Explanations for why older people are underserved vary. According to the American Association for Geriatric Psychiatry, they include the following.
- Stigma and a denial of problems by the patient
- Access barriers, especially for people with mobility issues
- Lack of collaboration and coordination between mental health professionals and other service providers
- A shortage of geriatric psychiatrists and psychologists
- Financial barriers, as older patients on a fixed income may not be able to afford antidepressants
Antidepressants can be problematic
As in younger populations, some antidepressants may be more appropriate than others for older individuals. "A lot of this is based on clinical judgment, not hard evidence," says Brent Forester, MD, a geriatric psychiatrist at McLean Hospital in Boston. For example, a depressed person who is also anxious, having trouble sleeping, and not eating may do well with an antidepressant like mirtazapine, which tends to stimulate the appetite, help with sleep, and calm anxiety. In contrast, people who lack energy and feel "blah" or apathetic may have associated vascular changes in the brain and may need medications that affect several different brain chemicals. "We use Wellbutrin and even Ritalin sometimes," he says.