Every time you treat depression among middle aged and older adults, you're not only addressing this one point in time, you're helping to protect their brain for years to come.

What if the depression that your client is experiencing today is increasing their risk for dementia tomorrow? Many therapists don't realize this, but midlife and later life depression that goes undetected and untreated increases the risk for dementia, and in this episode we'll talk about the research behind this and what you can do to help reduce the risk of dementia by treating depression.

So let's get into it. I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and geropsychologist, and I founded the Center for Mental Health and Aging, so that you have all the tools that you need to meet the mental health needs of older adults.

All right, so let's talk about the link between depression and dementia. Depression is not a normal part of aging, but it is one of the most common mental health conditions in older adulthood, and when depression goes untreated the consequences are not just emotional. They affect every aspect of life from physical health to brain health as well.

There have been multiple large scale studies looking at just this. One of those studies is the 2024 HUNT Study that found that depression in midlife increases the risk of developing dementia more than 30 years later. And there was a 2022 review that found that late life depression significantly increased the risk for dementia.

These two studies, along with the Lancet 2024 Commission Report that identified 14 modifiable risk factors for dementia, which included depression, point us in the direction of understanding that there is a link between depression and dementia. But when we treat depression, the good news is it can help to reduce our risk that's associated with depression for dementia.

So how does this happen? How does depression increase the risk for dementia? There are some behavioral components to it. When people are depressed, they may be more physically inactive. That physical inactivity, because maybe lack of motivation associated with depression or lack of interest in doing things that could be associated with depression—that lack of activity can increase the risk for dementia. And that's because what's good for our heart is good for our brain. And so if we're not taking care of our body, including our heart, that can impact our brain functioning and increase vulnerability to conditions like dementia disorders.

Another is that when we're experiencing depression, we might be more socially isolated and withdrawn, and social isolation and loneliness also increase the risk for dementia.

When people have a diagnosis of depression, they may also be more likely to not take medication as prescribed by their doctor, because sometimes there's a feeling of “what's the point?” If we're not seeing much joy or purpose in living, why would we take medications? So with depression, there can be an increase in medical non-adherence. And on that Lancet 2024 Commission list of modifiable risk factors for dementia disorders, there are several physical health conditions like diabetes and hypertension, high cholesterol that also increase the risk for dementia.

Biologically, depression also impacts brain function and our physiology—from chronic inflammation in our body to HPA axis dysregulation, to even neurodegeneration. And so there are many different pathways that depression increases the risk for dementia disorders. But the good news is we can change this trajectory, and this is because depression is highly treatable among middle aged and older adults.

So let's talk now about the power of treatment, and this is the good news.

First, we have to get a myth out of the way. The myth is that at a certain age, we're stuck in our ways and we are resistant to change, and that actually is not true when it comes to therapy. Older adults benefit from therapy at the same levels as other age groups when treating depression, and so the take-home point is that depression in older adulthood is treatable, and the impact of treatment is significant.

Let me give you an example. There was a study that looked at people with depression and mild cognitive impairment, and when people have a diagnosis of mild cognitive impairment, about 10% of those folks convert to a dementia disorder each year, so the risk is higher for this group of developing dementia. So again, they have mild cognitive impairment and depression, but when that depression was treated with an SSRI like citalopram, that treatment—when they engaged in treatment for four years with citalopram, taking it regularly—this group that had the highest, most vulnerable risk for developing dementia delayed the onset of dementia by three years.

And studies looking at midlife treatment of depression also delayed or prevented the onset of dementia later on. And so the good news here is that there is a lot you can do as a therapist to not only impact the person's life today, but also prevent illness and disease down the road like dementia disorders.

And so if you're sitting with a client with low mood or sleep problems or social withdrawal, your interventions and your psychotherapy with that person may be helping more than you know. You're not only easing emotional pain, you're helping to protect memory and independence down the road.

What about people with dementia who have depression? Can we effectively treat depression among people living with dementia? And the answer is yes.

When it comes to dementia, more than 95% of people experience neuropsychiatric symptoms like apathy and anxiety and agitation and so on—apathy being one of the earliest symptoms of dementia as it relates to neuropsychiatric symptoms, meaning mental health expressions of a brain disease, like a dementia disorder.

So depression actually is also seen as both an early sign of dementia as well as a risk factor for dementia. And so it becomes very difficult to tease these apart. But what we do know is that when we treat depression, even in the context of a dementia disorder, this helps the person as well. Let's talk about how.

One is it eases suffering. Two is, especially if we're able to identify dementia early in the disease course, we can help the person implement some scaffolding to help them live a full, meaningful, independent life for as long as possible.

We can help to connect them to communities of other people living with dementia disorders like with Dementia Alliance International. A few years ago, I did an interview with Chrissy Thelker, who is a woman living in Canada, who has a diagnosis of dementia, and she came on talking about her experiences with a dementia disorder. I'll link to that interview below, but she talks about how powerful the community she has with Dementia Alliance International is—which is an international group of individuals with dementia who created this organization. So it's founded by people with dementia, for people with dementia, run by people with dementia. And so it's profound and collective and provides a community for people who experience a lot of social isolation because of lost relationships.

We can help connect people to psychiatry and neurology to help manage some of the neuropsychiatric symptoms that can come with dementia so that they experience less suffering and maybe build a better quality of life.

We can also provide support and resources and therapy to caregivers, to family members who are coming to terms with understanding how to constantly calibrate their approach with their loved one living with dementia so that they don't overstep when the person with dementia can still maintain things independently and don't under-step when the person with dementia needs more supports in place.

And so there's a lot that we can do. Even our clinical assessment tools for depression can be modified for people with dementia. So for example, I use a Geriatric Depression Scale-15 often with people with mild cognitive impairment and earlier stages of dementia disorders. And then there are other scales that you can use to identify depression where there's more of a caregiver interview with caregiver observations, especially when the person is not as able to participate in psychotherapy or psychological assessments to better understand their symptoms.

And so there is a lot that we can do to help people living with dementia manage their depression.

And so when it comes to therapy, I hear many therapists say, “The person has dementia. There's not much I can do with them if they have depression,” and that's actually a false narrative. There is a lot that you can do to help the person with dementia or mild cognitive impairment manage depression and live a good life.

Therapy can help reduce the person's distress, increase their quality of life, improve their relationships with family members, and help the person find meaning and purpose and dignity in the life that they have now.

Family therapy with older adults and their loved ones—which is my favorite type of therapy—also helps to improve care and reduce burnout.

So the next time you think that the person has dementia and there's not much you can do, rethink that. Think about all of the possibility that exists.

When I used to face a challenge in therapy, and sometimes even when I still face a challenge in therapy, I think, “This is going to make me a better therapist,” and I was right. All of the challenges that I've experienced and continue to experience in therapy make me a better therapist.

And I want this to be an invitation to you to join me in being a better therapist for older adults, because there is a lot that you can do for older adults without dementia who have depression, and also older adults with dementia who have depression.

So here are four ways to bring this information into your practice.

The first is that you can screen for depression using tools that have been normed with older adults. And I'll link to another episode I did on just this very topic below.

Two is to recognize the link between mental health conditions and dementia disorders. And this is really important for therapists, because I'm going to be doing a series on the link between various mental health conditions and dementia disorders. Today we're addressing depression, but the same is true for anxiety and substance use, sleep disorders, trauma. So get to know the link between mental health conditions and dementia disorders or brain health conditions. This is important because you as a therapist may be the first to notice signs of memory loss, because these conditions increase the risk for brain disease. And so get to know the risk and also get curious and learn about what you can do to help when you see memory loss appearing in therapy.

Three—and you know how to do this well—provide mental health care. Provide psychotherapy to help address the presenting problem: depression. That’s what we’re talking about today, but tune in next time—we’ll be talking about anxiety. So provide psychotherapy to address depression. To treat depression. And that will help not only today with the person's quality of life and engagement in life, but down the road in terms of delaying or preventing dementia.

The fourth thing that you can do is to refer and collaborate with medical providers.

And this is because if you are noticing cognitive changes in your clients, you definitely want to be working with their medical providers to rule out any biophysiological process that might be happening that's creating the cognitive impairment—like vitamin B12 deficiencies, other metabolic issues and deficiencies, dehydration, high potassium, a urinary tract infection, or something medical that might be going on, medication interactions, a new medication, and so on.

And so you want to be working in concert with this. You want to be creating a beautiful symphony with the person's healthcare team.

Five. You want to be educating your colleagues, your clients, and their family members where appropriate. There are a lot of misconceptions about what's typical with aging and what's not. There's a misconception that depression is typical with aging when it is not. There's a misconception that older adults don't change, so why would we refer them to therapy for depression, which is also not true.

So change the narrative, flip the script, provide education on what is true so that we can detect and then treat depression when it shows up.

If you found this video helpful and you want to learn more about how to modify your practice for working with older adults, I invite you to join me in our continuing education courses that we provide all around meeting the mental health needs of older adults. I'll link to some courses down below so you can take a look and see what works for you in your practice.

Here is what I want you to remember. There is no expiration date on healing, transformation, and growth. All throughout our life, we benefit from healing relationships—psychotherapy being one of those relationships. Older age does not eliminate people from this journey and from this process. And so you have a really important role in meeting the mental health needs of older adults.

And it's only with your help that we can do it. So thank you for being here and doing your part.

I'm Dr. Regina Koepp. I'm a clinical geropsychologist and founder of the Center for Mental Health and Aging. If you found this episode helpful, would you follow, review, subscribe, and share it with others? It really helps other people to find us so that they too can join the movement for mental health and aging—because as you know, there is no expiration date on healing, transformation, and love.

I'll see you next time. Bye for now.