knowledge and traits. The death of her son at this critical point in time threatened her sense of generativity, marked her failure to perform the task of nurturing the next generation, and perhaps swung the balance toward stagnation, self-absorption and depression. It is interesting to note that during the interview the patient expressed "happiness" only when thinking about the times when she helped raise her deceased son's children, perhaps she felt that by doing so she was making up some of the "generativity" that she lost with her son's death. Currently she is coming into the last stage of Eriksonian development, that is "integrity versus despair." She appears to be struggling with her own condition and mortality, and has come to the medical community for help with her debilitating depression.

In many ways, Ms. Oldrid's case serves as an example for the struggles and issues people experience late in life, during the stage in which their close friends and family are dying, and during which they are increasingly made aware of their own mortality. Numerous studies have indicated that elderly populations are at higher risk for major depression than the general population.⁽⁴⁾ Furthermore, studies have indicated that medical devices such as defibrillators and pacemakers markedly increase depression and anxiety symptoms in elderly patients.^(5),(6) Such devices not only physically startle the patient and cause anxiety as the patient fears when the next shock will come, but also act as constant reminders of the patient's own mortality. Despite the high morbidity associated with depression, there are highly affective treatments for this condition. Medical treatments include drugs such as the tricyclic antidepressants, the selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, as well as other atypical drugs. Ms. Oldrid has only taken one of these types, the SSRI'S, therefore it is highly possible that a drug which acts via a different mechanism may relieve her symptoms. It would also be important to provide counseling and education about her medical conditions, and to encourage her to remain act' e in her social network. Ms. Oldrid's case as well as numerous studies in the current literature highlight the disabling affects associated with depression in the elderly population, and emphasizes the need for treatment of this highly prevalent disorder.

1. NIH Consensus Development Panel on Depression in Late life: "Diagnosis and treatment of depression in late life." JAA4A 1992. 268:1018-1024

2. Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF 3rd, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, and P Parmelee. "Diagnosis and treatment of depression in late life. Consensus statement update." JAMA 1997 Oct 8;278(14):1186-90

3. De Leo D, Diekstra RF, Lonnqvist J, Trabucchi M, Cleiren MH, Frisoni GB, Dello Buono M, Haltunen A, Zucchetto M, Rozzini R, Grigoletto F, and J Sampaio-Faria. "LEIPAD, an internationally applicable instrument to assess quality of life in the elderly." Behav Med 1998 Spn'ng;24(l):17-27

4. Butler RN, Finkel SI, Lewis MI, Sherman FT, and T. Sunderland. "Aging and mental health: primary care of the healthy older adult. A roundtable discussion: Part I." Geriatrics 1992 May;47(5):54, 56, 61-5

5. Aydemir 0, Ozmen E, Kuey L, Kultur S, Yesil M, Postaci N, and S Bayata. "Psychiatric morbidity and depressive symptomatology in patients with permanent pacemakers." Pacing Clin Electrophysiol 1997 Jun;20(6):1628-32

6. Dougherty CM. "Psychological reactions and family adjustment in shock versus no shock groups after implantation of internal cardioverter defibrillator." Heart Lung 1995 Jul-Aug;24(4):281-91