Older Adults, Alcohol and Depression


What is Depression?


Depression is a mental state where a person strongly feels sadness, despair, and discouragement. Depression in later life is very different than when an older person is temporarily feeling “blue” or the normal feelings of loss immediately following death of a spouse, a family member, friends, or is trying to adjust to a change in role or other things important to them.


Depression is much longer lasting and does not go away by itself. Instead it causes a severe disruption in the older person’s overall functioning that is both significant, and enduring. The person often describes the condition as feeling very different than his or her former self.


What’s “Causes” Depression?


The short answer is “We are not certain, because no one factor seems to be the 'cause'”. There seem to be several factors that leave some people to have a greater chance of developing depression in their lifetime. For example, depression is more common among

- women than men (Sonnenberg, et al, 2000)

- people who have few social supports,

- people who are experiencing stressful life events. (Scheider & Amerman, 1995)


Depression in late life is also more common where there has been

- previous depression,

- a family history of depression,

- a personal history of alcohol or other substance abuse problems,

- serious medical illness or chronic pain,

- prior suicide attempts.


There is bio-chemical basis for depression. Three major neurotransmitters in the brain (serotonin, dopamine and norepinephrine) need to be in the correct balance for people to have a positive, stable self image and optimistic mood. If these chemicals are not in balance, the person can become depressed.


How Common is Depression Among Older Adults?

 According to the National Advisory Council on Aging:

“Although most seniors enjoy good mental health, as many as 20% of people age 65+ suffer mild to severe depression, ranging from perhaps 5 to 10% of seniors in the community to as many as 30 to 40% of those in institutions. “ (citing Butler, also McEwan)


Depression is fairly common (12-20%) among people in who are in acute care or chronic care settings. (Blazer, 1999) Depression is also very common where a person is developing dementia, but isn’t showing the clinical signs of it yet. (Visser, 2000)


What Does Depression Look Like in Later Life: The Many Faces of Life Depression in Later Life


For some older adults, depression has been a chronic illness (one that comes and goes, but is a long term problem) throughout most of their lives. For others, depression is a reaction to specific situational stress (e.g. death of a spouse, or significant change in the person’s own health or functional ability). It can also arise in the context of forced retirement, or loss of a job or volunteer position that has been important to the person. Depression in an older person might developed after losing a loved pet; losing their driving license; losing their home or moving to a care home.


Women experience depression about twice as frequently as men. Women are also at greater risk for inadequate pain management, which is a very important factor associated with depression and with a person’s desire to die. (Roscoe, 1999) Bereaved mothers who have lost a middle aged child tend to have significantly higher levels of depression than widows. (Leahy, 1992-3)


The older person who is depressed can easily be

-     a healthy 85 year old man who has lost his spouse of 65 years,

-     a 65 year old man with many health problems.

-     a women just over 55 who feels life has no meaning because nothing is happening in her life and she feels “stuck”;

-     an 83 year old woman who suffered traumas fifty years ago that have never been adequately addressed (post traumatic stress);

-  a 78 year old woman whose 52 year old daughter has recently died;

- a veteran whose memories of losing his buddies in violent circumstances during the war are beginning to surface, for the first time in his life


Depression can also occur in the context of caregiving. An older adult can become overwhelmed in giving care to aging spouse or family member. Couples in long relationships may feel they have not only lost their life and personal freedom, but also the spouse they once had, even though the spouse is still physically present. Women tend to experience more caregiving demands than do men and as a result women caregivers may be more likely to be depressed.

Research shows depression is more common

·       if the person giving care is in poor health, receives little help from family and friends, or feels overwhelmed in giving the care. (Pruchno, & Resch, 1989; Clyburn, et al, 2000).

·       as the frequency of disturbing behaviours by the person receiving care increases.


How Common is Depression Among Older Adults with Alcohol Problems?

Older people who are depressed are three to four times more likely to have alcohol related problems than are older people who are not depressed. (Devanand, 2002) Between 15 and 30 % of persons with major late life depression have alcohol problems. (Devanand, 2002).


There are two main forms of depression among older adults that are tied to alcohol dependency.


1) Transient depression: Older adults who have been drinking heavily may be depressed on short term basis either from being intoxicated or as they withdraw from the alcohol. This form of depression will pass as the drinking subsides or as the acute and post acute phases of alcohol withdrawal occur.

2) Underlying depression: When depression or other symptoms persist unchanged for weeks or longer after the person has stopped drinking, then it is considered to be a “co-morbid disorder”. (Atkinson, 2002)


Identifying the Problem


Even health care providers used to working with older adults may overlook or not recognize depression among older people. For example, a recent study showed that one half of depressed older persons were not being identified as such by home care nurses (Brown et al, 2003).  A common sign is flat affect (emotion) which sometimes expressed by people as “I don’t know [how I feel], I don’t care. Leave me alone” and with the person “shutting down”.


Depression in older adults often is not identified  for several reasons.

A. Different signs:

- There is considerable variation in the kinds of signs and symptoms for depression in older adults.

- Frequently depression does not manifest itself in older adults in the same way as younger adults. For example, in contrast to inactivity often seen in depressed younger adults, older adults can experience anxiety and agitation during depression.

- Depression will have different clinical signs, and these vary with different older adults (not all older adults show the same signs).

- Older adults who are depressed are less likely to say they feel depressed, feel guilt, have low self esteem or have suicidal ideas. Instead the depression may show up more as somatic complaints (constipation, abdominal cramps, weight loss), or feelings of anxiety.

- Older depressed persons often show signs of carrying out actions more slowly, responding more slowly, slower mental processing, an inability to make decisions, and inappropriate social responses. So, not surprisingly, depression can easily be confused with dementia.

- Some older depressed persons may have somatic delusions (“I can’t eat properly anymore. I must have cancer in my stomach”) or may express feeling persecuted by family or friends. A depressed older person may have attempted suicide yet not expressed suicidal thoughts to others. (King and Markus, 2000)

B. Ageism: Service providers may overlook or discount relevant symptoms and changes in older adults' functioning because they view depression as a normal and inevitable aspect of growing older.  Or they erroneously consider depression as a normal response to a medical illness. (e.g., "Oh course he's depressed. Who wouldn't be after having a stroke and losing the ability to walk.") Depression is not inevitable and although it may occur with a medical illness, it should not simply be ignored.


Also, many medical conditions whose symptoms can mimic depression (e.g., multiple sclerosis, Parkinson’s disease, chronic obstructive pulmonary disease). (King & Markus, 2000) Depression is also common among older adults who are experiencing self-neglect. (Dyer et al, 2000).

This may reflect a person's deteriorating ability to take care of herself or himself because of an illness or disability. Self neglect can also be a manifestation of the depression-- giving up on and neglecting self, losing all the energy/will to eat, clean, or go out.


Tools Assessing For and Recognizing Depression

Formal Screening Tools: The Geriatric Depression Scale is a commonly used tool for assessing depression in older adults. Its short form is composed fifteen questions that can be answered “Yes“ or “No”; and the long form has 30 questions. There have been attempts to shorten it to 4 questions to make it more useful for clinical practice. English, French and other language versions of the GDS are available. (van Marwijk et al. 1995)

The Beck Depression Inventory II is another commonly used tool. It is comprised of 21 questions. Each item gives a list of four statements arranged in increasing severity about a particular symptom of depression. A score of 11-16 indicates mild mood disturbance; 17-20 for borderline clinical depression. 21-30 for moderate depression; 31-40 for severe depression; and over 40 for extreme depression. The useable age range for it has been expanded to 13-80 years of age.

The Hamilton Depression Rating Scale is another tool commonly used, but is highly dependent on the rater’s skills in asking the questions.
On the Internet, people can find self screening tests for clinical depression,  such as "HANDS" but it is not clear whether these are suitable 
or useful for screening depression in older adults.

Asking about feelings of depression:

It is generally pointed out that screening tools do not replace the need for a thorough history and physical examination, including 
- complete neurologic and mental status assessment (to help rule out dementia)
- review of the person’s drug use (including prescription, over the counter, herbal and illicit drugs) and alcohol use 
If the person is showing signs of dementia or is not very communicative, obtaining a history from family members or other informants can be helpful. (Merck)


Fear, Ignorance, and Resignation


It is important to recognize that many older adults fear disclosing they are feeling depressed. Many see being depressed as very stigmatizing, or consider it as a personal failure because they have not been able to deal with the depression on their own.


It is important for service providers to address these stigmas early,  otherwise the older person will likely discontinue with the treatment or other help being offered (Sirey et al, 2001). It is also important to recognize the subtle ways in which people respond to others who have self identified as experiencing depression. People's responses are not always positive, and people may inadvertently see depression as a limitation on what the person is capable of accomplishing, and end up responding to the person in paternalistic manner.


Health care providers who work with older adults often recognize that older adults with alcohol problems or depression may need help, but they feel uncomfortable offering it. (Ignaczak, 2002)


Older adults who have depression and who also have an alcohol problem are often placed in a doubly untenable position. They are often told by mental health workers “Stop drinking. Get the alcohol problem under control first, then we’ll help you.” In other instances they are told by addiction workers, “I can’t help you with your alcohol problem until your depression is treated.” In either of these situations it is easy for older adults to simply “fall between the cracks” or not receive any real help until the depression has deepened even further and a crisis has arisen, making recovery that much more difficult.


Research also shows that while physicians may recognize the depression and suicidal risk in situations involving younger and older adults, they are less willing to treat an older suicidal person than a younger one. In one study using hypothetical examples, physicians were

- more likely to consider an older patient’s suicidal thoughts as rational and normal; and

- less willing to use therapies to help the older patients.

The physicians also  tended to not be optimistic that psychiatrists or psychologists could help the older suicidal patient (Uncapher & Arean, 2000)


Which Drinkers Become Depressed?

If a drinker has never experienced alcohol problems, he or she will tend to not have symptoms of depression. Research indicates that people who experienced alcohol problems both before and after age 60 have the highest rates of depression. It has also been suggested that the existence of earlier alcohol problems (around ages 20 and 40) predicts depression in later life. (Reifman & Welte, 2001)


Depression and Older Adults' Health

There is a strong and complex relationship between depression and older adults’ health, particularly heart disease and chronic pain. Depression left untreated can lead to heart disease. National Institute of Mental Health (NIMH) notes:


"Depression and anxiety disorders may affect heart rhythms, increase blood pressure, and alter blood clotting. They can also lead to elevated insulin and cholesterol levels. These risk factors, with obesity, form a group of signs and symptoms that often serve as both a predictor of and a response to heart disease."


The Role of Alcohol in Depression

People are frequently told that alcohol is a “depressant” and may erroneously think that alcohol causes depression (makes a person become emotionally depressed). This is a bit of a misconception. For people who have been alcohol dependent for a long time, alcohol can have a toxic effect on their serotonin neuro-transmitters, but that does not necessarily lead to depression or anxiety. In other words, not all heavy or long time drinkers will become depressed. (Berrgren, 2002)

It is more accurate to say that alcohol contributes to the development of depression. It does this in several ways:

1. Effect on Cortisol: Alcohol slows down and relaxes (“depresses”) the central nervous system (for example brain function, breathing, pulse rate). The more alcohol that is consumed, more and more “relaxed” the functioning of the body's cells and organs become, until they are less efficient. For example, heavier drinking can lead to sedation and drowsiness.

Alcohol increases the amount of circulating cortisol. That, in turn, reduces serotonin levels as well as other important neurotransmitters norepinephrine and dopamine that are integral to thwarting off depression. In general, when serotonin levels drop, depression can quickly settle in.

2. Exaggeration of Feelings: Alcohol’s effect on the brain influences the center responsible for coordinating the senses, perception, speech and judgment. It produces slurring of speech and errors in the thinking process. Although alcohol depresses bodily functions, it often stimulates inhibitions. Emotions are more easily expressed because that part of the brain which enables us to control our behavior is depressed or relaxed, so the emotions become exhilarated.

A person’s mood is exaggerated by the use of alcohol. Alcohol can increase anxieties and sadness. If a person is depressed while drinking, the person may become more depressed. Taking other drugs can increase the effect of both the alcohol and the other drug, especially if the other drug is also a central nervous system depressant, such as a tranquilizer or antihistamine. Alcohol can act as a tranquillizer reducing stress for moderate drinkers. However, heavy drinking can increase stress when the drinker stops for a time or becomes tolerant to the effects.

3. Coping Mechanism: People who have depression  or anxiety may drink an attempt to relax  them and relieve  the anxiety or  negative feelings  (Carpenter & Hasin, 1999) and as the feeling of depression deepens, the more the person may drink to try to escape it. Alcohol becomes a form of "self-medication").

4. Increased Vulnerability: There is also evidence that overall tendency to decreased serotonin activity is associated with early onset alcoholism among men.

5.  Alcohol as an Intermediary: Alcohol stresses blood sugar control and can cause episodes of hypoglycemia (low blood sugar). As well, alcohol disrupts sleep. Both of these factors increase the risk and the severity of depression.


The Brain Chemistry of Depression

There are three major neurotransmitters in the brain (serotonin, dopamine and norepinephrine) which must be in the correct balance and constructive tension to affect and allow a positive, stable self image and optimistic mood. However, when these neurotransmitters are in an unbalanced state with one another, mood changes are inevitable. In general, when serotonin levels drop, depression can quickly settle in, and when serotonin levels can be made to rise, a contented mood generally results.

It is important to understand that stopping drinking does not stop depression from happening. Former drinkers who have previously had an alcohol dependence problem are four times as likely to have major depression as former drinkers who never had an alcohol problem (Haslin & Grant, 2002)



Strategies for Helping


A. At an Agency and Community Level


One of the biggest barriers for older adults is the policy in many mental health and some addiction circles that  “We won’t treat you if you are drinking”. This barrier to service must be removed or older adults will simply be left to struggle with the despondency caused by depression on their own. (Oslin et al, 2000). Because depression is complex and because it can imitate or mask other problems such as dementia, it is helpful to work with others skilled to identify if the presenting symptoms are depression or something else.


B. Working with the Individual


- Identify the depression problem early and begin to address it as soon as possible. (Merck) This helps the person from sinking into a deeper depression.

- Understand the strength it takes a person who is very depressed to pick up the phone to call you or to make it to your office.

- Don’t be afraid to ask. Ask the older adult "Do you ever feel that life is not worth living? Have you thought of harming yourself?" In asking you are not giving people the idea of committing suicide; you are removing the issue from being hidden.

- Be respectful and considerate in your dealings with the person: People with depression are often very sensitive to indications from others that they are somehow not worth the effort. A person is not respectful if not listening, if allowing the phone to interrupt the session.

-   Validate the person’s experiences, but do not try to problem solve for them.

-  Encourage the older adult to reduce drinking.  Getting the person to reduce the consumption even a bit will help the level of depression (Oslin et al.)

- If the older adult is on an anti-depression medication, encourage him or her to stay on it. These medications typically take several weeks to “kick in.” If the particular medication does not seem to be working after that time, work with the person and the physician to find another anti-depressant, or a combination of medications.

-   Educate the older adult to recognize personal signs and symptoms early on (e.g. sleeping days on end)

- Help older adult to identify successful coping strategies they have used at other points in life (Watt & Cappeliez,2000)

- Recognize the person may need new coping skills and help them develop new ones too. It is harder for an older person to use the same coping skills when his or her body doesn't work the same as years ago. (e.g. someone who use do to take a long walk and make them feel better but who can now no longer walk.

- Work with the older adult to enhance support. Help the older adult to have others around him or her who will be good reflections for the person; people that the older adult can safely share feelings and concerns with. If the older adult is isolated, the chasm is greater.

- Avoid giving simplistic advice – (such as "Why don’t you get some exercise? It will help you”.) While it is true that exercise can help moderate a person's mood, the decreased activity is part of the cycle of depression. An older person who is depressed may intellectually know how to do it or what needs to be done, but often does not know how to carry it along.

 People do not know how devastating it is to be given platitudes when depressed, such as “Get a good night sleep, you’ll feel better”. These responses are condescending to the person, and show that the other does not understand the nature and extent of the depression.

-      Work collaboratively (See below). Have a good link to a person and resources in the mental health system

-  Watch for the subtle signs of depression relapse; putting on an act of being “up”; pretending they are fine.


Treating Depression

Having both an alcohol problem and depression at the same time can complicates helping the older adult significantly. However there is growing evidence that the best possible outcome occurs when successful treatment of depression is combined with reduction of alcohol use (Oslin et al, 2000a)

What Works

It is important to recognize that for treating depression, “one size does not fit all”. Research indicates that a combination of counselling and medications works best. For major depression, counseling helps reduce the symptoms while the anti-depressant medication is to take effect. (King & Markus, 2000)


- Counselling: Depression can be caused by a number of psychological factors in the person’s life, and as the depression increases, more and more negative thinking intrudes. Cognitive therapy and other types of counselling may help break that cycle to help improve person’s outlook to a more optimistic, resourceful one. Counselling can also be helpful to educate older adults  to recognize symptoms (for example, sleeping days on end). Having depression is highly stigmatizing for some older adults. Counsellors can acknowledge this and address the stigma early on by normalizing the condition (letting older people know it is not uncommon to feel this way, and that with help, things can improve for them). (Sirey et al, 2001)

- Nutrition: Certain vitamins, minerals, amino acids, or fatty acids (for example, tryptophan Vitamin B6, and omega 3 fatty acids are used by the body to make and use serotonin). If these are deficient (the older adult is not consuming enough of them or is not absorbing them well), this can increase the likelihood of depression. Nutrient deficiencies can be determined by dietary analysis and by testing of blood, urine, and hair samples.


- There is considerable research on the role of folate in depression and dementia (Alpert & Fava, 1997; Lindeman, Romero, & Koehler, 2000). Studies suggest that folate deficiency may occur in up to one third of patients with severe depression, and that treatment with the vitamin may enhance recovery of the mental state. (Bottiglieri, et al. 2000)


- Antidepressants: These medications are quite effective for many people (60 -75%), but the medications often take weeks to have an effect. A medication that works for one older person will not necessarily work for another, so it is often a trial and error process. Certain antidepressants are recommended for older adults, and other must be avoided because of their serious side effects.


The anti-depressant drugs work by basically increasing the activity of one or more brain chemicals called monoamines. There are three categories of drugs that are used commonly used to treat depression:


- Tricyclic Anti Depressants (TCAs) (e.g. Elavil) are the oldest type of anti -depressant used. These are highly effective, with 70 80% of the people prescribed these medications feeling better. However, older adults are particularly sensitive to the anti-cholinergic side effects of these anti-depressants (sleepiness, dry mouth, constipation, difficulty urinating, a racing heartbeat, and dizziness when standing up to quickly). Also special precautions need to be taken in the first week of treatment with these medications. For example, Elavil affects the older adult’s driving ability (same as if drinking over.08). Hip fractures are also common among older adults taking Elavil.

- Mono Amine Oxidase (MAO) Inhibitors are used if a person cannot take use a TCA because of heart problems. They react with many foods and beverages so the older person must be on a very limited diet. However, this drug seems to work when others fail.

- Selective Serotonin Reuptake Inhibitors (e.g. Zoloft, Paxil, Prozac, Luvox) are the newest form of antidepressants. They have fewer side effects because these drugs are designed to only affect the serotonin level in the brain and leave the rest of the neurotransmitters unaffected.  They tend to be the ones considered safest for most older adults. SSRI are relatively free of cardiovascular and other side effects associated with the MAO inhibitors and TCAs. (King & Markus)


According to Merck Manual of Geriatrics, the usual starting doses in otherwise healthy older patients are typically one half the usual adult doses. However, it has been suggested that there is no need to adjust the dosage of SSRI sertraline (Zoloft) for older patients solely based on age. (Muijsers, Plosker, & Noble, 2002)


Tricyclics amplify the depressant effects that alcohol and other sedatives (tranquilizers and sleeping medications) have on the central nervous system, so it is generally recommended that these should be used cautiously by someone who is receiving a tricyclic. Alcohol taken in conjunction with some TCAs such as Tofranil (Imipramine) or Prothiaden may actually worsen the person’s depression, and combining either with alcohol can lead to increased sedation, confusion or delirium, particularly in older adults. The TCAs cannot be taken in conjunction with an MAO Inhibitor either.


What Anti-Depressant Medication Does Work Well When a Person is Drinking and is Depressed?


There is evidence that the SSRI antidepressant fluoxetine is effective for decreasing both the depressive symptoms and the drinking for people at least who have a major depression and an alcohol use disorder. (Cornelius, in press) SSRIs work in a different way than the TCAs. Instead, the SSRIs either do nothing when combined with alcohol or they may mildly antagonize the depressant effects of alcohol (See, Preskorn) But see for a different opinion:


SSRIs can have side effects though. For example, they may cause ongoing insomnia, which is likely to interfere with the person’s ability to recover from depression.


Collaborative Approaches


When seniors try to seek help for their depression, they often go to general medical services, which do not generally help them stick to a treatment or help them to continue further on with treatments. An important part of successful treatment for many seniors is for service providers to avoid working alone. It can be more beneficial to try collaborative approach instead involving the senior, physician and others. Depression in later life tends to be more likely to improve when

- people involved have a common definition of the problem,

-  a therapeutic alliance has been developed,

- where there is a personalized treatment plan that includes patient preferences,

- where there is proactive follow-up, and

- where there are protocols for stepped care (if one approach or medication isn’t working, following a plan to change the dose or type of medication, adding other therapies to existing ones)

Both self-management therapy and educational group therapy can be beneficial adjuncts (Rokke, et al, 2000)


The Help of Family and Help for Family

Depression affects not only the individual but those close to him or her (“All Together Now: How Depression Affects Families”, Health Canada, & CMHA). Family members’ understanding of the condition, and their interpretation of the older person’s action or inaction can have a significant effect on how well supported the person is while actively dealing with depression or in watching for signs of relapse. The likelihood of depression in later life increases if the person has constantly critical or demanding interactions from family.(Seeman, 2000)


How Well Do Depressed Older Adults Do?

A four year Canadian study showed that 70% of the older adults on antidepressants did well, and the depression did not recur (Flint & Rifat, 2000). Depression was more likely to recur when it took the older person a long time to begin to respond to treatment and where the person had high levels of anxiety at the time they were responding to treatment.

It can be harder for older adults to completely recover from depression than younger adults, but that is largely because older adults with depression also have long termk physical illnesses that may never improved, or they have dementia. However, for many older people treating their depression can lead to improvement in their functional limitations as well as the daily activities they need to keep them independent. ("IADLS") (Oslin et al, 2000b)

In December, 2002  the Journal of the American Medical Association reported a large scale study called IMPACT (Improving Mood-Promoting Access to Collaborative Treatment). Working with 1801 depressed older adults, it involved a depression care manager collaborating with primary care practitioners, patients, and specialists (Unützer, Katon, et al., 2002). By the end of one year, 45% of the IMPACT participants had a 50 percent decrease in their depression. Only 19 % of the other group not receiving a coordinated approach  had a decrease in their depression. The IMPACT patients also reported more contentment with their treatment, reduction of functional loss and an improved quality of life compared to patients who received conventional treatment.

However even in the IMPACT study, only 25% to 30% of the seniors became completely free of depressive symptoms. The researchers felt that may be due to greater medical co-morbidity than younger people face (the seniors had an average of 3.2 chronic medical illnesses and 65% were living with chronic pain) (Unützer, Katon, et al., 2002).


Deal with the Pain Too

This last finding points to the need to find ways to relieve the senior's underlying chronic pain, otherwise the alcohol problem and/ or the depression is likely to recur. Three keys to successful pain intervention are access to appropriate pain treatment, coordination of care between pain medicine specialists and primary care physicians, and the use of rehabilitation services that improve self-care and health maintenance activities (Gallagher et al, 2000)


How do Depressed Older Adults who have Alcohol Problems Fare When Treated for Depression

This is the good news. In a relatively recent large scale study of 2666 older persons who were hospitalized for depression, 11.1 % were drinking before admission, and 3.5 % were drinking daily. At follow-up, the patients in the "excessive drinking" category at admission had the greatest improvement in functioning. Overall, 80% of those who were drinking at the time of admission reduced their drinking by more than 90% during the follow-up period. (Oslin, et al. 2000, a)


Why Are People Concerned About the Concurrent Use of Alcohol and Antidepressants?


Alcohol affects the way that many anti-depressants are metabolized. In general, acute intoxication inhibits the metabolism of anti-depressants, whereas chronic abuse (without intoxication) induces the drug’s metabolism. (Cadieux, 1999). Some anti-depressants are safer than others if the person continues to drink.

Some older adults know that their physician will not prescribe them anti-depressants if they are drinking and so don’t tell their physician that they are. Some self monitor their alcohol consumption by not drinking within a window of time before or after taking the anti-depressant.

People are sometimes concerned that the person will use the anti-depressants in combination with the alcohol to commit suicide. However, the more appropriate practice may be to continue to monitor the suicide risk, rather than deny depressed older persons access to medication or other therapy that can be beneficial.



Are There Other Interactions to Be Concerned About?

It has been suggested that some anti-depressants (MAO-Inhibitors) may adversely interact with certain herbals, for example, ginkgo biloba. The research on ginkgo - antidepressant interaction is equivocal at present, with more research suggesting no effect. (See Herbalgram)

There are reports of increased serotonin levels in older persons who used selective serotonin reuptake inhibitors (e.g., sertraline) with St. John’s wort. (Lantz, 1999)

As usual, good practice is to always ask the person about what herbal medicines she or he is using. Make it a routine part of an assessment.


Depression Relapse Prevention

It is very important to work with the older person towards preventing a relapse into a depressed state. One of the ways of doing this is to help the person work on psycho-education, relaxation and concentration training, social skills training, and cognitive training.

This includes helping them understand their depression better, to use old coping skills and learn new ones, and helping them begin to build new supportive people and roles into their lives.


Depression Resources for Seniors

-      All Together Now: How Depression affects Families. Canadian Mental Health Association & Health Canada (1999). Online at:

www.hc youth/cyfh/pdf/together.pdf

Geared more to younger families but useful information for both families and persons who have depression.

- NACA “Dealing with Depression” Online at.

www.hc aines/pubs/expression/13 3/exp13 3_2e.htm

Good down to earth explanation for older adults.


- Depression: You don’t have to feel this way (Ask Your Family Doctor

Series, College of Family Physicians of Canada. Online at :


This is document has been prepared for the national project: Seeking Solutions: Canadian Community Action on Seniors and Alcohol Issues, an initiative funded through Health Canada, National Population Health Project. Our many thanks to Health Canada for making this possible. The views expressed in the document are those of the author, Charmaine  Spencer and are not necessarily those of Health Canada.



n.a. "Ginkgo"  in Herbalgram website. See:

Alpert J. E., & Fava, M. (May, 1997). Nutrition and depression: the role of folate. Nutrition Review, 55(5), 145-9.

Atkinson, R.M. & Misra, S. (2002). Mental disorders and symptoms in older alcoholics. In: A.M. Gurnack, R. Atkinson, and N.J. Osgood, Eds., Treating Alcohol and Drug Abuse in the Elderly, New York, NY: Springer Publishing Company, Inc., (pp. 50-71).

Berggren, U., Eriksson, M., Fahlke, C., & Balldin, J. (2002). Is long term heavy alcohol consumption toxic for brain serotonergic neurons? Drug and Alcohol Dependence, 65(2), 159-165, 2002.

Bottiglieri, T., Laundy M., & Crellin, R. et al. (August, 2000). Homocysteine, folate, methylation, and monoamine metabolism in depression, J Neurol Neurosurg Psychiatry, 69(2), 228-232

Brown, E. L., McAvay, G, Raue, P. Moses, S., & Bruce, M. (February 2003). Recognition of Depression Among Elderly Recipients of Home Care Services. Psychiatr Serv 54: 208-213.

Butler, R. N. & Lewis, M. (August 1995). "Late life depression: when and how to intervene", Geriatrics, 50(8), p. 44.

Cadieux, R. (November, 1999) Antidepressant drug interactions in the elderly : Understanding the P 450 system is half the battle in reducing risks, Vol. 106 (6). Postgraduate Medicine. Online at

Carpenter, K.M. & Hasin, D.S. (1999) Drinking to cope with negative affect and DSM IV alcohol use disorders: A test of three alternative explanations. Journal of Studies on Alcohol, 60(5), 694-704.

Clyburn, L. D., Stones, M.J., Hadjistavropoulos, T. & Tuokko, H. (Jan. 2000). Predicting caregiver burden and depression in Alzheimer's disease. Journals of Gerontology: Series B: Psychological Sciences and-Social Sciences. Vol. 55B (1), S2-S13.

Conwell, Y., Lyness, J. M., Duberstein, P., Coxm, C., Seidlitz, L., DiGiorgio, A.& Caine, E. D. (Jan, 2000). Completed suicide among older patients in primary care practices: a controlled study. Journal of the American Geriatrics Society; Vol. 48

Cornelius J.R., Salloum I.M., Lynch K., Clark D.B., & Mann J.J. (In Press). Treating the substance abusing suicidal patient. Annals of the New York Academy of Sciences.

Devanand, D.P. (2002) Comorbid psychiatric disorders in late life depression. Biological Psychiatry, 51(3), 236-242.

Dyer, C. B., Pavlik, V.N., Murphy, K.P., & Hyman, D. J. (Feb. 2000). High prevalence of depression and dementia in elder abuse and neglect. Journal of the American Geriatrics Society. Vol. 48 (2), 205-208.

Flint, A. J. & Rifat S.L (Spring, 2000) Maintenance treatment for recurrent depression in late life: a four year outcome study American Journal of Geriatric Psychiatry.; Vol. 8 (2), 112-116

Gallagher, R.M., Verma, S., & Mossey, J. (Sep. 2000). Chronic pain: sources of late-life pain and risk factors for disability. Geriatrics. Vol. 55 (9): p. 40-44+

Geriatric Depression Scale (French version)

Hasin, D.S. & Grant, B.F. (2002). Major depression in 6050 former drinkers: Association with past alcohol dependence. Archives of General Psychiatry, 59(9),794-800.

Hodgins, D.C., Dufour, M. & Armstrong, S. (2000).  Reliability and validity of the inventory to diagnose depression in alcohol dependent men and women. Journal of Substance Abuse, 11(4),369-378.

Ignaczak, C.A. (2002). Community health nurses' ability to identify and intervene with elderly who are depressed and /or abuse alcohol. Dissertation Abstracts International, 62(9), 3989B.

King, D. A. & Markus, H.E. (2000). Mood Disorders in Older Adults, in Psychopathology in Later Life. S. Krauss Whitbourne (ed.) John Wiley Publishing.p. 141-172.

Kirchner, J.E.; Curran, G.M.; Thrush, C.R.; Owen, R.R.; Fortney, J.C.& Booth, B.M. (2002). Depressive disorders and alcohol dependence in a community population. Community Mental Health Journal, 38(5), 361-373.

Lantz M.S., Buchalter E., & Giambanco V. (1999). St. John’s Wort and antidepressant drug interactions in the elderly. J Geriatr Psychiatry Neurol. Vol. 12, 7-10.

Leahy, J. M. (1992 -3) Comparison of depression in women bereaved of a spouse, child, or a parent. Omega: Journal of Death and Dying. Vol. 26 (3), 207-217.

Lindeman, R.D., Romero L. J., Koehler, K.M., et al. (February, 2000). Serum vitamin B12, C and folate concentrations in the New Mexico elder health survey: correlations with cognitive and affective functions J American College of Nutrition, Vol. 19(1), 68- 76.

McEwan, K.L. (1991). Mental health problems among Canada's seniors: Demographic and epidemiologic considerations (Ottawa: Health Canada).

Merck Manual of Geriatrics, Chapter 33. Depression. Online at :

Mueller, T.I. (1999). Depression and alcohol use disorders: Is the road twice as long or twice as steep? Harvard Review of Psychiatry, 7(1), 51-53, 1999.

Muijsers R.B., Plosker G.L., & Noble, S. (2002).  Spotlight on sertraline in the management of major depressive disorder in elderly patients . CNS Drugs 2002;16(11), 789-94. Online at :

National Institute of Mental Health. Depression and Heart Disease.

Oslin, D.W.; Katz, I.R.; Edell, W.S.& Ten Have, T.R. (2000a).  Effects of alcohol consumption on the treatment of depression among elderly patients. American Journal of Geriatric Psychiatry, 8(3), 215-220.

Oslin, D. W., Streim, J., Katz, I.R., Edell, W. S., TenHave, T. ( 2000b).  Change in disability follows inpatient treatment for late life depression. Journal of the American Geriatrics Society. April, Vol. 48 (4), 357-362.

Preskorn. Clinical Pharmacology of SSRI's. Online at :

Pruchno, R. A. & Resch, N. L.  (April, 1989).  Husbands and wives as caregivers: antecedents of depression and burden. Gerontologist. Vol. 29 (2), 159-165.

Reifman, A. & Welte, J. (2001).  Depressive symptoms in the elderly: Differences by adult drinking history. Journal of Applied Gerontology, 20 (3):322-337.

Rokke, P. D., Tomhave, J.A.,  & Jocic, Z. (2000) Self management therapy and educational group therapy for depressed elders. Cognitive Therapy and Research. Vol. 24 (No. 1) 99-119.

Roscoe, L. A. (Fall- Winter 1999). Physician assisted suicide: does gender matter? Journal of Ethics, Law, and Aging.; Vol. 5 (No. 2) 111-120.

Seeman, T. E., (Jul-Aug, 2000). Health promoting effects of friends and family on health outcomes in older adults. American-Journal-of-Health-Promotion. Vol. 14 (6),362-370.

Sirey, J.A., Bruce, M.L., Alexopoulos, G.S. Perlick, D. A., Raue, P., Friedman, S. J., & Meyers, B S. (Marc. 2001).  Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry. Vol. 158 (3) 479-481.

Schneider, B. & Amerman, E. (1995). Clinical protocol series for care managers in community based long term care: depression. Philadelphia Corporation for Aging, Philadelphia, PA.

Sonnenberg, C.M., Beekman, A.T.F., Deeg, D.J.H. & van Tilburg. W ( 2000). Sex differences in late life depression. Acta Psychiatrica Scandinavica. Vol. 101 (4), 286-292.

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W. et al. (December 11, 2002). Collaborative Care Management of Late-Life Depression in the Primary Care Setting JAMA. Vol. 288, 2836-2845 . 

van Marwijk H.W., Wallace P., de Bock G.H., Hermans, J., Kaptein A.A.; & Mulder J.D. (April, 1995). Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale. British Journal of General Practice, 45 (393), 195-9.

Visser, P.J., Verhey, F.R.J., Ponds, R.W., Kester, A. Jolles, J. (May 2000). Distinction between preclinical Alzheimer's disease and depression. Journal of the American Geriatrics Society. Vol. 48 (5), 479-484.

Watt, L. M.  & Cappeliez, P. (May, 2000). Integrative and instrumental reminiscence therapies for depression in older adults: intervention strategies and treatment effectiveness. Aging and Mental Health. Vol. 4 (2), 166-177.



(c) 2003, Charmaine  Spencer

Page last updated Sunday October 31, 2004

Questions? Comments? Contact Webmaster: 



Return to

Alcohol and Seniors Home Page