Fads in mental health diagnoses come and go. Something called Existential Neurosis was popular for a while, but seems to have lost some of its gloss in recent years. For a long time now, any high-energy, active child risked being diagnosed—often misdiagnosed—with Attention Deficit Hyperactive Disorder (ADHD).
Now, if you get old and experience a growing number of health problems, and if you complain about your problems, you are likely to be diagnosed with depression. As defined by the American Psychiatric Association, depression—a disorder that comes in a number of different forms—is a major mental illness
The more popular a diagnosis becomes and the more publicity and attention it gets, the more often unqualified people are tempted to make the diagnosis. That’s what seems to have happened with ADHD. Teachers, nurses and school counselors seem to be on constant lookout for new prospects for that label.
Back to depression: if, as seems natural, you get old and begin to think about death, that can close the case; you’re suicidal, severely depressed, and in need of immediate treatment for your depression.
One important reason why American psychotherapists are so fond of finding mental health problems is our profit-oriented health insurance system, uniquely archaic in the modern world. The health insurance industry demands that psychotherapists report the client’s mental disorder; otherwise, the therapist doesn’t get paid. The more diseases we recognize, the more opportunities we find to justify our existence and make some money.
A result of all this diagnosing is often a prescription for drugs, a consequence beloved by the drug industry.
Sadly, it seems that the more different diagnoses we invent, the less actual treatment our patients get. A psychiatrist may see four or more patients every hour, handing out a prescription here and there along with a brief word of advice. Psychologists and social workers, no matter how much they would like to do meaningful talk therapy, find that the number of visits allowed by the insurance company is severely restricted. Intensive, long term psychotherapy is a privilege only the rich can afford in the United States.
Getting old is a tough business, but I don’t think most old people talk a lot about their problems except, possibly, to other old people. Let me paraphrase what one old gentleman said to me not too long ago. He and I were talking about the politically hot topic of torture:
Torture? You want to talk torture? I was never taken prisoner by fanatics, never captured by an enemy, never abused by police or guards. My life involved no mean spirited violence, just your normal amount of torture. When I was a boy, we didn’t have cavity-protecting tooth paste. The dentist never used an anesthetic, and the drilling went on and on, but they told me that little boys don’t cry. That was just the beginning.
At the other end of life came shingles that burned for days and days, and gout in my feet that felt like broken bones. Along the way there were wrenching kidney stones, and the sudden lose of loved ones, friends, family, old school chums. So, now I’m pretty much alone and nobody seems to have time to talk.
In many of those awful moments I would have invented any lie, betrayed any friend, been traitor to my county, or committed any imaginable crime to make it stop. None of that would have helped. The only enemy is age itself. And, at 86, there’s nothing will help me much now. Long life comes with a high price.
If you live long enough, you will know torture, and you will know its futility. You will also know fury when someone tells you: “Cheer up, you’re just depressed. Maybe you should see our social worker.” I really wanted to hit the doctor when he said that.
Major Depression is a serious mental illness. It should not be a knee-jerk diagnosis awarded just because an older person has problems. Many older people, as they move into their seventies and eighties, have even worse problems than the man I paraphrased above.
Imagine what you would feel like if you could no longer taste the morning coffee, could not smell diner cooking, could not hear the doorbell, could not remember names, were taking up to fifteen medications every day, or couldn’t lift yourself out of a chair. These are very common problems among the elderly. And then imagine how you would feel if someone labeled you mentally ill with depression because you risked talking to them about your problems.
Denying the reality and inevitability of death, most of us still expect to devote energy and resources to avoid death regardless of the quality of life or the wishes of individual. The decision to die does not lie in the hands of the individual, and suicide is still against the law in most states. Only one state, Oregon, permits physician assisted suicide, and that only in the most advanced cases of terminal illness.
If old age starts at age sixty or sixty-five, some old people will live another thirty or more years, and they will experience major physical and psychological changes as they age. The young old (60 to 70) are very different from the old old (85 to 95).
Take the example of someone I’ll call Mary, a sixty-three year old lady who began giving her personal possessions—jewelry, photographs, art work—to her relatives. She was in relatively good health, but had frequent periods in which she was sad, tearful and irritable. She made a will and told others it would be best if she were dead.
Then consider a lady I’ll call Jane, a 92 year old woman confined to bed with a broken hip and taking a number of medications for a variety of conditions. She, too, wanted her most prized possessions to be in the hands of those she thought would most appreciate them. She was determined to see that each beloved object went to just the right family member who, she knew, would treasure it.
Are you going to call both Mary and Jane clinically depressed? Are you going to put them both an anti-depressive medication? I would hope not. Jane is close to death at age 92, and is making well thought out decisions. She wants to control her life as she always has. Mary, on the other hand, probably fits the criteria for a diagnosis of a major depression.
Not only does age within old age make a huge difference, personality is extremely important. Some people are better able to cope with stress, pain, and illness than others. Even in advanced old age, a strong personality and good intelligence will defeat or delay depression. A vulnerable personality probably had difficulties throughout life and will be more susceptible to depression.
In addition to personality and intelligence, financial resources and social support from family can be more effective than pills. Medication for depression should be a last resort, not the first thing to come to mind.
Like any mental health diagnosis, depression is one that should be made only by an expert and experienced practitioner. For the rest of us, let’s learn to listen with patience and understanding, and respect. Most old people are not seriously depressed, but most also do need a sympathetic ear once in a while.
