When most of us picture a depressed person we think of we picture someone who is very sad, possibly weepy and maybe even despondent.

However the signs can be quite different in an elderly person.

Johns Hopkins University geriatrician Alicia Arbaje said depression can be difficult for even doctors to recognise in elderly patients because it often manifests physically.

Seniors suffering from depression may not appear sad and weepy. Instead they may have low energy, a loss of appetite, or aches and pains in their bodies.

"It's very difficult to diagnose because so many other things look like depression in the elderly population," she said. "Low energy, weight loss, sleeping disorders – where either they sleep too much or not enough – or an inability to concentrate can be signs of depression, but they may also be symptoms of other conditions. That's the difficulty in diagnosing it."

Doctors at Johns Hopkins Bayview Medical Center cater to the geriatric community on an outpatient basis. According to Dr. Arbaje, depression is one of a group of conditions doctors there have classified as geriatric syndrome. They are not diseases but are a group of medical problems that affect the elderly.

"Depression is a big issue for older adults and has special needs for older people," she said. "It affects at least 25 percent of those with chronic illness and because the elderly have more illness they are more at risk."

Dr. Arbaje said more than half the residents in nursing homes in the US suffer depression. In Bermuda there are no statistics and it's not clear that depression is a significant problem in the senior population.

Fred Hassell, social gerontologist and director of the Senior Islanders' Club, said from his perspective it is rare.

"It's not something I've come across in my more than 30 years of working with seniors," he said. "If it exists these must be people of tremendous fortitude and strength that they have had some other source where they have dealt with things."

He said he felt the strong community networks of church, family and social groups had helped Bermuda's seniors to weather their hardships without suffering depression. But he admitted that complaints of aches and pains where no physiological problem existed are often attributed to old age.

"If it (depression) exists and manifests physically I don't know. But I hope [general practitioners] recognise it and are able to offer treatment," he said.

However a retired nursing home matron, who asked not to be named, disagreed.

She said she believes many of Bermuda's elderly are suffering depression. She guessed that some try to hide it while others are unaware that they are depressed.

She described a friend who constantly complains since her grandchildren have moved overseas, as not recognising that her emotional state has progressed to depression.

"I believe she needs to feel useful and the loss of her grandchildren coupled with her loss of freedom after she broke her hip, has made her depressed," said the retired matron.

"In the nursing home setting I think a lot of the elderly have time to reminisce. They think about their lives and what they could have done and should have done way back when, and then they go on a guilt trip and end up depressed," she added.

This is typical not only in Bermuda. Dr. Arbaje said depression in nursing home residents is significantly higher than in elderly patients living in their family setting.

"It's not clear if this comes from being outside their family setting or because they are too sick," she said.

Admitting and recognising the existence of depression in the elderly is particularly important, as treatments are available.

"Often the elderly are too embarrassed to seek treatment and often their doctors don't recognise it," said Dr. Arbaje.

She said caregivers should encourage the elderly to talk to their doctors about how they are feeling. Where a person does not do this, her advice is for a family member or other caregiver to inform the doctor.

"Family should play an active role and monitor the effect of treatment," she said. "There's no clear test for depression but you can look for changes in behaviour and mood. Have they stopped playing with the grandchildren, and after treatment have they resumed interacting with family and playing with grandchildren?"

The retired matron said she felt loneliness often sparked depression for Bermuda's elderly. Dr. Arbaje agreed and said that including them in family activities especially during the holidays was important both in helping to prevent depression and in its treatment.

According to Dr. Arbaje depression is successfully treated in about 80 percent of cases with psychotherapy and antidepressant medications. But she warned that it is usually more deeply rooted than in younger people.

"It is more difficult to treat because they usually have waited too long for treatment," she said. "In about half, the depression is a continuation of problem they had when they were young. It's usually a relapse of an earlier depression or triggered by the development of a new condition – like moving to a nursing home, another illness, death of a loved one, medication or hospitalisation."

She stressed that patients should stick to their treatment noting that it might take as long as two or three months to notice any improvement.

"I want to avoid people stopping after two weeks because they don't feel better. It will come," she said.

Exercise, eating well, maintaining healthy family relationships, dealing with problems as they arise and limiting alcohol consumption are all ways to reduce the risk of falling into depression.