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90–051 PDF 2003

S. HRG. 108–181

SENIOR DEPRESSION: LIFE-SAVING MENTAL

HEALTH TREATMENTS FOR OLDER AMERICANS

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

WASHINGTON, DC

JULY 28, 2003

Serial No. 108–17

Printed for the use of the Special Committee on Aging

(

SPECIAL COMMITTEE ON AGING 

LARRY CRAIG, Idaho, Chairman 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MIKE ENZI, Wyoming 

GORDON SMITH, Oregon 

JAMES M. TALENT, Missouri 

PETER G. FITZGERALD, Illinois 

ORRIN G. HATCH, Utah 

ELIZABETH DOLE, North Carolina 

TED STEVENS, Alaska 

RICK SANTORUM, Pennsylvania 

JOHN B. BREAUX, Louisiana, Ranking 

Member 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

JAMES M. JEFFORDS, Vermont 

RUSSELL D. FEINGOLD, Wisconsin 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

DEBBIE STABENOW, Michigan 

LUPE WISSEL, Staff Director 

MICHELLE EASTON, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator John Breaux ......................................................... 1

Statement of Senator Harry Reid ........................................................................... 2

Statement of Senator Elizabeth Dole ..................................................................... 5

PANEL I 

Diana Waugh, Spring Valley, CA ........................................................................... 6

Hikmah Gardiner, Senior Advocate, Mental Health Association of Southeastern Pennsylvania, Philadelphia, PA ............................................................ 10

Donna Cohen, Ph.D., Professor, Department of Aging and Mental Health, 

Louis de la Parte Florida Mental Health Institute, University of South 

Florida, Tampa, FL .............................................................................................. 15

Prepared Statement of Charlie Woods ................................................................... 33

Ira R. Katz, M.D., Professor of Psychiatry, Director, Section of Geriatric 

Psychiatry, University of Pennsylvania School of Medicine, and Director, 

Mental Illness Research, Education and Clinical Center, Philadelphia VA 

Medical Center, Philadelphia, PA ....................................................................... 37

Jane L. Pearson, Ph.D., Associate Director for Preventive Interventions, Division of Services and Intervention Research, National Institute of Mental 

Health, Bethesda, MD ......................................................................................... 45

APPENDIX 

Statement of Mark Pope, Ed.D., President, American Counseling Association . 65

(III) 

(1)

SENIOR DEPRESSION: LIFE-SAVING MENTAL 

HEALTH TREATMENTS FOR OLDER 

AMERICANS 

MONDAY, JULY 28, 2003 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The committee met, pursuant to notice, at 2:03 p.m., in room 

SD–628, Dirksen Senate Office Building, Hon. John Breaux, presiding. 

Present: Senators Breaux, Dole, and Reid. 

OPENING STATEMENT OF SENATOR JOHN BREAUX 

Senator BREAUX. The committee will please come to order. 

Good afternoon, everyone. I thank all of you for being with us. 

This is a very important subject, and I would like to thank all of 

the witnesses who have come before us to testify today. Your testimony will be very important to our committee as we continue to 

address some of the most important issues that face older Americans in our country. Our Nation truly stands at a crossroads as we 

prepare for the pending wave of some 77 million baby boomers. 

Our responsibility in the Congress is to help this country rethink 

and also redefine how we age. 

A few months ago, I chaired an Aging Committee hearing that 

looked at ageism in our Nation’s health care system. We learned 

that medical ageism is pervasive. It can be found in the use of preventative screenings, clinical trials for valuable treatments, the 

treatment of hospital-borne infections, and in the way mental 

health care is provided to seniors. 

Outdated thinking about aging leads to outdated public policies 

and also public health risks. We must certainly rethink our attitudes and our policies toward the elderly and eliminate any form 

of discrimination against them. 

Though much progress has been made to eradicate the stigma 

and the shame of mental illness, seniors have been left behind in 

this area. By the year 2030, it is expected that close to 15 million 

seniors will suffer from some form of depression. Many seniors and 

health professionals assume that the symptoms of depression are 

a part of the normal aging process. In fact, a survey of adults older 

than 65 found that only 38 percent believed that depression is a 

health problem, and more than half responded that it was a normal 

part of aging. 

2

Older Americans have the highest suicide rate in America, a rate 

that is 4 times the national average. Even more disturbing, 75 percent of the suicide victims saw their doctor within one month of 

their suicide, but were not treated or not referred for treatment for 

their depression. Our health care system simply failed them. 

We can no longer continue to fail our Nation’s seniors. Depression and suicide are not a normal part of aging. Those who need 

care must be properly diagnosed and properly treated. 

Today, I am very pleased to announce that I will be introducing 

the Positive Aging Act of 2003. This legislation will help seniors receive the mental health care that they need. The Positive Aging Act 

will provide grants for demonstration projects to integrate mental 

health services for seniors into the primary care settings. It will 

also provide the opportunity for community-based mental health 

providers to team up with other professionals to create outreach 

teams to better screen and diagnose our Nation’s seniors. 

I am very excited by the opportunity to work with my colleagues 

to get this very important legislation adopted. The bill that I am 

introducing and today’s hearing are important steps toward ensuring that depression and suicide in the elderly are no longer ignored 

to the extent that they are ignored today. We still have a great 

deal to do, and I look forward to hearing and learning from and 

working with the experts who are assembled before us this afternoon. 

I would like to recognize our distinguished Democratic leader, 

Senator Harry Reid of Nevada, for any comments that Harry might 

have. Senator Reid. 

STATEMENT OF SENATOR HARRY REID 

Senator REID. Senator Breaux, thank you very much. I always 

enjoy these hearings. I served on the Aging Committee in the 

House under the great Claude Pepper and then under Chairman 

Roybal, and it has been a pleasure to work in the Senate. 

First, I want to thank you, Senator Breaux, for your advocacy 

and for arranging this hearing. We have not had such a hearing 

since 1996, which was the first of its kind then. But the issues we 

will be discussing here are still as relevant as they were back then. 

In 1996, the committee, chaired by the Defense Secretary, Bill 

Cohen—who became Secretary of Defense, was chairman of this 

committee. It was called a hearing on mental illness among the elderly. At that hearing, Mike Wallace, the anchor for ‘‘60 Minutes,’’

came forward to testify about his depression and feelings of suicide. 

I was so impressed by this man’s courage—Mike Wallace—coming forward and exposing his soul to us, his ability to speak publicly about a problem he had and the treatment he had received, 

I at that time commended him for speaking about a condition that 

may people associate with weakness, a stigma that still persists 

some 8 years later. 

It was during this hearing that I learned that unmanaged depression results in suicide on many occasions. For the first time, 

I found the courage to share with my colleagues in the Senate that 

my father had killed himself when he was in his 50’s. He killed 

himself when he was in his 50’s. 

3

I requested there right at the time that the hearing was going 

that Chairman Cohen hold a special hearing on suicide in the elderly, which, of course, is a population at risk. This hearing took 

place just a short time later in 1996. At that hearing I spoke about 

my Dad’s suicide. By that time I also realized that suicide was a 

national problem. More than 30,000 people kill themselves in this 

country each year, and the problem is particularly bad in Nevada. 

It is worse in Nevada than any other State. So I came to the understanding that my father was not alone, and neither was I as a survivor. 

Following these hearings, I was contacted by people from Georgia—Marietta, GA—Elsie and Jerry Weyrauch. They had lost their 

orthopedic surgeon daughter with suicide. It was heartbreaking for 

them, to say the least. They founded an organization called the 

Suicide Provision Advocacy Network to raise awareness about this 

issue. That organization and we generally have made great strides 

since then. 

With their encouragement and the assistance of my then-staff 

member, a man by the name of Jerry Reed, who is now the Executive Director of SPAN, I proposed Senate Resolution 84, which declares suicide to be a national problem and sought to make suicide 

prevention a national priority. The resolution passed. It was followed by a similar resolution in the House led by others, but mainly by John Lewis, the great Representative from the State of Georgia. 

The importance of Senate Resolution 84 was its recognition that 

suicide is not just an individual’s health problem. In fact, every 

time someone commits suicide, we all lose in many different ways. 

After former Surgeon General David Satcher was confirmed, I invited him to approach suicide as a national health issue, and he 

did. In 1998, he convened a conference in Reno, NV. The Reno conference brought together experts from all over the country to address the problem of suicide. By the time they were finished, they 

had come up with a national strategy for suicide prevention. 

In 1999, Dr. Satcher issued what he called ‘‘A Call to Action to 

Prevent Suicide,’’ which introduced a blueprint for addressing suicide. The plan called for awareness, intervention, and methodology. 

This gave the issue momentum. 

I requested the Subcommittee on Appropriations on Labor, 

Health and Human Services to hold a hearing on suicide awareness 

and prevention. Dr. Satcher and others testified at that hearing in 

February of 2000. This was another opportunity for me to talk 

about my being a survivor of suicide, part of a family of people all 

over this country who have suffered this unique yet preventable in 

many instances loss. 

Since the hearing before the Appropriations Committee, Federal 

dollars backed up the Surgeon’s call to action, and the results have 

been tangible. In 2001, the Department published its National 

Strategy for Suicide Prevention which outlines 11 goals and 68 

objectives for action to prevent suicide using a public health approach. In 2002, the Institute of Medicine published its report, ‘‘Reducing Suicide: A National Imperative.’’ Now we have suicide research centers, suicide hotlines, and, most recently, the National 

Suicide Prevention Resource Center. This center is designed to proVerDate 0ct 09 2002 10:00 Nov 13, 2003 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 C:\DOCS\90051.TXT SAGING1 PsN: JOYCE
4

vide States and communities with evidence-based strategies for suicide prevention. There are websites, bibliographies. There are a lot 

of different things we did not have just a short time ago. 

No one wanted to talk about it in 1996. Now you even see ads 

for antidepressant medication on TV. We have come a long way. It 

is amazing what a few congressional hearings can do to bring needed attention to such an important hearing. 

Again, Senator Breaux, thank you very much, and I extend my 

appreciation to Senator Craig also. 

I have just a few more things. I am sorry to take so long, but 

I wanted to outline this in a little more detail. 

There is a lot more we can do. As of the year 2000, suicide was 

still on of the leading causes of death in my age group, John, our 

age group, Senator Dole, our age group, age 55 through 64. All 

pathways that lead to suicide—biological, physiological, psychological—affect senior citizens. If you are not a senior now, you soon 

will be. It is not normal for seniors to be depressed. As a group 

called SAVE has put it, ‘‘Treating depression is preventing suicide.’’ The rate of suicide among seniors is proportionally higher than any 

other age group. In addition to continuing to work on reducing the 

stigma of mental illness, we need to train primary health care providers, including nurses and aides, to recognize the signs of depression in all age groups, especially the elderly. We also need to promote the training of geriatric specialists, including geriatric psychiatrists. We need to do more regarding mental health parity in insurance coverage. We need to value our seniors and keep them involved in our communities. We need to continue to talk about these 

issues. 

Senator Breaux, I have looked at these statements. I am tremendously impressed with Diana Waugh’s statement. Suicide does run 

in families. I have a friend in Las Vegas, a charming young 

woman, who confided in me after a television interview we had 

that she had lost her father and her brother. Six months later, I 

received a telephone call from her that her sister committed suicide. 

You, Hikmah Gardiner, you do a lot in outlining the fact that the 

cost of drugs is a problem, and the fact that people simply cannot 

afford drugs has caused suicides. 

So I apologize for coming and leaving, but the Senate floor is left 

bare, and I have got to go. We have an energy bill there today, and 

I have to be there to take care of some of the problems that exist 

on that. 

So, Senator Breaux, thank you so very much for doing this hearing and keeping this issue in the forefront of medical problems in 

America today. 

Senator BREAUX. Well, Senator Reid, thank you so much for 

sharing your thoughts, your personal experiences. That is very important. I think as you said, the more we are able to get leaders 

in the political field to talk about this, the more we can get Congress to focus in on it, the more we can encourage our health professionals to do more about it, the quicker we will find solutions 

to this national problem. That is what we are trying to do here 

today, and certainly, Senator Reid, your testimony and your commitment in this area goes a very long way to helping us reach the 

5

goals that we all are attempting to do so, and we appreciate very 

much your statement. 

Now we will hear any comments Senator Dole might have. 

STATEMENT OF SENATOR ELIZABETH DOLE 

Senator DOLE. Thank you, Senator Breaux and Senator Reid. 

This is a very important topic, and I am grateful to all of those 

who are here today to share their personal stories of how depression and suicide have affected their lives. It is essential that we 

come together to discuss depression—young, middle-aged, seniors—

because when a person suffers from depression, it affects the whole 

family. A child who does not receive the intervention of a school 

psychologist or outreach services may grow into an adult who finds 

it increasingly difficult to cope, and then a senior who battles depression and ultimately takes his or her own life. 

A key step to making sure this scenario does not happen is having open discussions of the problems of depression and removing 

the social stigma of mental illness. We as lawmakers and as a society must ensure that we do not create nor perpetuate a system 

that isolates those who suffer from mental illness. We absolutely 

must remove barriers to access and deterrence to treatment and 

ensure that those in need of help receive it. 

I am very interested in the testimony of our researchers on areas 

that are quite disturbing, including homicide-suicide in the elderly, 

and the high prevalence of suicide among elderly men. There are 

gender differences that I want to explore. 

I also want to learn more about the interventions, the treatments, and the solutions to address depression and mental health 

in the elderly. I have worked with Mike Faenza, who is head of the 

National Mental Health Association, when I served as president of 

the American Red Cross. We had started a program in 1992, mental health counseling for those who had been victims of disasters 

such as earthquakes or hurricanes or the terrible tragedy of September 11th. We found that this help with mental health counseling dealing with traumas was very important for those workers 

as well who were trying to address the problems. 

So I want to thank all of you who do research and work in this 

area for your tireless efforts on behalf of the seniors in our country 

and all our citizens. I certainly want to thank you, Senator Breaux, 

for organizing this hearing, for the legislation which you have written, which I certainly look forward to pursuing. 

Thank you very much. 

Senator BREAUX. Thank you very much, Senator Dole, for your 

work on our Aging Committee. It is outstanding and we appreciate 

your being with us. 

The first two witnesses this afternoon will be individuals who 

have personal experience with both depression and suicide. The 

first witness will be Diana Waugh, who is from Spring Valley, CA. 

We thank you for coming all the way out here to be with us on the 

other coast. She is also a volunteer coordinator for the National Association of Mental Illness, where she continues her work as a volunteer. We thank you very much, Ms. Waugh, and we will take 

your testimony first. 

6

STATEMENT OF DIANA WAUGH, SPRING VALLEY, CA 

Ms. WAUGH. Well, thanks. I really appreciate the opportunity to 

tell you about my personal experiences with this most vicious killer 

of seniors: clinical depression and suicide. 

As he said, I am Diana Waugh. I live in San Diego County, CA. 

I have three grandchildren, and I am 60 years old. 

Stigma and ignorance about depression killed both my parents 

and almost killed me. 

My mother killed herself at age 50. There were several events in 

a row that should have been a clue that she was in trouble. However, the family didn’t see it. She was in menopause and seemed 

worried about getting old. She quit a job she loved and moved with 

my father from California to Montana in the middle of winter. My 

father shortly thereafter asked her for a divorce. Her beloved dog 

died, she had no job or friends since she was 20 miles away from 

her nearest neighbor. My normally happy and vivacious mother 

thought her life was over. She took a gun, put it in her mouth, and 

pulled the trigger. The family was shocked, grief stricken, angry, 

and ashamed. Suicide was considered an act of cowardice and not 

talked about. 

It is estimated that 4.4 million Americans suffer the loss of a 

loved one to suicide. Suicide is like terrorism in a family. The result is devastating. 

My father was never the same after mother’s suicide. He killed 

himself 25 years later at age 79, also with a gun. He complained 

a lot about getting old. He had various aches and pains, was irritable and cranky and listless. He could not concentrate to read. He 

was having trouble sleeping. He didn’t want to do anything. He 

gave up the loves of his life—hunting and fishing. The family just 

accepted that this was part of getting old. He continuously complained about his symptoms to his doctor up until the week he 

pulled the trigger. 

I know Dad would have thought it a weakness to talk about his 

feelings. He had been taught that a man should be strong. Even 

though he exhibited all the physical signs of depression, he was 

never diagnosed or treated for it. 

I suffered from post-traumatic stress disorder and went into a 

deep depression after Dad’s suicide. I was 52. I had been a dynamic, energetic person, with a successful career for a government 

contractor, who could no longer concentrate and my job suffered. I 

was irritable, negative, and listless. I didn’t want to do anything. 

I ached all over. I felt like my legs were encased in cement. Eventually I couldn’t get out of bed and even do the simplest things to 

take care of myself. I lost my job and I was isolated from everyone. 

My life was empty and gray. I was ashamed, afraid, and hopeless. 

I wanted to kill myself, but I remembered the pain and suffering 

I had gone through after my parents’ suicides, and I didn’t want 

my family to suffer the same. I asked for help. 

My sister took me to a psychiatrist who diagnosed me with clinical major depression. He explained that I had a brain disorder 

and, just like a diabetic, would probably have to take medication 

for the rest of my life. I was relieved. It wasn’t that I was weak 

or had a character defect. I had a disease of the brain. 

7

My ignorance, fear, guilt, and shame prevented me from getting 

treatment earlier. As a result, I lost my job, my home, and suffered 

health and dental problems that could have been avoided had I 

known more about my illness. 

I still suffer from depression, but medication and therapy have 

helped me regain clearer thinking, a purpose and joy in my life 

again. 

I have just been hired by NAMI San Diego, an affiliate of the National Alliance for the Mentally Ill. NAMI’s goal is to erase the 

stigma attached to mental illness and to improve the lives of the 

mentally ill and those affected by it. 

Many seniors live at poverty level. Low incomes and limitations 

on health care insurance coverage severely impacts access to mental health care. The Medicare system only pays 50 percent of mental health services and no prescription drug coverage. Private insurances also discriminate against mental health by allowing a less 

dollar amount or number of visits allowed than for any other disease. 

Psychiatric drugs are often expensive, as you said, and if there 

is a choice between taking a heart medicine and a medicine for depression, seniors will often take the medicine for their heart, not 

realizing that the medication for depression also is imperative to 

their lives. 

Primary care physicians must be trained to recognize and treat 

depression. I suggest that depression screenings be routinely a part 

of any doctor visit. 

I ask this committee to support the recommendations from the 

President’s study on mental illness to allocate funds for education, 

to stop stigma, as well as funds for research to put an end to this 

killer disease. Also, Medicare must have parity and prescription 

drug coverage as well as private insurance parity be implemented 

throughout the country. 

I hope that my experiences have opened your eyes and hearts 

about depression and suicide in older adults. 

We can no longer remain ignorant and apathetic about depression. The attitude that ‘‘everyone gets depressed, just get over it’’

helps seniors take the overdose of pills, slit their wrists, put their 

necks in a noose, put the plastic bag over the heads, or pull the 

trigger. 

Help stop this vicious killer. Depression does not have to be a 

part of growing old. 

Thank you. 

[The prepared statement of Ms. Waugh follows:]

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90051.001
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90051.002
10

Senator BREAUX. Thank you so very much, Ms. Waugh, for a 

very eloquent statement and a very important statement and for 

your work in this area. 

Our next witness this afternoon will be Ms. Hikmah Gardiner, 

who has come to us from Philadelphia. She is very active with the 

Older Adult Consumer Mental Health Alliance, has been President 

of the Senior Advocacy Team of the Mental Health Association of 

Southeastern Pennsylvania, also on the board of the Pennsylvania 

Protection and Advocacy Committee, where she is very active. We 

are delighted to have you with us and appreciate your statement. 

STATEMENT OF HIKMAH GARDINER, SENIOR ADVOCATE, 

MENTAL HEALTH ASSOCIATION OF SOUTHEASTERN PENNSYLVANIA, PHILADELPHIA, PA 

Ms. GARDINER. Thank you very much kindly, Senator. Good 

afternoon, everyone, and thank you for allowing me this time to 

speak to you about depression. 

First of all, before I forget, I want to thank you and Senator 

Reid, who had to leave us, and Senator Dole. This is very dear to 

me, very, very dear, and very personal. I don’t know too many people in high places, if I may say, that would take the time to do 

what you are doing. I will remember you for the rest of my life. 

That is a promise. Now that I know who you are, you will hear 

from me, too, for the rest of my life. [Laughter.] 

Anyhow, depression has been my unwanted companion for at 

least 60 years. We know each other very well. This adversarial relationship has taken me to the very bowels of Hell, which includes 

several attempts at suicide, my children being taken from me for 

a time, two failed marriages, a serious bout of alcoholism, which I 

thought would cure my mental illness, a loss of self-esteem and 

personal dignity, and relationships with my siblings. 

However, I am slowly being restored to sanity and sobriety 

through treatment and loving family and friends. You know what? 

Treatment works. 

Senator BREAUX. Ms. Gardiner, I want to hear you. Would you 

pull the mike just a little closer? 

Ms. GARDINER. Sure. Treatment works. There are those among 

us who would gainsay me, but treatment works. The researchers, 

such as Dr. Katz sitting over there, can tell you that. His research 

work proves that treatment works. 

I heard so many people say that, ‘‘You are getting old. We expect 

you to be depressed.’’ That ain’t necessarily so. That ain’t necessarily so. Treatment works. 

But in many cases, it costs so much. As my lady here on the 

right said, as Diana said—really, I thought she was reading from 

my paper. We are both saying the same thing, and she is on the 

west coast and I am on the east coast. So there has got to be something going on. She is saying the same thing that I have written 

down here. 

I get real angry when I think about how seniors are treated in 

this country. I get real angry. We are at the bottom of the budget. 

It should not be. There are some things in place for seniors in the 

mental health arena, sure, but nowhere near enough. Nowhere 

near enough. 

11

We have to pay too much for medication, and now that most of 

us are no longer working—we are living on Medicare or some pension or something—we can’t afford those outrageous prices for 

medication. We just can’t afford them. As Diana said, ‘‘We make 

some decisions: Am I going to pay my rent? Am I going to take my 

medication? Am I going to buy food?’’ This is horrible. 

This is America. We live in America, where, God knows, there is 

a lot to be done. But this is the best country in the world. 

I know many seniors who have worked, including myself, 50 or 

60 years, honest labor. This is my reward? No. 

But I will tell you something, and that is not what I have on this 

paper, either. I was born in 1929, and people in my age bracket 

were taught to be quiet. You weren’t allowed to speak out. You 

dare not. So that is the way we grew up. 

Fortunately, I was able to get out of it, obviously, whatever. So 

the old folk don’t say anything. We are just satisfied with the status quo. 

Now, you baby boomers and you folk who are younger have a 

whole heap to say. So you call attention to what is going on, and 

people come to you to see what you want. But because we, the old 

timers, don’t say anything, you know, if you don’t say anything, 

people will go on believing that it is OK. 

I believe in the squeaky-wheel theory, and I am sure, Senators, 

you know what that is. So here I am today to make some noise. 

You know, speaking of medication, if I were taking Prozac 

today—and thank God I am not—it would cost me about $213 a 

month. Old timers take three, four, five medications. Now, that is 

a whole lot of money out of a possible $600 or $700 check a month. 

No wonder they have to make such decisions. 

I consider myself fortunate. I am still able to work. I am very, 

very blessed. Very blessed. So things are not as hard for me as they 

could be. Then I have got a bunch of kids who stay around me, 

won’t let me alone. They stay around me all the time. We have 

done some role reversal kind of thing now. They are telling Mom 

what to do. But, anyhow, I have it a tad easier than many of my 

peers do. But I know what that suffering is because it was not always that way. 

I also had trouble with alcohol. I thought I found a perfect cure—

perfect—alcohol. Initially it was. It took away those God-awful feelings that I had about myself, about anybody, about anything, about 

my children. The alcohol initially took those feelings away. But 

eventually it caught up with me, and I reached the stage where I 

could not deal with my mental illness. I could not deal with my alcoholism, so there was only one thing to do. Go out of the window. 

Thank God I failed, or I wouldn’t have the pleasure of sitting here 

in front of you today. 

I tried the pills and that failed, and once again, I am very grateful that I couldn’t even do a wrong right, as my children used to 

tell me. I am very grateful for that. 

I have come to you today with a lot of challenges, and I realize 

it. As, once again, Diana said, talking about Medicare, something 

has got to be done about Medicare. It is not a thing of maybe, perhaps. Something—something positive, let me add that—has got to 

be done about Medicare. It is only a matter of time. I know that 

12

something will be done. I realize that. But I hope Medicare remembers that it is put there for those of us who can no longer do as 

we have done for ourselves. 

I don’t consider Medicare a friend of mine anymore. I don’t. Neither does anybody else, any of the senior citizens who have mental 

health problems, who have to make all these decisions. Medicare 

is no longer a user-friendly program. That shouldn’t be. That 

shouldn’t be. That is not what it was designed for. 

You know, we have so many—we are so sophisticated today. We 

know how to do all these things and go to outer space and have 

all this equipment. Look at all this stuff here. We have got to remember—I have such a passion for this. I can barely talk, which 

is unusual for me. But we need to remember that but for the grace 

of God, it would be one of you. We need to remember that. We need 

to remember that—I believe Senator Breaux said that coming in 

back of me is a whole heap of old timers, you baby boomers around 

here, and you are coming right in back of me. We need to remember that. We need to do something about this mental health system. 

The President’s—what is it?—Freedom Commission, I went to 

speak. They invited me to come and speak for the old timers, and 

I got that report. Frankly, I was disappointed. There was very little 

talk there about seniors. You have to point us out. We are thrown 

into a pile with adults. When it gets down to the seniors, all the 

money is gone. The children in the mental health system have a 

separate part, and the adults have a separate part, and the old 

folks should have a separate part. That is what I say. 

Additionally, I believe if you have problems, you need to come 

with some solutions, and I have some suggestions. Once again, 

work on the Medicare decision and get rid of the unfairness of 

copay in the physical versus mental. Medicare folks have to pay 50 

percent for mental health care, but I only have to pay 20 percent 

for physical care. It should be the same 20 percent. 

We should support outreach programs for the old timers. I am 

not going to go to the mental health center down the corner from 

me. I am just not going to go. I am just not. First of all, I don’t 

want to be seen there. A lot of young people are there, and they 

have all those problems and use those drugs and drink that alcohol. I am not going down there. I don’t want my neighbors to see 

me. I don’t want my minister to know that is where I go. Bring 

something to me. Do some outreach. Once again, medicine, lowering the cost of medicine or help seniors pay for their medication. 

This is another one of my bugs. I wouldn’t let my primary physician give me a sugar pill for my mental illness. I wouldn’t. No. I 

have a therapist. That is who knows about my brain, and that is 

who I want to go see. 

Many of us—‘‘us’’ meaning senior citizens—go undiagnosed with 

depression with primary care physicians. That is not their training. 

I am not criticizing them nor am I blaming. That is simply not 

their training. If we are going to use primary care physicians, then 

they should be trained to recognize mental illness, especially depression, and to treat it, not to overdiagnose or overmedicate. That 

is not the right way. 

13

My hostess told me when I saw a red light, it was time for me 

to wind down, and I just remembered that. 

Senator BREAUX. We are going to ask you some questions, too, 

and continue this. 

Ms. GARDINER. Once again, I really appreciate this opportunity, 

and I certainly will be here for questions. Thank you. 

[The prepared statement of Ms. Gardiner follows:]

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Senator BREAUX. Thank you very much, Ms. Gardiner. 

Next we will hear from three other panelists who are experts in 

this area. First, Dr. Donna Cohen. Dr. Cohen is an Internationally 

Distinguished Scientist and Educator, a Clinician, a Humanist, in 

the field of aging and mental health and long-term care and violence—it seems like all of the subjects that this committee deals 

with—from the University of South Florida. We are delighted to 

have you here. 

STATEMENT OF DONNA COHEN, PH.D., PROFESSOR, DEPARTMENT OF AGING AND MENTAL HEALTH, LOUIS DE LA PARTE 

FLORIDA MENTAL HEALTH INSTITUTE, UNIVERSITY OF 

SOUTH FLORIDA, TAMPA, FL 

Dr. COHEN. Thank you, Senator Breaux, Senator Reid—who has 

left us—Senator Dole, and other members of the committee. 

Senator BREAUX. Get that mike right in front of you. It will pick 

it up better. 

Dr. COHEN. I thank other members of the committee who I know 

will read the testimony or may have already read it. 

I echo what the panelists said, thanking you for your leadership. 

Albert Einstein said that you cannot solve a problem with the same 

consciousness you bring to the problem, and your history with the 

elder justice bill and now the successful aging bill, followed by the 

activities that will come from this hearing will have a dramatic impact on the problems of older people. 

Older people are the children of yesterday, and we are dealing 

also with children, who will be the aged of tomorrow. So your actions here, will make a difference. The beautiful testimony given by 

Diana and Hikmah—I am so sorry that one of my colleagues, a covictim of homicide-suicide, was not able to be here today, suffering 

great pain and still in depression, recovering from his parents’ homicide-suicide 12 years ago. His testimony, I dare say, will bring 

a tear. 

We have in our choir here, the ability to repeat what you have 

said admirably in your statements, both you and Senator Reid. I 

do want to highlight a few things that are important. There is a 

great deal of other material in my testimony. 

Depression is a devastating illness, said brilliantly and beautifully and poignantly. It can be lethal. Older people have more intent. They are thinking about this. It is not a precipitous act. They 

think about it for a long time. Older people use guns 72 percent 

of the time, compared to 57 percent of the time in the general U.S. 

population. These are statistics analyzed by the National Institute 

of Mental Health. 

Older people don’t attempt it as much. Younger people attempt 

it 100 to 200 times for every completed suicide, older people one 

in four. Careful planning, physical vulnerabilities, depression, isolation, hopelessness and desperation lead to suicide. Pacts are rare, 

but a suicide pact that occurred in Fort Lauderdale, FL, this past 

New Year’s Eve, shows the desperation of older suicides. The 

Spivacks—and this picture is provided by the niece who wanted 

her aunt and uncle to be shown—crawled to their deaths. Their 

method is unusual. They had told the condominium handyman 

they wanted him to remove the screens, so they could feel the 

16

breeze. Within hours, they had crawled from their walkers to the 

window. Mrs. Spivack helped push her husband over before she followed. This is an unusual method, but the antecedent circumstances—incapacitating illness, unrecognized depression, and a 

suicide note—are not. 

I am going to focus my comments on depression in people with 

Alzheimer’s disease and related disorders, the impact on family 

caregivers, and then on the lethal consequences of homicide-suicide, a phenomenon we also pushed under the rug until 10 to 12 

years ago. 

Alzheimer patients number roughly 4 million. They will increase 

to 9 million by the year 2030. Roughly—and Dr. Katz probably has 

the better stats—30 percent or more of Alzheimer patients, maybe 

50 percent, have depression which goes unrecognized and undetected it leads to behavioral problems, unnecessary use of psychotropic medications, and a premature deterioration, and an ultimate 

indignity. 

We know very little about the risk factors for suicide, and also 

homicide-suicide, in dementia patients. David Cohen—no relation—

3 years ago wanted to commit suicide in Naples. He didn’t want his 

wife to die, so he closed the bedroom door hoping that this would 

protect her. He set himself on fire, panicked, left the house, and, 

unfortunately, his wife died from breathing in the fumes. This man 

was thrown in jail and put on a suicide watch. It took our Governor 

and a series of mental health advocates to get him into a residential facility that would be able to meet his needs. 

These violent deaths are preventable, but we have to learn a lot 

more about prediction, what my colleagues and I are serious about. 

The high prevalence of depression in family members is extremely well documented. Older spouses have the highest levels. It 

can be as high as 60 percent in older women caring for their 

spouses with Alzheimer’s disease, 40 percent in men, and roughly 

a third of daughters and daughters-in-law. This depression goes 

unrecognized despite the fact that older people are being seen in 

medical care system. Men don’t like to admit they are depressed, 

and I congratulate the NIMH for having a new special initiative on 

men and depression, something that needs continued support. 

Depressed caregivers also do violent things. With the support of 

an NIH-supported grant, we saw that 17 percent of family members caring for a relative with Alzheimer’s disease at home were involved in severe violence—kicking, hitting, stabbing, beating. Six 

percent of this was interactive violence, undetected, untreated. 

Thank you for your interest in homicide-suicide, Senator Dole. In 

the old days, up until probably 1990, we assumed that these are 

just two old people, who were sick, old, and they deserved to die 

rather than go on living. We are finding that the portrait of homicide-suicide mirrors the portrait of depression. These are men, who 

almost always kill their wives, who are usually 4 to 6 years younger than they are. In the Hispanic community, it is 20 years. These 

are men who are depressed. Our study using—medical examiner 

reports showed that none of these men are on antidepressants, and 

in some other studies in New York and elsewhere, maybe one or 

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tion, inappropriate medications again, emphasizing the importance 

of the primary care community. 

Charlie Woods has been affected by depression. His brother tried 

to commit suicide. Families suffer. For every one completed suicide, 

there are roughly six family members who were affected. In the 

homicide-suicide literature, we are finding the same thing. 

I will wrap up by saying that some people don’t succeed, and if 

you could just pull the—this chart simply shows that Florida does 

lead the country in the rate of homicide-suicide. 

Leo Visco took care of his wife for 5 years. He was depressed. He 

was taking his wife to six different doctors, but they never screened 

him. He killed her. He was taken into a court of law. This was a 

situation where a man did commit a killing, but the mitigating circumstances were undetected depression. Leo is now with his family 

in New York, serving probation. 

You have seen the many reports that have been published by the 

Office of the Surgeon General, the CDC, and the Institute of Medicine. We know what will work. We have got the recommendations. 

We cannot afford to not meet these recommendations. As Walt 

Kelly said through Pogo’s mouth: ‘‘We’ve met the enemy and they 

is us.’’ We have met the aged, and they is us. 

Thank you. 

[The prepared statement of Dr. Cohen follows:]

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Senator BREAUX. Dr. Cohen, thank you so very much. A very 

powerful statement. 

You mentioned Charlie Woods of Tampa, FL, and he was going 

to be a witness this afternoon. He became ill and cannot join us. 

He has a very eloquent statement describing that homicide-suicide 

of his parents, and that will be made part of our record. 

[The prepared statement of Mr. Woods follows:]

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Senator BREAUX. Next we will hear from Dr. Ira Katz, who is 

Professor of Psychiatry and Director of the Section of Geriatric Psychiatry at the University of Pennsylvania, and also the Director of 

the Mental Illness Research, Education and Clinical Center, Philadelphia VA Medical Center. 

Dr. Katz, very glad to have you. 

STATEMENT OF IRA R. KATZ, M.D., PROFESSOR OF PSYCHIATRY, DIRECTOR, SECTION OF GERIATRIC PSYCHIATRY, 

UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE, AND 

DIRECTOR, MENTAL ILLNESS RESEARCH, EDUCATION AND 

CLINICAL CENTER, PHILADELPHIA VA MEDICAL CENTER, 

PHILADELPHIA, PA 

Dr. KATZ. Thank you. Thank you for giving us the opportunity 

to testify. 

I am here before you as a geriatric psychiatrist and an investigator on the NIMH-supported PROSPECT study on the treatment 

of depression and the prevention of suicide. I am proud to recall 

testifying in this room in 1996, when witnesses emphasized a number of points that you have outlined: first, older people, especially 

older men, who are at the highest risk for suicide; second, the vast 

majority of these suicides are due to depression; third, although depression is treatable, depressions in late life are only rarely diagnosed and treated appropriately; and, fourth, about 75 percent of 

older people who commit suicide have seen their primary care doctors within a month. Therefore, there are major opportunities for 

preventing suicide by improving the recognition and treatment of 

depression in the elderly. 

At the hearing in 1996, I was privileged to hear Senator Reid 

emphasize the importance of these issues. I want to thank him and 

the committee as a whole for all you have done. 

Since the time of the hearing, there have been significant advances in the treatment of depression in the elderly, including the 

increased availability of newer and safer antidepressant medicines 

and evidence that specific forms of psychotherapy are effective. 

However, many cases of depression still go unrecognized, and treatment that is long enough and intensive enough to work is rarely 

given. 

Late-life depression is still a fatal illness. As will be emphasized 

by Dr. Pearson, suicide rates remain high. In addition, there is increased evidence that depression in older adults is associated with 

increased mortality from natural causes in the overall population 

and in people with heart disease, lung disease, and stroke. 

Primary care remains an important setting. As shown in the first 

figure, our research in the MIRECC at the Philadelphia VA has 

shown that the older veterans who have committed suicide had, by 

and large, never had treatment for mental health problems. More 

than for younger veterans, the initial recognition and diagnosis of 

depression is the key to prevention. This has led us to develop 

interventions to improve screening. However, we know this isn’t 

enough. In addition, it is important to make sure that adequate 

and effective care is provided. 

In this context, converging findings from the NIMH-supported 

PROSPECT and the Hartford Foundation-supports IMPACT studVerDate 0ct 09 2002 10:00 Nov 13, 2003 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 C:\DOCS\90051.TXT SAGING1 PsN: JOYCE
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ies are highly promising. Both tested interventions that were designed following models developed for disease management and 

other medical illnesses. 

Actually, could we go to the next one and then come back? 

Key elements in these interventions include: augmenting primary care practices with nurses or others who assist the doctor in 

managing patients; providing help with case recognition; following 

guidelines for first-line treatments and for sequences or combinations to use when patients don’t respond; educating patients and 

families; and assisting the doctors in keeping treatment on target. 

The findings shown there demonstrate that these programs work. 

Although there were substantial rates of antidepressant prescribing for the patients receiving usual care, the chart shows that 

the PROSPECT and IMPACT interventions worked to increase response rates. There we demonstrate that the PROSPECT intervention worked across all of the three settings in which it was delivered, and the IMPACT intervention works over time. 

In both studies, however, improved outcomes are robust and demonstrable across a number of analyses. Moreover, as shown in 

that third slide, the PROSPECT findings demonstrate that the 

intervention decreases the frequency of suicidal thoughts in older 

people. Thus, treatment works. But only when it is good treatment 

of adequate duration and intensity and when it is modified or augmented for those who don’t respond to first-line approaches. However, even though we know how to provide effective care for latelife depression, we most often cannot deliver it to those in need. 

As suggested by the President’s new Freedom Commission and 

all of my colleagues here today, barriers include stigma, high copayments for mental health care in Medicare, and system difficulties in integrating mental health with other components of care. 

The answer to preventing suicide in late life is to make high-quality mental health care available to America’s elderly. However, 

there are a number of starting points where we can begin to address these gaps more immediately. 

I urge you to consider a number of beginning steps. One is augmented funding for NIMH that specifically targets intervention and 

services research on the mental disorders of late life. Another is direction to the Center for Medicare and Medicaid Services to implement a Medicare demonstration project evaluating primary carebased care management for late-life depression. 

Thank you for giving me the opportunity to testify before you. 

[The prepared statement of Dr. Katz follows:]

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Senator BREAUX. Thank you very much, Dr. Katz. 

Next we will hear from Dr. Jane Pearson, who is Associate Director for Preventive Interventions, Chair of the National Institute of 

Mental Health Suicide Research Consortium at the National Institute of Mental Health with NIH. Thank you so much for being with 

us. 

STATEMENT OF JANE L. PEARSON, PH.D., ASSOCIATE DIRECTOR FOR PREVENTIVE INTERVENTIONS, DIVISION OF SERVICES AND INTERVENTION RESEARCH, NATIONAL INSTITUTE 

OF MENTAL HEALTH, BETHESDA, MD 

Ms. PEARSON. Thank you for the opportunity to highlight the research of the National Institute of Mental Health. 

As highlighted in the recently released President’s new Freedom 

Commission on Mental Health, suicide is the most distressing and 

preventable consequence of undiagnosed and untreated mental disorders. Ninety percent of people who kill themselves have a mental 

disorder or substance abuse disorder. 

We at NIMH are very concerned about the alarming numbers of 

older adults who suffer from depression and thoughts of suicide, 

and because they are often undiagnosed and untreated, may go on 

to take their own lives. We understand the heartbreak that the 

tragedy of suicide causes to families, and we want to pursue answers so families don’t have to go through this and we don’t lose 

more lives. We want to prevent suicide and the hopelessness that 

precedes it. 

In 2000, which is the most recent year we have statistics available on suicide, over 29,000 Americans took their own lives. U.S. 

suicide deaths outnumber homicides by 5 to 3. In 2000, over 5,000 

persons aged 65 and older died by suicide. The elderly account for 

18 percent of all suicides even though they are only 13 percent of 

the population. 

I apologize. I don’t have Figure 1 up here on the board, but if 

you have your handout, there is a figure—I don’t know if the audience has this or not. But in this figure, it is pretty clear that older 

adults have the highest suicide rates. If you look at the breakout 

by different ethnicities, you will see that it is older white males 

that have the highest rate. They comprise 81 percent of all elderly 

suicides. This is a rate that is 6 times the national average. 

This graph also illustrates variation in suicide rates, among 

whites and African Americans. The direction of these differences 

are quite surprising given what we know about health care disparities. Where we would expect ethnic minorities to have lower access, 

there are many ethnic minorities who are protected against suicide. 

Since 1996, when I was last here to talk to you about elderly suicide, we now have more investigators examining protective factors, 

such as religious beliefs and social supports that seem to help certain cultural groups. 

In 1996, we described how late-onset depression was the most 

common medical condition among elderly suicides. As several of 

you have noted already in your press releases, over 70 percent of 

older adults have been to their primary care provider in the month 

which they die. 

46

More research has confirmed this since, but we also now know, 

as Dr. Katz just said, ‘‘that depression detection and treatment is 

woefully inadequate in those settings.’’ More research is needed to 

figure out how to improve detection and treatment in late-life depression in the primary care setting. 

In 1997, the NIMH set aside funds to test models of depression 

and suicidality recognition and treatment among older adults in 

the primary care setting. The outcome of this was the request for 

the support of the three-site study that Dr. Katz referred to, the 

PROSPECT study. This is the most directly targeted NIMH research investment in terms of reducing elderly suicide. But the investment in studies of aging and suicide have also doubled over 

time in the past 7 years. In fact, the NIMH portfolio on aging and 

suicide research has outpaced overall NIMH funding increases. 

NIMH aging research has also shown that late-life depression 

can be deadly in other ways. Persons with heart attacks and depression, and persons with hip fractures, and depression are more 

likely to die than their non-depressed counterparts. 

We have also learned more about a particular type of late-life depression that is due to small strokes called vascular depression. 

New research is acknowledging and, more importantly, preventing 

depression among persons threatened with blindness due to 

macular degeneration, and we are trying to figure out how to best 

prevent and treat depression in these conditions. 

The prevention of depression in these conditions hopefully will 

allow people to function better in their day-to-day lives, and either 

maintain or improve their emotional well-being. 

While there are many terrible outcomes from depression in later 

life, suicidality probably signals the greatest distress with regard 

to hopelessness and despair. Since 1996, we have substantially increased the number of funded treatment studies focusing on two 

important areas: one is reducing suicidal thoughts and behaviors 

specifically, and another area is expanding studies of treatments 

for mental illnesses to better reduce the suicide risk. 

The second figure, illustrates that we are trying to increase the 

study’s focus specifically on reducing suicide. This shows a dramatic 10-fold increase in those studies. What we have learned so 

far is that treatments focused specifically on targeting suicidal 

thoughts and behaviors suggest that that is a necessary step to reduce the risk. 

The NIMH, along with the National Institute on Drug Abuse, 

and the National Institute on Alcohol Abuse and Alcoholism, will 

likely soon announce a new research opportunity to create some developing centers to expand interventions for suicide prevention. 

This is in response to the IOM report, which Senator Reid mentioned, ‘‘Reducing Suicide: A National Imperative.’’ We are hoping 

that this request will speed intervention research by promoting 

networks across centers, and this initiative could promote partnerships with community providers and organizations and provide infrastructure for career development for young investigators. 

In closing, I want to emphasize that NIMH collaborates with 

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ically proven practices for preventing suicide. NIMH is also providing technical support to the Administration on Aging for their 

upcoming national summit conference in September. I am optimistic that we will soon have additional treatments to guide practice. But we need to work to see that these effective treatments are 

utilized. Depression and suicidality in later life are not normal features of aging. 

Thank you for the opportunity, and I would be happy to answer 

questions. 

[The prepared statement of Ms. Pearson follows:]

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Senator BREAUX. Thank you very much, Dr. Pearson, and indeed, 

I thank everyone on the panel. We have had a good mixture of people, I would say, in the real world and in the professional world 

dealing with this important issue. 

Can anyone give me a definition of depression? You want to try 

it? What is depression? What I am trying to find out: Is depression 

always an illness? Is it a state of mind that gets worse and becomes an illness? Is it an emotion? I mean, what is depression? 

Ms. WAUGH. Can I answer that personally? 

Senator BREAUX. Let me get them, then I will see how it applies 

to you guys. 

Dr. COHEN. Depression has many faces. We all know what it is 

like to be lonely and sad. But depression is a disease of the brain, 

as has been stated here. We have consensus criteria for diagnosing 

depression, major depression, characterized by a lack of ability to 

feel pleasure. Older people often feel empty, lonely. There are bodily changes—gain of weight, loss of weight. In men, you can see 

more agitation. There are a series of criteria for the diagnosis 

major depressive disorders. 

Senator BREAUX. Is it a physical condition? 

Dr. COHEN. It is a physical condition. It is a disease of the brain. 

Just as a heart attack is a disease of the heart, depression is a disease of the brain Ira, do you want to talk about this. 

Dr. KATZ. Yes, it is interesting. We can talk about the biology of 

depression, and there is a very powerful biology developing. But depression is also a disease of the mind and spirit as well as the 

brain. 

The central question I think is: What is the difference between 

depression as an illness and normal sadness? What we like to teach 

about this is that anyone can get sad and anyone can get exhausted. But if we get stuck in a state of sadness and cannot get 

out of it, and if we get stuck in a state of exhaustion and no longer 

enjoy the things we usually do, then that is an illness. 

Also, when that is disabling and when it leads to restriction of 

life space or decrease in acceptance of needed medical care, when 

it leads to disability and impairment, it really has to urgently be 

evaluated as a medical illness because it can be a fatal one. 

Senator BREAUX. Anything to add, Dr. Pearson? 

Ms. PEARSON. I think that is well said, and I also think that in 

late-life suicide, we are facing the challenge of figuring out when 

it is normal for older people think about death. As people reach the 

end of their lives, they do think about death. But the difference is 

taking your own life and feeling distress and despair about that. 

So we are trying to figure out better ways of measuring that and 

helping physicians think that through and figure out ways of talking about that with older adults. So it is very important to understand how that works in a professional setting to make sure people 

aren’t mis-alarmed about some things that are actually normal. I 

think Dr. Katz’s point about when it starts interfering with the 

older person’s functioning, it is a problem to address. 

Senator BREAUX. Does anyone attempt suicide or commit suicide 

who is not mentally ill? 

Ms. PEARSON. It is very rare. When I mentioned the 90 percent 

of people who die by suicide have a mental illness or substance 

56

abuse, it can happen that there is no disorder, but it is often a precipitating event that distresses somebody, embarrasses them. They 

might impulsively act on it. It is unusual. 

Senator BREAUX. Ms. Waugh, you had a comment on it from your 

perspective. 

Ms. WAUGH. Well, you know, I think everyone suffers, you know, 

some depressed time. There is situational depression, and I have 

had it in my own life. But like the doctor said, when it continues, 

you know, like over 2 weeks, that becomes some kind of chemical 

imbalance, a brain disorder that needs to have some kind of treatment. It requires more than just a pill. It requires therapy. It requires change in lifestyle. Recovery is living the best possible lifestyle while you have the disease. 

I said I still suffer depression, and that means that the symptoms still come up. I don’t have to be afraid of them anymore. I 

still have suicidal ideation. But I know I don’t have to act on it, 

I don’t have to be afraid of it, because I have gotten tools about 

how to deal with my disease. 

Senator BREAUX. One more question, and then I will let Senator 

Dole ask questions. 

How treatable or how successful is treatment for depression, a 

proper regime, which I take it includes pharmaceuticals as well as 

other type of life adjustments? How successful is treatment of depression if it is done in a proper fashion? Anybody? 

Dr. KATZ. Yes, I think our current evidence is that about 50 percent of patients remit, get better, with good treatment; and another 

30 percent have a large degree of response for whom treatment 

makes a real difference. 

Of the more severe depressions, there are still people that really 

are not helped yet, and that is why we need more research. One 

thing that we are learning, though, these are the results I am talking about for a course of treatment. The number of people that are 

helped from the first treatment, the first medicine or the first 

course of therapy, is really much smaller. One of the things we 

really have to learn is the importance of doctors, psychologists, 

other providers following patients, seeing those who get better and 

seeing those who do not, and if the treatment does not work, 

changing it. 

Let me tell a story about my daughter. She is a nursing home 

administrator, and she talked about going on rounds in her facility 

and saying to some of the other people on the staff, ‘‘Hey, isn’t Mrs. 

Greene depressed?’’ One of the nurses said, ‘‘Well, don’t worry. Mrs. 

Greene is on an antidepressant. Let’s go along and talk about Mrs. 

Harris.’’ My daughter, bless her, said, ‘‘Hey, wait a minute, if Mrs. 

Greene is still depressed and she is on an antidepressant, we 

shouldn’t move on. We should be talking about what else we should 

do for her.’’ That is a message that we really have to deliver more 

and more. 

Senator BREAUX. Senator Dole, questions? 

Senator DOLE. Thank you, Mr. Chairman. 

We are told that women experience chronic depression at about 

a 5:1 ratio to men, and, of course, that 80 percent of the suicides 

in the elderly are committed by men. 

57

Help me understand these gender differences. How do services 

and interventions need to be altered to address the different ways 

that men and women handle depression? 

Dr. COHEN. The gender difference, by the way, is unique to the 

United States. A World Health Organization survey of the world, 

there are questions about the accuracy of the reporting, reported 

for the year 2000, there were 1.6 million deaths, violent deaths. Almost 900,000 were suicides. Suicides accounted for more deaths 

than homicide and war put together. 

In other countries, the rate is still highest for the population over 

age 60, but the available data indicate that there is no gender difference. So in the United States, I think your question is really 

well targeted. Women will talk more about their symptoms, will 

talk to their friends more. Men hold it in. Men will get anxious and 

talk about giving things away. They will not admit to their symptoms. 

I think that across the panel you have heard that the issue really 

is accessibility of mental health services and having enough services to provide the care. Depression is treatable, Senator Breaux, 

but there are personal issues, compliance issues, in terms of the 

patient complying with these things. There are gender differences 

in the way men and women will accept services. 

We also have a bias within the mental health system 3 percent 

of older people go to outpatient mental health centers. So we really 

have to deal with this ageism and this fatalism and the stigmatism 

in the broad community through education as well as through targeted research about these gender differences. 

Senator DOLE. Any other comments on the gender difference? 

Ms. PEARSON. Sure. Part of it is also the overall difference due 

to methods, where men are more likely to use firearms. But that 

difference is actually less in late life. There are more older women 

who use firearms than there are younger women. I also think Dr. 

Cohen is right. The whole help-seeking paradigm is very genderspecific, so the NIMH has a campaign to tell men it takes courage 

to go get help. It is a strategy consistent with the culture to go get 

help. So we are trying that, hoping that it is going to get the message out. 

Senator DOLE. To those who—and thank you very much for sharing your personal experiences with us today. I would like to ask the 

two of you if you would just elaborate more on the signs that could 

have been recognized so that those around you might know that 

there was a need for help and intervention. There has been some 

mention in reading the materials of panic attacks. What exactly is 

this? What triggers of depression led you to attempt suicide? Help 

us to understand more about those signs. 

Ms. GARDINER. I am trying to think about what led me to suicide. Everything and nothing—which does not make too much 

sense, but neither does suicide, really. 

I had nothing to live for. My parents were dead. I was divorced. 

I had at that time two children. The world was just one big ball 

of slime. I could look in the mirror and not see anything. My family 

had long since disassociated itself from me. They did not understand mental illness. 

58

I just did not have anything to live for, did not want to live, had 

nothing to live for, not my children nor—it was just nothing, absolutely nothing. My mental illness hurt me. Right in the middle of 

my belly, I envisioned a hole. I envisioned myself sinking in this 

hole. Sometimes the feet would come up and the head would meet, 

and they would sink in this whole, and I would be a big ball. Then 

I would have to be taken to a hospital. Just one of the most horrible things I have ever experienced in my life. 

What led up to that? I wish I could tell you, Senator Dole. I really do. 

Ms. WAUGH. Well, first of all, mental illness means we do not 

have a clear thinking, and hopelessness literally means that you 

feel totally alone and negativity is beyond anything that normal 

thinking would have negativity. It is like running a tape of every 

possible scenario of everything you did wrong, all the mistakes you 

have ever made, a lot of self-hatred happens with depression. 

So fear and a lot of shame and anxiety, like you said, panic attacks, not being—— Senator DOLE. What is a panic attack? 

Ms. WAUGH. OK. A panic attack is simply not being able to cope 

at the moment. The heart starts racing. I would get sweats. I 

would be afraid to leave the house. I can remember walking back 

and forth at the front door wringing my hands. I remember at one 

point calling a friend and saying—crying. I said, ‘‘I have to clean 

the bathroom, and I don’t remember how.’’ She literally walked me 

through it: Put some bleach in the toilet, call me back. Dah, dah, 

dah, call me back. 

So, for me, panic attack wasn’t about anybody else. It wasn’t 

about crowds. It was just total overwhelm and not being able to 

think rationally. 

Senator DOLE. Dr. Pearson, let me ask you if you would expand 

on a little bit on your written testimony, and you mentioned also 

here social supports, religious beliefs as a means to provide protection against depression and suicide. 

Ms. PEARSON. Right. 

Senator DOLE. I wonder, too, as people grow older, about the 

need to continue to feel relevant. 

Ms. PEARSON. Absolutely. 

Senator DOLE. In other words, to be involved in something bigger 

than yourself. 

Ms. PEARSON. Right. 

Senator DOLE. To feel you continue to contribute, and I think of 

organizations like Foster Grandparents and RSVP. I remember 

President Carter’s mother, you know, joining the Peace Corps in 

her early 70’s, I think. My mother, who is 102 years old, she has 

this heart for helping young people. So they will come and sit with 

her for 3 or 4 hours, and she is like a grandparent to a lot of these 

kids. 

To what extent does this sort of continuing involvement help 

with the kinds of problems we are talking about here? 

Ms. PEARSON. I think we are just beginning to understand that. 

We have had these statistics for years that showed this high risk 

distribution of older white males who we thought were isolated. Actually, about a third of them are still married when they kill themVerDate 0ct 09 2002 10:00 Nov 13, 2003 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6633 C:\DOCS\90051.TXT SAGING1 PsN: JOYCE
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selves. But it is the style of being so independent and not wanting 

to rely on others, where I think women are more likely to be more 

interdependent, and you can translate that into different cultural 

groups where it is still very important to be a part of your community and feel like you are still needed and still essential. 

With regard to what you heard here in terms of what precipitated thinking about suicide, some of the interventions we are 

funding at this point are trying to get people to think about why 

they should stay around and why they do belong, among are some 

protective factors, and trying to make that type of thinking at least 

equal or exceed why I should be gone. I think we could translate 

that into interventions in different cultural groups that is consistent with the culture, not to change the culture necessarily, but 

to say, OK, what is important within older men’s culture that 

makes them feel like they belong, still think well of themselves, not 

say that it is bad to be interdependent, for example. 

Durkheim, the French sociologist, talked about integration in society being a protective factor many, many years ago, but we just 

have not thought about it in terms of a clinical intervention, until 

recently. So we are finally looking at that. 

Senator DOLE. Good. Dr. Cohen, to what extent are seniors included in clinical trials for new treatments and drug therapies for 

depression? 

Dr. COHEN. I believe the overall inclusion of older people in clinical trials is only about 20 percent. It may be higher—— Ms. PEARSON. I don’t think so. 

Dr. COHEN. The nice thing about colleagues, they are there for 

you to back you up when the future looks pretty bleak. 

We also, until recently, did not include women, older women—— Senator DOLE. Why not? 

Dr. COHEN [continuing]. With the Women’s Health Initiative. So 

it is critical to look at older people in these clinical trials because, 

you know, we are prescribing medications and older people use 

more medications than any other age group, and their bodies are 

changing. 

Senator DOLE. Yes, I think it was Bernadine Healy who really, 

when she was head of NIH, did a great deal to get women included 

in clinical trials that particularly involved women, if it is 

osteoporosis or chronic depression. Women were not in the trials. 

Now that has changed. We need to see the same thing happen 

where our seniors are concerned. 

Thank you, Mr. Chairman. 

Senator BREAUX. Thank you, Senator Dole. 

Is depression more common among any particular age category 

of citizens? Is there a difference in the amount of depression among 

older Americans versus middle-aged Americans versus teenagers? 

Dr. KATZ. You know, there are really interesting findings that 

the current generation of older people is less vulnerable to depression than people in my generation and less vulnerable than my 

children’s generation. This isn’t true only right now, but if you follow suicide rates through the trajectories of these different cohorts 

of generations, you have seen it over time. 

What this means is that our society and country is going to face 

a sort of double jeopardy, that as baby boomers age, there are going 

60

to be more and more older people who are more and more vulnerable to depression facing the chronic medical and neurological illnesses of late life that are the major risk factors for depression. 

That is why we have to learn to deal with this problem now, or else 

we are really going to be in trouble when my generation begins to 

experience these problems. 

Senator BREAUX. If depression is a physical mental illness, then 

can cultural interventions cure it? It would seem to me that if it 

is a mental disorder of the brain that something is out of whack, 

then you can have all the cultural interventions you want, but you 

are not going to cure the illness. It is still going to be there. 

Ms. PEARSON. Well, like a lot of other mental illnesses and physical illnesses, sometimes you might have a genetic predisposition, 

but it is a certain environment where that gets expressed. So some 

prevention efforts, especially in young adults or in childhood, try to 

get more protective factors for children so they are not exposed to 

the stressful events that would lead to the illness exposing itself. 

Senator BREAUX. But, I mean, does the environment cause it? I 

mean, a person who has just a terrible life situation, a family that 

is non-existent, abuse, et cetera, is that person more likely to have 

clinical depression which is a physical disorder than someone who 

is not? 

Ms. PEARSON. I think they are probably more likely, but they are 

not destined to, and that is what scientists are beginning to understand now in terms of how the environment and genetics play at 

together. That is actually a very powerful model now to figure out 

what does happen to certain sub-groups; what might be unique 

about them in terms of their constitution, what made them more 

vulnerable, and then looking at people who seem to be so resilient 

who suffer all these stresses. What makes them different and what 

makes them more resilient. 

So I think we are beginning to understand some of those clues. 

We are getting a little bit of information on what areas of genetics 

to explore but we still have a long ways to go. 

Senator BREAUX. Let’s talk about how easy it is to diagnose it. 

One of the things we are going to do with Medicare, which is not 

required now, is to require that anyone who comes into the Medicare program, as a prerequisite to getting in on Medicare, has to 

have a complete physical. Many people come on Medicare and don’t 

ever see a doctor over the next 5 years, when they really should 

have at least a baseline study on who they are, what they are, 

what their conditions are when they start the program. They 

should have it a lot sooner than that. We just don’t have a way of 

requiring it, but we can at least require it on the Medicare program. 

But how difficult is it to diagnose it for a person who may not 

be a specialist in depression? I take it that if we require every senior to go to a general practitioner for a baseline physical before 

going into the Medicare program, that is not going to catch a lot 

of depression. 

Dr. COHEN. Currently, in the primary care system, 80 percent of 

depression is missed in the old, and it is 50 percent for all age 

groups. One of the key issues that my colleagues have brought up 

is the issue of training in the primary care community. Since so 

61

many older people see a primary care practitioner before they commit suicide, there are data showing that if physicians do screening 

in their offices, you can increase the detection of depression. But 

we also have to teach them proper treatments and the complexities 

that are involved. 

We also have to get older people to talk about their depression, 

because they are a partner in this dialog. 

Senator BREAUX. Is it easier to diagnose in a younger person or 

a middle-aged person versus an older American? 

Dr. COHEN. Depression—and let my other colleagues address this 

as well. There are standards for diagnosing depression. They can 

be taught. You can improve detection and improve treatment. This 

is not something that requires, you know, technological imaging 

studies, although that is essential to some of the research. 

Dr. KATZ. Yet the statistics are that if you do the test, i.e., if you 

ask the person, ‘‘Are you depressed?’’ and ‘‘What have you enjoyed 

doing lately?’’ the diagnosis of depression can be made just as well 

as the diagnosis of hypertension or diabetes. 

The issue is that the test is a conversation, and it takes time. 

As you know, the current medical system is biased against the lowtech of this sort of conversation towards a high-tech of blood tests 

and machines and all. One of the things that will have to be done 

to improve the recognition is to incent in some financial or non-financial way doctors’ spending time with patients to be able to 

know. 

Senator BREAUX. I take it that a CT scan or an MRI cannot identify depression. 

Dr. KATZ. Right. 

Ms. PEARSON. Right. 

Senator BREAUX. Because if you have heart disease or diabetes 

or any other disease that is prevalent among seniors, I take it even 

Alzheimer’s to a certain extent, you can find out through clinical 

testing, but I guess with depression you cannot. 

Dr. KATZ. Not yet. 

Senator BREAUX. Is there a standard form of treatment that is 

now available? Or is it just open shop on what you want to try? 

Ms. PEARSON. There are treatments and part of the PROSPECT 

study used an algorithm that used the best treatments known. As 

people have already referred to this, I think Dr. Katz was saying 

you really have to think through—try your first-line treatment. 

You probably want to minimize side effects. Then you go to the 

next-line treatment if that does not work. I think it——

Senator BREAUX. What is the first line of treatment? 

Ms. PEARSON. It is probably a type of serotonin reuptake inhibitor because it minimizes side effects, and there are different ones 

that have different types of side effects. 

Senator BREAUX. Say that again, because I want to make sure 

she gets it down for the record. 

Ms. PEARSON. Sure. It is a serotonin reuptake inhibitor. 

Dr. KATZ. Or a brief psychotherapy. 

Ms. PEARSON. It could be psychotherapy as well. 

Dr. KATZ. Depending on the severity of depression and the patient and family preference. 

62

Senator BREAUX. How effective is the proper utilization of drugs 

to treat depression? 

Dr. COHEN. They are very effective if they are used appropriately. There are 40 to 50 antidepressant medications. 

Senator BREAUX. How many? 

Dr. COHEN. Over 40 or 50 antidepressant medications. We mentioned the SSRIs, the serotonin reuptake inhibitors, which, as Dr. 

Pearson said, don’t cause the serious side effects which affect compliance. But we are getting, you know, good information on the efficacy of psychotherapy with depression. In minor depression, selfhelp books have been shown to improve depressive symptoms. 

The issue really comes down to, again, the training of the primary care community and the lack of manpower. All these 

antidepressants probably are about equally effective, but we just 

don’t know who they are equally effective with. So we have to play 

around with the medications and start off, and if the treatment 

does not work——

Senator BREAUX. Well, there is a huge lack of geriatric training 

among all of our doctors. We have only got—what?—two or three 

medical schools that even require geriatric training or offer degrees 

in geriatrics. It is just a huge problem. 

Let me ask Ms. Waugh and Ms. Gardiner, what was the best 

treatment that you had? Was it the drugs that they may have put 

you on, or was it any clinics that you went to? 

Ms. WAUGH. It is a combination of both, but I have to tell you 

that we are trial and error with most of our psychiatrists, even, 

and it depends on what particular drug they have been given to 

try. 

Senator BREAUX. Did you try several before you found one that 

was more——

Ms. WAUGH. Yes. My psychiatrist gets a rep coming who says, 

‘‘Try this,’’ and so he says, ‘‘Let’s try this.’’ I mean, I was on ten 

particular antidepressants before we found something without horrible side effects for me. I gained 50 pounds on one. I was totally 

nauseated all the time on another. I was agitated on another. I 

mean, I could go on. 

Luckily, I did not have a lot of other physical problems that prohibited me from having the strength to go through this. I cannot 

even imagine what it would be like to be on six or seven other 

medications that probably have some contraindicative side effects 

and have an insurance company that allowed me maybe 6 minutes 

with my doctor, and during that time I had to tell him about my 

knee, about my heart problem, about maybe inactive kidneys or 

whatever. So I am not going to have time to deal with the other, 

so I will probably stop taking these medications that make me feel 

so terrible. 

Senator BREAUX. But you finally found one that was effective? 

Ms. WAUGH. Absolutely. I am so grateful. But we are talking 

over a 3-year period. 

Senator BREAUX. Ms. Gardiner, what was the most effective for 

you? 

Ms. GARDINER. I went through pretty much the same thing as 

Diana did, plus I was drinking. There was no therapy involved. I 

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just went and talked to this guy, a doctor, and he gave me some 

pills. I went to State store and bought some booze. 

Intervention in my life came, truly came when I met some folk 

who really cared about me, the 12-step group. They let me be 

among them to see how they did things. There was a psychiatrist 

in this 12-step group who had been sober for some time, and he 

took me aside. Between the medication he gave me and the therapy 

and the 12-step group, here I am today. 

Senator BREAUX. Is that a pretty common story as far as treatment? There has got to be a little bit of everything, right? 

Dr. KATZ. Yes. You know, we talk about integrating mental 

health and medical care as an important issue. Two other very separate systems are mental health and alcohol or substance abuse 

care. So if I as a middle-aged person get a heart attack, get depressed over it, and try to treat my depression by drinking, I will 

have to go to three separate systems in order to get care. It just 

cannot be done. 

Senator BREAUX. Well, all of this—— Ms. WAUGH. I just wanted to say that for me it is a combination 

of three things: I go to individual therapy; I am in a group so that 

those people can help me gauge when I am starting to slip, and 

they can always recognize it sooner than I can; plus I have medication and I see my psychiatrist for med checks monthly. 

Senator BREAUX. Well, all of you have been very helpful. I particularly thank Ms. Gardiner and Ms. Waugh for giving us your 

personal experiences. There are millions that I think have probably 

had the same experiences to an extent as you have described here 

today. So your testimony really has the potential to affect many 

millions of Americans, and we thank you for telling your story. It 

is very important that you did this. 

To our professionals, we thank you for the work that all of you 

do. It is incredibly important. This is a problem that is enormous, 

and with the baby-boom generation soon to become eligible for all 

of our senior programs, it is going to even be a greater challenge 

in the future. We thank you for your help and your assistance. 

With that, this hearing will be concluded, and we will stand adjourned until the further call of the Chair. 

[Whereupon, at 3:29 p.m., the committee was adjourned.] 

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