Is he just cranky or depressed?


IF YOU are an elderly man, you are at the highest risk of suffering from depression.

According to a World Health Organisation (WHO) study, one out of five adults (aged between 18 and 60) will suffer from depression at any one time in their life. This is seen more in the elderly. Among the elderly, men are likely to have depression and commit suicide.

Datuk Dr Andrew Mohanraj, deputy president of the Malaysian Mental Health Association, admits that depression is high among the elderly.

Another WHO study of disability caused by depression measured by disability-adjusted life years (DALYs), shows that depression today ranks No. 2 behind cardiovascular diseases as the main cause of disability. What is more frightening is that WHO projects that in 2020, depression will overtake cardiovascular diseases to become the No. 1 contributor of disability in the world.

The causes of depression in the elderly can be anything from losing their independence, financial problems, loss of a spouse, loss of mobility, or any debilitating disease or illness.

It can also be the result of some medications such as statins and prolonged use of steroids.

Signs and symptoms

How do you detect depression in the elderly? Some of the signs to look out for are:

  • Persistent low mood
  • Anhedonia (loss of interest in pleasurable activities in life)
  • Forgetfulness
  • Loss of weight
  • Loss of appetite
  • Poor sleep
  • Irritability
  • Non-specific pains

According to Dr Mohanraj, depression in the elderly is a bit atypical.

“For example, if a depressed young adult has difficulty sleeping, the elderly who is depressed might just sleep the whole day. There might not be any difference in terms of the appetite or the elderly might just eat more. But what is termed as psychosomatic complaints (complaining about non-specific kind of pain in the body – typically, it would be backache, body ache or persistent headache) is seen more in the elderly,” explains Dr Mohanraj.

Datuk Dr Andrew Mohanraj: 'The risk is that the depression can get severe, and that can result in suicidal acts and suicidal thoughts.'
Datuk Dr Andrew Mohanraj: ‘The risk is that the depression can get severe, and that can result in suicidal acts and suicidal thoughts.’

According to him, the feeling of depression is channelled as body ache, persistent headache, back pain or lethargy or no interest in doing their normal routine, rather than admitting that they have low mood.

If an elderly goes to the clinic and complains of backache, body ache and headache, the doctor would try to find the source of the pains and would not always be able to detect depression.

Dr Mohanraj says it becomes harder for the doctor to detect depression when the elderly patient goes from one clinic to the next, just to get the medications that they want. Often, they might also just go to the pharmacy to get painkillers.

It is often also difficult to detect anhedonia in an elderly person unless you are close to them.

Dr Mohanraj suggests the family note if they are no longer keen to participate in activities that used to be part of their routine, such as playing golf, or reading the newspaper.

If they suddenly stop these activities, then warning bells should go off as it could be a sign of depression.

The elderly who have a lot of illnesses or have suffered a stroke, had a heart attack, suffer from diabetes or are battling cancer, depression is to be expected.

“While the physical illnesses can cause depression, it has also been shown that for people with cardiovascular disease or diabetes, the depression can actually worsen their physical health,” says Dr Mohanraj.

Another symptom is forgetfulness. While we often think of it as part of ageing, here the forgetfulness is more distinct.

For example, the depressed elderly person might be watching a movie and suddenly forget what movie they are watching, or they might have had lunch and then forget that they already ate.

If they also have dementia, you will notice that they are very accusatory and they might develop paranoid ideas towards people, accusing their own family members of stealing their things, or accusing the helper of not feeding them.

As a result of that, they might be irritable.

Dr Mohanraj advises the family to pay attention to the elderly to spot these signs and symptoms as it is not necessarily a part of ageing, but could be part of a bigger underlying problem – which is depression.


The approach for treatment is biopsychosocial:

Bio / biological – This is where antidepressants are used to correct the neurotransmitter imbalance in the brain by increasing the production of serotonin.

A word of caution though. Antidepressants do not work overnight. It may take a few weeks before you start to see any changes in the depressed person.

“Tangible changes in the person’s mood can only be seen at the earliest a week after starting medication. In my experience, it takes 10-14 days to see a palpable lift in the mood,” says Dr Mohanraj.

He also warns that certain antidepressants, like Prozac, need to be taken in the morning as they could result in agitation and poor sleep if taken later in the day.

While antidepressants can help improve the mood of the elderly, it needs to be monitored as there are side effects and could have an interaction with other medications.

“Some of these medications, because of the interaction will not bring out the efficacy of the antidepressants,” he explains.

Psycho / psychological – Counselling or therapy is needed so that the elderly can talk about what is causing the depression.

“The psychological intervention will help the elderly seek different solutions to the problem and it will help to get rid of the negative thoughts,” says Dr Mohanraj.

If the elderly person is not willing to go to a psychiatrist or psychologist, Dr Mohanraj suggests a sibling or religious leader might coax him or her to see a counsellor.

Social – This is where the family comes in to provide support and to be more understanding. They might also need to spend more time with the elderly to prevent them from feeling isolated and to reassure them that they are not a “burden” to the family and still play an important role.

Dr Mohanraj says all three aspects – bio, psycho and social – are important in tackling depression.


He warns family and friends not to pass judgment on the elderly who are depressed as some may just be predisposed to depression or they may find it hard to adjust when the children leave the nest or a spouse dies.

Everybody copes differently and it is unfair to assume everybody must react in the same way to life events.

“The risk is that the depression can get severe, and that can result in suicidal acts and suicidal thoughts. Many in our culture will not say that they have suicidal intentions but they will entertain death wishes. They might not say they want to end their life, but they might say something like, ‘Even if I sleep tonight and God takes me and I don’t wake up tomorrow morning, it’s okay’.

“This should ring alarm bells,” warns Dr Mohanraj.

He reminds families to monitor for the signs and symptoms, especially since elderly men are at a very high risk of suicide.

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