It may seem obvious that people with disabilities should be depressed. "Of course she's depressed", we say. "I'd be depressed too if I couldn't get out and about any more". Although physical disability obviously increases the risk of depression, depression itself may in turn cause considerable disability. Disabilities are important to the lives of older people, as, like depression, they are associated with a lot of negative outcomes - confined to the house, need for home-help, admission to a nursing home, etc. Older people often worry more about the risk of disability than about a medical disease itself. A clinical survey has explored the relationships between depression and disabilities in older people, and has found that there are three main approaches to improving the situation.

The survey was carried out at Duke University, USA, in patients aged 60 and over who had significant depression. Two main groups of disabilities were recognized. The first involved self-care (or what the authors called self-maintenance skills), such as the ability to eat, dress oneself, and use the toilet. The second group were disabilities affected more complex activities (known as instrumental activities of daily living, or IADL), which included domestic items, like preparing meals, housework or yardwork, and social items, such as caring for children, getting around the neighborhood, and shopping.

In addition to the questionnaires rating the existence and severity of disabilities, all participants were asked about the various aspects of their depression, as well at any chronic medical conditions (such as asthma, diabetes, rheumatism or heart trouble), and their impression of the social support they were receiving from relatives, friends, caregivers, etc.

There were 211 participants in the survey. The average age was 70, and 59% of them were women. Over 68% were married. The average score for the self-care items in the questionnaires was quite low, showing that the participants were fairly independent. However, the average score for the IADL items was higher, showing a considerable degree of disability with respect to the more complex activities of daily living.

The results comparing various factors with the degree of disability were different for the two types of disability. More pronounced problems with self-care were seen in older people, those with more severe chronic diseases, less social support and a generalized slow-down of activity. Slow-down in activity was the most obvious factor for depressed patients with self-care disabilities.

The patients with IADL deficits had two of the same factors - older age, more severe chronic diseases. In addition, however, they had more severe symptoms of depression, (including considerable apathy, anxiety, and weight loss), as well as less social interaction and perceived social support (in spite of greater instrumental social support).

These findings suggest that the ideal treatment of the two different types of disability in depressed patients might vary. For those with problems in self-care, the major features to be addressed would be vigorous treatment of chronic medical conditions (which should take care of much of their slow-down in activity) and improved social support.

For those with disabilities of the IADL-type, it was found that the depression itself was a major factor, even after medical conditions had been discounted. This suggests that successful treatment of depression is likely to have greater benefits in these elderly patients than in those with self-care difficulties.

One of our readers sent us this feedback on the above article, and gave us permission to post it here. If you want to contact him, his e-mail address is mmoore@ccrtc.com . If you would like to contribute to this discussion, please use the box in the feedback form below. Robert Griffith MD, Content Editor.

I am only 49, yet that may in itself be a factor, but I can easily relate to the subject. I have now been disabled a year after the failure of my fourth back surgery. I found your article fairly accurate as to the psychological effects of disability, but I noticed two additional causes of depression missing, facing a life of chronic pain and dealing with physicians and government bureaucrats that do not seem to have the time or desire to adequately help. In fact with me this has been the biggest cause of depression. Not knowing what to expect, going from doctor to doctor without getting answers that make sense. And then, in my case as also attested to by others who are younger who have to go through the Social Security disability process, there is the uncertainty of supporting a family while the government plays their game for usually 3-5 years while the claimant often loses his savings, his home, and even sometimes his family. I personally have come to grips with a lifetime of ever increasing limitations, I just have trouble with the days that breakthrough pain confines me to bed, and with watching my lifetime savings evaporate, watching my wife work three jobs to keep it from evaporating any quicker, looking on as my children wear clothes with holes and frayed, and eating only the cheapest of foods because there is usually the choice between groceries and medications or medical insurance. And all of this because the government has decided dragging out the processes can often force the disabled back some type of work, or many times the claimant will die before getting approved, thereby reducing the budget. I once had a group of the elderly come to me to sympathize. One of the oldest women said that the saddest part is that, with all the problems that come with age and disability, it doesn't do any good to complain because nobody cares. I think that may be the greatest source of depression; the people that should be caring, don't. The article may be helpful to someone that is in the early stages of disa bility, but does not include much new information for someone further down the road. And in my case trying to sell me antidepressant is fruitless sense I am also bipolar and the drug would throw me into a severe manic state.

Another reader has sent us this feedback on the above article, and has given us permission to post it here. If you want to contact her, her e-mail address is vnvlady@cox.net . If you want to contribute to this discussion, please use the box in the feedback form below. Robert Griffith MD, Content Editor.

As a 57 year old woman with both rheumatoid arthritis and asthma I find that what used to be normal activities, house cleaning and gardening, as well as walking any distance are very hard for me. I used to be very active and I loved to dance and take long walks and hikes in nature to get in touch with my higher power. I can no longer enjoy these activities and I get so frustrated that I can no longer keep my house and garden as tidy as I used to. I feel that I have to apologize when people come to visit and I feel guilty which in turn leads to depression. My one saving grace is that my fiance has a motorcycle that has been converted into a 'tricycle', and we take long rides here in Arizona where the scenery is beautiful. As long as I can get on the back of that Harley my spirits are lifted, it's just a matter of refocusing my priorities.