Why depression in later life is a missing diagnosis

Older people are being routinely let down when it comes to their mental health. Over the past 20 years I have worked on and off in old age psychiatry—and have seen repeated examples of how poor the provision is for this group of people.

Despite there being a surge of interest in mental health over recent years, with celebrities and even the Royals raising its profile, the mental health of older people rarely gets a consideration. Instead, the focus is always on more fashionable topics such as the mental health of youngsters. Older people don’t get a look in. Services for older people remain a Cinderella speciality.

It’s clear that underpinning this is ageism. It’s also ageism that underpins many of the assumptions and prejudices that mean that older people with depression in particular are dismissed or ignored.

Depression in older people is more common than dementia, yet it is significantly underdiagnosed and undertreated. Old people are seen as a lost cause. There’s an assumption the old are supposed to be down and a bit grumpy and miserable. Their distress and despair is dismissed in a way that would never happen to any other marginalised group.

Over half of older people with depression have no previous history. This "late onset" depression often has subtly different symptoms to depression that affects young people which can make it tricky to spot unless it is specifically considered by the doctor.

They tend not to complain of "feeling sad" but rather have no enjoyment in life. They tend to become more preoccupied with physical health symptoms and develop anxiety or OCD. In over 70 per cent of cases, there is evidence of poor memory or thinking, which often mimics dementia (a condition called psudeo-dementia). As a result depression is all too easily missed.

It would be wrong to put all the blame on GPs. I’ve seen many hospital doctors overlook depression in older people too. The problem is endemic.

I remember one patient I saw early on in my training while working in geriatrics.  She was sitting in the chair by her bedside, staring out of the window. She was in her late eighties, frail and stooped. She had been on the ward for the past month after she fell at home.

She rarely spoke and when people asked her questions she stared at them then shrugged her shoulders. Her memory was very bad and she frequently forgot what people told her. She obviously had dementia and it was decided on the ward round that it is best if she went into a home.

She had no family, her husband having died four months ago, so I telephoned her GP to explain what our plan is. Yet the GP was dumbfounded when I explained she had dementia. "I only saw her a few weeks before she fell and she was fit as a fiddle. She had a better memory than me", they explained. The GP was adamant though.

After I put down the phone I went over to Mrs Baldwin and asked her basic questions about where she was and what the date was. She shrugged her shoulders each time. But it niggled at me that she could have been so different to when her GP saw her so I telephoned the old age psychiatrist who, after an hour of assessment, confirmed that she actually had depression.

She was transferred to the mental health unit, began treatment and incredibly, over the next few weeks her memory improved and she returned home. It had a profound impact on me and was a valuable lesson in not jumping to conclusions, particularly how easy it is to dismiss someone because of their age.