Volume 18 · Issue 3 · April 2008 | Download PDF
by Maria D. Llorente, MD, and Julie Malphurs, PhD
Marc decided Wednesday would be the day. It was the middle of the week, and he figured there wouldn’t be too many people around. He waited until 3 a.m., walked the three blocks to the beach, and took his shoes off at the edge of the sand. The sand felt cool and soft, and he started to walk towards the Atlantic Ocean. He was right – there weren’t any beachgoers this time of day. As he waded into the warm water, it rocked him back and forth gently. He reflected on the irony that he had come into this world from salty, warm fluid, and would die the same way.
He started to swim, and the lights from shore gradually receded into the darkness. His plan was to keep swimming until he reached the point of no return. Then it would all be over; he wouldn’t have to worry anymore. He wouldn’t wake up at 2 a.m. and just stare at the clock, unable to fall asleep. He wouldn’t care about whether he could concentrate on his book or whether he felt hungry, even though he hadn’t really eaten anything for a week. Most importantly, he could stop feeling hopeless about his life and his future.
He swam for over 2 hours. But nothing happened. Finally, the sun began to rise, and he decided to go home; maybe it just wasn’t his time. He was supposed to have surgery on Thursday to amputate three toes because the diabetes had gotten to them. He called his doctor and told him what had happened at the beach. The doctor convinced Marc to see a psychiatrist, and soon, Marc began to understand that he was experiencing a late-life depressive disorder, and that there was hope – and treatment – available.
Each year, more than 15 million Americans experience a major depressive episode like Marc; about 15 of every 100 persons are age 65 or older. Among amputees, depressive symptoms are a common psychological reaction, and as many as half of all amputees will need some type of mental health services. There are several reasons why amputees are at greater risk for developing depression. The amputation may have resulted from a traumatic injury (gunshot wound, car accident, etc.). The threat of losing one’s life or witnessing others’ lives in jeopardy can trigger sadness, anxiety and other psychological symptoms. Depression and other psychological conditions may be more common in traumatic amputees, partially because the amputation is usually unexpected, so preparation and pre-operative psychological intervention are not possible.
Among older adults, amputation is usually the result of chronic medical conditions, such as diabetes and vascular disease. Depression is more common in people with diabetes than in the general population, and those who have both depression and diabetes tend to have more medical complications, such as amputations. Amputations in this group of individuals are generally planned, giving the individual more time to think about the loss of the limb, the change in how one sees oneself, and to consider how this changed body will affect social relationships. Older persons who undergo an amputation – either medical or trauma-related – are significantly more likely to be at risk for long-term psychiatric complications. This may be related to the increased likelihood of older adults having additional medical illnesses and comorbidities (coexisting diseases) prior to amputation.
How can I tell if I am depressed?
The diagnosis of a major depressive disorder is based on physical and psychological symptoms. Figure 1 provides a simple two-question screen for depression. Additional symptoms that strongly suggest depression include:
- Difficulty falling or staying asleep or sleeping too much
- Feeling tired or easily fatigued
- Loss of appetite, or significant increase in appetite
- Feelings of guilt, or that you are a failure, or that you have let yourself or others down
- Trouble concentrating when reading, watching TV, playing cards, etc.
- Feeling fidgety and restless or tense
- Thoughts that you would be better off dead, or of hurting yourself in some way.
Over the past 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling down, sad or hopeless
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
2. Little interest or pleasure in the things you normally enjoy doing
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
A score of 3 or higher suggests that one is experiencing significant psychological distress.
Marc was experiencing many of these symptoms. Like Marc, many people are unaware that they have a medical condition, and that treatments areavailable and effective. An important first step toward feeling better is letting your doctor know which symptoms you are experiencing and that you are concerned about them. The most common available treatments include counseling, therapy and antidepressant medications. Which type or combination of treatments will work best for you depends on several factors, including the severity of the symptoms and your personal preferences.
What if I am experiencing thoughts of self-harm?
Suicidal thoughts are a frequent symptom of depression, especially among older adults. It is extremely important to recognize that these thoughts are symptoms of a medical disorder, are temporary, and, with treatment, will go away. People are often embarrassed about having these kinds of thoughts, and may not discuss them with others. In other cases, people may mention them to friends or family who may not know what to make of the thoughts or may not take them seriously. Asking for help can be life-saving, because suicide is an extremely preventable cause of death. Contact your doctor or call the National Suicide Prevention Lifeline (800/273-TALK) if you are, or someone you know is, talking or writing about death, feeling hopeless or looking for ways to die.
What can I do to help myself if I am depressed?
Discussing your symptoms and following the recommendations of your healthcare provider are important in managing your depression. Additional things that you can do to feel better include:
- Staying physically active
- Making a list of things that you enjoy and doing one of these activities each day (even if you don’t really feel like doing it)
- Recognizing when you feel worried or anxious, and engaging in activities that help you relax, such as doing a crossword puzzle, meditation or listening to music
- Spending time with people who provide you with emotional support (family, friends, religious group, etc.).
Five years later, Marc recalls that night at the beach. He looks back and laughs at how silly the whole thing seems to him now. His entire life was certainly not worth the couple of toes that he had been about to lose, and yet, he wasn’t able to see that at the time. Since then, he has been able to go fishing every week, has had three more grandchildren, and doesn’t worry anymore about what people might think of his missing toes. And these days, he only goes to the beach for exercise.
Acknowledgements and Resources
“Depression in men with traumatic lower part amputation: A comparison to men with surgical lower part amputation.” Cansever, A. Military Medicine 2003; Feb.
Depression in Late Life: Not a Natural Part of Aging.
Geriatric Mental Health Foundation
“Psychiatric and emotional sequelae of surgical amputation.”
Cavanaugh SR, Shin LM, Karamouz N, Rauch SL. Psychosomatics 2006; 47:6.
MacArthur Initiative on Depression and Primary Care
National Suicide Prevention Lifeline
About the Authors
Dr. Llorente is Professor of Geriatric Psychiatry, Miller School of Medicine at the University of Miami, and Chief of Psychiatry at the Miami VA Healthcare System. She is Board certified with Added Qualifications in Geriatric Psychiatry and is listed in Best Doctors in America.
Julie Malphurs coordinates research of the Mental Health Service at the Miami VA Healthcare System and is an Assistant Professor of Psychiatry, Miller School of Medicine at the University of Miami. She received her doctorate in Aging Studies and focuses her research on chronic conditions of older adults, especially diabetes and depression.