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Older adults often deny feeling sad while exhibiting other characteristics of depression. Elderly patients with depression who do not present with sadness often have unexplained somatic complaints and exhibit a sense of hopelessness. Anxiety and anhedonia (a general loss of ability to feel pleasure) are also encountered frequently. Other features that may indicate underlying depression include slowness of movement and lack of interest in personal care. A screening device, such as the Center for Epidemiologic Studies-Depression Scale, Revised (CES-D-R), may identify depression in suspicious cases. When this condition is identified, treatment should generally include the use of an antidepressant medication, usually a selective serotonin reuptake inhibitor. (Am Fam Physician 1999;60:820-6.)
"When I was first aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word, `depression."' -William Styron, Darkness Visible Ider persons may not exhibit the typical symptoms of sE depression, including sadness.2-4 Standard criteria for major depression, such as those found in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSMIV),5 require depressed mood or loss of interest in activities that were once enjoyable, and at least four additional symptoms: appetite disturbance; sleep disturbance; fatigue; psychomotor agitation or retardation; feelings of worthlessness, sinfulness or guilt; trouble with concentration; and thoughts of death or suicidal ideation (Table I).5 While patients who deny feeling sad, blue or depressed may still meet standard criteria for major depression as set forth in DSM-IV, this review will emphasize alternative clinical clues to depression in older persons, in whom loss of interest in activities is sometimes difficult to assess. When these clinical clues are present, the symptoms of depression should be sought (Table 1).5 Sleep disturbance, decreased appetite, weight loss, irritability, difficulty with concentration and fatigue, which are common signs of depression in older patients, will not be specifically addressed in this article.
Older persons with significant depression may have fewer symptoms than the number required by the DSM-IV criteria for major depression. In one study,6 older adults who expressed feelings of hopelessness or worthlessness, admitted to thoughts of death or suicide, and had at least two other symptoms of depression were at increased risk for functional disability, cognitive impairment, psychologic distress...