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Reducing Suicide: A National Imperative
are part of the aging process (Duberstein et al., 1995; Seidlitz et al., 1995). The vast majority of surveyed primary care physicians think that, because of losses in late life, depression is understandable (Gallo et al., 1999). They are less alert to the complications of widowhood, which include depression, traumatic grief, and suicidality (Rosenzweig et al., 1997; Szanto et al., 1997; US DHHS, 1999). Depression and grief, in particular, are often misattributed to normal aging (Unutzer et al., 1999). Thus, stereotypes about aging thwart efforts to identify and diagnose depression and traumatic grief on the part of patients, families, and providers (US DHHS, 1999).
Under-detection and under-treatment of depression in older people is considered a major public health problem (Lebowitz et al., 1997; US DHHS, 1999). Most research focuses on primary care because this is where older patients present for, and prefer to receive, mental health care (Mickus et al., 2000; Unutzer et al., 1999). Most older people with depression in primary care remain undiagnosed (US DHHS, 1999). Detection of depression is worse in older than in younger patients, a well-recognized problem that does not appear to be improving (Harman et al., 2001c). Even with detection, up to 50 percent are given inadequate treatment (Katon et al., 1992; Unutzer et al., 2000; US DHHS, 1999), although a more recent study shows some improvement in treatment rates for depression (Harman et al., 2001b). More specifically, depressed older women are about two times more likely than depressed older men to receive antidepressants (Brown et al., 1995). Untreated or inadequately treated depression in primary care plays a role in suicide of older people (Lebowitz et al., 1997).
The reasons for lack of detection and treatment are a complex combination of clinician and patient factors (Pearson et al., 1997; Unutzer et al., 1999; US DHHS, 1999). Family physicians attribute their difficulty in detection to the atypical nature of depression’s symptoms in older people (Gallo et al., 1999).6 Further complicating the diagnosis is that older people commonly report somatic symptoms, as opposed to mental symptoms. Older men, in particular, are less likely than older women to be detected because they report fewer mood symptoms and crying spells (Unutzer et al., 1999). Greater reporting of somatic symptoms by older people might be an attempt to avoid the stigma of mental illness. It also might be that symptoms of physical disorders are amplified by depression (US DHHS, 1999), or that the depressive symptoms are relatively mild (Hotopf et al., 2001). Older persons are more likely to attribute their depression symp-
Depression symptoms have somewhat different manifestations in older people. Many have “minor depression,” a subsyndromal form of depression with fewer symptoms and less impairment (US DHHS, 1999).