How COVID-Lockdowns & Eternal Nursing Home Prison Makes Late Life Depression Happen

... and how it makes it harder to treat.

One of the things I’ve always been interested in is mental health in late life, particularly late life depression. While for anyone, depression, particularly major depression, can be a terrible thing and often can lead to grave outcomes up to and including suicide, for older adults it brings additional problems

And yes, geriatric depression is a thing, in that it tends to present itself differently in older adults (particularly for older adults experiencing their first lifetime episode of depression, a ‘first-break episode’).

Depression tends to look different - for example, whereas in younger people, depression often expresses itself in terms of what I like to call existential symptoms (e.g., thoughts of suicide, poor self-esteem, subjective depression, crying) - older adults are much more prone to the other side of the coin - so-called neurovegetative symptoms. That is to say, poor sleep, poor appetite, trouble thinking and concentrating.

Interestingly enough, in older adults they can even manifest a curious form of depression, called depression without sadness (yes, such a thing exists) - and it’s just like it sounds. The older adult often presents in the doctor’s office with nonspecific, nagging problems with sleep, they’ve lost weight, they’ve lost their get-up-and-go! But when asked, “yeah doc, I’m not depressed, I’m just not feeling right.” Often they are surprised when they are told they are depressed.

What’s the Best Way to Treat Depression in Older Adults?

Obviously, a popular way to treat geriatric depression is with antidepressants (typically of the selective serotonin inhibitor class, or SSRIs - because they tend to have the kindest side effect profile - appropriate for such a sensitive population).

But the truth is - in older adults the first-line treatment for depression isn’t with drugs. It’s actually with “behavioral activation” - which sounds mildly technical a term, and in fact while there are psychotherapeutic approaches built around the idea, the basic notion is that the more pleasurable (and ideally meaningful ) activities that an older adult engages in, the more likely they can maintain a positive mood or outlook.

What causes Depression in Long Term Care?

Back to that idea of ‘first-break’ depression.

I’ve seen it many times in my residents over the years. Many of them have led relatively functional lives with typical ups and downs (a divorce here, perhaps the untimely passing of a sibling or parent earlier in life, etc. - we’ve all had our issues) but for the most part they’ve avoided clinically significant depression. They’ve never seen a psychiatrist, taken an antidepressant, or been to a therapist in their lives.

But for the first time in their lives, they’re depressed.

What is it about the LTC environment that does this?

Well - think about what’s brought them here. It’s losses.

• Functional: This is the reason why older adults (or anyone, really) ends up in a nursing home - they are unable to perform ADLs, or Activities of Daily Living independently, like going to the bathroom, walking, or dressing themselves. This by itself is a huge stressor - can often precipitate at least sad mood or poor coping response.

• Vocational: While many of the older adults that are first admitted to my nursing home have been retired for some time, for others it may be more recent and this can often be a precipitant for a first episode of depression. Even if the older adult has been retired for some time, they may have been involved in hobbies or activities (a train club, their workshop in the garage, fixing cars) at home that they no longer have access to.

• Relationships: Often one of the precipitating events that lead older adults into my facility is the death of a spouse.¹ Even without that, admission to a nursing home almost always means disruption to social connections, friends groups, etc.

• Cognitive: According to widely accepted industry estimates, at any given US nursing home, between 50-70% of the given population has some form of diagnosable cognitive impairment or dementia.

Geriatric Depression in Long Term Care is caused by Loss of Personhood

So - while all the above is true in a clinical sense - in the subjective and existential sense, what in my opinion drives the high incidence of first-break depression in my residents, is the loss of self.

Think about it - you were a butcher, a teacher, a husband, a wife. You were a grandfather. A babysitter. A pet owner, a homeowner. You had all of these identities. You were a person.

And now you’re just a patient. You are no longer in your own home. The rhythms of your home are gone, replaced by the routines of the nursing home. Breakfast is at 7am, lunch at 11, dinner at 5. You don’t like that? Too bad, that’s when they serve it. Medications multiple times a day. You are your illnesses. That’s why you’re here!

Prior to COVID, we had all sorts of sayings and ideas as to how to mitigate this. We talked about offering residents a “homelike environment” where they were allowed to choose when to eat, when to wake up, when to sleep, when to shower. We offered 24/7 visitation privileges. Liberal allowances for visits for pets, and we made sure people could get medically approved passes whenever they liked. We put “Getting to Know You” placards all over the hallways, with pictures and bios of our residents on the walls, in an attempt to personalize the depersonalized.

At least up until around 2020, I’d say we were doing OK, with a lot of work ahead of us.

COVID Has Accelerated the Loss of Personhood

The Coronapanic of 2020 completely turned all of this around.

I don’t need to necessarily go through it all again in excruciating detail, but you can probably guess where I’m going with this. For a time, all visits completely stopped. Then there were the prison-like “window visits” and the FaceTime digital versions of the same, for months on end. Finally, visits came back - but tighty regimented, time limited, scheduled, masked.

Community outings have just barely resumed over the last couple of weeks, but at a glacial pace, with limited uptake (our residents and families are scared, I think - something I’ll talk about later). Volunteers, still a trickle compared to what they used to be.

Communal dining? Still gone.

Most of them haven’t seen the faces of their families, friends, and loved ones in person for years now - much less the faces of the caregivers who have provided care for them.

For the last 2.5 years, our nursing home residents have become entirely empty vessels, they have had their entire lives oriented around virus avoidance and little else aside from their preexisting functional and medical issues. They are there to avoid viruses, and to stay alive - but they aren’t there to live. It’s a toxic, depressogenic stew we’ve subjected them to.

Over the last 2.5 years of what I have now taken to calling “The Great Coronapanic” - I cannot think of any residents in our facility who have thrived.

Unfortunately I can think of more than a few who have pitifully withered away, broken-hearted: because our nursing home died during COVID.

1. As an aside, this calls to mind the phenomenon of “unmasking.” Older adult couples, as they’ve aged, very often have developed deficits in functioning that complement each other as they care for each other. For example, the wife may have developed legal blindness & crippling arthritis and can no longer drive and needs a wheelchair, while the husband, while visually intact, may have mild cognitive impairment. So, the wife provides the direction and memory support, while the husband manages mobility and transportation. When the wife dies, however, is when the true level of deficits in the husband become clear to family members and the husband later gets admitted to a care home.