TIME GOES BY | GRAY MATTERS: Depression

by Saul Friedman

For those of us along the East Coast, flooded by weeks of rain and buried by five feet of snow since December, this surely is our winter of discontent, or worse. Add to that the state of the economy and the stock market, and as I warned during the approaching winter after 9/11 2001, older people need to be very aware of the danger of depression.

That desire to crawl under the covers and hibernate can be more than the winter blues. I know; I had a brush with depression only because of a fall and a bump on the noggin, which laid me low for a few days and nagged at my thoughts: “Why wasn’t I bouncing back faster? Will I regain my strength?

When last I wrote about depression, an unprecedented surgeon general’s report on mental health in 2000 pointed out that depression, in one form or another “is strikingly prevalent among older people,” too often accompanied by alcohol or drug dependence. But many older people tried to ignore their symptoms as simply a sign of age.

Coincidentally, just after my fall, Ilaina Edison, a vice-president and researcher for the superb Visiting Nurse Service of New York, the nation’s leading home health care provider, told me that ten to 20 percent of older people seen by primary care physicians “have critically significant depression.”

Moreover, many of these physicians, not specializing in geriatrics, don’t diagnose or they under-treat depression. Edison wants home health care nurses, who know their patients best, to be able to diagnose a case of depression before it takes root.

In one of her papers, Edison says that depression “places a significant burden on the health system” and impedes a patient’s ability to comply with medical treatment. The classic symptoms – sad, empty, hopeless feelings, trouble concentrating, a lack of energy, trouble sleeping, a loss of interest in what you like to do, and even vague or passing thoughts of suicide – can complicate getting better from even a routine illness.

The surgeon general’s report noted that there is no need for older people to put up with depression and risk their health further because there are modern and relatively safe drugs, among other treatments. And since the report, Medicare has led the way in recognizing and paying closer to parity for the treatment of mental as well as physical illness.

However, Medicare has been slower in understanding how its regulations can become a barrier to home health care for depression which, in a sense, is the front lines for the discovery and treatment of depression. Says Edison, ”Mental health status is not being addressed by hospitals when discharging a patient, even if he or she is taking an antidepressant.”

When I was discharged from a fine hospital after my fall, a doctor prescribed home health care for my physical problems, including physical therapy. But no one asked after my emotional well-being.

“Another barrier,” said Edison, “is the way Medicare reimburses for depression and mental health services in home health care.” Medicare has been demanding a positive diagnosis before it will pay. But if a home health care nurse discovers a patient’s depression, mild or severe, during a visit for other purposes, reimbursement may be complicated.

Thus she believes Medicare should allow and train the visiting nurse practitioners to diagnose depression and help guide a patient’s treatment with guidance from a psychiatrist.

Medicare Part A helps pay for inpatient mental health care; Part B covers outpatient visits to mental professionals, subject to the yearly deductible ($155). For a visit with a doctor to diagnose your problem, Medicare pays 80 percent of the cost. But to get treatments, such as psychotherapy, the patient now pays 45 percent and that will decline to the parity of 20 percent in 2014.

But to return to the surgeon general’s report, it recommended getting help from modern drugs that can treat and even prevent anxiety and depression. And if you feel you need something, a pre-emptive strike to get you through the winter, consult with your physician but be very careful about what you choose.

The surgeon general reported that certain widely used anti-anxiety drugs, called benzodiazepines – Ativan, Lorazepam, Librium, Valium, Xanax – are immediately effective but have been misused by many older people because they are chemically addictive over time, which means the more you take, the more you need. Some Medicare Part D drug plans are not required to provide these drugs.

These drugs are often over-prescribed and withdrawal from these drugs is likely to be difficult and could be dangerous. Similarly, sedatives and sleeping pills such as barbiturates, including Butisol, Nembutal and Seconal are highly addictive.

Less dangerous or addictive, although they take longer to work, are the anti-depressants including the granddaddy, Prozac, along with Zoloft and Paxil and other newer compounds such as Celexa, which are purged more quickly from the body and present fewer problems for older adults. These are a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), which can prevent mild depression from getting worse.

Other new anti-depressants (SNRIs), including Cymbalta, are being advertised for more serious problems.

However, all these drugs may produce unpleasant side effects and dependency. Your physician can fit the drug to your needs – if you need drugs at all. A pet that you can care for where you live, or perhaps a trip this winter to somewhere sunny could give you the lift you need.

What we’ve been calling the winter blahs has been given an appropriate name, SAD, for Seasonally Affective Disorder. And if you use a computer (which can be a great help in keeping you mentally fit (I play freecell or spider solitaire to check on my mind.), you can find sources for special lamps and lighting which, according to many legitimate-sounding claims, helps brighten those dark days.

You may want to visit the Medicare website and search for “mental health care and Medicare.” To learn more about the services of the Visiting Nurse Service of New York, visit their website.

Write to saulfriedman@comcast.net.