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Talking About Mental Illness in Long-Term Care: "But She`s So Depressing"
Depression is a mental health affliction that affects nearly every age group, including older adults. However, confusion may arise if we begin to assume that “being depressed” necessitates having a clinical, psychiatric illness. Of course, we know this not to be the case; there are many experiences in our lives that can bring about periods of sadness. One example is the grief that follows the death of someone close to us. Over time, we are able to “recover” from these experiences and refocus ourselves on our day-to-day lives. Even though during such a time we may be feeling symptoms of depression, we would not hurry to label this as a psychiatric illness until the point at which these symptoms negatively impact our daily activities. For older adults, one commonly speaks of these activities as activities of daily living (ADLs) and independent activities of daily living (IADLs)—activities that represent independent living and self-fulfillment. However, it has been shown that the experience of depressive symptoms in these individuals can quickly lead to functional deficits in quality of life.1
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The reason that the designation of “depressed” has become so commonplace may be attributed to the fact that there exist triggers—anxiety, isolation, stress, regret, and others—that put us all equally in a state of “feeling down.” Taking these triggers in isolation, they are often manageable. Taken together, however, their synergistic effects can rapidly result in a severe state of despair.
Aging and Depression
Anyone who operates in close contact with the elderly may have come to view “aging” as a trigger of depression. After all, the very process of growing old is rarely met with optimism. For many, the negative aspects of living begin to outweigh the positive aspects at the onset of our late, senior years. Illness, chronic pain, functional decline, loss of independence, and the deaths of loved ones are some of the few triggers for depression at any stage in life. Yet, as we age, these events not only become more probable, they become stacked. Eventually, the time we have to “recover” from one bad experience is significantly shortened before another occurs.
The response to an increased occurrence of negative events often manifests as a persistent state of sorrow and sadness, which can give the impression that the older adult in question is constantly “depressed.” However, this comes at a greater cost as older adults become subjected to the effects of a perpetuating stigma that is taken to be pseudo-reflective of the entire elderly population. This warrants a discussion on the notion of depression among older adults and how such a label remains a barrier to overcoming the stigma surrounding sadness in older adults.
A Shared Burden
There is a fear, or at least an apprehension, that an interaction with a “depressing senior” will result in us somehow becoming depressed as well. For lack of a better phrase, their burden becomes our burden. Granted, avoiding such interactions is much more difficult, if not impossible, when one is the primary caregiver for an older parent or if one works in direct contact with this age group (eg, in long-term care settings).
The following examples illustrate dialogue heard among family members and in long-term care facilities:
“I think we should go visit grandma at the seniors’ home.”
“But she’s so depressing, do we have to?”
“If you’re having trouble with Mary, try playing some classical music. That should get her to open up, because she’s pretty depressing otherwise.”
“Look at all the things he’s living with. Frankly, I’d be depressed too.”
The issue surrounding mental health among older adults is more complex. As mentioned earlier, compounding emotionally difficult life events can make it appear as though aging is, by default, coupled with becoming depressed. Life events can be described as “depressing,” but living with depressive symptoms and being depressed hold very different clinical and social meanings. In addition, research has shown that when we assume that symptoms of depression are the expected response to a life situation (eg, moving into a long-term care facility), we have already limited ourselves in our ability to provide care.2 Thus, the label of depression we put on older adults severely skews our perception of their life circumstances and our ability to provide them with the necessary support.
The Search for Alternative Descriptors
Our conceptualization of aging would be much less stigmatized if we reserved the use of the term “depression” to describe the clinical, psychiatric malady that requires interventional therapies. Slowly, we are beginning to acknowledge the limitations and dangers of “depression” to describe the normal, expected human response to aging, living with illness and chronic pain, loss of independence, functional decline, and loneliness. Instead, we ought to employ more descriptive terms in our language that do not immediately label an older adult with an illness.
The search for alternatives has already begun. One example of a new term being used more commonly both in day-to-day language and in literature is the notion of “demoralization” as opposed to “depression.” Demoralization was a concept introduced into psychiatry by Jerome Frank in 1968 and has been characterized by feelings of being unable to cope, distress, apprehension, helplessness, hopelessness, personal failing, and aloneness.3,4 It maintains many of the same constructs of depression while acknowledging that external life stressors, rather than a purely chemical imbalance, are driving someone into this state of mind.
The term “demoralized” is one such example, but there are many others:
“I think we should go visit Grandma at the seniors’ home.”
“Is everything okay? She seemed quite sad on the phone.”
“If you’re having trouble with Mary, try playing some classical music. That should get her to open up, because she can get quite down on herself otherwise.”
“Look at all the things he’s living with. I can imagine that he’s having difficulty coping.”
Without resorting to using “depressed” in our descriptions of these individuals, we immediately see a dramatic shift in the tone.
As with any process of de-stigmatization, there exist learning opportunities for those around us (eg, co-workers, grandchildren, and spouses) to perceive aging in a different light. A state of demoralization may still interfere with ADLs and IADLs, but at least acknowledgement of this phenomenon begins the conversation as to what may be the exacerbating factors.
When the burdens of life become too difficult to bear, we can support older adults by being emotionally present with them in their isolation. Although these are vulnerable, even uncomfortable, positions in which to be placed, demoralization is greatly amenable to change. For as we age, it is the “simple things”—spending more time with family, regaining aspects of one’s independence, providing a contribution to society—that provide the most meaning to our lives.
References
1. Lyness JM, Caine ED, King DA, Conwell Y, Duberstein PR, Cox C. Depressive disorders and symptoms in older primary care patients: one-year outcomes. Am J Geriatr Psychiatry. 2002;10(3):275-282.
2. Sarkisian CA, Lee-Henderson MH, Mangione CM. Do depressed older adults who attribute depression to “old age” believe it is important to seek care? J Gen Intern Med. 2003;18(12):1001-1005.
3. Clarke DM, Kissane DW, Trauer T, Smith GC. Demoralization, anhedonia and grief in patients with severe physical illness. World Psychiatry. 2005;4(2):96-105.
4. Frank J. The role of hope in psychotherapy. Int J Psychiatry. 1968;5(5):383-395.
