New Look at Scrooge: He Was Just Depressed : Health: Fifty years before Freud, Charles Dickens not only portrayed the problem of depression in the aged, he outlined the treatment.
Ebenezer Scrooge wasn’t the mean-spirited misanthrope most of us believe him to be. He was just depressed, in the view of Gene D. Cohen, acting director of the National Institute on Aging.
Many people know Scrooge as the protagonist of Charles Dickens’ “A Christmas Carol,” but to psychiatrist-geriatrician Cohen, he is “the famous London case of 1843.”
“A lot of the older people who are depressed may look like they are easily irritated, angered or hostile,” Cohen said. This is “a behavioral defense against the inner helplessness that depression creates.” It is this, he said, that gave birth to the cliche of the old person who is crotchety.
“We know from aging research that personality is stable, so if you see a personality change, it should be a signal of trouble,” he said.
Scrooge illustrates that, Dickens tell us, but Scrooge had the good fortune to run into what Cohen calls a “crisis-oriented intervention team--the ghosts--who, using very contemporary approaches from community mental health along with creative dream work, helped turn him around.
“Dickens showed the course of depression in aging, showed that it is never too late to intervene and showed the value of psychotherapy 50 years before Freud’s classic work on the interpretation of dreams,” Cohen said.
Sad things happen to old people. Friends and relatives become ill or die. Their physical health may begin to fail. They may have financial problems. They may be lonely. Indeed, they may be clinically depressed, but that may be so lost in the multitude of other problems that nobody--including the old man or woman and their doctors--may notice.
Even sadder is the fact that a genuine depression is as treatable in old people as it is in the young. With drugs, psychotherapy, support groups, occasionally electroshock therapy or various combinations of these, 80% to 85% of depressions can be effectively treated.
About 15% of Americans over age 65 are clinically depressed, according to Arnold Friedhoff, chairman of a special National Institutes of Health panel on late-life depression. And in nursing homes, the number rises to 25%, he said. Yet, the panel found, more than 60% of depressed older Americans are not being treated for the condition.
“One of the problems,” said Nathan Billig, Georgetown University specialist on aging, “is our inattention to old people.” For example, he said, there has been very little research done on treatment of their depression. “We don’t even know how long to keep someone on medication,” he said.
Older people themselves tend not to seek help, Billig said, “although we know they respond to both medication and psychotherapy. But they too are prejudiced,” reflecting society’s stigmatization of mental illness and the mentally ill.
Moreover, he added, when a patient goes to a doctor with financial problems, complicated with “this disease and that disease,” the doctor figures, “Well, I’d be depressed too” and doesn’t think of the depression as something to be treated but merely as another inevitable consequence of growing old.
Physical illness may mimic some of the symptoms of depression--apathy, for example, or loss of appetite, Friedhoff said. The symptoms get the attention, and the depression is ignored. Cohen calls it the mask of depression; Scrooge masked his depression with a cloak of meanness.
“Sometimes, depression is a sign of medical illness,” Billig said, “but it often is a complication of medical illness, and we can’t just write it off. There is also some evidence that treating the depression facilitates treatment of the medical illness.”
A study done at the University of Washington in the 1980s found that at one hospital, 25% of 400 elderly people entering for physical problems had “significant depressive symptoms.” These people will have less motivation and optimism about the future, and each will become less of a partner in discharge planning and more likely to end up in a nursing home.
During the last decade, several studies have shown a weakening in the immune systems of depressed elderly people in hospitals and of elderly care givers for people with such chronic illnesses as Alzheimer’s disease. Some studies also show that older people with hip fractures and cardiac conditions have better outcomes when their medical treatment is augmented by psychiatric counseling.
And in one study published last year in the Journal of the American Medical Assn., researchers from Johns Hopkins found that depression “increased the likelihood of death by 59%” among nursing home residents. In the study, psychiatrists examined 454 new admissions to eight Baltimore nursing homes and followed them for a year. The majority of the cases of depression they found were “unrecognized and untreated by nursing-home physicians.”
The point, specialists agree, is that although treatments work, the depressions in the elderly go unnoticed, wreaking a kind of silent havoc among members of this increasingly vulnerable population.
For a free booklet, “If You’re Over 65 and Feeling Depressed,” write to National Institute of Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C05, Rockville, Md. 20857.
