Depression in later life often does not look like sadness

Depression is not a normal part of ageing. It is more common in older adults than in the general population in some settings — particularly in those with chronic illness, in residential care and after bereavement — but it is a disorder, not a stage, and it responds to treatment at any age.

It is also systematically missed. Several factors conspire: the presentation differs, older patients are less likely to describe emotional symptoms, clinicians attribute the features to physical illness or to age, and the whole thing is often filtered through a generation's reluctance to frame anything as psychiatric.

How it presents differently

Fewer older adults with depression report sadness as their main complaint. What they report instead:

Physical symptoms. Fatigue, poor appetite, weight loss, insomnia, aches and pains, gastrointestinal complaints. These dominate the presentation and lead to extensive physical investigation.

Anhedonia rather than sadness — nothing is interesting, nothing is enjoyable, without a subjective sense of misery. This is easily misread as contentment or as slowing down.

Cognitive impairment. Concentration, attention and memory all suffer. When severe, this produces what used to be called pseudodementia — a presentation genuinely difficult to distinguish from dementia, and one of the more important reversible causes of cognitive symptoms.

Anxiety and agitation, sometimes prominent, sometimes the only complaint.

Excessive worry about health, and repeated presentations for symptoms that do not yield a diagnosis.

Irritability, especially in men, which families interpret as personality change.

The specific risk factors

Some are obvious: bereavement, isolation, disability, chronic pain, financial insecurity, moving into care.

Others are less so. Depression is unusually common after stroke, in Parkinson's disease, and in the early stages of dementia. Vascular depression — associated with white matter changes on imaging — is a recognised entity, tends to present later in life without a prior psychiatric history, and often features executive dysfunction and a poorer response to antidepressants.

And a long list of medications can contribute, including some beta blockers, corticosteroids, benzodiazepines, opioids and interferon.

Suicide risk, which is the reason this matters most

Suicide rates in men over 75 are among the highest of any demographic group in many countries. Older adults who attempt suicide use more lethal means, plan more, give fewer warnings, and are more likely to die than younger people who attempt.

A substantial proportion have seen a primary care clinician within the month before their death, frequently for a physical complaint. The opportunity exists and is missed.

Asking directly about suicidal thoughts does not plant the idea — this has been studied and the fear is unfounded. It is one of the more important questions available and one of the least asked.

Treatment works

Psychological therapy. Cognitive behavioural therapy, problem-solving therapy and behavioural activation all have good evidence in older adults, with effect sizes comparable to those in younger populations. Problem-solving therapy in particular suits people whose depression is entangled with genuinely difficult circumstances. Age is not a reason to skip therapy in favour of a tablet, though it is frequently used as one.

Antidepressants are effective, with some age-specific caveats. SSRIs are usually first-line. Response may take longer — eight to twelve weeks rather than four to six. Start low, go slow, but do reach a therapeutic dose; under-dosing is a common failure.

Specific risks matter more here: hyponatraemia, particularly with SSRIs and particularly in the first weeks and in those on diuretics; increased falls risk; gastrointestinal bleeding when combined with NSAIDs or anticoagulants; and QT prolongation with citalopram at higher doses. Tricyclics are generally avoided because of their anticholinergic burden.

Exercise has reasonable evidence as an adjunct and, for mild depression, as a primary intervention.

Electroconvulsive therapy is worth mentioning because its reputation is far worse than its record. In severe, psychotic or treatment-resistant depression in older adults it has high response rates and is often better tolerated than in younger patients.

Grief is not depression, and sometimes it becomes it

Bereavement produces sadness, disturbed sleep, poor appetite and withdrawal, and these are normal. Grief characteristically comes in waves, preserves self-esteem, and permits moments of pleasure and connection.

Depression is more pervasive and constant, involves worthlessness and guilt rather than yearning, and does not lift. Prolonged grief disorder — intense, disabling grief persisting beyond about a year — is now a recognised diagnosis with specific treatments.

If someone is still unable to function six months after a death, that is worth taking to a doctor. Time helps most people. It does not help everybody, and waiting longer is not a treatment.