Recognizing Depression in Older Men

Depression presents uniquely in older men compared to older women, bringing attention to symptoms that often go unnoticed. Carol Podgorski, Ph.D., Director of the Finger Lakes Center for Excellence for Alzheimer's Disease and Clinic Director of the University of Rochester Memory Care Program, emphasizes the importance of recognizing the distinct signs of depression in older men, particularly those aged 85 and above who are at a heightened risk of suicide.

First, however, Podgorski says it's important to clear up a common misconception about mental health and aging.

According to a survey conducted by Mental Health America, 60% of older adults believe that it's normal for people to get depressed as they grow older.

"In reality, that's not true. Studies that have looked at life satisfaction have found that people over the age of 75 happened to be the people who are most satisfied with their lives," says Podgorski.

Frustratingly, this ageist fallacy persists.

"Unfortunately, in our society, we have this notion that if you're old, of course you would be depressed. Like memory loss, depression is not a normal part of aging, and it's something that we do have to screen for," says Podgorski 

Depression can affect everything from your heart to your immune system to your memory and cognitive function.

"When you think about your whole body being affected by depression, you can imagine how this carries out to day-to-day activities," says Podgorski. To maximize quality of life at any age, it's important to get screened.

A standard form known as the "Patient Health Questionnaire" (PHQ) is one of the most commonly used depression screeners, according to Podgorski. You may have filled one out during a visit to your primary care provider. The problem with standard screeners is that they don't include questions related to several symptoms that are commonly seen in depressed older men.

"What we know about men is some of their traits aren't going to show up on a PHQ. They go under the radar, because if they don't have somebody going to the primary care doctor with them who says, 'You know, they're just not acting like themselves or something's off,' it might not show up as depression to the primary care physician," Podgorski notes.

While the loss of interest in previously enjoyed activities is a symptom of depression in both genders, women tend to experience more passive symptoms of depression, such as sadness, withdrawal and excessive feelings of guilt. Depressive symptoms often manifest somatically in women through headaches, backaches and gastrointestinal issues, says Podgorski.

Men, on the other hand, are more likely to display "acting out" or externalizing symptoms of depression (which are not included on standard screeners), she says. Personality changes may include irritability, aggression or reckless behavior. Men might drive fast and take risks they haven't taken before, or they may use alcohol or drugs to numb pain.

Depression symptoms can manifest as cognitive impairment, says Podgorski.

"You want to make sure that if somebody starts showing symptoms of cognitive impairment that they get screened for depression because it's treatable. There are actually wonderful stories of people who have looked cognitively impaired, but with the course of medication ended up having their cognitive impairment resolved."

Podgorski says grief can also be confused with depression. However, grief is more of a "roller coaster" ride of fluctuating emotions, where you experience "up" moments of happiness or pleasure as well as "down" moments of sadness. In contrast, in depression, feelings of emptiness or despair tend to be constant.

"While there's no timetable for grieving, if it doesn't let up over time, then it might be depression," says Podgorski.

Caregiver burden, when coupled with loneliness, increases the risk of depression fourfold, says Podgorski. "The good news is that when caregivers access therapy, it attenuates the risk of depression," she says.

Diagnostic and clinical treatment decisions for depression are made by professionals based on frequency, duration and intensity of symptoms. A PHQ score of 10 or above warrants clinical treatment.

Other populations most at risk for untreated or undetected depression include those who are isolated or live alone, those with less formal education or mental health literacy, and individuals who live in small tight-knit communities where there may be a stigma associated with seeking help for mental health conditions, says Podgorski.

"If there's one family-owned pharmacy and one primary care practice in your community and you don't want people to know, that's going to be a barrier," she explains.

Of particular treatment concern, says Podgorski, are men ages 85 and up, who experience a startling 55 per 100,000 suicide rate. "This maps on to that sense of recklessness, and men are more likely to use lethal means, so they're more likely to succeed at suicide attempts. It's really something to be taken seriously," she says.

According to the Mental Health America study, only 42% of older Americans said they would seek help for depression. Another study done in 2020 showed similar sentiments, concluding that older adults prefer to manage things by themselves rather than seeking out help, says Podgorski.

"Professional interventions were sometimes considered necessary for severe depression, but a lot of people didn't really have a lot of faith that professional intervention would make a difference," she says.

Types of psychotherapy that have been proven to be effective in older adults include cognitive behavioral therapy, acceptance and commitment therapy, problem-solving therapy, mindfulness-based cognitive therapy, interpersonal therapy, reminiscence therapy, and art and music therapy. Podgorski has noted that older men are especially responsive to problem-solving therapy, which breaks problem-solving into logical steps.

For those willing to seek out and engage in therapy, a shortage of mental health professionals, particularly in rural areas, causes disparities in accessing care.

"Over 60% of rural Americans live in a designated health provider shortage area," says Podgorski.

This illustrates the need for more education about evidence-based interventions that can be used by older adults with mild symptoms of depression who prefer to self-manage. One way to do this is by rewiring the brain.

"We have to consider the brain to be like a muscle. We can train it, and we can strengthen it," says Podgorski.

Jackie Perrin A consumer-focused journalist with 20 years of experience, Jackie Perrin has covered home, health, leisure, food, travel, and business topics for publications ranging from TripAdvisor to Gannett News Service. Read More