For months, the Montreal grandmother's energy had melted away; she became a listless, anorexic insomniac, overwhelmed by the tasks of daily living. Her weight dropped to 94 pounds from her usual 118. After decades of energy, she became, in her words, "a log." She was suffering the classic symptoms of a severe depression. But at the emergency room that night, she was prescribed sleeping pills and sent home. Her family physician ordered physical tests, assuming the problem was her heart. "They pegged my mother as another sad old lady," said David Bakish, her son. "With older people, they tend to do that; they say: 'She's getting older; of course she's depressed.' "

But depression is not normal for an 83-year-old, any more than for a 23-year-old. "Depression is not a natural process of aging. That's a myth," said Dr. Stan Kutcher, head of the department of psychiatry at Dalhousie University in Halifax. Geriatric depression, a shockingly common condition, is only now starting to be taken seriously.

One in four women and one in eight men will suffer from depression at some point in their life, and, for a host of reasons, rates are much higher in the older population. The condition, due to an imbalance in brain chemicals, can be brought on by some physical ailments and by some medication, and problems such as failing health and isolation can act as triggers. Yet the condition is grossly underdiagnosed and undertreated among the elderly. "I'm not certain your average physician recognizes depression as the serious disease that it is, particularly when they are dealing with older patients," said Dr. Rita Schreiber, a professor of nursing at the University of Victoria. "The attitude in our society is: 'Of course Granny's depressed, she's old.' "

Dr. Schreiber said there is also a great reluctance among older people to seek help for psychiatric problems. If they do complain, it will often be to say their stomach hurts or their bowel movements are irregular rather than to mention the real feelings of despair. That's why it is important for family members, friends and health professionals to engage older people about their mental health as well as their physical health, Dr. Schreiber said.

Luckily for Mrs. Bakish, her son took an active interest in her health. It didn't hurt that he happens to one of the country's leading psychopharmacologists, a psychiatrist who does research on drug treatments. Much of his work is with depressed patients. With his help, Mrs. Bakish was admitted to the Royal Ottawa Hospital, home to a world-renowned psychogeriatric program. She spent months in treatment until the staff got her medication right. She is now taking venlafaxine (trade name Effexor XR), a popular drug treatment for depression. Mrs. Bakish has seen her anxiety dissipate and her vitality return. She is back to her normal weight and her busy social calendar. "At 86, I am not a young woman," she said. "But my story should tell everyone that you should not abandon people because they are old. Our problems, our depression, can be resolved just like it is in younger people."

Dr. Bakish readily agrees, though he acknowledges that treating the elderly for depression can be challenging. Because many take medication for physical ailments, there is a danger of drug interactions. Because their metabolism is slower, older people also react more slowly to drugs and suffer more side effects, so clinicians have to be patient and vigilant. Although depression is not a given with aging, some biological changes make it more likely. Levels of a certain enzyme in the brain, monoamine oxidase, increase. This enzyme normally breaks down various brain chemicals including serotonin and norepinephrine, and low levels of these brain chemicals make depression more likely.

Alzheimer's and Parkinson's disease are both associated with depression, as are many hormonal disorders, congestive heart failure, anemia and even infectious diseases. Depression after a stroke affects up to 30 per cent of stroke victims. A number of drugs used to treat common medical conditions, cancer and heart disease among them, can also cause depression. Even some arthritis medication may do so. Then there are the feelings of sadness that come from losing friends and one's abilities, and the powerlessness and marginalization that too often accompany old age.

But all the experts warn against confusing normal sadness with depression. "We have to be careful not to pathologize all our feelings, Dr. Schreiber said. "Our society doesn't allow us much room for anything but being perky and happy. It doesn't allow us time to grieve any more." She said that if we learn to "normalize" mourning, to accept losses as part of life, it will be easier to spot and treat clinical depression, regardless of age. "Anyone can get depressed," she said. "What we have to ensure now is that anyone can get treated for depression too."

Detecting depression in the elderly
A simple checklist has been specially developed to detect depression in the elderly. Choose the best answer to describe how you have felt over the past week. Answers indicating depression are in the bolder type. Each answer counts as one. A score from 5 to 9 indicates a strong possibility of depression, while a score of 10 is almost always a sign of depression.
1. Are you basically satisfied with your life? Yes No
2. Have you dropped many of your activities and interests? Yes No
3. Do you feel that your life is empty? Yes No
4. Do you often get bored? Yes No
5. Are you in good spirits most of the time? Yes No
6. Are you afraid that something bad is going to happen to you? Yes No
7. Do you feel happy most of the time? Yes No
8. Do you often feel helpless? Yes No
9. Do you prefer to stay at home rather than going out and doing new things? Yes No
10. Do you feel you have more problems with memory than others? Yes No
11. Do you feel it wonderful to be alive now? Yes No
12. Do you feel pretty worthless the way you are now? Yes No
13. Do you feel full of energy? Yes No
14. Do you feel that your situation is hopeless? Yes No
15. Do you think most people are better off than you are? Yes No

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