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FINDING LIFE AFTER DEPRESSION

More than 20 years ago, Helen Janulis paid $10,000 to send her daughter to a rehabilitation center to help her stop drinking. Her daughter stayed sober, drinking only Coke when she visited.

But in January 2000, when her daughter visited, she got out of the airport limousine at Janulis' home and promptly said she was thirsty. Janulis suggested a Coke. "I'm talking about a drink drink," her daughter growled. "I know you've got something here, and I'm going to find it."

Shortly after dawn the next day, Janulis heard her daughter call a taxi. She returned about noon, with packages loaded with vodka, tequila and beer. She flopped on the couch and slept. Janulis sat in a recliner watching television.

During an episode of Touched by an Angel, the daughter woke up.

"She started talking about something that happened 40 years ago," said Janulis, 72. "I said, "I don't know what you're talking about.' That's when she jumped on top of me, punching and screaming."

The daughter kneeled on her mother's thighs, bouncing up and down as she punched her. She broke her mother's nose, cracked her pelvis and dislodged her hip replacements. Her blows detached the retina of her mother's right eye, causing permanent vision loss, and damaged some teeth. When Janulis covered her face with her hands, the daughter kept punching, breaking several of her mother's fingers.

A neighbor, hearing the screams, ran in and pulled the daughter off Janulis, but the daughter kept swinging. When three police officers arrived, she punched one officer in the jaw so hard that he fell. The officers finally subdued the daughter, and paramedics transported Janulis to the hospital. Doctors put a cast on her ankle, secured the hip replacements with staples, and set her broken nose and broken fingers. After several weeks, Janulis was transferred to Integrated Health Services of Pinellas Park, where she received five months of physical therapy. But some of her worst injuries were invisible.

Hurting so much

After the attack, Janulis had trouble sleeping and would be wakened by nightmares. Her hands shook so much that she could not write a check, and she would lapse into uncontrollable crying spells. She told friends to stop calling. "I'm tired of talking about myself," she snapped. Finally, she thought of a solution to her troubles. "I just won't eat," she said. "I'll starve to death. Who's going to miss me?"

With a cast on one ankle and surgical scars in several places, Janulis was in pain and didn't feel much like eating anyway, so hospital personnel were not surprised when her weight dropped below 100 pounds.

"How much can you eat when you hurt so much?" Janulis said. "I'd just pick at my food. Besides, the food was lousy."

Her story could have ended with a quiet death from malnutrition, but the Area Agency on Aging of Pinellas/Pasco Inc. maintains a Senior Victim Advocate Program, and because Janulis was a victim of a crime, the police reported her case to Gabrielle Wiechec, a victim advocate with the agency.

"When seniors are victimized _ when anyone is victimized _ it can trigger depression," said Wiechec. "Helen clearly was in need, especially with a broken hip; so as a victim advocate, I try to link seniors to the services they need."

Wiechec connected Janulis with Kimberly Tennant, a licensed mental health counselor and the director of the Geriatric Crisis Response Team for Gulf Coast Community Care. (Tennant is now director of Elder Behavior Health Services for GCCC). Tennant recognized that Janulis, in addition to suffering from depression and post-traumatic stress syndrome, was having suicidal thoughts.

"She had the classic symptoms," Tennant said. "She never came out and said, "I'm going to kill myself,' but when I met Helen I recognized she was having suicidal ideation."

Tennant met with Janulis frequently, providing therapy and support well beyond the typical 90 days.

"I've been with her for three years because of the unrelenting crises," Tennant said. She has helped Janulis with everything from counseling to filing insurance forms to getting the newspaper delivered. Tennant reminded her that her grandchildren would miss her if she were gone, and she persuaded Janulis to start going out.

"We started small," Tennant said. "We started with trying to get out of the house once a week, even if it was just to go to the grocery store."

In the beginning, Janulis resisted. "I thought, "Who wants to look at this old bag hobbling around?' " she said.

But eventually she started to engage with people. She has had other problems since the incident with her daughter. Her mother and her brother died. Her son got into trouble with the law, damaged her car and ransacked her house while she was recuperating. She developed circulation problems in her legs and fell last year while making breakfast, shattering her ankle. Despite all that, Janulis is coping and no longer has thoughts of suicide.

"If I hadn't met Kim, I don't know how I could have managed," Janulis said. "The thing about her was, I knew I could call her any time, day or night."

Necessary help

In the United States, people older than 65 commit suicide more often than those in any age group. Although they make up about 12.7 percent of the population, seniors account for about 19 percent of all suicides. Among people older than 85, the suicide rate is nearly double the national average. The elderly also have a higher completion rate when they attempt suicide. Among people 65 and older, the ratio is four attempts per suicide. Older Americans are less likely to survive a suicide attempt, but they also tend to plan their demise carefully and use firearms or other highly lethal methods.

"Unrecognized and untreated depressed older persons are at high risk for violent, tragic and unnecessary deaths: suicide, homicide and homicide-suicide," said Donna Cohen, a professor in the Department of Aging and Mental Health at the University of South Florida.

When Cohen arrived at USF in 1992, she was surprised by the frequency of homicide-suicide cases in the Tampa Bay area. Cohen discovered that little research had been done on homicide-suicide cases among the elderly, so she began to study the problem. She discovered that older people have higher rates of homicide-suicide than do younger people.

"Eighteen people a day 65 and older commit suicide in the United States _ two a day in Florida alone," said Cohen, who is also the founding director of USF's Institute on Aging and head of the Violence and Injury Prevention Program at the Florida Mental Health Institute in Tampa. "Florida is eighth (in suicides among people 65 and older), but we're No. 2 in suicides among people 85 and older."

In fact, white males commit 80 percent of elderly suicides, according to Cohen.

What's important is that the number of suicides could be reduced if someone _ a family member, a spouse, a friend, a physician or even a neighbor _ detects the signs of depression and suicidal intent and takes steps to intervene and provide support.

Even though depression is not a normal part of aging, seniors are more susceptible because of health problems, bereavement, loneliness and other forms of stress, which often are precursors to depression among people of any age.

Some evidence suggests that the cardiovascular changes common in old age might trigger depression. Researchers at Duke University have found a correlation between depression and "silent strokes," which are tiny disruptions of blood flow in the brain that may produce minor symptoms and barely detectable damage to brain cells.

"In these patients the stroke involves areas of the brain primarily related to cognition and mood regulation," said K. Ranga R. Krishnan, chairman of the department of psychiatry at Duke.

"This type of depression is called vascular depression; however, the relation between depression and vascular change is not clear."

Depression in the elderly is also easily mistaken for fatigue and listlessness, according to David Steffens, one of Krishnan's colleagues.

"The symptoms may not be the boo-hoo depression you see in people in their 20s and 30s," Steffens said. "Instead, you'll see more apathy and inability to enjoy activities. Older people are more likely to pull away and lose interest in life, which is very different from profound sadness and crying. That's why it's harder to identify. These elderly people aren't saying, "I'm so sad. I'm crying all the time.' They just don't seem as interested in things, which many people may take as a sign of dementia."

Signs of depression in seniors can be difficult to recognize; even primary-care physicians often miss some of them.

According to the National Strategy for Suicide Prevention, 20 percent of the elderly who committed suicide saw a physician on the day they died, 41 percent had seen a physician within a week and 75 percent within a month.

"Doctors should routinely screen for depression," said Cohen. "In the forms they have patients fill out, they could include 10 or 20 questions that might help them screen for depression. In talking with patients, they could ask them how they're feeling."

In an editorial she wrote last year for the Journal of Mental Health and Aging, Cohen discussed the difficulty of predicting which seniors are at risk for suicide.

"Suicides are a preventable problem," she wrote. "However, prevention is predicated on prediction, and, sadly, we are not very good at predicting suicidal behavior."

The best strategy is to know the warning signs. In November, the Area Agency on Aging Pasco-Pinellas held "Suicide Prevention in the Elderly," a conference at St. Petersburg College.

Gwen Williams-Lewis helped organize the conference and said one of the primary goals was to help people recognize signs of depression, such as sadness, lethargy and apathy, sleeping too much or too little, sudden weight loss, etc.

One of the greatest obstacles to awareness, she said, is the reluctance of the elderly to discuss depression and suicide.

"There's a lot of stigma among the elderly regarding depression and suicide," said Williams-Lewis, the health and wellness coordinator for the Area Agency on Aging of Pinellas/Pasco Inc.

"When I do presentations on depression, I use titles such as Staying Emotionally Healthy, or Being Happy. We tell them that depression is a chemical imbalance. That seems to go over well with seniors."

For Janulis, recovery continues. She walks with a walker and is in constant pain from her injuries, but stomach problems force her to limit her pain medication. Her daughter spent a year in the Pinellas County Jail after the beating and was transferred to a facility out of state.

Janulis does not know where her daughter lives and does not expect to have any contact with her, although she suspects that daily hang-up phone calls might come from her. Her son still struggles with a drug problem, and she has given up the piano and teaching music.

"The only pleasure I ever received was from music," she said.

"I've never really gotten over it (the beating)," she said. Still, with the help and support of Tennant, Janulis has been able to get on with her life.

When asked what her goals are, Janulis replies ruefully, "I hope to stay alive another year or so."

Tennant, always looking for the positive in her client's life, reminds her, "You've come a long way Helen _ three years ago you wanted to die."

Tom Valeo writes the Body of Information column and is a freelance writer in Chicago.

TEXT OF CHART ACCOMPANYING STORY NOT PROVIDED FOR ELECTRONIC LIBRARY. PLEASE SEE MICROFILM.

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