Depression in older adults

Depression is a mental illness that affects the way you think and feel. It is quite common, and affects people of all ages. Around 3 in 100 people in England are diagnosed with depression every week.

Depression isn’t just feeling sad. If you have depression, you might:

• feel unhappy, hopeless or that life isn’t worth living
• feel anxious or worried
• struggle to do things
• struggle to concentrate or remember things
• lose interest in the things you once enjoyed.

In your body you might:

• feel exhausted or restless
• struggle to sleep, or sleep too much
• have physical health problems like headaches or stomach aches
• lose interest in sex
• eat less or more than usual.

Other people might notice that you:

• seem more quiet, worried, irritable or sad than usual
• struggle to focus
• sleep more or less than usual
• complain about aches and pains
• stop looking after yourself or your home
• seem more isolated or lonely.

Depression can be mild, moderate or severe, and depending on the severity of your depression you might have different symptoms. It might not be obvious straight away that you or someone else is experiencing depression. You can find out more about depression in our information resource on the topic.

Most of us have some of these feelings from time to time. However, it’s important to ask for help if:

• you experience a lot of these feelings
• the feelings go on for more than a couple of weeks
• the feelings start to affect lots of areas of your life
• you feel that life is not worth living.

Depression isn’t something new. However, in the past talking openly about mental health and mental illness wasn’t encouraged. There were also a lot of misconceptions and stereotypes about depression and the people who had it. Some of the words used to describe depression were stigmatising and unkind.

Over the years, we have learnt more about why depression happens and how best to treat it. While stigma around depression and other mental illnesses still exists, things are much better than they were. There is now a lot of support available to people of all ages who have depression.

There are lots of reasons why people develop depression, such as difficult life experiences, physical health problems and genetic factors. You can find out more about the causes of depression in our depression resource.

There are also some things that might make older people more likely to develop depression. These include:

Physical health problems

Older people are more likely to be diagnosed with one or more long-term health conditions. Research has shown that this can make people more likely to develop depression.

Dementia

Dementia is a condition that affects your memory, language and behaviour, and mostly affects older people. It’s estimated that around 3 in every 10 people living with dementia are depressed.

Parkinson’s disease

Parkinson’s disease is a condition that affects how your brain works. It causes symptoms like shaking, slow movement and stiff muscles, and is most common in people over the age of 50. Feelings of depression are common in people with Parkinson’s disease.

Loneliness

Loneliness is more common in people who have been widowed, have health problems or live alone. However, even people who have support from friends and family can experience loneliness. While being lonely is not the same as being depressed, older people who experience loneliness are also more likely to experience depression.

Grief

When someone you care about dies, it is normal to experience feelings of grief, especially if the person who died was very close to you. You probably won’t ever completely ‘get over’ the death of a loved one. However, if your feelings of grief continue to feel intense for a long time, or feel like they are getting worse, you might need professional help.

When someone dies, it is also common to have trouble sleeping, or to lose your appetite. Changes to your sleep and diet can also have a negative effect on your mental health.

Vascular depression

Illnesses that affect the circulation of blood to the brain can make someone more likely to develop depression. These include heart disease, strokes, and high blood pressure or cholesterol.

Alcohol use

Alcohol affects the chemistry of the brain, increasing the risk of depression. If you already have depression, alcohol can also make this worse.

Moving into care homes

Depression is more common in people who live in care homes than in people who don’t. This could be because people who live in care homes are more likely to be experiencing some of the factors we’ve already mentioned. It could also be because people who live in care homes can lose their usual familiar routines and supportive environments.

Depression is treatable. There are lots of different kinds of support available, and research has shown that these can be very effective.

The first thing you should do if you think you are experiencing depression, is to speak to your GP. They will ask you questions about how you have been feeling and what is going on in your life. They might use a questionnaire to find out whether you have depression and how severe it is.

Once you have discussed what is happening, your GP can support you to get the help you need.

Helping yourself

If your depression is mild or this is the first time you have experienced depression, your GP might recommend that you do some things to support yourself.

The NHS suggests 5 steps you can take to improve your mental health and wellbeing. These are:

1. Connecting with other people – This could be a friend or family member, religious leader, or anyone you know who you trust and respect. Often when we talk to others about how we are feeling we find out that they have had similar experiences, and that we aren’t as alone as we thought.
2. Being physically active – This could be anything from going for a daily walk around your local park to joining a dance class. Staying active, cutting down on alcohol, quitting smoking, eating healthily and sleeping well are good for everyone, but can be particularly helpful if you are experiencing depression.
3. Learning new skills – You could try cooking a new meal, taking on new responsibilities, or signing up for a course. This can help you to improve your self-confidence and connect with others.
4. Give to others – This could mean giving your time by volunteering in your local community, giving your skills by helping a neighbour or friend with a task, or just telling a friend something you appreciate about them.
5. Pay attention – This is also called mindfulness, and is when you pay attention to yourself and the world around you. This can help you to feel more connected to your environment, and to become less overwhelmed by your thoughts and feelings. There are lots of different ways to practice mindfulness.

Find out more about these steps  on the NHS website.

Social prescribing

Social prescribing helps to connect people to community services and local groups to support their mental and physical health.

Your GP can refer you to a ‘link worker’ who can help you to find activities that you might be interested in. You can take part in these activities alongside other treatments like medication or talking therapies.

You can find out more about social prescribing on our website.

Psychological therapies

If you have tried helping yourself and are still struggling, or if your depression is moderate or severe, your GP might suggest a psychological therapy.

Psychological therapies, or talking therapies, are when you talk to a professional, known as a therapist, about how you are feeling. There are lots of different kinds of psychological therapy, and they work in different ways. Which you are offered will depend on your needs and your unique life circumstances.

You can find out about the different psychological therapies available on our website.

At first, it might feel uncomfortable to talk to a stranger about your life, but remember that:

• These sessions are confidential. Your therapist won’t share any information with your friends or family unless you say they can. There are some other specific situations where your information might be shared with someone else, which you can find out more about in our resource on caring for someone with a mental illness.
• Your therapist won’t judge you or be shocked by anything you tell them. It is their job to listen respectfully.
• Psychological therapies have been shown to be effective, and if you give them a chance you are more likely to get well.

Research suggests that older adults with depression are even more likely to benefit from psychological therapies than younger people are, so it is important that they are offered them. If you feel you would benefit from a psychological therapy, speak to your GP. You can find out more about the therapies available for depression in our depression resource.

Antidepressants

Antidepressants are medications that can help to improve the symptoms of depression. You normally take them as a pill once a day. Your GP might prescribe you an antidepressant at the same time as a psychological therapy.

There are lots of different kinds of antidepressants, and your GP will speak with you to understand the kind of antidepressant that might work for you. In some cases, you might need to take more than one medication. It will usually take one or two weeks before you start feeling the benefits of an antidepressant.

When taking medications, an older person may need to start on a lower dose than someone younger, and increase their dose slowly.

Can people with dementia take antidepressants?

There is no medical reason why people with dementia can’t take antidepressants.

However, research has found that antidepressants are less effective in people who have dementia than in people who don’t. People with dementia should not be offered antidepressants to manage mild to moderate depression unless they have had depression in the past.

Do antidepressants have side-effects?

Like any medication, antidepressants can cause side-effects. These can affect some people more than others, and the kinds of side-effects you have might depend on the kind of antidepressant you are taking.

The person prescribing your medication should talk to you about any possible side-effects. Ask your prescriber or pharmacist for some written information on side-effects and read this carefully.

Some antidepressants used in the past had more side-effects than more recent medications. If you were given antidepressants in the past, they might not be the same ones you will be given now. Make sure that you let your doctor know if you have taken antidepressants before.

What if I get unpleasant side-effects?

If antidepressants are giving you unpleasant side-effects or aren’t working for you, speak to your GP.

You should usually not stop taking any medication without first speaking to the person who prescribed them. However, if you start to have suicidal feelings, or any other serious side-effects, you should stop the antidepressant and get help urgently. This can be done by contacting the person who prescribed them or your GP.

If you feel you are in danger, you should call 999 or go to A&E.

You can find out more about antidepressants and side-effects on our website. We also have information on stopping antidepressants. 

What if I’m taking other medications?

If you are taking other medications, or have other health problems, you might not be able to take certain antidepressants. Or your doctor might need to monitor you more than usual. Tell your doctor about any other medication you are taking.

I’m not sure if antidepressants are right for me

It can feel like a big step to start taking antidepressants. You might be unsure about whether it’s the right decision for you.

It can be helpful to think about antidepressants in the same way you would any other medication. For example, if you had a problem with your heart and your doctor gave you medication for it, you probably wouldn’t hesitate to take it.

Finding out more about antidepressants can help you to make an informed decision.

Antipsychotics

Sometimes antipsychotics are given to people who are experiencing psychosis and depression, or people who are experiencing high levels of anxiety.

When you are given antipsychotics, your doctor will talk to you about the increased risks of falls, heart problems and circulation problems. If you are taking antipsychotics, this should be reviewed regularly.

Practical support

Your mental health might be linked to the other things in your life, even if those things don’t seem related. Problems with money, housing, care, work and retirement can all have a negative effect on your mental health. Working to fix these could be an important step in treating your depression.

There is lots of information at the end of this resource that can help you to get support with different areas of your life.

Further treatment

If your depression is very severe, you might be referred to a specialist mental health service or team. You may need to spend time in hospital if you need a lot of treatment and support, or if you are a risk to yourself or someone else. You may be offered other medication instead of or as well as antidepressants.

Sometimes, when someone is very unwell and other treatments haven’t worked, electroconvulsive therapy (ECT) might be considered. In ECT, you are given a general anaesthetic and your brain is stimulated with short electric pulses while you are asleep. ECT has been shown to be successful in treating severe cases of depression.

Older adult mental health services take into account the unique needs that older people might have, and provide them with appropriate care.

When someone gets older, there are changes that happen in their lives that need to be considered if they have a mental illness. Older people might have:

• multiple health issues
• frailty, which means they find it harder to recover from illnesses or injuries
• experienced bereavements and other losses.

If an older adult has other conditions like dementia, these might be confused with anxiety or depression. Older adult mental health services have the expertise to consider this when making a diagnosis of depression.

Older adult mental health services also have the facilities to help people who need assistance with mobility.

When does someone need older adult mental health services?

The decision for you to be referred to an older adult mental health services should be based on your individual needs, and not just your age. The following things should be considered:

• the kinds of services available locally
• other health conditions you might have
• your level of frailty.

If you move from a mental health service for adults to one for older people, the people who have been treating you should make sure that the new service understands your needs, such as:

• your treatment history
• your preferences
• the support systems available to you
• your personal history.
  

People in care homes are entitled to mental health support just like everyone else. If you are in a care home, this means:

• you should be provided with activities that promote your physical and mental health
• care home staff should be trained to know if you might be experiencing a mental health problem
• any mental health problems identified should be recorded in your personal care plan.

Depression is more common in people who are in care homes. If you have depression and are in a care home, it is important that you receive the high standard of care that you are entitled to. You should have your medication reviewed regularly, and any side-effects should be carefully considered.

How can I get mental health care in a care home?

Through a GP

If you live in a care home, you should be registered with a GP. You have the right to choose your GP practice. You might choose to remain with your previous GP practice or to move to a practice that is linked to your care home.

If you are in a care home and are experiencing a mental health problem, you should speak to your GP. Your GP should work to rule out other physical health problems that can have a negative effect on mood.

Through care home staff

Care home staff are sometimes trained to provide psychological support like counselling. If care home staff feel that you need more intense support or have a mental illness, you or your carer can speak to your GP, who can refer you to a dedicated care home liaison team.

Care home liaison teams are available at most care homes, and will be able to provide psychological therapies like cognitive behavioural therapy (CBT) or psychodynamic therapy.

The charity Age UK provides information on care homes, while the charity Carers Trust has useful information on caring for someone who is in a care home.

There are some things that can make it more challenging for older people to get support for depression.

Other health problems

If you have another health problem, it could be difficult for you or your doctor to work out whether you are also experiencing depression.

Depression can sometimes be confused with other mental or physical health problems. For example, memory problems that can happen with depression can be mistaken for dementia, or the other way around.

Depression might also make it difficult for you to take medications or go to appointments. As a result, your physical health might get worse, which might make your depression worse.

Stereotypes

Unfortunately, some people hold harmful stereotypes about older people. For example, some people think that it is normal for older people to feel tired all the time, or that loneliness is a normal part of getting older.

People who hold these stereotypes might be less likely to recognise that an older person they know is depressed. Feelings of depression are not a normal part of aging, and you deserve help and support whatever age you are.

Many years ago, they changed the phrase from old age pensioner to senior citizen to sort of try to change the label. But the reality is, it’s not about changing labels. It's about treating people the same.” - Bernie

Stigma

In the past, mental illnesses and the people who had them were treated very differently to how they are now. If you heard negative things about people with depression in the past, you might find it hard to get help for depression now. It’s important to remember that depression is common, treatable and you deserve help. All sorts of people get depression, and it isn’t a reflection on who you are as a person.

Seeing depression as just a part of life

If you are used to feeling depressed, you might not think there’s any point in getting help. Even though it can feel difficult, the sooner you ask for help the sooner you can start getting better.

Technological barriers

Some GP appointments are now held over the phone or online. Some older people can find digital technology more challenging to use, or just prefer to do things in person. It can also be hard to talk about sensitive things over the phone or online.

It can also be hard for doctors to tell if someone is experiencing depression through a phone call. It might take a face-to-face appointment for this to be noticed.

If an older person you know has depression, it can be hard to know how to help. Here are some things you can consider when you are supporting an older person with depression:

Communicating sensitively

It can be hard to know what to say to someone who is experiencing depression. Sometimes the most important thing you can do is listen and encourage someone to get help.

You should try to avoid saying things that could be taken negatively. For example, telling someone they’ll ‘get over it’ or telling them that other people have it worse than they do. This can make it harder for the person to get help.

Remember the individual

All the things that make someone unique, like their life experiences, values and interests, don’t disappear when they get older. By seeing the person you know as an individual, you will be able to support them better.

Encourage independence

While some older people might need support with certain things, such as accessing services or managing their care, it’s important to think about how the person you know can remain independent. Work with them to understand how you can both be involved in their care and help them to do things for themselves.

Consider cultural differences

There are some things to consider if the person you know grew up or spent time in another country, or speaks a different language.

• Communication barriers – If the person you know doesn’t speak English, or it isn’t the language they are most comfortable using, they might struggle to communicate with healthcare professionals. They should be offered a professional interpreter if this would help them to communicate their needs more clearly. More time should be given in appointments for this to happen.
• Stigma – Different cultures and generations have different attitudes to mental illness. If the person you know grew up in a place or time where there was stigma around mental illness, they might struggle to ask for help. Psychoeducation, where someone learns about their mental illness, can be helpful. They might also benefit from the support of a faith leader or community group.
• Peer support – Everyone can benefit from speaking to people with similar cultural experiences to them. There might be groups near you where the person you know can meet people of the same ethnicity or cultural background. You can find out about peer support near you and the kinds of services they offer on the Mind website.
• Challenges accessing records – If the person you know has lived in another country and received care there, it might be challenging to get hold of their records.

A carer is anyone who looks after someone else because they find it hard to look after themselves. Carers can offer practical, emotional and financial support, and might be involved in the medical care of the person they care for.

Being a carer can be very challenging, and as a carer you might experience difficult and conflicting emotions, such as anger, guilt, worry or sadness.

Being a carer can also be rewarding. Many carers have very close relationships with the people they care for, and learn important practical and emotional skills. Whatever your experiences and feelings are, they are legitimate.

As a carer, there are lots of things that you can do to support the person you care for, including:

• encouraging them to get help when they need it
• working with them to understand how much they want you to be involved in their care
• forming positive relationships with the people who provide their medical care
• making a plan for what to do in an emergency.

There are also things that you can do to support yourself, including:

• sharing your stresses and worries with a trusted friend or family member
• taking care of your physical and mental health. This is just as important as looking after the person you care for, and can be beneficial for you both
• getting a break with the help of friends or a professional caring service
• accessing support like carers assessments and workplace adjustments
• meeting with other carers for support
• planning ahead for the future
• applying for the benefits you are entitled to.

It is important to remember that it is not your responsibility to ‘fix’ the person you are caring for

You can find out more about being a carer in our resource on caring for someone with a mental illness.

“As a carer I need to plan, everything is connected. Not just the next few weeks, but the next few years.” Sofija

Information on depression

• Depression, NHS – NHS information on depression.
• Depression, Royal College of Psychiatrists – The Royal College of Psychiatrists’ information on depression.
• Depressions and anxiety, Age UK – Information from the charity Age UK about depression and anxiety in older people.

Information for carers

• Carers UK – Carers UK is a charity offering support, information and advice to carers.
• Help and support for carers respite and support, Age UK – Information for carers from the charity Age UK.

Further information for older people

• Get help with loneliness, British Red Cross – Information on getting help with loneliness from the British Red Cross.
• Advice and support for veterans & ex-forces, Veterans' Gateway – Advice and support for veterans from the charity Veterans’ Gateway.
• Advice for LGBT older people, Age UK – Information from lesbian, gay, bisexual and transgender older people from the charity Age UK.

National Institute for Health and Care Excellence (NICE) guidance on depression

• Depression in adults: recognition and management guidance, NICE – NICE guidance on the management of depression in adults.
• Depression in adults with a chronic physical health problem: recognition and management guidance, NICE – NICE guidance on the management of depression in adults with chronic physical health problems.

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert authors: Dr Manoj Rajagopal, Dr Kapila Sachdev and Dr Qutub Jamali

Thank you to the people with lived experience of depression who helped to develop this resource: Bernie, Philip and Sofija Opacic. Some of their experiences have been included in this resource as quotes.

Full references available on request.