© Springer Science+Business Media LLC 2017
Amir Sharafkhaneh, Abebaw Mengistu Yohannes, Nicola A. Hanania and Mark E. Kunik (eds.)Depression and Anxiety in Patients with Chronic Respiratory Diseases10.1007/978-1-4939-7009-4_22. Depression and Anxiety Across the Age Spectrum
(1)
Department of Psychiatry, University of Virginia, 1215 Lee Street, Charlottesville, VA 22903, USA
(2)
Baylor College of Medicine, Houston, TX, USA
Keywords
AnxietyDepressionElderlyBiopsychosocial modelAgingIntroduction to Anxiety and Mood Disorders and Their Symptoms
Careful consideration of mental illness in differential diagnoses and its inclusion in problem lists and treatment plans improve the effectiveness of care and patient outcomes, especially in the geriatric population. Mental health issues are frequently overlooked in this group because of the overlap of medical symptoms. The unfortunate result is a failure to optimize the treatment of both medical disease and mental illness. The persistent cultural and social belief that mood and anxiety symptoms are part of the normal aging process impedes diagnosis and management of these important and treatable problems. This chapter provides an overview of anxiety and mood disorders and symptoms, with particular attention to changes with aging. The discussion concludes with a review of treatment options and issues related to mental health care in the elderly population.
Symptomatology and Key Disorders
Anxiety and mood disorders are both associated with a wide range of symptoms, some of which may present differently in older as opposed to younger adults. Medical professionals in all fields should be familiar with these symptoms and their variable presentations according to age to detect mental health problems early and begin appropriate intervention or treatment.
Anxiety
Anxiety is a psychological and physiologic response to stress manifested in a feeling of dread or worry and associated with increased arousal. It is a biologically adaptive symptom but can graduate to a pathologic disorder if it becomes overwhelming or limits a person’s functioning. Anxiety is distinct from fear in that it is a general feeling of ongoing distress as opposed to an acute emotional response to a perceived threat; but both anxiety and fear can manifest in physiologic symptoms, such as increased heart rate, palpitations, sweating, and other symptoms of autonomic arousal. Many medical conditions can cause symptoms of anxiety, and thus, it is necessary to rule them out prior to treatment of any anxiety disorder. Possibly because the typical age of onset of anxiety disorders is quite early (11 years) [1], these disorders in the aging population tend not to be readily recognized and treated. Additionally, anxiety is commonly comorbid with depressive symptoms, with attention predominantly focused on depression, compounding the issue. It is very important for symptoms to be detected and treated as anxiety, as it was recently suggested that even mildly elevated symptoms of worry are associated with future cognitive impairment [2]. However, considerable variation exists in prevalence estimates of most anxiety disorders. More research is needed to further investigate anxiety disorders in the aging population [3].
Key anxiety disorders in older adults include the following:
Generalized anxiety disorder (GAD) is characterized by chronic excessive worry or anxiety. These feelings must occur most days for six months or more and cause significant impairment. GAD is frequently associated with comorbid psychiatric illness and in the elderly often progresses to depression or to a mixed disorder of both anxiety and depression [4]. Anxiety in older patients tends to follow traumatic events or threats, whereas depression more often follows loss events [5].
Specific phobias feature an irrational, overwhelming fear of a certain object or situation and cause marked impairment. The patient recognizes that the fear is irrational and commonly avoids phobic stimuli. Exposure to the phobic stimulus can trigger panic attacks. Social phobia is another common phobia, also known as social anxiety disorder, which is specifically associated with an intense fear of social situations.
Posttraumatic stress disorder (PTSD) is characterized by intense fear, helplessness, and horror after a traumatic event. The patient must have directly experienced or witnessed an event that involved threatened or actual death, injury, or threat to physical integrity. Patients have a persistent avoidance of stimuli associated with the traumatic event, as well as a re-experiencing of the event that is associated with psychological distress; physiological reactivity to stimulus cues to the event and/or distressing recollections, dreams, and flashbacks. Patients may also have a numbing of general responsiveness or symptoms of hyperarousal. These symptoms must persist for longer than one month.
Mood
Depression is both a symptom and a disorder, marked by feelings of sadness, guilt, hopelessness, and apathy. It is quite common, as evidenced by its high lifetime prevalence (16.6% according to Kessler et al. [1]). The stereotypical impression of the elderly is that they may be more prone to depression because of loneliness or difficult life changes, but depression is not a normal part of aging and is often a treatable disorder [6]. Studies show that older people are satisfied with their lives and less likely to experience depression than younger adults [7]. However, depression is still a serious problem in the elderly, with consequences both for the individual and for society [8]. It is an important public health issue that leads to increased morbidity and disability [9]. Depression can also be more difficult to diagnose in the older population because some of its symptoms can be mistaken for normal physiologic changes of aging or side effects of medicines more commonly taken in later life.
Key depressive disorders in older adults include the following:
Major depressive disorder requires the presence of at least one major depressive episode, which is defined by five or more specified depressive symptoms that occur in a single two-week period, one of which must be depressed mood or anhedonia. The symptoms are present a minimum of most of the day on most days and result in clinically significant impairment of the patient’s social or work life. Depressive symptoms include depressed mood, anhedonia, loss of interest, change in sleep patterns and/or appetite, guilt, psychomotor retardation, inability to concentrate, decreased energy, and thoughts of suicide. In older adults, depression can present in an atypical fashion. They often complain of more somatic symptoms; and apathy, irritability, and social withdrawal are more common complaints than depressed mood [7]. In fact, elderly patients often deny being depressed. A key feature of major depression in aging is an unrelenting, ruminative focus on a self-perceived cognitive impairment with or without supporting evidence. Major depressive episodes can present with psychosis, in older adults often associated with delirium and/or dementia but also possibly related to sensory impairments (visual or auditory). Patients with both dementia and a mood disorder may present with irritability or elevated mood. As in any patient with major depressive disorder, it is important to rule out somatic causes of the mood disorder. It should also be noted that the highest rate of suicide in the USA is in individuals in the age range of 65 and above.
Bipolar disorder is a different type of depression that can feature manic, mixed, hypomanic, and depressive episodes, depending on the subtype. A manic episode is defined by an abnormally elevated, expansive, or irritable mood that lasts continually for at least one week. Symptoms include but are not limited to excessive or pressured speech, a decreased need for sleep, grandiosity, increased activity, racing thoughts, flight of ideas, distractibility, and impulsivity. Ten percent of patients with bipolar disorder develop first-onset mania after age 50. In older adults, this is often because of medical or neurologic disease or the use of steroid medications.
Dysthymic disorder is another type of mood disorder, characterized by chronic depressive symptoms that are less severe than those of major depression but that last longer.
Adjustment
Adjustment disorders with anxiety or depressive symptoms, commonly diagnosed by specialists following psychosocial stressors, do not meet the criteria for a major depressive episode. There is still much to be learned about the significance of these syndromes, as well as effective treatment [10]. It seems logical that adjustment disorders would be more common in later life because the risk of stressful events and loss of life become greater; however, it appears that many older persons’ expectations of major stressors and loss change, leading to a lower prevalence of adjustment disorders with aging. In addition, coping mechanisms develop over the course of a lifetime that can lower the risk of adjustment disorders. Bereavement is a diagnosis that features depressive symptoms. It is considered normal grieving when it occurs within two months of the death of a loved one.
Prevalence
Struggling with a psychiatric disorder at some point over the course of one’s lifetime is quite common. Anxiety and mood disorders, in particular, have a high rate overall that decreases with aging. Symptoms of anxiety and depression often occur together and in older adults are commonly subthreshold (do not qualify for a full diagnosis).
Lifetime Prevalence and Age of Onset of Psychiatric Diagnoses
The lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) [11] diagnosis across all ages is 46.4% [1]. In particular, the lifetime prevalence of anxiety and mood disorders is 28.8 and 20.8%, respectively [1]. The age of onset of anxiety disorders is much earlier (age 11 years) than that of mood disorders (age 30 years), and mood disorders have a wider range of age at onset than other classes of psychiatric disorders [1]. There has long been an association between symptoms of anxiety and depression [12], but it is still uncertain whether these are distinct entities that may co-occur or whether they are points along the same continuum. Mixed anxiety-depressive disorder (MADD) is a provisional diagnosis in the DSM–IV and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision that describes co-occurring, subsyndromal anxiety, and depressive symptoms. A study done in Great Britain showed that, in patients with MADD, 47.9% had both specific depression and anxiety symptoms; and 98.9% had nonspecific somatic symptoms, fatigue, concentration problems, sleep problems, irritability, or worry [13]. Some critics of the provisional diagnosis point out that, although MADD is associated with impaired functioning, the disorder as described has low diagnostic stability over time; and its incidence may be dependent on the defining criteria [14]. However, studies have concluded that patients with the provisional diagnosis of MADD have more severe and chronic pathology than patients with depression or anxiety only, resulting in greater vulnerability [4, 15].
Prevalence of Mood and Anxiety Disorders in Older Adults
National. Although the prevalence of mood and anxiety disorders declines with increasing age, they are still common and require preventive considerations, as well as intervention [7]. Special considerations in the elderly include the prevalence of chronic illness and the effect that medical comorbidities have on psychiatric complaints and vice versa. According to data from the National Comorbidity Survey Replication, the 12-month prevalence rates of any mood disorder and any anxiety disorder in adults ages 55 and older were 4.9 and 11.6%, respectively. Comorbid mood and anxiety disorders have a prevalence of 2.8% in older adults. In general, rates of both mood and anxiety disorders decrease steadily with age, except in the oldest old (age 85 or older); but this age group is the least available for study [7], and selective nonresponse of the most frail is an issue in community-based studies [8]. The most common anxiety disorder in older adults is specific phobia, followed by social phobia, PTSD, GAD, panic disorder, and agoraphobia. Being married or cohabiting is protective against mood and anxiety disorders, and low education level is a risk factor for anxiety in aging. There is a significantly higher risk of anxiety in women [7, 16]. There are no significant changes in prevalence of disorders according to race or geographic location [7]. Some considerations should be kept in mind when reflecting on these data, including possible underreporting of psychiatric illness in the aging population. Potential causes of this include embarrassment associated with the stigma of mental health problems, difficulty recalling symptoms or associating those symptoms with psychological distress, and the underrepresentation of the homeless, institutionalized, and non-English-speaking older-adult populations [7].
Worldwide. Results of a study investigating the prevalence of anxiety among older adults in low- and middle-income countries were comparable to the rates in high-income countries, with the exception of China, which had a remarkably low prevalence of anxiety. This finding may be because of a cultural stigma associated with mental illness. The highest prevalence of anxiety among older adults was found in Latin America. This study confirmed that the risk factors for anxiety in older adults in the USA parallel those in the other countries surveyed. The most important factors were gender, socioeconomic status, and comorbid physical illnesses. Significant levels of comorbid depression and anxiety were reported, with more than one fifth of the anxiety disorders featuring comorbid depression in all countries surveyed [17].
Prevalence of Depressive and Anxious Symptoms in Older Adults
Although the prevalence of diagnosable mood and anxiety disorders decreases in later life, the elderly population still often experiences subclinical symptoms of anxiety and depression [5]. According to the US Center for Disease Control’s (CDC) report, The State of Mental Health and Aging in America, 9.2% of US adults age 50 or older and 6.5% of US adults age 65 or older reported “frequent mental distress,” defined as 14 or more days of poor mental health over the past 30-day period. Current depression was reported by 7.7% of adults age 50 or older, with 15.7% reporting a lifetime diagnosis of depression [18].
Pathophysiology
Although anxiety and depressive symptoms may either co-occur or may be distinct, their biological causes are closely linked. Evidence shows that abnormalities of both the serotonin and norepinephrine neurotransmitter systems are present in anxiety and depression [19].
Special Considerations for Older Adults
There are some important concepts to keep in mind when working with geriatric patients. In the geriatric population, attention should focus on level of functioning and quality of life as well as safety. The physician should take a comprehensive medical history and review all medications to rule out any alternative treatments for psychiatric complaints. Care should also be taken to evaluate cognitive functioning and frontal-lobe impairment. With regard to psychiatric complaints, the patient is often not the complainant, so it is important to find collateral sources of information, such as family members or caregivers. Because of a decreased functional reserve, when illness strikes the older adult, he or she may be less equipped than the younger adult to bounce back and be more vulnerable to quick deterioration, loss of functioning and difficulty with activities of daily living. Care must be taken to recognize the bidirectional association between medical illness and psychiatric complaints that negatively affects treatment of both and results in a poor prognosis.
With the increasing number of medical problems and chronic disease in the elderly, some physicians expect symptoms of anxiety and/or depression as a natural consequence. The effect of medical comorbidities and chronic pain on anxiety and depression is significant, and the reverse is true as well. Anxiety and depressive symptoms can adversely affect the course and complicate the treatment of chronic medical diseases [6]. For example, in some chronic respiratory diseases, particularly chronic obstructive pulmonary disorder, the presence of anxiety and depression can compound the physical and emotional effects of breathing disorders [20]. This leads to the question, what level of anxiety and depressive symptoms is normal in adults; and how is the treatment of one intertwined in the other? Refer to Chaps. 10, 11, and 17 for further discussion.
Biopsychosocial Model
The World Health Organization defines health as “… a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” [21]. This definition sparked extensive discussion and theories on how to approach health care with a comprehensive, multifactorial viewpoint. Here we will explore the biopsychosocial model and the transformation of thought to a subsequent conceptual model that refocused attention on chronic illness and its association with psychiatric problems.
History of the Model
The theory behind the biopsychosocial model, a concept described by Dr. George Engel in a 1977 article in Science [22], was not new at that time by any means. Physicians have a long history of incorporating patients’ background and attitudes toward disease in their diagnosis and clinical decision making. In fact, this type of holistic approach to healing dates all the way back to Hippocrates. At its heart, the biopsychosocial model implies that a person’s biologic tissue changes his/her personal history, and his/her social circumstances all contribute to illness. The notion of “treating sick people and not diseases” [23] was emphasized again and again over time. It is notable that, in Engel’s description of the model, he added the role of the healthcare system as a social factor. At the time of the published description of the model, the so-called biomedical model of disease was falling out of favor, as people suspected the powers of pharmacologic tools focused solely on altering molecules had a limited ability to cure disease. In fact, people may have been losing faith in the healthcare system itself. Emphasis in Engel’s article was placed on the interpretation of the terms sick and well, and the idea that more factors than just biology played a role in wellness, especially in the way patients viewed their own disease. However, Engel did not diminish the importance of the biomedical in his description. His training background as an internist and the passion for psychoanalysis he later developed seem to have heavily influenced his desire to link somatic illness with life situation and personal development [24].
Modernization and Application to Psychiatric Symptoms and Disorders
In 2003, an article was published that presented a new conceptual model by Wayne Katon. Despite having many similarities to the biopsychosocial model, this model was updated to become more biologically focused in presenting the reciprocal cause-and-effect pattern of chronic diseases on depressive and anxiety disorders and vice versa. It was based on a number of studies showing a link between chronic disease and mental disorders. Patients with any chronic medical condition are more likely than those without to experience depression [25], and the most common reason for new onset of major depression is the diagnosis of either the patient or his or her spouse with a life-threatening illness [26]. Because of the association between mental disorders and poor physical health, psychiatric assessment becomes all the more important in the elderly population [7]. Katon investigated the link between depressive and anxiety symptoms and disorders in patients with various neurologic diseases, diabetes, heart disease, and HIV and realized that depression plays a significant role in the development of some diseases. Depression can also develop as a result of the psychological reaction to disease. There is a causative role between depression and complications related to disease. Finally, depression is known to be a side effect of many medications and treatments. Katon also pointed out that chronic medical illness has a pathophysiologic effect on brain chemistry and function [27].
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