In my first year of medical school an instructor posed a question to our class: “If you could develop a cure for one disease what would you choose?” The year was 1989 and the disease that was on everyone’s mind was acquired immunodeficiency syndrome (AIDS), an illness that at the time seemed to be blossoming faster than the black plague epidemic of the dark ages and for which no treatment was available. Most of my classmates voted to cure AIDS while others opted for various different types of cancer. A few suggested diseases affecting third world countries, such as malaria and tuberculosis. No one volunteered a cure for heart disease (I guess that means job security for me).
The lecturer then spent the next hour making a case for finding a cure for a particular disease that affects over a third of the population and is associated with considerable impact to personal productivity and quality of life: depression. His perspective was that people afflicted with depression suffered as much or more than patients with any other ailment, only in a less visible way. He also suggested that the high suicide rate among those with severe depression implies that, at least for these individuals, living with their illness is even worse than death.
I have since thought a lot about the point that our instructor was trying to make and have come to agree with him. My opinion on the matter has strengthened since I began caring for many older patients who have a combination of heart disease and depression.
While I don’t consider myself (even remotely) an expert in the treatment of depression I often discuss this issue with my patients, usually at their request. In some ways I think my patients put me in the same category as their bartender—for some reason they have an easier time discussing some problems with me (who, they suspect, will provide an impartial opinion but who won’t commit them to some type of treatment) than their own physician. “My family doctor thinks I have helminthic halitosis and wants to start me on sublingual metronidazole. What do you think about that?” I suspect a lot of times they are more forthright with me than they would otherwise be simply because a question to a heart doctor about a non-heart item makes it an unofficial question.
This is how I often end up on the topic of depression. If you were to open a textbook on the subject you’d find a dozen different types of screening tests and questionnaires that help you identify patients with depression. I have come to rely on a simple approach that involves a single question: do you think you’re depressed? True professionals will take me to task on this over-simplification but I find that it works well for most patients willing to open up about this.
Depression among older patients is an interesting phenomenon. If a young person loses interest in life, lacks enjoyment and happiness, and drifts into hopeless despair, most likely he’ll be correctly diagnosed by family and doctors. When older people exhibit the same characteristics, however, those around them simply write it off to the effects of aging. The average 85-year-old person is widowed, has lost half her friends to death or incapacitation, is unable to engage in the type of physical activities she’s enjoyed in the past, has difficulty remembering recent events, is plagued by chronic pain and discomfort, has to rely heavily on others (for transportation, meals, housekeeping), loses a taste for food, has difficult reading because of poor vision—and none of these things is getting any better. Of course she’s depressed, they say.
It’s for this reason that depressed seniors rarely reach out for help. The problem is made worse by the stoicism of the Greatest Generation, the D-Day heroes and Rosie the Riveters who grew up during the austere 30’s and knew darn well that June Cleaver never moaned about her domestic dissatisfaction. Despite this, depression is present in more than a third of elderly individuals with heart problems and is seen in about 40% of those who are hospitalized, have cancer, or have suffered a stroke. Worse, the 12% of the U.S. population that makes up the 65-and-older crowd accounts for a disproportionate number of suicides (16% of all suicide deaths in 2004).
Depression is a big problem for our youth, but it’s at least on the radar of doctors and counsellors. Does a sad and hopeless heart attack survivor raise the same red flags? He should. Depression among this class of patient portends a four-fold increase in death. Among stroke survivors, the diagnosis of depression predicts a ten-year survival rate 70% lower than their happier counterparts. And these death rates aren’t due to suicide—depression itself is a disease that somehow degrades the elderly body as much as any other chronic illness.
It is human nature to hope for a better tomorrow when we suffer from sickness today. The belief that “things will improve” allows us to muster the strength to recover from even the most miserable illness. When a life-threatening ailment such as a heart attack is compounded by the inability to foresee a brighter future, the result can be an outcome that is significantly worse than predicted in our cardiology textbooks.
So, keep an eye out for this problem—in yourselves, in your parents and grandparents, and in your patients. While we don’t have a silver bullet cure (my medical school instructor will have to wait a few more years before we can eradicate this scourge) we have therapies for depression that can help substantially. Our family members will be better off, our cardiac patients will recover more fully, and I’ll gladly give up my job as bartender.