By Robert P. Roca, M.D., M.P.H.
Director of Geriatric Services
Sheppard Pratt Hospital

Aging is accompanied by many changes and challenges. Bereavement, retirement, illness, and disability are facts of life for many of us as we grow older, and transient sadness is a normal and understandable component of our emotional response to these kinds of losses and disappointments. Major depression on the other hand, is not a normal response to loss and is in fact a source of disability in its own right. It must be detected and treated, not mistaken as an inevitable concomitant of aging. But proper detection isn't always easy. How can we distinguish major depression from reactive sadness in an elderly person who may have "good reasons" to be depressed?

Major depression is the term we use to denote a syndrome of persistent and pervasive unhappiness accompanied by diminished vitality and a negative self-appraisal. Persons with this syndrome have little energy, poor self-esteem, and great difficulty experiencing pleasure, initiating activity, and thinking clearly. They tend to be overly self-critical and excessively worried about being burdensome to others. They often feel worse in the morning and improve marginally during the day, only to feel terrible again the next morning. They may lose their appetite and have difficulty falling and staying asleep (or they may eat and sleep too much). They may have the daily experience of intense anxiety, often without discernible cause. They may become preoccupied with fears about their health and physical functioning and even become convinced that they are dying. At the same time, they may be so unhappy, uncomfortable, and hopeless that death seems their only potential source of relief.

This is major depression. It is identified by its component signs and symptoms. It may occur in response to loss or to life difficulty, but also may just occur "out of the blue"; provocations or precipitants are often present but not necessary. Reactive sadness, in contrast, arises directly in response to particular precipitating losses and disappointments, and it is not associated with the signs and symptoms of major depression. The intensity of reactive sadness is usually proportionate to the severity of the loss and diminishes over time as the person reaches a new level of adaptation or adjustment.

When major depression is precipitated by loss, disappointment, or life difficulty, including serious illness, picking up the signs and symptoms of major depression becomes especially challenging. In such cases, depressed persons have perfectly "reasonable" explanations for their sadness and may even charge us with insensitivity for failing to interpret their sadness as an ordinary response to extraordinary circumstances. Yet recognizing major depression and encouraging the pursuit of treatment is critical and can be life-saving.

Case situation. A 70-year-old man was admitted to the hospital after an intentional overdose of anti-hypertensive medications. He said that he had been extremely discouraged about his health over the past few months. He had been suffering from almost constant leg and back pain for which no cause had been found, and he was experiencing urinary problems despite recent prostate surgery. "No one could help me," he said, "and I couldn't stand it anymore. Would you want to live if you were suffering like that?"

The physician obtained further history. The patient acknowledged that he slept poorly, generally awakening at 4:00 A.M. and remaining awake thereafter ("The pain keeps me awake"). He had abandoned friends and hobbies ("I'm too uncomfortable"). He felt worthless in his present condition and "disgusted" with himself, and he regarded himself as a burden to his wife ("She would be better off without me"). He admitted that he felt depressed ("Wouldn't you?") and had no energy ("I hurt too much to do anything"). His appetite was poor, and he had lost 10 pounds over the previous two months. He wished he'd succeeded in committing suicide.

Although he could provide "reasonable" explanations for many of his symptoms, he clearly had the features of major depression, and he agreed to psychiatric admission. He was treated with an antidepressant medication. Over the course of one month his sleep and appetite improved markedly. His mood brightened, and his self-regard rose to its normal level. Suicidal ideas disappeared, and his wish for death faded. He would still acknowledge leg and back pain when asked about it, but he did not complain spontaneously and was not preoccupied with his discomfort.

This case illustrates how important it is to listen for the signs and symptoms of major depression (e.g., self-criticism, withdrawal from enjoyed activities, disturbances of sleep and appetite) even as we listen empathetically to a sad story of disappointment and loss. We can under-stand how this man might become despondent in response to his demoralizing medical encounters and persistent discomfort. At the same time, the presence of the formal symptoms of major depression indicates that his sadness had "taken on a life of its own" and that he therefore now had an additional source of suffering and disability. He was doubly jeopardized. Fortunately, his physicians took note of his major depressive symptoms and arranged for effective treatment. >/p>

All sadness in late life does not betoken major depression. Demoralization in the face of illness and disability does not by itself indicate a need for antidepressant medication. At the same time, the presence of life difficulties, losses, and disappointments must not distract us from recognizing the signs and symptoms of major depression when they are present. Such recognition will pay dividends in terms of reduced suffering, enhanced day-to-day functioning, and lives saved.