Week 2: Depression in the Brain
Recording:
If you would like a synopsis of this class, view this short video created by instructor Minoo Pakgohar. This is a great way to learn more about depression.
Mental Health in Older Adults is an Important Issue
The older population is increasing fast in the United States. Number of Americans over the age 65 is projected to nearly double from 52 million in 2018 to 95 million by 2060, and the 65 and older age group’s share of the total population will rise from 16% to 23%. (Statista Research Department, 2022) These statistics show that the United States is an aging country, and healthy aging is a national priority to help older adults live longer, healthier, and happier. (Office of Disease Prevention and Health Promotion, 2023) Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act as we cope with life. It also helps determine how we handle stress, relate to others, and make choices. (Medline Plus, 2020)
Mental health has a significant effect on older adults' wellbeing. In other words, mental health problems can have a high impact on an older person's ability to carry out basic daily living activities, reducing their independence, autonomy and quality of life. (Mendonça Lima & Ivbijaro, 2013) Mental disorders among older adults account for 10.6% of the total years lived with disability for this age group (World Health Organization, 2023) and the most common issues are depression, anxiety, and dementia. (Brennan, 2021) Mental health is important at every stage of life, including older age. In fact, enhancing the mental and behavioral health of older people maximizes the well-being and contributions of all of us as we age. (National Coalition on Mental Health and Aging, 2021)
This semester we will learn about the most common mental health conditions including depression, anxiety, and Alzheimer’s which is the most common type of dementia. This lesson we will look at depression by focusing on changes in the depressed brain, risk factors, signs and symptoms, optional treatment, and when to seek professional help.
What Is depression?
Depression is a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Depression is different from regular mood changes and feelings about everyday life. It can affect all aspects of life, including relationships with family, friends, and community. (World Health Organization) Depression affects how a person feels, thinks, and behaves and can lead to a variety of emotional and physical problems. People who suffer from depression may have trouble doing normal day-to-day activities such as sleeping, eating, or working, and sometimes they may feel as if life isn't worth living. (Mayo Clinic)
Video: From the APA, a look at depression
Video:
This short video provides a look at several types of depression.
There are several types of depression that older adults may experience:
● Major Depressive Disorder – includes symptoms lasting at least two weeks that interfere with a person’s ability to perform daily tasks.
● Persistent Depressive Disorder (Dysthymia) – a depressed mood that lasts more than two years, but the person may still be able to perform daily tasks, unlike someone with Major Depressive Disorder.
● Substance/Medication-Induced Depressive Disorder – depression related to the use of substances, like alcohol or pain medication.
● Depressive Disorder Due to A Medical Condition – depression related to a separate illness, like heart disease or multiple sclerosis.
Other forms of depression include psychotic depression, postmenopausal depression, and seasonal affective disorder. (National Institute on Aging, 2021)
How Many Older Adults Are Depressed?
Older adults contribute to society as family and community members, and many are volunteers and workers. While most have good health, many are at risk of developing mental health conditions such as depression and anxiety disorders.
As people age, they may experience certain life changes that impact their mental health, such as coping with a serious illness or losing a loved one. Although many people will adjust to these life changes, some may experience feelings of grief, social isolation, or loneliness. When these feelings persist, they can lead to mental illnesses, such as depression and anxiety. (Centers for Disease Control and Prevention, 2023)
The World Health Organization (WHO) reported that approximately 14% of adults aged 60 and over live with a mental disorder and 5.7% of them experience depression worldwide. (World Health Organization, 2023) At least 5.6 million to 8 million--nearly one in five--older adults in America have one or more mental health and substance use conditions. (Eden et al., 2012) As of 2021, 4.5% of Americans aged 50 and over have experienced a major depressive episode in the past year. (Vankar, 2023) Some estimates of major depression in older Americans living in the community range from less than 1% to about 5% but rise to 13.5% in those who require home healthcare and to 11.5% in older hospitalized patients. (Centers for Disease Control and Prevention, 2023)
What Are the Risk Factors of Depression?
Research has shown that these factors are related to the risk of depression, but do not necessarily cause depression:
● Brain chemistry: There may be a chemical imbalance in parts of the brain that manage mood, thoughts, sleep, appetite, and behavior in people who have depression.
● Brain structure: There’s a greater risk for depression if the frontal lobe is less active. However, scientists don’t know if this happens before or after the onset of depressive symptoms.
● Medical conditions: Depression, especially in midlife or older age, can co-occur with other serious medical illnesses, such as diabetes, cancer, heart disease, and Parkinson’s disease. These conditions are often worse when depression is present, and research suggests that people with depression and other medical illnesses tend to have more severe symptoms of both illnesses.
● Family history: People who have a family history of depression may be at higher risk for developing depression.
● Stress, including caregiver stress: Researchers in a systematic review and meta-analysis concluded that subjective caregiver burden is a significant risk factor for depressive symptoms in carers of older people and may precipitate clinical depression. Those caring for people with dementia experience a greater burden. (Del-Pino-Casado et al., 2019)
● Sleep problems: Depression and sleep issues have a bi-directional relationship. This means that poor sleep can contribute to the development of depression and having depression makes a person more likely to experience sleep troubles. (Newsom & Dimitriu, 2023)
● Social isolation and loneliness: Studies show that loneliness and social isolation are associated with higher rates of depression.
● Lack of exercise or physical activity: Findings of a systematic review showed that adults meeting physical activity recommendations (equivalent to 2.5 h/wk. of brisk walking) had a lower risk of depression, compared with adults reporting no physical activity. (Pearce et al., 2022)
● Substance use: People who have a history of substance or alcohol misuse may be at higher risk for developing depression. (Washington, 2023)
What Are the Signs and Symptoms of Depression?
Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as: (Mayo Clinic, 2022)
● Feelings of hopelessness and/or pessimism
● Feelings of guilt, worthlessness and/or helplessness
● Irritability, restlessness
● Loss of interest in activities or hobbies once pleasurable
● Fatigue and decreased energy
● Difficulty concentrating, remembering details and making decisions
● Insomnia, early–morning wakefulness, or excessive sleeping
● Overeating or appetite loss
● Thoughts of suicide, suicide attempts
● Persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment (Centers for Disease Control and Prevention, 2023)
What Happens to The Brain During Depression?
Brain chemistry changes during mental health conditions like depression. Understanding how the brain reacts to depression helps to have a better grasp on the mental state and what kind of treatment is effective. We will review key health information on the effects of depression on the brain and how these translate to changes in both mental and physical health.
The brain is physically changed when a person suffers from depression. Research by the National Institutes of Health shows that gray matter volume (GMV) reduces during depression. This loss is caused by parts of the brain shrinking due to the hormone cortisol impeding the growth of the brain cells. (Qi et al., 2014) The image to the right shows gray matter volume reductions in depression patients without anxiety disorder compared with normal controls. Depression patients without anxiety disorder showed significant gray matter reductions in the left insula and the left triangular part of the inferior frontal gyrus.
People who suffer from depression lose gray matter volume, and it depends on their depression severity. The more serious depression a person suffers, the more GMV she/he loses. GMV contains most neurons or nerve cells, so losing more GMV might be correlated to cognitive impairment. (Amiel, 2024)
Three major things that happen to a depressed person's brain:
1. Shrinkage of hippocampus, thalamus, frontal cortex, and prefrontal cortex:
Shrinkage in the hippocampus, thalamus, frontal cortex, and prefrontal cortex is one of the most common changes in a depressed patient’s brain. How much these brain areas shrink depends on the length and severity of depression.
During depression, the hippocampus releases more cortisol hormone which impedes the development of neurons in the brain and triggers this shrinkage. While other cerebral areas thalamus, frontal cortex, and prefrontal cortex shrink due to high levels of cortisol the amygdala enlarges and leads to increased amygdala activity that is linked to a person's ability to remember emotionally charged events, which may explain why depressive episodes often trigger negative emotional memories. The amygdala controls emotion, so this may cause issues like sleep disturbances, mood swings, and other hormone-related problems. The prefrontal cortex, responsible for executive functions like decision-making and impulse control, often shows reduced activity in depressed individuals. This decrease could contribute to difficulties in concentration and decision-making that many depressed individuals experience. (Grouport, 2024)
Depression shrinks some areas of the brain (thalamus, frontal cortex, prefrontal cortex) while enlarging others (amygdala).
2. Brain Inflammation:
Major depression is linked to cerebral inflammation. Inflammation mediates the relationship between chronic stress and the evolution and progression of depression and comorbid conditions. (Hassamal, 2023)
A new study published in JAMA Psychiatry suggests that clinical depression is associated with a 30% increase in brain inflammation. (UC San Diego School of Medicine, 2015)
Since cerebral inflammation kills neurons, it can lead to many complications. The death of neurons and neurotransmitters may lead to shrinkage as well as reduce a person’s neuroplasticity – the brains ability to change as the person ages. Since new neurons and neurotransmitters will have a tougher time growing, this leads to cognitive problems in the affected person. (Amiel, 2024)
3. Restricted Oxygen Intake:
Major depression may reduce oxygen intake. The leading theory is that depression induces a change in breathing patterns, which can lead to oxygen restriction or hypoxia.
Even minor hypoxia can impede cerebral function. People who suffer from minor hypoxia exhibit poor judgment, decreased motor skills, and memory loss. If sustained for long periods, reduced oxygen intake can lead to inflammation and brain cell damage. The aim of the study in 2019 was to find out how the decrease in oxygen saturation level and its duration during sleep are affected by the degree of depression and its extent. Results showed that the value below 90% of the average oxygen saturation during sleep time will more than double the risk of developing depression. It is also a risk factor for the severity of depression. (Szabó & Ihász, 2019)
Image: Effects of hypoxia
Common when spending time in high altitude, may occur with major depression.
Depression vs. Grief
We experience many losses with age such as loss of independence, mobility, health, our loved ones, or long-time career. Loss is painful and grieving over these losses is normal. Depression and grief share many symptoms and distinguishing between them is not easy.
However, there are some differences:
● With grief she/he still has moments of pleasure or happiness. Because grief involves a wide variety of emotions and a mix of bad or good days, it's like a roller coaster.
● With depression feelings of emptiness and despair are constant.
The point is to see a doctor right away if all signs of joy such as laughing at a good joke, brightening in response to a hug, or appreciating a beautiful sunset extinguishes, and all or several signs and symptoms of depression last for more than two weeks.
Depression vs. Dementia
Depression and dementia are common among older adults. Both of them share many similar symptoms including memory problems, low motivation, and slow-moving. However, there are some differences:
Depression or Dementia?
Symptoms of Depression
Mental decline is relatively rapid
Know the correct date, time and location
Difficulty concentrating
Language and motor skills are slow but normal
Notice or worry about memory problems
Symptoms of Dementia
Mental decline happens slowly
Becoming confused and disoriented, become lost in familiar locations
Difficulty with short-term memory
Writing, speaking and motor skills are impaired
Not noticing memory problems
It is important to see a doctor for cognitive decline right away, whether it is due to depression or dementia. (Robinson et al., 2023)
How is Depression Different for Older Adults?
● Depression is not a normal part of aging. However, older adults are at an increased risk of experiencing depression because 80% of them have at least one chronic health condition, and 50% have two or more. We know that depression is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited.
● Depression in older adults is not different in its symptomatology, nor is it more chronic, more difficult to treat, nor more attributable to psychosocial factors than depression in younger persons. (Blazer, 1997)
● Depression is a treatable medical condition in older adults. However, older adults with depression assume that the symptoms they are experiencing are just related to their illnesses, not to depression, and do not seek help because they don’t understand that they could feel better with appropriate treatment. Also, healthcare providers may mistake an older adult’s symptoms of depression as just a natural reaction to illness or the life changes that may occur as we age, and therefore not see depression as something to be treated. (Centers for Disease Control and Prevention, 2023)
Depression in older adults compared to other age groups
How is depression treated?
Depression is among the most treatable mental health conditions. Between 80%-90% of people with depression who seek treatment eventually respond well to those treatments. If there are symptoms of depression the first step is to see a family physician or psychiatrist and request a thorough evaluation. Treatment options include: (Torres, 2020)
● Medication: Antidepressants can help change the brain chemistry that causes depression.
● Psychotherapy: Talking with a mental health professional helps to identify and change unhealthy emotions, thoughts, and behaviors. Cognitive behavioral therapy (CBT) is the most common type of psychotherapy.
● Brain Stimulation Therapy: Brain stimulation therapy can help people who have severe depression or depression with psychosis. (Cleveland Clinic, 2023)
● Self-help and Coping: There are some tips that people can employ to help reduce the symptoms of depression including:
● Regular exercise helps create positive feelings and improves the mood.
● Eating a healthy diet and avoiding alcohol.
● Getting enough quality sleep on a regular basis, (a depressant) can also help reduce symptoms of depression.
● Spending time in the sunlight at least 15 minutes a day can help boost serotonin levels and improve mood.
● Joining a depression support group helps to reduce the sense of isolation and to know how others cope with depression.
● Finding new meaning in life and continuing to feel engaged in the world. For example, learning a new skill.
● Practicing relaxation techniques such as yoga, deep breathing, progressive muscle relaxation, or meditation helps to relieve symptoms of depression, reduce stress, and boost feelings of joy and well-being. (Smith et al., 2024)
How Can Friends and Family Members Be Supportive?
Depression is a medical condition that requires treatment from a doctor. While family and friends can help by offering support in finding treatment, they cannot treat a person’s depression.
As a friend or family member of a person with depression, here are a few things you can do:
● Encourage the person to seek medical treatment and stick with the treatment plan the doctor prescribes.
● Help set up medical appointments or accompany the person to the doctor’s office or a support group.
● Participate in activities the person likes to do.
● Ask if the person wants to go for a walk or a bike ride. (National Institute on Aging, 2021)
Important reminder: If you and or your loved ones have several of these signs and symptoms and they last for more than two weeks, talk with your doctor immediately. These could be signs of depression or another health condition. Don’t ignore the warning signs. If left untreated, serious depression may lead to death by suicide. (National Institute on Aging, 2021)
Here are some resources for you or any of your loved ones who may be in need of immediate help:
211 (https://211sandiego.org/)
Up to Us San Diego (https://up2sd.org/)
SD Access and Crisis Line: 1-888-724-7240
Resources for immediate help: https://mhanational.org/crisisresources
Suggested Activity: Movie and a chat
This optional activity has two parts: A short video (from TedEd) on Antidepressant medications and a talk, where you can share your insights with us.
The Movie
Movie: How do Antidepressants Work?
What do you know about antidepressant medications? This excellent Ted Talk video describes the history, the trends of use and the current viewpoint on treating depression with medicine.
The Chat
Discussion:
There are many ways of treating depression. Medications are one of them. But there are many other ways that we deal with depression. Use the link on the right to take you to a form where you can share your thoughts. Just type your response into the "Your answer" slot and submit. You will come back to this page, but will have to scroll down.
Summary
Depression is not a normal part of aging. However older adults are at an increased risk of experiencing depression. Depression is a treatable medical condition; it may grow worse over time if left untreated. Therefore, seeking professional help is important in feeling better as soon as possible. Also, applying self-help tips along with professional help can be part of the treatment plan, and helps to speed recovery and prevent depression from returning.
References
Amiel, M. (2024, January 1). What Happens to The Brain During Depression - Transformations Center. Transformations Treatment Center. Retrieved January 14, 2024, from https://www.transformationstreatment.center/treatment/what-happens-to-the-brain-during-depression/
Blazer, D. G. (1997, March 1). DEPRESSION IN THE ELDERLY: Myths and Misconceptions. Psychiatric Clinics of North America, 20(1), 111-119. https://www.sciencedirect.com/science/article/abs/pii/S0193953X05703968?via%3Dihub
Brennan, D. (2021, November 1). What to Know About Mental Health as You Get Older. WebMD. Retrieved January 14, 2024, from https://www.webmd.com/healthy-aging/mental-health-in-older-adults
Centers for Control Disease and Prevention. (2023, June 30). Depression and Aging. CDC. Retrieved January 14, 2024, from https://www.cdc.gov/aging/olderadultsandhealthyaging/depression-and-aging.html
Centers for Disease Control and Prevention. (2023, June 29). Mental Health and Aging - Mental Health and Aging. CDC. Retrieved January 14, 2024, from https://www.cdc.gov/aging/olderadultsandhealthyaging/mental-health-and-aging.html
Centers for Disease Control and Prevention. (2023, June 30). Depression and Aging. CDC. Retrieved January 14, 2024, from https://www.cdc.gov/aging/olderadultsandhealthyaging/depression-and-aging.html
Cleveland Clinic. (2023, January 13). Depression: Causes, Symptoms, Types & Treatment. Cleveland Clinic. Retrieved January 14, 2024, from https://my.clevelandclinic.org/health/diseases/9290-depression
Del-Pino-Casado, R., Rodríguez Cardosa, M., López-Martínez, C., & Orgeta, V. (2019). The association between subjective caregiver burden and depressive symptoms in carers of older relatives: A systematic review and meta-analysis. PloS one, 14(5), e0217648. https://doi.org/10.1371/journal.pone.0217648
Eden, J., Maslow, K., Le, M., & Blazer, D. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? National Academies Press. https://nap.nationalacademies.org/read/13400/chapter/1
Grouport. (2024, January 1). The Neurological Differences: Depressed Brain vs. Normal Brain | Grouport Journal. Grouport Online Therapy. Retrieved January 14, 2024, from https://www.grouporttherapy.com/blog/depressed-brain-vs-normal-brain
Hassamal, S. (2023, May 11). Chronic stress, neuroinflammation, and depression: an overview of pathophysiological mechanisms and emerging anti-inflammatories. Frontiers in Psychiatry, 14. doi.org/10.3389/fpsyt.2023.1130989
Mayo Clinic. (2022, October 14). Depression (major depressive disorder) - Symptoms and causes. Mayo Clinic. Retrieved January 14, 2024, from https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
Medline Plus. (2020, May 5). Older Adult Mental Health. MedlinePlus. Retrieved January 14, 2024, from https://medlineplus.gov/olderadultmentalhealth.html
de Mendonça Lima, C. A., & Ivbijaro, G. (2013). Mental health and wellbeing of older people: opportunities and challenges. Mental health in family medicine, 10(3), 125–127.
National Coalition on Mental Health and Aging. (2021, September 7). Why We Should All Care About Older Adult Mental Health & Substance Use and What We Can Do about It. National Coalition on Mental Health and Aging – Your resource for information about mental health and aging. Retrieved January 14, 2024, from https://www.ncmha.org/
National Institute on Aging. (2021, July 7). Depression and Older Adults | National Institute on Aging. National Institute on Aging. Retrieved January 14, 2024, from https://www.nia.nih.gov/health/mental-and-emotional-health/depression-and-older-adults
Newsom, R., & Dimitriu, A. (2023, November 16). Depression and Sleep. Sleep Foundation. Retrieved January 14, 2024, from https://www.sleepfoundation.org/mental-health/depression-and-sleep
Healthy Aging | health.gov. Office of Disease Prevention and Health Promotion. Retrieved August 30, 2023, from https://health.gov/our-work/national-health-initiatives/healthy-aging/about-healthy-aging
Pearce, M., Garcia, L., Abbasi, A., & Strain, T. (2022, April 13). Association Between Physical Activity and Risk of Depression. JAMA Psychiatry, 79(6), 550-559. 10.1001/jamapsychiatry.2022.0609
Qi, H., Ning, Y., Li, J., Guo, S., & Chi, M. (2014, December 2). Gray Matter Volume Abnormalities in Depressive Patients With and Without Anxiety Disorders. Medicine (Baltimore), 93(29), e345. 10.1097/MD.0000000000000345
Robinson, L., Smith, M., & Segal, J. (2023, November 17). Depression in Older Adults: Signs, Symptoms, and Treatment. HelpGuide.org. Retrieved January 14, 2024, from https://www.helpguide.org/articles/depression/depression-in-older-adults.htm
Smith, M., Robinson, L., & Segal, J. (2024, January 10). Coping with Depression. HelpGuide.org. Retrieved January 14, 2024, from https://www.helpguide.org/articles/depression/coping-with-depression.htm
Statista Research Department. (2022, October 20). World population by age and
region 2022. Statista. Retrieved August 30, 2023, from https://www.statista.com/statistics/265759/world-population-by-age-and-region
Szabó, K., & Ihász, F. (2019, May). The effect of reduced oxygen saturation during sleep on depression. Orv Hetil, 160(20), 780-783. 10.1556/650.2019.31401
Torres, F. (2020, October). Psychiatry.org - What Is Depression? American Psychiatric Association. Retrieved January 14, 2024, from https://www.psychiatry.org/patients-families/depression/what-is-depression
UC San Diego School of Medicine. (2015, March 5). A new study published in JAMA Psychiatry suggests that clinical depression is associated with a 30% increase in brain inflammation. Alzheimer's Disease Cooperative Study. Retrieved January 14, 2024, from https://www.adcs.org/2015/03/05/a-new-study-published-in-jama-psychiatry-suggests-that-clinical-depression-is-associated-with-a-30-increase-in-brain-inflammation/
Vankar, P. (2023, November 29). Major depressive episode U.S. adults by age and gender 2021. Statista. Retrieved January 14, 2024, from https://www.statista.com/statistics/252312/major-depressive-episode-among-us-adults-by-age-and-gender/
Washington, N. (2023, October 27). Depression: What It Is, Symptoms, Causes, Treatment, and More. Healthline. Retrieved January 14, 2024, from https://www.healthline.com/health/depression#treatment
World Health Organization. (2023, March 31). Depressive disorder (depression). World Health Organization (WHO). Retrieved January 14, 2024, from https://www.who.int/news-room/fact-sheets/detail/depression
World Health Organization. (2023, October 20). Mental health of older adults. World Health Organization (WHO). Retrieved January 14, 2024, from https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults