context: Clinical depression in the elderly is common. That doesn't mean it's normal. Late-life depression affects about 6 million Americans ages 65 and older. But only 10% receive treatment for depression. The likely reason is that the elderly often display symptoms of depression differently. Depression in the elderly is also frequently confused with the effects of multiple illnesses and the medicines used to treat them. Depression impacts older people differently than younger people. In the elderly, depression often occurs with other medical illnesses and disabilities and lasts longer. Depression in the elderly is associated with an increased risk of cardiac diseases and an increased risk of death from illness. At the same time, depression reduces an elderly person's ability to rehabilitate. Studies of nursing home patients with physical illnesses have shown that the presence of depression substantially increases the likelihood of death from those illnesses. Depression also has been associated with increased risk of death following a heart attack. For that reason, it is important to make sure that an elderly person you are concerned about is evaluated and treated, even if the depression is mild. Using a series of standard questions, a primary care doctor can provide an effective screening for depression, allowing for better diagnosis and treatment. Doctors are encouraged to routinely screen for depression. This can happen during a visit for a chronic illness or at a wellness visit. Depression also increases the risk of suicide, especially in elderly white men. The suicide rate in people ages 80 to 84 is more than twice that of the general population. The National Institute of Mental Health considers depression in people age 65 and older to be a major public health problem. In addition, advancing age is often accompanied by loss of social support systems due to the death of a spouse or siblings, retirement, or relocation of residence. Because of changes in an elderly person's circumstances and the fact that elderly people are expected to slow down, doctors and family may miss the signs of depression. As a result, effective treatment often gets delayed, forcing many elderly people to struggle unnecessarily with depression. Insomnia is usually a symptom of depression. New studies reveal that insomnia is also a risk factor for depression onset and recurrence -- particularly in the elderly. To treat insomnia, experts sometimes recommend avoiding or minimizing exposure to benzodiazepines (such as Ativan, Klonopin or Xanax) or the newer "hypnotic" drugs (such as Ambien or Lunesta) that, according to the American Geriatric Society, pose an increased risk for impaired alertness, respiratory depression, and falls. Geriatric experts often favor treating insomnia in the elderly with the hormone melatonin, or a low-dose formulation of the tricyclic antidepressant doxepin ( Silenor). Other potentially sedating antidepressants, such as Remeron or trazodone, are also sometimes prescribed for both purposes. The novel sleep aid Belsomra also has demonstrated both efficacy and safety in older adults. If there's no improvement in the sleep disorder or depression, a psychiatrist or psychopharmacologist may prescribe other medications, psychotherapy, or both. Factors that increase the risk of depression in the elderly include: Being female Being single, unmarried, divorced, or widowed Lack of a supportive social network Stressful life events Physical conditions like stroke, hypertension, atrial fibrillation, diabetes, cancer, dementia, and chronic pain further increase the risk of depression. Additionally, the following risk factors for depression are often seen in the elderly: Certain medicines or combination of medicines Damage to body image (from amputation, cancer surgery, or heart attack) Family history of major depressive disorder Fear of death Living alone, social isolation Other illnesses Past suicide attempt(s) Presence of chronic or severe pain Previous history of depression Recent loss of a loved one Substance abuse Brain scans of people who develop their first depression in old age often reveal spots in the brain that may not be receiving adequate blood flow, believed to result from years of high blood pressure. Chemical changes in these brain cells may enhance the likelihood of depression separate from any life stress. There are several treatment options available for depression. They include medicine, psychotherapy or counseling, or electroconvulsive therapy or other newer forms of brain stimulation (such as repetitive transcranial magnetic stimulation (r TMS)). Sometimes, a combination of these treatments may be used. The option a doctor might recommend depends on the type and severity of depression symptoms, past treatments, and other medical conditions a person might have, among other factors. Studies have found that while antidepressants can be helpful in older adults, they may not always be as effective as in younger patients. Also, the risk of side effects or potential reactions with other medicines must be carefully considered. For example, certain older antidepressants such as amitriptyline and imipramine can be sedating, may cause confusion, or cause a sudden drop in blood pressure when a person stands up. That can lead to falls and fractures. Antidepressants may take longer to start working in older people than they do in younger people. Since elderly people are more sensitive to medicines, doctors may prescribe lower doses at first. In general, the length of treatment for depression in the elderly is longer than it is in younger patients. Most depressed people find that support from family and friends, involvement in self-help and support groups, and psychotherapy are helpful. Psychotherapy is especially beneficial for those who have endured major life stresses (such as loss of friends and family, home relocations, and health problems) or who prefer not to take medicine and have only mild to moderate symptoms. It also is helpful for people who cannot take drugs because of side effects, interactions with other medicines, or other medical illnesses. Psychotherapy in older adults can address a broad range of functional and social consequences of depression. Many doctors recommend the use of psychotherapy in combination with antidepressant medicines. ECT can play an important role in the treatment of depression in older adults. When older patients are unable to take traditional antidepressant medicines because of side effects or interactions with other medications, when depression is very severe and interferes with basic daily functioning (such as eating, bathing and grooming), or when risk for suicide is especially high, ECT is often a safe and effective treatment option. The stigma attached to mental illness and psychiatric treatment is even more powerful among the elderly than among younger people. This stigma can keep elderly people from acknowledging that they are depressed, even to themselves. Elderly people and their families sometimes also may wrongly misidentify depression symptoms as "normal" reactions to life stresses, losses, or the aging process. Also, depression may be expressed through physical complaints rather than traditional symptoms. This delays appropriate treatment. In addition, depressed older people may not report their depression because they wrongly believe there is no hope for help. Elderly people may also be unwilling to take their medicines because of side effects or cost. In addition, having certain other illnesses at the same time as depression can interfere with the effectiveness of antidepressant medicines. Alcoholism and abuse of other substances may cause or worsen depression and interfere with effective treatment. And unhappy life events including the death of family or friends, poverty, and isolation may also affect the person's motivation to continue with treatment.