Many factors conspire to undertreat their depression.

Many factors conspire to undertreat their depression.(ANDERSON ROSS/VEER)Antidepressant medication and counseling seem to work better together than either alone for depressed geriatric patients. Unfortunately depressed seniors rarely get the treatment they need.

Only half of older adults with mental health problems receive treatment from any provider (over half of those get it from their primary care physician). Only 3% of seniors with mental health problems get treatment from a mental health professional. But untreated depression increases an elderly person's risk of death, according to Burton V. Reifler, MD, a professor of psychiatry at Wake Forest University.

More about depression

Why the elderly are undertreated
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

Next Page: Antidepressants can be problematic [ pagebreak ]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.

"I make sure that patients and their family—who I always try to include—understand how long it can take to respond to an antidepressant. People need clear expectations. The drugs take longer to work in older people than younger ones, usually 8 to 12 weeks. The longer they stay on the medicine, the more improvement they are likely to see," says Dr. Forester.

He describes how it's important to keep increasing the dose so that the drug is as effective as possible, but also to go up slowly, so as not to trigger side effects. SSRIs can affect the lining of the stomach, so older people are usually advised to take the drugs with food to prevent nausea.

Studies also suggest that SSRIs can speed bone loss in the elderly, though this side effect is the subject of ongoing research.

To make things more complicated, numerous medications, especially heart and blood pressure drugs, can cause mood changes. "You have to be a detective to figure it all out," Dr. Forester says. He adds that most doctors will take a close look at all the medications a person is taking to see if dosages could be reduced or eliminated. Thyroid tests also may help rule out a medical problem that could lead to depression.