Dr Daniel Knoepflmacher (Host): Hello and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research and other important topics on the mind.

Our focus today is on depression in later life. Depression is a serious illness affecting approximately 15 out of every 100 adults over age 65 in the United States. The rates are even higher among older adults in the hospital, nursing homes and after serious illness such as stroke or heart attack. Depression in later life is associated with higher mortality rates, suicide and nursing home placement. A host of age-related factors put older adults at increased risk for depression, including chronic health conditions, decreased functional ability, chronic pain, financial issues related to retirement, isolation and elder abuse. Depression is often missed in seniors with core symptoms being attributed to aging or other medical conditions, such as dementia.

While there are many effective treatments for geriatric depression, many older Americans never get access to the care they need. Our guest on the podcast today has done important work to address the significant barriers faced by seniors struggling with depression and other mental illnesses. Dr. Jo Anne Sirey is a Professor of Clinical Psychology and Psychiatry here at Weill Cornell Medicine and Director of TRIO for Successful Aging, a program providing mental health services to older adults in the community.

She has deep expertise in researching and treating late-life depression, having investigated the barriers to treatment faced by older adults, and then creating and studying solutions to address these problems. She has extensive experience working with the diverse population of seniors in New York City, having created community-based programs to improve engagement in mental health treatment among aging adults who might otherwise slip through the cracks in our mental healthcare system. Jo Anne, thank you so much for joining me on the podcast today.

Dr Jo Anne Sirey: Thanks for having me. I really appreciate the opportunity to be here.

Host: Well, it's wonderful to have you. I want to begin, as I often do on this show, by asking how you developed an interest in your specialization, specifically in geriatric mental health. Were there specific reasons why you gravitated toward work focusing on older adults?

Dr Jo Anne Sirey: When I think about it, there's probably two reasons. One is very personal and one more professional. On a personal note, I grew up in New York City and I spent a great deal of time with my maternal grandmother, and she spent a lot of time with her friends and family. When I look back on them, they were physically active, they were social; they spent a lot of time together eating, playing cards, laughing. They really didn't fit the stereotypes I saw of older people. And I think back and I think my affection for them growing up really grew into my appreciation of older adults in general. And then, when I came to Cornell, which was over 30 years ago, I came with a very strong research focus and I met Dr. George Alexopoulos, who was a leading researcher in late-life depression. I was honored to be offered a position to work with him and to really learn about research in later life with him. He's been a mentor and a guide for my career, so I think those two paths have really led me to where I am today.

Host: I remember Dr. Alexopoulos when I was a first year resident working on the geriatric inpatient unit, and just his wisdom and learning so much from him, but also having my first experiences seeing profound depression in older adults and seeing them get better in profound ways, which was really actually inspiring to me as an early resident.

So, thinking about that depression, which I witnessed at that point and have seen subsequently in my career, late-life depression, can you highlight the key features of this disorder in older adults and what aspects of it are similar to other ages or maybe unique to individuals at this stage of life?

Dr Jo Anne Sirey: In some ways, I think depression is similar, whether it's in younger adults, midlife adults or older adults. There are two features of depression that really characterize it, sad or low or irritable mood and decreased interest in usual enjoyable activities. And I want to pause for a second because that second item, decreased interest in pleasurable activities is really important because in later life, some people may stop doing things that they enjoy because of physical disability or medical burden. And that's very different than stopping, participating in something you really enjoy because you don't have an interest anymore, because you don't feel like doing it, because it just doesn't give you pleasure anymore. And I think that's an important difference between younger and older adults.

That said, the profile of depression, and this is part of what makes, I think, depression interesting, if you will, from an academic perspective, there's a tremendous amount of variability amongst individuals, both old and young, and the profile of symptoms. When I go out to the community, I like to remind audiences that I'm talking to that someone can say they're not enjoying things. They're having difficulty concentrating. They're not reading like they used to or have difficulty watching television. They have sleep difficulties, they're waking up a lot, or they're having trouble falling asleep or waking up very early. They have very low energy. And they're feeling kind of hopeless about the future. And so, they can report that profile of difficulties and never see the word depression or sadness and still meet criteria for depression. So, I think we have to be kind of open in how we think about depression in later life.

Host: And so, having clinicians who can assess this see the hallmarks of depression is hugely important, because as you said, the patient may not name it as such because there are treatments that are effective and I'd like it if you could describe some of them, some of the main evidence-based treatments for geriatric depression and what modalities maybe are uniquely effective for older adults if there are some.

Dr Jo Anne Sirey: There are a number of really effective treatments for depression. I think it's really important to frame depression as a public health issue because we do have such effective treatments. Both therapy and medication are effective for late-life depression. There are a number of brief therapies that have strong evidence and can improve depressive symptoms, such as cognitive behavioral therapy, behavioral activation. And here at Cornell, with our colleagues at the University of Washington, we developed something called Engage therapy. And in all of these therapies, the clinician is working with the older adults to set goals, to address the symptoms. They really have the opportunity to personalize what they're doing to address their particular set of symptoms and that's very effective.

 Of course, antidepressant medications are also very effective. And these days, antidepressants have much lower side effects, and they're much more quick acting than they were in the past. I think one of the things that's a bit of a challenge is our older adults often remember when our medication treatments and our therapy treatments were a little cruder and a little less effective, and so they may be a little reluctant to use what we're offering.

Host: Well, I certainly know that there's been a lot of advances in the biological treatments. But you specifically talked about some of the therapy advancements. I just was wondering if you could give us a little more detail on Engage and what that entails.

Dr Jo Anne Sirey: So, Engage is a really interesting therapy because it focuses on working with the individual to rebuild activities that they have withdrawn from because of the depression. So, they'll set targets, they'll set plans, they'll set a schedule of what they're doing. And what Engage does is, for some people, that's really enough. Just setting those plans and preparing for these kinds of activities can kind of increase their engagement and that engagement decreases depression. That's the mechanism of action. But for some people, there are presentations that they have. They may feel like there's nothing that's going to make any difference. They may feel like they have some apathy. And Engage addresses those specific barriers. So, it's really, truly very personalized.

The other thing that's interesting about Engage is because it is so tailored for the individual's life, the patients or clients who participate often feel like it's very personal and meaningful. They enjoy it. Therapists enjoy delivering it. And that's really nice because I think everybody feels like they're doing something meaningful and personal. And then, the therapy feels like it resonates with the individual's goals, not just something that we are kind of grafting onto their experience.

Host: Engaging. And I think engaging is key in what we're discussing today, because as you just described, there's many effective evidence-based treatments, but geriatric depression is undertreated in our country. Can you tell us about this treatment gap? What are the causes?

Dr Jo Anne Sirey: Yeah. And I think, again, going back, that's why I really feel like thinking about this as a public health issue is really important because depression, as we know, is one of the key predictors of suicide. And so, we really want to get across the message to people that depression doesn't go away by itself. It really does require treatment. And that kind of myth or stereotype that depression is either a part of aging or it will go away by itself is one of the key kind of psychological barriers.

But there are a lot of barriers that people can face. Symptoms, if they are recognized, can be attributed to illness or even aging. Somebody can see somebody who's depressed and say, "Oh, she's not participating anymore because she's old. She's sad because she's old or because she's sustained losses." And while it is true that later life does come with losses, that doesn't necessarily mean that it has to come with depression.

So, I think we have some preconceived notions about aging and about what aging looks like, that can be a very important barrier both for the person who's experiencing depression for family members, but even for providers. Providers may look at a profile of symptoms and I think they really want to do a good job. And so, they'll investigate medical causes for the symptoms and it's very difficult to tease apart low energy that might be related to a chronic illness versus low energy related to depression. So, I think it's a challenge, and it's a challenge for everybody.

Host: Everybody sounds like has their biases that can be ageist in working with this population. And then on the other side, you have alluded to stigma as a factor preventing older adults from seeking care. You've researched this specific problem, I know. Can you describe for our listeners how mental health stigma impacts seniors and what can be done to address this?

Dr Jo Anne Sirey: I think it keeps them away from us. That's the most important thing, is that they worry a tremendous amount of about what will happen if their symptoms are mental health symptoms, if they have depression. They worry about the impact on their life, they worry about how people will treat them. Will they exclude them from social activities? Will they not invite them to family gatherings or not hold them in the same level of esteem that they held them in?

 They're really concerned that it will make a difference. Also, as I said, they worry about the side effect profiles. They worry about being in therapy for very long periods of time. And I think we have to be very conscious of the fact that to be older means to be subjected to ageism, to be older and depressed means being subjected to ageism and mental health stigma. And to be older, have mental health need, and to be part of a marginalized group is really a triple whammy.

So, I think people are very cautious about how they approach treatment. I believe that people, when they approach many treatments, do a kind of a cost-benefit analysis. What will I get out of it and what will it cost me not just financially, but emotionally? And that then determines whether they'll reach out and access care. You know, we're talking about financial as well. I think that's important because many of our older adults are living on fixed incomes and they may be making some important choices about how they want to spend their money. So, I think there are many barriers at multiple levels. There's a complexity to this that is unfortunate.

I have to say that one of the things that happens is people ask me what I do for a living and I tell them. And inevitably, I met with a story of a family member, an aunt, a grandparent, who in retrospect had depression that went undiagnosed. And it's very sad because these, to me, are missed opportunities, but it speaks to the prevalence of this illness.

Host: I'm not surprised that that comes up in your work. And in previous episodes of this podcast, we've repeatedly explored entrenched issues of mental health equity and how the needs of so many in this country remain unmet despite the existence of treatments that can help, which is exactly what we're talking about today.

So, I want to inject some hope into this, because what's really exciting to me about your work is you've created solutions to these problems. You've designed, implemented and studied community-based treatment programs in New York City. Can you describe these interventions to our listeners?

Dr Jo Anne Sirey: With pleasure, I'm really excited by the programs that we've set up and the opportunity to serve older adults in New York City. And I'll tell you about two programs specifically. The first one is funded by the National Institute of Mental Health where we're offering a brief therapy program for older adults with depression. We call it Do More, Feel Better. And I think that really speaks to what we're doing. We're partnering with some excellent Manhattan centers, and we're testing to see if behavioral activation and evidence-based program that we spoke about earlier is as effective when it's delivered by peer coaches as it is with a social worker. So, it's a really interesting study because it's a workforce development study. So, we're really seeing could trained, certified, supervised peer coaches do some of this brief therapy work in the communities where we're offering these programs.

And what's really exciting about it is that we imagine that it's possible that for some older adults, working with somebody who's part of their community, who is maybe more culturally and age-related aligned with them, that might be more preferable to them than coming to the Upper East Side Medical Center. So, we might actually be able to set up programs where people are served in communities where they're receiving other services, where they may be going to their senior center or a faith-based community. So, it's a really exciting program. And because it is research, the therapy is free. So, it gets around that issue about co-payments and worrying about the costs of treatment. So, that's a really exciting program. That's a research program.

And then in addition, I've been very lucky to partner with the New York City Department for the Aging. It's called NYC Aging Now, where we set up mental health services in 20 senior centers in Brooklyn and Staten Island, and that's the program that we call TRIO for Successful Aging. We call it that because we believe that mental health, good medical care, and staying engaged in social programs like senior centers are really the trio for successful aging. My wonderful staff are out located at the senior centers and they provide education, they do needs assessments, and they provide brief therapy located at the center. And that's particularly nice because somebody can come and take advantage of the resources at the center. They can have lunch, they can do chair yoga, they can meet with a case assistance worker and get help with Accessoride and, at the same time, get a mental health service. So, it's a much more holistic approach towards mental health care. It's a real win-win as far as I'm concerned.

Host: This makes so much sense because you're specifically addressing the barriers to care, and what you've described in those programs where we have a shortage of providers and that's where peer coaches come in, but then peer coaches have added benefit in terms of their connection and similarity to the people that they're working with. Maybe perhaps doing away with some of the stigma that comes with having to see a mental health professional. And then in TRIO, you're bringing the services to where people are. So, these are great examples of how to deal with barriers to care. I was thinking about this specifically because in our last episode, I spoke with George Makari, who spoke about our mental health crisis and how that there isn't a lot of funding from the NIMH for treatment programs out in the community. But I look at your work as a shining example of exactly that.

Dr Jo Anne Sirey: Yeah. I actually think that we may see a change. There have always been some monies allocated to public health programs and community-based programs. I've been funded for quite a few years and very lucky in that sense. But I think that there's an increasing understanding that there may be a limit to what we can learn with brain-based research that doesn't have a clinical component. And so, I have wonderful colleagues who do great brain-based research and MRIs before and after therapy. So, there's some really nice work out there. But I think there's an increasing appreciation of the clinical impact. Does it make a difference, and for whom? Does it only make a difference for those people who participate in trials, who know about academic medical centers that tend to be funded by the federal government? Or can we get these interventions out to a kind of broader community? So, I'm hopeful that we can see a change that will include dollars.

Host: I'm really happy to hear that. And again, your work is a shining example of that. So, thinking about the work out in the community in New York City, one of our, I believe, greatest strengths is the diversity of our population, yet the richness of this multifaceted urban culture does present challenges. It requires a sensitivity to the unique cultural aspects of different communities, especially when it comes to a topic as sensitive as mental health, which as you pointed out, is full of so much stigma for many, many people. So, can you speak to how you were able to navigate this in your work with a diverse population of older adults in New York City?

Dr Jo Anne Sirey: We take this very seriously. New York City is very large and very diverse. It represents a wide range of languages, cultures, faiths as well as broad geographic areas, some of which have a lot of services and some really don't.

I think at the most practical level, we speak the languages of the communities we serve. So for research programs, we offer care in Spanish and English. And for our senior center program, we offer services in seven languages. And this is kind of interesting because pre-pandemic, the individual who spoke Polish was only located at one center. But now, we are working both in person and hybrid or telehealth. And so, we have the opportunity to take advantage of those seven languages across New York City. So if my Russian-speaking clinician is located in Staten Island, but we have somebody who speaks Russian in the Bronx, we can actually offer them remote services. So, I think that's a really important characteristic of the services that we offer, is that we take that very seriously, because that can be the first and most difficult barrier to overcome.

The other way I think we try and address the diversity is with these kind of more personalized therapies that we were talking about earlier. The therapy is very tailored to the goals of the individual, to their personal context, to what's meaningful and valuable in their life. And so in that sense, if they're part of a faith-based community and they are active in that community, then doing more could include going to services. It could include participating more with that faith-based community. If it's somebody who has a particular cultural orientation that they really want to focus in on, the therapy can help them work to achieve that goal. So, I think our therapies have gotten more personalized and that really allows individuals to work within their unique context and highlight what's important to them.

Host: This is wonderful, the different ways in which you can really meet people where they are. And another thing I wonder about is in the Do More, Feel Better Program. You are using peer coaches and I imagine those peer coaches as peers are able to engage in some of the same contexts and cultures of some of the people they're trying to help.

Dr Jo Anne Sirey: Absolutely. And I think our older adults may be then looking at somebody who looks more like them and might be more in the context that they're living in and that again might reduce some of the stigma, that sense of dealing with another and might make it more accessible.

The other thing that's really interesting about Do More, Feel Better is that, as I said, it is behavioral activation and many people use that, but this particular version starts with a values clarification process where we step back and we work with the individual to identify what's meaningful in their life, where they want the emphasis to be. Is it social? Is it spiritual? Is it health-related? Is it family? And so, that kind of values clarification can even kind of help somebody really tailor the treatment so that it fits their unique goals and their unique context.

Host: Thank you for describing that aspect of it. I mean, I think, again, the community-based nature of this is really what makes it special. And I want to congratulate you on receiving a $2.7-million NIMH grant for your study of an intervention to reduce depression among elder abuse victims.

Dr Jo Anne Sirey: Thank you. Thank you so much.

Host: What should people know about elder abuse and how it's related to geriatric depression? And what's the intervention that you're going to be investigating in this study?

Dr Jo Anne Sirey: Elder abuse is far too common. In the United States, it's estimated that approximately one in 10 Americans over the age of 60 have experienced some form of elder abuse. And many times, it goes unreported because the alleged abuser is a trusted person. That's the nature of the abuse. It's a friend, it's a family member, it could be a caretaker. So, it really makes it extremely difficult for the older adult to report the abuse.

In New York City, we actually have an interesting system where we have two sets of programs who help elder abuse victims. One program helps victims who don't have the ability to make their own decisions, either because of cognition or because of medical burden. And then, we have another program of services that's specifically designed to help people who can make decisions about their own treatments and make decisions about their lives, who have, as we would call it, capacity, capacity to make decisions. And these community-based programs work with victims to provide them information, to help them create safety plans, set limits with the abuser, even get legal help like an order of protection.

And I think when we began to work with the New York City Department for the Aging, they were aware that in addition to offering these kinds of services, there might also be mental health needs. And so, they actually reached out to us to work with them to address the depression that might make it even harder for elder abuse victims to do the kinds of tasks that they're being asked to do, like set limits or put a safety plan. And if you think about it, I think it makes a lot of sense if you are feeling hopeless or you have low energy or low mood and you're being asked to get an order of protection or to set limits with somebody who's very important to you, like a grandchild.

Depression can really make things more difficult, so we actually have this program where we offer a mental health intervention at the same time that they're getting those elder abuse services. It works in tandem, so the two programs go hand in hand. At the same time that they're working with the community-based program, we are offering a brief behavioral therapy for depression. The program, we call it PROTECT, which is an acronym. But PROTECT works with the victim to do two sets of things. One, engage them in goal setting to really define what the goals are related to the elder abuse. What do they want to see happen? What do they need to do to get those goals? Where they want them to be, what steps have to be taken? And goal setting is the kind of thing that can be very mobilizing and create a real sense of empowerment when you set goals. And we often start with small goals and then build to larger goals. So, we offer goal setting. And at the same time, we use that behavioral activation technique that I was talking about earlier, where we're working with the victim to get re-engaged in the activities that they have probably withdrawn from.

One of the things that we know about elder abuse is that social isolation is both a risk factor and a product. So, many of these older adults may have stopped going to the activities or to the places that they enjoyed over the years because of the abuse. So, getting them kind of reconnected is one of our important goals.

Host: One in 10. I mean, this is such an important subgroup of a population that as we described is already overlooked. It's, I think, amazing that you've been able to do this research at the same time that you're working with the New York City Department of Aging, New York City Aging to implement the program. So, you're both offering the services and researching it at the same time. Is that correct?

Dr Jo Anne Sirey: That's correct. And, you know, one of the things that characterizes my work in the community is it's always partnered. We always have a community partner that we're working with, whether it's aging services or it's elder abuse, or even when we're working in primary care or a rehabilitation hospital, we are always in somebody else's living room, if you will. And building a partnership where they trust us and we can work with them allows us to both offer the services and evaluate the outcome. And that really comes also from our goal to make sure that when we're moving services into the community, that we're moving quality care, that we're having the kinds of effects that we're looking for, and that we see reductions in depression that we would see in the, as we call it, lab into more controlled conditions. We want to make sure that when we're bringing it out to the community that they're seeing the same results as we've seen in a more controlled environment, and that's very important.

Host: I wanted to ask you about technology. And you alluded earlier to having remote sessions or telehealth sessions using platforms like Zoom. Can you speak to how these have offered advantages and are there some disadvantages to this technology?

Dr Jo Anne Sirey: I always laugh to myself when somebody asks me about this because many years ago, Karl Pillemer actually asked me about remote delivery of one of the interventions I was working with at that point. And I really said, "Oh, no, I don't think we're ever going to do that. It won't work as well. Got to be in person." Boy, was I wrong. I guess the important message is things change, which is good. so, you know, I think for those older adults who are comfortable with technology or interested in even learning. Virtual care can be a real opportunity. It can offer them the opportunity to have therapy from their home. It can reduce the burden of transportation. It can also reduce weather-related cancellations, which is really nice. So, it can really make it much more accessible, which can be really ideal for some people. We offer the therapy by telephone as well, because there are individuals who don't have smartphones or don't have Wi-Fi and have only a landline. So, we really try and make it accessible for them to have therapy in whatever modality works for them. That being said, we also work with a number of individuals who want to be seen in person. And they want to come to the senior centers or they want to come to our offices, either by choice or again because they may have some limitations in terms of their technology use. And so, I really think actually having the flexibility is the ideal scenario to be able to work with the individual's preference, is really the most effective way to offer services.

Host: I would imagine over time, more and more older adults are going to become more and more familiar with technology. And I'm wondering, are there other technologies you envision being helpful in narrowing the care gap for older adults who are struggling with depression?

Dr Jo Anne Sirey: Yeah. I think there's a tremendous amount of variability in terms of the current knowledge of technology, and I agree with you. I think over time we really will see more and more people comfortable with the technology as we age. So, that's nice. I think if I imagine what we could be seeing in the future, there are some really wonderful technology-based apps that really can help individuals track their mood, practice therapeutic strategies. And as people become more and more comfortable with technology, these applications could help them extend the work that they're doing in the individual therapy sessions throughout the rest of their week. So, we can help them keep track of their moods or stay on target with their goals. And so, I think this might actually extend the work that we're doing and maybe even make it more powerful. So, that would be a nice opportunity in the future.

Host: What other resources do you recommend for older adults who struggle with depression or for their family members who are trying to help them?

Dr Jo Anne Sirey: Yeah, that's always tricky, right? Because the internet is the wild, wild west in some ways. But I really like the NIH website. The National Institute of Health has an excellent website and it's very user-friendly, which is very important. The CDC has a great website. The American Association of Geriatric Psychiatry, also very user-friendly and can help an individual find if they need a geriatric psychiatrist. So, I think there's some really excellent websites out there and I would encourage people to go to those websites.

I think the most important thing is to have individuals reach out and talk to somebody. There are some great resources at Cornell. We have some great programs in the community. We also have some wonderful research programs taking place at the medical center as well, as well as services. So, I think being able to feel comfortable reaching out, even if it's just to learn more. They don't have to make the commitment, but just learn more about what the opportunities are, is really the most important steps that I think people can take. I think if I leave you with one thought, it's just really important for us to always remember that depression is definitely not a normal part of aging.

Host: I think that's a really important thing for us all to remember, that again, so often this is overlooked and this is not a normal part of aging. So really, I'm going to reemphasize what you said. But I also want to do something that I do on every episode, as I end this podcast, which is to ask you as one of our guests to share any tips on things you do to support your own mental health.

Dr Jo Anne Sirey: I think I aspire to be like my grandmother. I keep active. I get up every morning and I go for a hike in the woods with my dog and I think being connected to nature and exercising is great. I also work very hard to stay socially engaged. I'm lucky to have a wonderful spouse and amazing grown daughters and dear friends. And I think we like to enjoy spending time together, laugh together. I think humor gives us perspective and, it really makes us feel great.

So, one of the things that I want to leave with your listeners, is that anybody who wants to learn more about our programs or our services can go to our website. It's called Sirey Lab at Weill Cornell and there's a description of our programs and a number of numbers to reach out to learn more about the kind of work we do. So, I really want to encourage people even just to look at the website and call us and ask us a question.

Host: Thank you. Well, Joanne, I'm so grateful to you for joining me on today's episode of On The Mind. You shed light on this important, but often overlooked topic that we all should be thinking about as the baby boom generation enters this advanced stage of life. And I think you and I are heading there before we know it ourselves.

So for our listeners, if you're interested in learning more about mental health for aging adults, you can look up the Sirey Lab as Dr. Sirey just highlighted. You can also learn more from Dr. Sirey in Weill Cornell Medicine Psychiatry's Suicide Prevention Month Programming that takes place each September. Visit our website to view upcoming events and resources on suicide prevention for aging adults. Thank you so much once again for joining us.

Dr Jo Anne Sirey: Thank you for having me. I really appreciate the opportunity to share my work with you and your listeners.

Host: And thank you to all who listened to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts and iHeart Radio. If you like what you heard today, tell your friends, give us a rating and subscribe so you can stay up to date with all of our latest episodes. We'll be back soon with another episode.

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