University of Pittsburgh psychiatry professor Richard Schulz has been one of the nation’s foremost researchers on caregiving stress for
Geriatric psychiatrist Charles “Chip” Reynolds III has for decades been one of Pittsburgh’s and the nation’s leading scholars and clinicians focused on depression and other mental disorders affecting the older population.
Dr. Reynolds, 69, a University of Pittsburgh distinguished professor of psychiatry and UPMC endowed professor in geriatric psychiatry, is winding down a local career that began at Western Psychiatric Institute & Clinic in 1974. Also director of the Aging Institute jointly sponsored by Pitt and UPMC, he will take on emeritus and advisory status July 1 while retiring to Maine with his wife to be close to family there.
Dr. Reynolds has focused his voluminous research on sleep disorders and suicide as well as depression, among various mental health issues that can impact the elderly differently from the younger population. Aging Edge interviewed him on those and related topics for the latest Aging Edge Expert Q-and-A. (The interview has undergone editing for purposes of brevity and clarity.)
Aging Edge: Many people focus on aging issues as a result of some personal experience they encountered with older people they knew. Was that the case for you?
Reynolds: I did experience a life event in 1977 that had an enduring impact. My grandfather, known as “Mr. Charley,” was a very prosperous plantation owner in Mississippi who shot and killed himself at the age of 90 in the wake of post-stroke depression. It focused my interest in depression and suicide among older adults. That was 40 years ago, and I remember it well. It’s been a wellspring.
Aging Edge: Did you come to understand what led him to that?
Reynolds: It was probably a combination of things — it usually is — and he illustrates several of the issues that come up commonly. He was living in a rural area about 100 miles south of Memphis, and so many rural adults have limited access to mental health services. The other main issue is it was very likely that he had developed a post-stroke depression, and depression is a very important risk factor for completed suicide late in life. The availability of firearms, as was the case here, was also important. When I visited after the funeral with Mr. Charley’s primary care doctor, he said to me, “You know, Chip, your granddaddy just didn’t have any more windmills to tilt at.” I think the PCP was touching on a deep, existential issue faced by many older adults: Do you feel a sense of utility or purpose in going on? And if not, and your quality of life is degraded by illness or disability, could suicide be a rational choice? My own bias as a psychiatrist is that you can treat depression and pain, and once you make people more comfortable and relieve some of their distress, the suicidal issues go away.
Aging Edge: You’ve spent your career dealing with older adults with such problems, yet surveys asking people about their level of happiness typically conclude that people are happier in retirement than at any other stage of life. So how many people really have depression late in life?
Reynolds: For older adults residing in the community who have quality of life, their rates of depression are pretty low — maybe 2 to 3 percent acknowledge symptoms of depression that are clinically significant. Once you get beyond the community to other care settings and to seniors who have a greater rate of disability, the rates of depression rise. Depression and medical disability are co-travelers that feed off of each other.
Aging Edge: How is that depression different for older people from younger adults?
Reynolds: It’s a bit more complicated. There’s the concurrence of other medical disorders; co-prescriptions of lots of other medications; the presence often of some degree of cognitive impairment. Those often pose challenges to a clinician who is treating an older adult with depression. There’s also psycho-social issues that pose challenges, be they unwanted retirement, bereavement, conflicts with family members or social isolation. The good news is there’s very good evidence that pharmacological therapy works along with a particular kind of counseling that is evidence-based. The challenge is we need to make access to mental health services greater in the world of primary care medicine, which is where most older adults with depression would prefer treatment.
Aging Edge: There’s still a stigma among older adults that has them avoiding mental health specialists?
Reynolds: It’s still an issue, but it’s changing and getting better. Increasingly, people are willing to accept help for depression, particularly if that can be offered in the general medical sector.
Aging Edge: But there’s still a lot of people who don’t get treated?
Reynolds: Probably only half of the population of older adults with depression get any treatment at all, and of the half that get treatment, probably only half of those get appropriate evidence-based treatment. There’s a lot of work yet to do.
Aging Edge: If you struggled with depression as a young person, does that mean it will be a problem when older? And if you never had it, will it still come up out of nowhere in later years?
Reynolds: We see both patterns. Looking at hundreds of folks who participated in National Institutes of Health trials, roughly half of them experienced initial onset of depression after 60, and roughly half reported previous episodes going back to the early years of adulthood. What you see across the life cycle is depression tends to recur. If you experience an episode of depression as a young or middle-aged adult, you have about a 50 percent chance of experiencing a second episode at some point, and if there’s a second episode, the odds of additional episodes are even higher, maybe 70 to 80 percent.
Aging Edge: Part of your focus has been on preventing depression to avoid the need to treat it. What’s the key to prevention?
Reynolds: It’s relatively straightforward for older adults who have relatively mild symptoms. We teach people better coping skills, better problem-solving skills and better sleep habits, and we encourage healthier lifestyles with more physical activities and better diets. Better self-care helps reduce the risk of depression in older adults, maybe by 20 to 25 percent over a one-to-two-year period. That’s a very meaningful figure in terms of the public health burden averted and the dollars saved.
Aging Edge: You mention better sleep habits. How does the chance of achieving good sleep change as we age?
Reynolds: The brain’s ability to generate sleep decreases by the time people get into their 60 and 70s. Sleep becomes more fragmented, there are more frequent awakenings at night and the ability to get into the deepest level of sleep decreases. The good news is we can help by fairly simple behavioral interventions that obviate the need for sleeping pills or antidepressants. We try to avoid sleeping pills because they can cause a lot of mischief — things such as falls and cognitive impairment and sleep apnea.
Aging Edge: What kind of simple interventions can help eliminate the need for pills then?
Reynolds: One key thing is to decrease time in bed to maybe seven hours a night. Many older adults spend an increasing amount of time in bed and thereby destroy their sleep. If you reduce the time in bed to maybe 7 or 7½ hours out of 24, your sleep drive is preserved so you get deeper and more continuous sleep. The other important thing is to keep as regular as possible in the time when you go to bed and when you get up in the morning. If we stabilize the schedule, we help the brain’s clock that determines the time of sleep and time of wakefulness. That can be a problem after losing a spouse who might have been an important source of social cues and time cues, which can be a factor in an irregular sleep and wake schedule.
Aging Edge: Outliving not just a spouse but many family and friends is common for people with successful longevity. How much of depression gets tied in with grief over those losses?
Reynolds: If you look across the life cycle, including old age, about 75 percent of people who experience attachment bereavement — the loss of a spouse or parent or child — are able to adapt, to accept the loss and move on. Somewhere around 20 to 30 percent develop mental health complications including depression, with a variety of anxiety disorders including post-traumatic stress and substance abuse. Somewhere around 7 to 8 percent who experience the loss of a loved one develop a severe reaction — complicated grief — which often concurs with clinical depression. It’s not the same thing as depression and benefits from a special type of counseling.
Aging Edge: But if grieving is a necessary stage to go through, when does it actually become a problem?
Reynolds: If you see evidence of suicidal feelings or agitation, that’s a tipoff. And if it’s been six months or longer and someone is still having these intense feelings of yearning or longing, still feeling that their world has turned upside down, that’s a tipoff that something is amiss.
Aging Edge: How would someone show that?
Reynolds: It may be someone expressing a strong wish to rejoin the partner who passed away, or endorsing feelings that “Life has no purpose anymore. I’d be better off dead than continuing.”
Aging Edge: And the proper steps then would be what?
Reynolds: I would start with the primary care physician, who can evaluate whether depression or anxiety is part of the problem and can provide supportive care or medication. They may have access to social workers or others with expertise in mental health and grief, who can provide counseling that can be helpful to seniors to free up some energy for life going forward.
Aging Edge: So in general, should someone contact their regular physician or reach out quickly instead to a specialist like yourself?
Reynolds: Very often primary care docs can initiate treatment, and in the absence of any improvement they can then involve a mental health specialist. If a family caregiver sees an older person with signs of depression, someone not having fun, always worried, not sleeping well, not eating normally, feeling downhearted and blue, expressing death wishes, those are indicators their loved one probably has a degree of clinical depression, and it’s very important that the primary care doctor become involved. The first stop is the PCP’s office.
Gary Rotstein: firstname.lastname@example.org or 412-263-1255.