[Senate Hearing 108-181]
[From the U.S. Government Publishing Office]


                                                        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






                        U.S. GOVERNMENT PRINTING OFFICE
90-051                         wASHINGTON  : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001







                       SPECIAL COMMITTEE ON AGING

                      LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama              JOHN B. BREAUX, Louisiana, Ranking 
SUSAN COLLINS, Maine                     Member
MIKE ENZI, Wyoming                   HARRY REID, Nevada
GORDON SMITH, Oregon                 HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri            JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois        RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah                 RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska                  EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania          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)

  


   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.
    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.
    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 provide 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 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.

          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.
    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:]
    [GRAPHIC] [TIFF OMITTED] 90051.001
    
    [GRAPHIC] [TIFF OMITTED] 90051.002
    
    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.
    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 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.
    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:]
    [GRAPHIC] [TIFF OMITTED] 90051.003
    
    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 co-victim 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 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 two were 
on an antidepressant. They are on other kinds of medication, 
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:]
    [GRAPHIC] [TIFF OMITTED] 90051.004
    
    [GRAPHIC] [TIFF OMITTED] 90051.005
    
    [GRAPHIC] [TIFF OMITTED] 90051.006
    
    [GRAPHIC] [TIFF OMITTED] 90051.007
    
    [GRAPHIC] [TIFF OMITTED] 90051.008
    
    [GRAPHIC] [TIFF OMITTED] 90051.009
    
    [GRAPHIC] [TIFF OMITTED] 90051.010
    
    [GRAPHIC] [TIFF OMITTED] 90051.011
    
    [GRAPHIC] [TIFF OMITTED] 90051.012
    
    [GRAPHIC] [TIFF OMITTED] 90051.013
    
    [GRAPHIC] [TIFF OMITTED] 90051.014
    
    [GRAPHIC] [TIFF OMITTED] 90051.015
    
    [GRAPHIC] [TIFF OMITTED] 90051.016
    
    [GRAPHIC] [TIFF OMITTED] 90051.017
    
    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:]
    [GRAPHIC] [TIFF OMITTED] 90051.018
    
    [GRAPHIC] [TIFF OMITTED] 90051.019
    
    [GRAPHIC] [TIFF OMITTED] 90051.020
    
    [GRAPHIC] [TIFF OMITTED] 90051.021
    
    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 
studies 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 late-life 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 care-based care management for late-life 
depression.
    Thank you for giving me the opportunity to testify before 
you.
    [The prepared statement of Dr. Katz follows:]
    [GRAPHIC] [TIFF OMITTED] 90051.022
    
    [GRAPHIC] [TIFF OMITTED] 90051.023
    
    [GRAPHIC] [TIFF OMITTED] 90051.024
    
    [GRAPHIC] [TIFF OMITTED] 90051.025
    
    [GRAPHIC] [TIFF OMITTED] 90051.026
    
    [GRAPHIC] [TIFF OMITTED] 90051.027
    
    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.
    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 
other HHS agencies. That includes CDC, SAMHSA, IHS, FDA, HRSA, 
as well as with the Department of Veterans Affairs and 
Department of Defense, to work toward building additional 
scientifically 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:]
    [GRAPHIC] [TIFF OMITTED] 90051.028
    
    [GRAPHIC] [TIFF OMITTED] 90051.029
    
    [GRAPHIC] [TIFF OMITTED] 90051.030
    
    [GRAPHIC] [TIFF OMITTED] 90051.031
    
    [GRAPHIC] [TIFF OMITTED] 90051.032
    
    [GRAPHIC] [TIFF OMITTED] 90051.033
    
    [GRAPHIC] [TIFF OMITTED] 90051.034
    
    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 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.
    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 gender-specific, 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.
    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 themselves. 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 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 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 low-tech 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.
    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, self-help 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 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.]
                            A P P E N D I X

                              ----------                              

[GRAPHIC] [TIFF OMITTED] 90051.035

[GRAPHIC] [TIFF OMITTED] 90051.036

[GRAPHIC] [TIFF OMITTED] 90051.037

                                   - 
