Depression in Older Adults

Feeling down, hopeless and low energy are not normal signs of aging — they could be signs of a treatable mood disorder

Bethany Brookshire

Reviewed by

Dilip V. Jeste, M.D.

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En español

Published January 17, 2024

A man and woman sitting and consoling each other

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If there is just one thing you should take away from this article, it’s that there is a world of difference between feeling depressed and having depression, which is a diagnosable mood disorder. We all feel sad or defeated at times; staying perpetually upbeat and cheerful is hardly the natural human experience, be it today or at any time in history. But a relatively short period of melancholy isn’t a medical condition.

Depression, in contrast, is a specific and serious mood disorder with a clear definition. To be diagnosed with depression (doctors also use the terms “clinical depression” and “major depressive disorder”), a person must be experiencing five or more of the common symptoms of the condition (see "Warning Signs of Depression in Older Adults") most of the day, nearly every day, for at least two weeks, says the American Psychiatric Association’s DSM-5.

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What is depression?	What happens in the brain to cause depression?
What are the risk factors for depression?	Diagnosis and treatment for depression

Likewise, clinical depression has a range of causes that go far beyond how you might be responding to challenging times. It has a biological basis involving genetics and brain chemistry; on top of that are life experiences and psychological and social factors. Given clinical depression’s complexity, researchers are still trying to untangle how all these factors combine to create depression symptoms. But most people with depression need treatment, as appropriate for a medical condition, to feel better.

Given the complex web of depression triggers, telling someone with depression to “snap out of it” or “buck up” is about as helpful as telling someone with a cold to cure themselves by not coughing. Asking “How bad can it be?” or saying “Things could be worse” will do no good. What will? There are medicines, talk therapies and other approaches that can help most people. It will probably take some trial and error to find the right one, but it’s definitely important to get well.

Expecting the losses experienced in older age to spark lasting low moods might seem reasonable, but that assumption is wrong. “There are a lot of people who think depression is a normal part of aging, and it is not,” says Erin Emery-Tiburcio, a geropsychologist at Rush University Medical Center in Chicago.

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Warning Signs of Depression in Older Adults

Here are the more common symptoms. This list is not exhaustive.

Persistent sadness or emptiness
Inability to experience pleasure
Hopelessness, guilt, worthlessness
Sleeping much more or less than usual
Decreased appetite
Weight loss
Low energy or fatigue
Moving or talking more slowly
Problems concentrating
Physical symptoms: aches, pains, headaches, digestive problems
Thoughts of death or suicide

If you or someone you know is considering suicide, call, text or chat the 988 Suicide & Crisis Lifeline.

In fact, older people are less likely than younger people to face depression. In a 2023 Gallup poll, almost 25 percent of U.S. adults 18 to 29 reported having or being treated for depression, while about 16 percent of people 45 to 64 and 12 percent of those 65 and older reported the same. And the illness occurs more often in women than in men: almost 24 percent versus 11 percent, respectively. At the same time, so-called minor depression, which means having fewer than five of the symptoms mentioned above, is more common in older adults and can also lead to worse health overall.

What is depression?

To be diagnosed with major depression, “you must have one of the two cardinal symptoms of depression or both,” says George Alexopoulos, M.D., a geriatric psychiatrist at Weill Cornell Medical College. The two main symptoms — lasting at least two weeks — are sadness and anhedonia, an inability to experience pleasure.

Other symptoms that can contribute to a diagnosis are decreased appetite, weight loss and sleeping much more or much less than usual. A person with depression might feel tired, and their movements may appear to others as agitated or slowed down. They might also be unable to concentrate or think, feel excessive guilt and have thoughts of death.

In older adults, the symptoms may look slightly different, Alexopoulos says. “The inability to experience pleasure is more frequent in older adults than younger,” he says. Imagine an opera lover who turns down free opera tickets because they just can’t rally themselves to go.

Trouble sleeping is another big one that Alexopoulos sees often in older patients. “They fall asleep, typically 8, 9 or 10 o’clock. And then an hour later, they’re up climbing the walls.” Insomnia can be a symptom of both depression and anxiety — another common mental illness that often goes hand in hand with depression. Finally, he says, older adults might have similar ratings on scales of depression as younger people but be far more disabled by their symptoms. “Essentially, they either take to their bed or they sit in front of the television [but] don’t watch it,” he says. “They neglect their hygiene; they neglect eating.” People of all ages will do this when severely depressed, but in older adults, even moderate depression can affect how well they care for themselves.

What happens in the brain to cause depression?

From ads for antidepressants, you’d think the key to treating the mood disorder is to reset a few brain chemicals that have dropped too low. For years, that was the main theory: Three chemicals, or neurotransmitters — mainly serotonin, dopamine and norepinephrine — weren’t doing their job, which is to carry messages from nerve cell to nerve cell in the brain. But there’s been a shift in thinking as scientists try to paint a fuller picture of the changes in the brain that lead to depressive episodes.

There are other neurotransmitters that regulate how the brain changes and adapts over time, namely glutamate and GABA. Both work in parts of the brain that regulate mood and emotion, says John Krystal, M.D., chair of the department of psychiatry at Yale School of Medicine. Plus there’s how the body responds to stress, along with hormone changes in women. When people experience chronic stress, as they do in depression, there’s a drop in the number and strength of the synapses, the spaces where messages flow between neurons. The loss of the synaptic connections contributes to the biology of depression.

There are also structural and functional changes in the brain. Two major areas, the hippocampus and the cortex, shrink. And two other areas of the brain become overactive: the hypothalamus, which coordinates the stress response, and the amygdala, which signals threat and generates negative emotions.

“There are clear differences between a healthy brain and a depressed brain,” said psychiatrist Rachel Katz, M.D., assistant professor at Yale University in a 2021 interview for Yale Medicine. “The exciting thing is that when you treat that depression effectively, the brain goes back to looking like a healthy brain.”

What are the risk factors for depression?

All those biological changes of depression can be set in motion for several reasons. Social isolation and loneliness are risk factors for depression, and in 2018, 31 percent of women and 19 percent of men 65 and older lived alone, according to a 2020 report from the Federal Interagency Forum on Aging. “Loneliness is certainly a predictor of depression,” Emery-Tiburcio says.

Grief is not depression, but grief can trigger depression, says psychiatrist J. John Mann, M.D., at Columbia University. Loss is a major life stress, and stressful life events can trigger depressive episodes, particularly in people who may have experienced depression in the past.

A lonely man sitting by himself on a bed

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Triggers for Depression in Older Adults

Depression can develop for several reasons. Here are some common ones.

Social isolation and loneliness
Major life stress, such as death of a loved one or heavy caregiving load
Previous depressive episodes
Family history of depression
Illnesses such as Parkinson’s disease, dementia, heart disease and stroke
Economic problems
Sleep problems
Addiction or alcoholism
Lack of physical activity or physical limitations

“For the vast majority of people, [depressive] episodes start fairly early in life, mostly when they’re teenagers or in their 20s,” Mann says. “Depression for 80 percent of people is a recurrent episodic disorder.” Episodes last three months, on average, though some can last years, he says. In between, there is a period of time when the person feels normal.

For those who developed depression earlier in life, Mann says, “the episodes tend to last longer as you get older, and the well interval tends to get shorter.”

Depression can run in families, Mann says. “A lot of the rest is accounted for by … childhood experiences, the kind of stresses that they’ve gone through in their lives.” Traumatic experiences, for example, can cause changes in the brain that predispose people to depression. The same goes for living in poverty or having trouble accessing medical care or facing language barriers. A precarious socioeconomic situation may also prevent people with depression from seeing a doctor for screening or treatment.

Then, of course, there are diseases that are more common in older adults in which depression is a side effect, such as Parkinson’s disease and dementia. And as people age, the blood vessels in their brains can stiffen, as in arteriosclerosis, causing damage in some brain areas, Mann says. Along with increasing risk for stroke, he notes, those stiff vessels can boost risk for a type of depression called vascular depression. This is most common in older adults and can be accompanied by cognitive decline as well as changes in mood, according to a 2022 report in Dialogues in Clinical Neuroscience.

Diagnosis and treatments for depression

Primary care providers can diagnose a person with depression after asking questions, such as when the symptoms began, how long they last, how often they occur, and whether they stop you from your usual activities. The provider will want to rule out other causes, such as viral infections or thyroid problems, and consider any medications you’re taking, since some can cause depressive symptoms.

The stigma around mental health can get in the way of people’s receiving a diagnosis and treatment, especially older adults, Emery-Tiburcio says. “They grew up in the generation where we don’t share our dirty laundry.” They often have the misguided idea, she explains, “that mental illness is a weakness as opposed to an illness.”

But there are many options to treat depression. And antidepressant pills shouldn’t always come first, Emery-Tiburcio says. For those who see a lot of stigma around depression and its treatment, she says, psychotherapy might be a preferable first step rather than medication.

Psychotherapy can be helpful even if the person with depression is also experiencing mild or moderate cognitive impairment, she says. It’s a good fit for those feeling lonely as well, she adds. “Having someone to talk to is more preferable for a lot of older adults.”

Although some people may want to avoid using medication, “the combination of psychotherapy and medication tends to have the best long-term health outcomes,” Emery-Tiburcio says, pointing to several randomized controlled trials.

It may take some trial and error to find the right one among the many different medications approved to treat depression. The selective serotonin reuptake inhibitors, or SSRIs, increase levels of the brain chemical serotonin to improve symptoms. These drugs include sertraline (Zoloft) and escitalopram (Lexapro). Some doctors avoid prescribing the SSRI called Prozac (fluoxetine), as it may have longer-lasting side effects in older adults.

A second group of drugs increases brain levels of serotonin and another neurotransmitter, norepinephrine. They are called serotonin and norepinephrine reuptake inhibitors, or SNRIs, and include drugs like duloxetine (Cymbalta) and venlafaxine (Effexor XR).

The tricyclic antidepressants, such as nortriptyline (Pamelor), are similar to the SNRIs but often have more side effects. The monoamine oxidase inhibitors (MAOIs), such as tranylcypromine (Parnate), can also increase levels of dopamine, serotonin and norepinephrine in the brain. But they are not prescribed as often because they can interact with other medications as well as common foods such as cheese or wine.

Other drugs that may be prescribed for depression include ketamine, which blocks the action of a chemical messenger called N-methyl-d-aspartate (NMDA), or antidepressants like bupropion (Wellbutrin), which affects dopamine, norepinephrine, serotonin and another chemical messenger called acetylcholine.

Some treatments aren’t drugs at all. Instead, they use magnets or electricity to stimulate cells in the brain that are thought to be involved in depression. These treatments, such as electroconvulsive therapy and transcranial magnetic stimulation, are often tried after other therapies have failed.

Activity — physical or mental — is always a plus, especially if that activity has meaning. In one mentoring program, Emery-Tiburcio observed that seniors at risk of isolation and multiple illnesses who taught young students benefited from being able to mentor. Taking on even the smallest tasks can help. She points to studies demonstrating that older adults in nursing homes who were responsible for the simple job of watering a plant had better health outcomes than those who had no responsibilities.

Depression can be crushing to both the person experiencing it and the people around them. Dismissing it as inconsequential or as a normal part of aging just tightens its grip. “Normalizing it means we ignore it, we don’t screen for it, we don’t do anything about it,” Emery-Tiburcio says. “And so it goes untreated.” There are legitimate reasons to do better.

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Bethany Brookshire is a science writer with a Ph.D. in physiology and pharmacology and the author of the 2022 book Pests: How Humans Create Animal Villains.

Dilip Jeste, M.D., is a geriatric neuropsychiatrist who conducts clinical research on mental health and mental illnesses in older adults. He has published papers and books on various topics, including depression in late life. He is a past president of the American Psychiatric Association and the American Association for Geriatric Psychiatry and president-elect of the World Federation for Psychotherapy.