GERIATRI CS / GÉ RI ATRIE
GERIATRIC DEPRESSION: A BRIEF REVIEW
http://www.lebanesemedicaljournal.org/articles/60-4/review3.pdf
Georges Elie KARAM*
Karam GE. Geriatric depression: A brief review. J Med Liban
2012 ; 60 (4) : 200-206.
INTRODUCTION
Depression is a common mental disorder that presents
with symptoms well beyond depressed mood. Loss of
interest or pleasure, feelings of guilt or low self-worth,
disturbed sleep or appetite, low energy, poor concentra-
tion, and a multitude of physical ailments may accom-
pany clinical depression. These problems can become
chronic or recurrent and lead to substantial impairments in
an individual’s ability to take care of his or her everyday
responsibilities. At its worst, depression can lead to sui-
cide, a tragic outcome associated with the loss of about
850,000 lives every year worldwide.
Depression occurs in persons of all genders, ages, and
backgrounds. It is the leading cause of disability as mea-
sured by Years Lived with Disability and was the fourth
leading contributor to the global burden of disease in
2000, according to the World Health Organization [1]. By
the year 2020, depression is projected to rank second in
the DALYs (Disability Adjusted Life Years) calculated for
all ages and both sexes [1-2]. Today, depression is already
the second cause of DALYs in the age category 15-44
years for both sexes combined [1].
Depression can be reliably diagnosed in the primary
care setting. Antidepressant medications and brief struc-
tured forms of psychotherapy are effective for 60-80%
of those affected with depression. However, fewer than
25% of those affected (in some countries like Lebanon,
fewer than 10%) receive such treatment. Barriers to effec-
tive care include the lack of resources, lack of trained
providers, and the social stigma associated with mental
disorders including depression.
DEFINITION
Depression is a mood disorder that involves the body and
the mind. Major depressive disorder (MDD) is a medical
condition characterized by many symptoms emerging
together. To be diagnosed with MDD, one must meet the
criteria established in the fourth edition of the Diagnostic
*Department of Psychiatry and Clinical Psychology, Saint
George Hospital University Medical Center; Faculty of Medi-
cine, Balamand University Medical School & IDRAAC, Insti-
tute for Development, Research, Advocacy and Applied Care,
Beirut, Lebanon.
e-mail: georges.karam@idraac.org
200 Lebanese Medical Journal 2012 • Volume 60 (4)
Aging Successfully
and Statistical Manual of Mental Disorder (DSM-IV) [3]
for MDD. Five (or more) of the symptoms must have
been present during the same 2-week period and represent
a change from previous functioning; at least one of the
symptoms should be either depressed mood or loss of
interest or pleasure. The criteria are:
1. Depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g., feels
sad or empty) or observation made by others (e.g.,
appears tearful);
2. Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every
day (as indicated by either subjective account or ob-
servation made by others);
3. Significant weight loss when not dieting or weight
gain (e.g., a change of more than 5% of body weight
in a month), or decrease or increase in appetite near-
ly every day;
4. Insomnia or hypersomnia nearly every day;
5. Psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective feel-
ings of restlessness or being slowed down);
6. Fatigue or loss of energy nearly every day;
7. Feelings of worthlessness or excessive or inappropri-
ate guilt (which may be delusional) nearly every day
(not merely self-reproach or guilt about being sick);
8. Diminished ability to think or concentrate, or inde-
cisiveness, nearly every day (either by subjective
account or as observed by others);
9. Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing
suicide.
The above symptoms should cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning. Also, the symptoms must
not be due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism). While depression may
occur as only one single episode in a person’s lifetime, for
many it is a recurrent disorder with repetitive episodes of
varying severity.
There are many types of depression. Depression can be
unipolar, where the mood disturbance is characterized by
feeling sad or down during each episode, or it can be part
of a bipolar disorder, where some episodes are character-
ized by depressed mood and others by euphoric and elated
(or irritable) mood associated with increased levels of
energy, talking a lot, spending much more money than
usual, and decreased need of sleep – a state also known as
mania (or hypomania). Depression can also be seasonal,
where depressed mood, low energy, and appetite change
predominate in the winter months, and typically improve
in spring and summer. This is known as Seasonal Affec-
tive Disorder (SAD) and is probably related to the inten-
sity of light that reaches the brain.
In later life, depression frequently coexists with other
medical illnesses and disabilities. In addition, advancing
age is often accompanied by loss of key social support
systems due to the death of a spouse or siblings, retire-
ment, relocation of residence, or social isolation due to in-
firmity. Because of these changes, and the fact that older
people normally experience functional and physiological
decline, doctors and family may miss the diagnosis of
depression in the elderly, hence delaying effective treat-
ment. As a result, many seniors find themselves having to
cope with symptoms that could otherwise be easily treat-
ed. In addition, depression tends to last longer in older
adults. It doubles their risk of cardiac diseases and in-
creases their risk of death from other illnesses [4], while
reducing their ability to rehabilitate.
PATHOPHYSIOLOGY
The underlying pathophysiology of major depressive dis-
order has not been clearly defined. Clinical and preclini-
cal trials suggest a disturbance in central nervous system
(CNS) serotonin (5-hydroxytryptamine, or 5-HT) activity
as a prominent factor. Other neurotransmitters implicated
include norepinephrine (NE) and dopamine (DA) [5]. The
role of CNS serotonin activity in the pathophysiology of
major depressive disorder is suggested by the efficacy of
selective serotonin reuptake inhibitors (SSRIs) in the treat-
ment of major depressive disorder. Furthermore, studies
have shown that an acute transient relapse of depressive
symptoms can be produced in research subjects in remis-
sion using tryptophan depletion, which causes a temporary
reduction in CNS 5-HT levels. Serotonergic neurons impli-
cated in affective disorders are found in the dorsal raphe
nucleus, the limbic system, and the left prefrontal cortex.
Studies suggest that seasonal affective disorder is also
mediated by changes in CNS levels of serotonin and ap-
pears to be triggered by alterations in circadian rhythm and
sunlight exposure.
Vascular disease may contribute to depression by dis-
rupting the neuronal networks involved in emotion regula-
tion – in particular, frontostriatal pathways that link dorso-
lateral prefrontal cortex, orbitofrontal cortex, anterior cin-
gulate, and dorsal cingulate [6]. Microvascular disease in
other components of the limbic circuitry, in particular the
hippocampus and amygdala, has also been implicated in
depression.
Endocrine changes in depression are evident across the
life span, but some are particular to aging. Women with a
previous history of depression are at higher risk of devel-
oping depression during menopause, suggesting a role for
estrogen in mood regulation. Similarly, low testosterone
levels have been associated with depression in older men.
G.E. KARAM – Geriatric depression
ETIOLOGY
Genetics
Genetic susceptibility plays a role in the development
of major depressive disorder. Individuals with a family
history of affective disorders, panic disorder, and alcohol
dependence carry a higher risk for major depressive disor-
der. Studies such as those by Akiskal and Weller [7] and
Weissman et al. [8] suggest a genetic component in the
etiology of depressive disorders. Other evidence suggests
that late-onset depression (after age 60 y) is an etiological-
ly and clinically distinct syndrome [9] and that genetic fac-
tors likely play less of a role in late-onset than early-onset
depression. A family history of depression is less common
among older adults with depression than younger adults.
However, certain genetic markers have been associated,
although inconsistently, with late-onset depression, includ-
ing polymorphisms of the apolipoprotein E, brain-derived
neurotrophic factor (BDNF), and 5-HT transporter genes.
Interestingly, these markers have also been associated with
cognitive impairment, hippocampal volume, and antide-
pressant response, respectively.
Stressors
Although major depressive disorder can arise without any
precipitating factors, stress and interpersonal losses cer-
tainly increases the risk. Psychodynamic formulations
indicate that significant losses in early life predispose to
major depressive disorder over the lifespan of the indi-
vidual, as does mental trauma, either transient or chronic.
Cognitive-behavioral models of depression posit that de-
pression is a behavioral response to repeated stressors and
that cognitive distortions (i.e., negative thoughts) contrib-
ute to and perpetuate depressed mood [9].
Chronic pain, medical illness, and psychosocial stress
can also play a role in both the initiation and maintenance
of major depressive disorder. Older adults may perceive
medical illness as psychologically distressing, and illness-
es may lead to increased disability, decreased indepen-
dence, and disruption of social networks [10]. Other psy-
chosocial risk factors for depression in late life include
impaired social supports, caregiver burden, loneliness, be-
reavement, and negative life events [11]. Of particular
interest is the association between chronic uncontrolled
pain and depression, each of which can make the other
worse thus initiating a cycle of escalation. The limited
pharmaceutical options for pain management in Lebanon
hinders the clinician’s ability to potentially arrest this vi-
cious cycle.
Vascular depression
The vascular depression hypothesis posits that cerebro-
vascular disease may cause or contribute to late-life de-
pression. Various lines of evidence support this hypothe-
sis, including the high incidence of depression following
a stroke and higher prevalence of ischemic white-matter
changes in older adults with depression compared to those
without [12]. Additional evidence can be found in the
Lebanese Medical Journal 2012 • Volume 60 (4) 201
 bidirectional association between depression and coro-
nary artery disease (CAD), and higher rates of depression
among patients with vascular dementia than those with
Alzheimer’s disease [12].
EPIDEMIOLOGY
Interest in geriatric depression has increased in recent
years and several population studies have examined its
prevalence, with results ranging from 1% to 20%. Meth-
odological differences may account for this wide variabil-
ity [13].
The WHO World Mental Health (WMH) Survey
Initiative was launched in 2000 to obtain such data in
large-scale psychiatric epidemiological surveys. Lebanon
was the only Arab country included in the WMH survey
(other countries have joined since). The Lebanese survey,
the Lebanese Evaluation of the Burden of Ailments and
Needs of the Nation (LEBANON), was undertaken by
the Institute for Development, Research Advocacy and
Applied Care (IDRAAC) with the Department of Psychi-
atry and Clinical Psychology at Balamand University, and
St George Hospital University Medical Center. The prima-
ry goal was to produce nationally representative data for
prevalence, correlates, and treatment of mental disorders,
to raise awareness about mental illness, and to influence
healthcare policy in Arab countries [14].
Based on the LEBANON study that interviewed near-
ly 3,000 subjects (nationally representative sample),
12.6% of the Lebanese population suffer from a lifetime
prevalence of mood disorder. As for the geriatric popula-
tion (65 years and older), 9.3% suffer from a lifetime
prevalence of mood disorders (Fig. 1) [15].
The USA took part in the WHO World Mental Health
(WMH) Survey Initiative. Nationally, 19% of the Amer-
icans suffer from a lifetime prevalence of mood disorder.
As for the geriatric population, 12.4% suffer from a life-
time prevalence of mood disorder [16]. However, these
rates may be higher in the community as the WMH
Survey Initiative excluded people suffering from demen-
tia. Some studies estimate that 20% to 40% of people suf-
16
14.4
14
12.6
12.4 12.1
12
10.9
10
8.5
Percentage
8 disorder and major depression
6
4
2 There was no statistical significance
0
18-34 35-49 50-64
202 Lebanese Medical Journal 2012 • Volume 60 (4)
fering from early to moderate stages of dementia also suf-
fer from depression.
STIGMA AND LACK OF AWARENESS OF DEPRESSION
IN LEBANON AND DEVELOPING COUNTRIES
To some, the increased prevalence of depression in the
United States compared to Lebanon may seem surprising.
Residents of developing countries in general contend with
stressors to a greater degree than in developed countries,
and Lebanon is no exception. Political uncertainty, secu-
rity concerns, and economic stress are the obvious con-
stants, but in addition increasingly fragmented family
structure, limited healthcare access and social support,
attitudes towards the elderly, and a widening gap between
the rich and poor, all provide additional layers of stress.
One explanation lies in the stigma attached to mental
illness and depression in Lebanon. Depression is often
viewed as a sign of weakness – a character flaw that must
be addressed by self-improvement. In some conservative
societies of various religions, mental illness is considered
a punishment from God for discretions committed by the
family. Afflicted patients are kept away from public view,
and the problem is not talked about. The shame of seeking
help for depression is sometime sensed in the primary care
setting, when patients present for “other” conditions, then
apologetically seek help for stress and depression. It is
quite possible that a sizable segment of the population re-
mains undiagnosed and suffers in silence. In order to over-
come this cultural hindrance, public awareness campaigns
may prove helpful.
Another explanation would be the lack of awareness of
this disorder among the public and primary care physi-
cians alike. In the LEBANON study, people were asked if
they would be ashamed to seek help for their depression
and the answer was overwhelmingly in favor of seeking
help. However, those that did suffer from depression often
were not aware of their condition. Healthcare profession-
als must be vigilant and actively screen for depression,
and initiate treatment when appropriate, or refer the pa-
tient when necessary.
Mood disorder
MDD FIGURE 1
9.3 9.1
Lifetime prevalence of mood
by age groups in Lebanon.[14]
MDD: Major depressive disorder.
among age groups.
65+ Age (years)
G.E. KARAM – Geriatric depression
 6
5.5
18-34 y 35-49 y 50-64 y 65+ y
5

3.8
4

FIGURE 3 3
2.7

Percentage
3
2.4 2.6
Suicide ideation, plan, and 2
2
attempt by age groups 1.4
in Lebanon. [14] 0.8 1 1.1 0.9
1

0
Suicide Ideation Suicide Plan Suicide Attempt

DEPRESSION AND THE RISK OF SUICIDE
Suicide rates are generally higher among the elderly com-
pared to younger age groups, and are highest among
elderly white males [17] (Fig. 2). More than two thirds of
suicides in the elderly take place in the context of depres-
sion, and 75% of all geriatric patients who succeed in sui-
cide had seen their primary-care physician in the previous
month [18]. Depressed elderly persons with suicidal idea-
tion (active or passive) have higher depression ratings (i.e.
severity) than depressed elders without suicidal ideation.
Any suicidal ideation should be taken seriously since the
elderly are less prone, compared with other age groups, to
use the threat of suicide as a tool to manipulate others or
as an attention-seeking measure.
In Lebanon, 4.3% of the population experienced sui-
cidal ideation and 2% attempted suicide. As for the el-
derly population, 3% experienced suicidal ideation and
almost 1% attempted suicide (Fig. 3). These rates were
70
60
50
Suicide Rate per 100,000
calculated from the LEBANON study [14]. It is believed,
however, that these rates may be an underestimation of
the actual rates due to moral, religious, and social reasons.
Until the present time, there is no official suicide registry
in Lebanon. Frequently, the cause of death (when due to
suicide) is changed on official death certificates.
DIAGNOSIS
The differential diagnosis for depression includes other
psychiatric disorders such as dysthymia and bipolar disor-
der, CNS diseases such as Parkinson’s disease and neo-
plastic lesions, endocrine disorders such as hypothyroid-
ism and hyperthyroidism, drug-related conditions such as
alcohol abuse or side effects of ß-blockers, infectious dis-
ease such as syphilis, and sleep-related disorders. When
indicated, alternative diagnoses and secondary causes of
depression must be ruled out by appropriate tests. Com-
plete blood count, serum electrolytes, blood urea nitrogen,
White Male
White Female
Black Male
Black Female

40
FIGURE 2

Suicide rates 30

by age, race and

gender. [17] 20

10

0
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-85 85+

Age (years)

G.E. KARAM – Geriatric depression Lebanese Medical Journal 2012 • Volume 60 (4) 203
creatinine, serum toxicology screen, and thyroid function
tests should be considered in the initial workup of depres-
sion.
Depression is a clinical diagnosis. In addition to a
thorough history and physical examination, standardized
screening tests can be used to screen for depression and
bipolar disorder. The most widely used tests are the
Hamilton Depression Rating Scale (HDRS) [19] and the
Geriatric Depression Scale (GDS) [20]. While many instru-
ments of varying degree of sophistication exist to measure
depression, the GDS, first created by Yesavage et. al. in
1983, has been tested and used extensively in the older
population. It is a brief questionnaire in which participants
are asked to respond to the 30 questions by answering
“yes” or “no” in reference to how they felt on the day of
administration. Scores of 0-9 are considered normal, 10-19
indicate mild depression and 20-30 indicate severe depres-
sion. The GDS may be used with healthy, medically ill, and
mild to moderately cognitively impaired older adults. It has
been extensively used in the community, acute and long-
term care settings, and in research. The GDS was found to
have 92% sensitivity and 89% specificity when evaluated
against the DSM-IV diagnostic criteria. Validity and relia-
bility of the tool have been supported through both clinical
practice and research.
However, the GDS is not a substitute for a diagnostic
interview by mental health professionals. It is a useful
screening tool in the clinical setting to facilitate assess-
ment of depression in older adults especially when base-
line measurements are compared to subsequent scores.
Also, it is important to understand that the results
obtained from the use of any depression rating scales are
imperfect in any population, especially elderly patients.
COMORBIDITIES
Commonly, depression in the elderly is accompanied by
other medical illnesses. A threshold or sub-threshold psy-
chiatric disorder was detected in 42.5% of all patients con-
sulting general practitioners [21]. Increased longevity of
the elderly is accompanied by an increase in chronic med-
ical problems such as osteoarthritis, chronic pain, sensory
impairment, or debility. Quality of life may be compro-
mised by the morbidity associated with these conditions,
which, in turn, can contribute to further depression. It is
also well documented that depression has direct bearing
on physical health. As a result, an escalating cycle may de-
velop where failing health triggers further depression, and
depression worsens medical illness and disability [22].
For example, symptoms of depression affect between
20% and 25% of diabetics – nearly twice the prevalence of
non-diabetics. In a cohort study of more than 78,000 wom-
en older than 54 years, investigators found a 35% increas-
ed risk of any cause of death for those with diabetes, a 44%
increased risk for those with depression, and twice the risk
of death for those with both conditions compared to their
counterparts with neither [23]. Even after demographic
variables, body mass index, smoking status, alcohol intake,
204 Lebanese Medical Journal 2012 • Volume 60 (4)
physical activity, and comorbidities (including hyperten-
sion, hypercholesterolemia, heart diseases, stroke, and can-
cer) were adjusted for, women who had both conditions
still had the highest relative risks for all cause mortality
and cardiovascular mortality [23].
Regarding coronary artery disease, worsening depres-
sion in patients suffering from heart failure is associated
with a doubling of the risk for cardiac-related hospitaliza-
tion or death [24].
A significant increase in poor cardiovascular outcomes
is seen regardless of any changes in the status of heart fail-
ure, suggesting that depression exerted the biggest influ-
ence on the increased risk. Moreover, depression is three
times more common in patients after an acute myocardial
infarction than in the general community [25].
Recognizing depression in an older patient with a host
of medical ailments is not always straightforward. It is,
therefore, not surprising that the diagnosis is often missed
in the primary-care settings. However, when the diagnosis
of depression is made correctly, and effective treatment is
started, studies have shown that patients’ functional abil-
ity improve even though their underlying medical condi-
tion has not changed.
TREATMENT
A wide range of effective treatments are available for the
management of major depressive disorder. Medication
alone can relieve symptoms, and brief psychotherapy (e.g.,
cognitive-behavioral therapy, interpersonal therapy) has
also been shown in clinical trials to be an effective treat-
ment option, either alone or in combination with medica-
tion.
In 2011, the American Psychiatric Association (APA)
updated its Practice Guideline for the Treatment of Pa-
tients with Major Depressive Disorder [26]. The guideline
emphasizes the need to customize treatment for each pa-
tient based on a careful assessment of symptoms (includ-
ing depression rating scale measurements) as well as an
analysis of therapeutic benefits and side effects. Treat-
ment should maximize patient function within specific
and realistic goals. The initial treatment modality should
be determined by clinical assessment, comorbidities, stres-
sors, patient preference, and responses to previous treat-
ments.
Medications
Currently, six classes of antidepressants exist on the mar-
ket: selective serotonin reuptake inhibitors (SSRIs), selec-
tive serotonin/norepinephrine reuptake inhibitors (SNRIs),
atypical antidepressants, tricyclic antidepressants (TCAs),
monoamine oxidase inhibitors (MAOIs) and recently mel-
atonergic agonists. A detailed discussion of these medica-
tions is beyond the scope of this review.
n Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) have
the advantage of easy dosing and relatively low toxicity in
overdose. This class includes: fluoxetine, fluvoxamine,
G.E. KARAM – Geriatric depression
sertraline, citalopram, escitalopram, paroxetine and dapo-
xetine. SSRIs are greatly preferred over the other classes of
antidepressants due to their superior tolerability and more
benign safety profile. The recommendation as first-line
agents is supported by the 2011 APA guideline. Common
adverse effects include gastrointestinal upset, sexual dys-
function, and changes in energy level (i.e., fatigue, rest-
lessness). The SSRIs are not as problematic in patients
with cardiac disease, as they do not appear to exert any
effect on blood pressure, heart rate, cardiac conduction,
or cardiac rhythm. Because the adverse effect profile
of SSRIs is favorable, improved compliance over other
agents is promoted.
n Selective serotonin/norepinephrine reuptake inhibitors
Selective serotonin/norepinephrine reuptake inhibitors
(SNRIs), which include venlafaxine, desvenlafaxine, and
duloxetine, can be used as first-line agents, particularly
in patients with significant fatigue or pain syndromes
associated with the episode of depression. SNRIs also
have an important role when used sequentially as second-
line agents in patients who have not responded to SSRIs.
n Atypical antidepressants
Atypical antidepressants effectively augment therapy
in major depressive disorder. These agents include bupro-
pion, mirtazapine, and trazodone. This group also shows
low toxicity in overdose and may have an advantage over
the SSRIs by causing less sexual dysfunction and GI dis-
tress.
n Tricyclic antidepressants
These agents have a long record of efficacy in the
treatment of depression and have the advantage of lower
cost. They are used less commonly at present because
of the need to titrate the dose to a therapeutic level, and
due to their considerable side effects and toxicity in over-
dose.
n Monoamine oxidase inhibitors
Monoamine oxidase inhibitors (MAOIs) are quite
effective in a broad range of affective and anxiety disor-
ders, and include phenelzine and tranylcypromine. Be-
cause of the risk of hypertensive crisis, patients adminis-
tered MAOIs must follow a low-tyramine diet. Other
adverse effects include insomnia, anxiety, postural hypo-
tension, weight gain, and sexual dysfunction. Due to their
side effect profile, MAOIs are rarely used at the present
time.
n Melatonergic agonists
This is the newest class of antidepressants, and cur-
rently includes only one molecule agomelatine. This drug
was approved for treatment of depression by the Euro-
pean Medicines Agency (EMEA) in 2009, but has not
gained FDA approval due to concerns with efficacy (but
not safety). Agomelatine is a melatonergic agonist. It is
indicated for the treatment of major depressive episodes
in adults. Only limited clinical data is available on the use
of agomelatine in elderly patients (≥ 65 years old) with
major depressive disorder. Therefore, caution should be
exercised when prescribing it to those patients [27].
G.E. KARAM – Geriatric depression
Psychotherapy
The National Institute of Mental Health (NIMH) collabo-
rative study (non-geriatric-age adults) reported that psy-
chotherapy was equivalent in efficacy to antidepressant
medication for all but the most severe cases of depressions
[28]. If the depression occurs in the context of psychoso-
cial stressors, psychotherapy may be all that is necessary to
achieve a remission of depressive symptoms in an older
person willing to engage in self-reflection. For those with
more severe depression that includes considerable vegeta-
tive symptoms, such as disorganized sleep or significant
weight loss, an antidepressant is also often required. Since
depression is always experienced in a social context, with
frequent disruption of interpersonal relationships, com-
bined treatment with antidepressant medication and psy-
chotherapy often seems the most reasonable choice. A psy-
chotherapeutic component to treatment strategies can also
help ensure adherence to a medication regimen, as well as
educate the patient about the symptoms and mechanisms
of depression in order to place the patient’s social dys-
function in a rational perspective. Several short-term psy-
chotherapy approaches have been developed for the elder-
ly. A full description is beyond the scope of this review
but can be found elsewhere [29].
Electroconvulsive therapy
Electroconvulsive therapy (ECT) is a very effective treat-
ment for depression; it is usually undertaken after several
medication trials have failed or when a patient is severely
vegetative or suicidal. In 1938, the question of inducing
seizures as treatment for depression was explored after
it was noted that epileptic patients who were depressed
showed a marked improvement in mood after a seizure.
Treatment with ECT for depression was found to be suc-
cessful [30]. Despite a long history attesting to the safety
and efficacy of this intervention (particularly with the
advent of neuromuscular blocking agents), ECT continues
to suffer from negative connotations in the public mind.
Misguided impressions are based more in popular culture,
such as the graphic depiction of the process in movies,
rather than in clinical facts. As a result, ECT may be shun-
ned as a treatment option, when, in fact, in select patients
it can be as (or more) effective than pharmacological in-
tervention.
Typically, 6 to 12 ECT treatments are required for an
antidepressant response. Maintenance antidepressant med-
ication is begun upon completion. Unilateral ECT causes
less memory loss and confusion compared with bilateral
ECT and is attempted first. Patients with coexisting de-
mentia are prone to post-ECT confusion and may require
a longer time-interval between treatments. Some centers
offer outpatient maintenance ECT for patients who cannot
be stabilized on antidepressant medication.
A common myth is that ECT causes permanent memo-
ry damage. The seizure induced by ECT certainly causes
temporary interference with the laying down of new
memory, such that patients often have impaired recall of
events experienced immediately prior to their ECT treat-
Lebanese Medical Journal 2012 • Volume 60 (4) 205
ment. However, long-term follow-up studies have not
demonstrated any difference in memory at six months after
a completed course of ECT, compared with baseline [31].
Hospitalization
Depressed geriatric patients should be considered for in-
patient psychiatric hospitalization if they are suicidal, have
complex medical problems, are candidates for ECT, show
severe psychotic symptoms, or do not have an adequate
social support system. A specialized geriatric psychiatry
unit is preferred in order to maximize the benefit of a
trained multidisciplinary team of psychiatrists, internists,
nurses, and psychologists to address the patient’s needs.
CONCLUSION
Research, improved awareness, and treatment advances
have revolutionized the care of depressed elderly persons
in the last fifteen years. With current resources and know-
ledge, optimism has justifiably replaced therapeutic nihil-
ism. The current task at hand is to educate the public
in general, and all healthcare workers in particular, about
the availability of effective treatments. Depression should
never be considered normal, neither in childhood nor in
later life.
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G.E. KARAM – Geriatric depression