Three out of every 10 older residents in Massachusetts have been diagnosed with depression -- the most commonly diagnosed mental health issue among older people, according to the recent 2018 Massachusetts Healthy Aging Data Report.

Nationally, the numbers are bit lower. One report shows that 15% of seniors have depression. And another report shows that estimates of major depression in older people living in the community range from less than 1% to about 5% but rise to 13.5% in those who require home healthcare and to 11.5% in older hospital patients, according to the Centers for Disease Control and Prevention.

No matter the numbers, the questions remain: What are the causes of depression and what can those who have depression, their loved ones, caregivers, and policymakers can do about it? Here's what experts had to say.

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The Causes of Depression

First, it's worth noting that depression is a very widespread problem, said Carolyn Rosenblatt, an elder law attorney with Aging Investor.com. "Seniors are suffering from depression from multiple causes that are different from the general population because so much loss is involved, their physical decline and maybe cognitive decline as well are involved in the picture of why so many elders are depressed."

According to Rosenblatt, aging itself creates a lot of loss and it's not just loss of the spouse or the friends as people get older and then others around them reach the end of their life cycle. "It's loss of their physical functioning and that's very depressing for people," she said.

In some cases, she said, they haven't taken excellent care of themselves. "Most people don't," says Rosenblatt. "They develop chronic illnesses. The chronic illnesses require that they go to the doctor a lot. They have to take a lot of medication. The medication has side effects. You look at what affects the American population. We have an enormous problem with diabetes."

In essence, she said, it's the changes that cause depression -- the loss of hearing, the loss of things they are used to being able to do. "I used to be able to run," she said. "I used to be able to ski. I used to be able to walk upstairs. And now they can't, and it's depressing."

Those declines are part of it and it gets exacerbated in the context of retirement, gets glorified in the media, said Rosenblatt. "People have expectations," she said. "Maybe they didn't like that job but they stuck it out and they're supposed to be celebrating because they now have all this free time and then they find themselves with loss and cognitive impairment."

Another cause of depression has to do with money: People might not have enough money saved to do the things they envisioned in retirement. And that leads to isolation, said Rosenblatt.

And that isolation leads to the loss of connection to community. "When people feel bad and that they are experiencing loss, they often withdraw," said Rosenblatt. "They withdraw from friends, family, people around them. They just don't go out much and that creates a serious sense of isolation which leads to greater depression and health problems, which are directly connected to social isolation."

According to Mikol Davis, a geriatric psychologist with AgingInvestor.com, one of two elements are present in most cases of depression. "That is a sense of helplessness and a sense of hopelessness," he said, noting an increase in suicides among adult men. "That social isolation factor is a major one and I think it tends to be in our society much more common that men socially isolate and have less effective social networks than females do."

The reason isolation affects men more so than women, according to Rosenblatt, is that men have gained their networking and their fun and their social connections through the workplace and then, once they retire, they lose that. "And unless they seek an alternative way to build a sense of community through, let's say, volunteer work or a smaller job or some other things that enables them to have something on the calendar every week or even every day, they can then feel that they don't have any worth or any purpose in life," she said.

Tackling the Issue

So, what can be done to address depression?

"People as they get older need to be able to seek and find a greater sense of purpose," said Davis. "They need to have structure in their life. That's very, very critical. And... they've got to have an established sense of community."

To be sure, that sounds easier said than done. It can be difficult for people to seek and find a greater sense of purpose, to find reasons to get out of their homes. And it's quite possible that someone who is depressed can't flip a switch and say, "I'll now become more socially engaged and find my purpose."

All true, said Rosenblatt. And that's why families must step up. "They have to encourage," she said. "They have to accompany. They must connect the elder with somebody nearby who can say, look, I'll go down to the senior center with you. I know you don't feel like going, but just come on with me. Just try it out this one time. Let's go have lunch and I'll stay with you."

And then, she said, they may meet somebody else. Maybe the program director will pay special attention to help them become engaged by introducing them to other people and by learning their interests.

Of course, people with depression have difficulty making decisions and they have great difficulty taking action, said Davis. "There's lots of internal dialogue that sabotages an elder's ability to get out of the house and to take action."

So, what's critical, he said, is this: "Who is it in the community that's going to step up for an older person who is struggling with depression?" Davis asked. "And get some help and get them involved."

Another issue that those who are depressed must deal with is medical professionals. "They don't look at older people as worthy of a lot of attention to these so-called minor complaints because they're told things like, well, you're just getting old or you're just fat," said Rosenblatt.

The medical establishment doesn't see it -- the minor complaints -- as a symptom of depression, added Davis. "The symptoms that surface when older people have depression are not necessarily that they feel sad and depressed," he said. "It often is manifested in terms of physical complaints."

According to Rosenblatt, the medical establishment often overlooks depression. "It's very undertreated in our aging population and the remedies are not terribly complicated," she said. "There's resistance among the oldest people in our society to even see a mental health provider because that was taboo in their era. It's less stigmatized now but there's no question that when they were younger people and that subject of psychotherapy came up, it was like we have to be crazy to do that. I'm not crazy. I'm not going to do that."

So, she said, medical professionals tend to overlook depression and not even raise questions about how an older person is feeling, who is in their life, how often do they get out of the house, and whether there is anybody who is near them to help you if they need to be accompanied somewhere. "They don't ask those questions, so the symptom doesn't get into the system, the medication, the straight-up medications that Medicare does pay for that are there to treat depression, like say Prozac, they work really well for older people, but they're under prescribed," she said.

How, asked Davis, are you going to treat somebody that really needs mental health treatment within the scope of the existing insurance policies that do not often support therapy as a needed benefit?

Part of the policy dilemma that we have, said Rosenblatt, is that mental health issues like depression are still stigmatized. "It's your fault," she said. "Why don't you just get over it? Snap out of it. It's your problem. That's kind of a nasty response that still exists."

What's more, Rosenblatt said the doctors who could treat and help those with depression are "disincentivized by making sure that their payment is so low they won't accept insurance."

The remedies, said Rosenblatt, consist of families recognizing that elders who don't want to go anywhere and can't be motivated may need a helping hand from their loved ones to encourage and accompany them to participate in things that they're reluctant to do.

What's more, Rosenblatt said physicians, mental health providers, nurses, nurse practitioners and physician assistants, need to pay closer attention. "Everybody needs to be more attuned into this reality so that we can address it," she said.

And finally, Rosenblatt said, at a policy level, "we must stop ignoring and marginalizing elders and we must treat them with equal dignity to somebody who has a heart disease or a gastrointestinal problem."

As for those who want to avoid depression, Rosenblatt offered this advice: "People have to keep moving," she said. "We can't start watching television every day after you quit your job and you're tired. You have to keep moving. In a way, retirement is a wonderful opportunity because you can't say, I don't have time to exercise. There is a critical link between being physically active in some way or another and preventing depression... physical activity is a very bedrock preventive strategy for anybody who might be struggling with depression."

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