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Epidemiology and diagnosis of depression in late life
Abstract
Depression is a significant concern in elderly patients. Reported prevalence rates differ greatly depending on the definition of depression and the population of interest, with increases reported in settings where comorbid physical illnesses are more common. In community-dwelling elderly patients, prevalences of depressive symptoms and major depressive disorder are 15% and 1% to 3%, respectively. Factors associated with depression in the elderly include female gender, alcohol and substance abuse, pharmaceuticals, family history, and medical conditions such as stroke, Alzheimer's disease, cancer, and heart disease. Recognition of depression is complex because patients often deny their depression, present with somatic complaints, or may have comorbid anxiety or cognitive impairment. Depression is underrecognized and undertreated in the elderly, despite evidence that the benefits of treatment outweigh potential risks.
... A depressive episode may or may not qualify for a diagnosis of a depressive disorder, including but not limited to major depressive disorder and dysthymia. The term 'clinically depressed' is also sometimes used to denote a depressive syndrome warranting clinical attention" [5]. ...
... Depression is a problem of major public health importance in late life too [5]. ...
... Overall, the prevalence of depression ranges from 8.8% to 18.3% in people aged 60 years or older [7]. In community-dwelling elderly patients, prevalences of depressive symptoms and major depressive disorder are 15% and 1% to 3%, respectively [5]. Health ...
... The literature on depressive disorder prevalence is extensive. For example, major review papers from 1980 to 2020 suggest community point prevalence estimates for MDD in late life ranged from 1-5%, with most falling at the lower end of the range (Beekman et al., 1999;Fiske et al., 2009;Knäuper & Wittchen, 1994;Lilford & Hughes, 2020;Mulsant, 1999;Renn et al., 2020;Tanaka et al., 2011). A meta-analysis of community-based older persons ≥75 years indicates slightly higher rates of the older-old as compared to studies using samples ≥60 years (7.2% pooled prevalence;Luppa et al., 2012). ...
... Clinically relevant symptoms of depression were often more frequently observed in community samples compared to categorical estimates of disorder prevalence (1.7% to 15%;Büchtemann et al., 2012;Esfahani et al., 2021;Mulsant, 1999;Sherina, 2004;Thapa et al., 2020;L.-T. Wu & Anthony, 2000). ...
... Compared to community settings, primary care and acute short term inpatient settings showed higher prevalence of both MDD diagnoses (5-12% inpatient and 10-16% acute inpatient) and clinically relevant symptoms (5.9-22.9% primary care and 17-25% acute inpatient; Alamri et al., 2017;Fiske et al., 2009;Ganatra et al., 2008;Mulsant, 1999Mulsant, , 1999 W. L. Wang et al., 2019;Wongpakaran et al., 2019). Similar or slightly higher estimates were shown for depressive diagnoses (14-54.5%) ...
Background: Late life is typically accompanied by unique physical and mental health challenges. Fewer older people are diagnosed with mood or anxiety-specific disorders than their younger counterparts. However, older people score more highly than younger people on symptom screens indicating high levels of clinically relevant depressive, anxiety, and nonspecific psychological distress symptoms which cause high morbidity, mortality, disability, and poor quality of life. The unique presentation of late life psychiatric syndromes, such as depression and anxiety, remain largely unaddressed in existing psychiatric nosology and measurement techniques, as do depictions of depression and anxiety across diverse cultural contexts. Very few studies exist investigating either the descriptive epidemiology of depression and anxiety among older adults living in low-middle income countries (LMIC) or the unique challenges of mental health measurement in LMIC contexts. This dissertation contributes to this developing evidence base by providing a critical analysis of point prevalence estimates of depression, anxiety, and nonspecific psychological distress (distress) symptoms in two samples of Indonesian rural older persons. Methods: We enumerated greater than or equal to 60-year-olds in 12 Indonesian rural villages as part of the Ageing in Rural Indonesia Study in 2015/16 (N=2526; sample 1). We re-enumerated two of the 12 villages surveyed in 2015 in 2017 (N=536; sample 2). Depressive and distress symptoms were each measured using three scales: PHQ-8/9, CES-D, GDS, and K6, DQ5 and SRQ-20 respectively. Anxiety symptoms were evaluated with the GAD-7. Classical Test Theory and Item Response Theory were used to investigate the psychometric properties of symptom screens. We also undertook mixed effects modelling and Moderated Nonlinear Factor Analysis to identify sources of variability in prevalence estimates. Results: Commonly used cut points of short symptom screens used to approximate diagnostic depressive disorders produced estimates that typically lacked comparability (e.g., sample 2 point-prevalence 3.2%-39.9%). Psychometric analysis further identified mental health scales with better (PHQ-8/9, GAD-7, K6, DQ5) and poorer (GDS, SRQ) construct validity. Sources of variability in point prevalence estimates of depression, anxiety and distress symptoms were identified, and related to study design, cognitive ability, marital status, financial means, level of social support, lifestyle, and health related status. Pervasive non-invariance was identified in participant responses to scale items related to gender, literacy, and ethnicity. However, when modelled, measurement non-invariance did not substantially modify means. Females, respondents with lower literacy levels, and Batak and Sundanese sample villages had significantly higher levels of depression, anxiety, and distress symptoms. Conclusion: The practice of using existing mental health symptom screens combined with commonly used cut points as proxies for depression and anxiety in older rural Indonesians and other diverse populations should be avoided. Rigorous psychometric and diagnostic validation evidence should be ascertained. In the interim, better performing symptom screening tools (i.e., PHQ-8/9, GAD-7, K6, DQ5) may be used as measures of continuous symptom severity. Future research should focus on evaluating the distinctive and overlapping features of mental ill-health in specific subpopulations of Indonesians.
... The link between age and the severity of physical symptoms may be explained by the increased likelihood of presenting with physical symptoms in older participants. Indeed, although SSD has received little attention in older people [37], physical illnesses in older people are known to be associated with prominent somatization [38,39]. Finally, people infected during the second wave were more likely to present SSD than people who were infected during the first wave. ...
... In agreement with the results obtained by previous studies [38,39,40], patients with SSD were found to report significantly higher health care use than other patients with COVID-19. This result confirms the high level of distress of these patients [15], which is likely related to the association of persistent physical symptoms and excessive and disproportionate health-related behaviors, both of them contributing to a risk of overdiagnosis and overtreatment [16,39]. ...
Objective:
Evidence shows that many patients with COVID-19 present persistent symptoms after the acute infection. Some patients may be at a high risk of developing Somatic Symptom Disorder (SSD), in which persistent symptoms are accompanied by excessive and disproportionate health-related thoughts, feelings and behaviors regarding these symptoms. This study assessed the frequency of persistent physical symptoms and SSD and their associated factors in patients with confirmed COVID-19.
Methods:
We conducted a longitudinal retrospective study after the first two French lockdowns at the Lille University Hospital (France), including all patients with confirmed COVID-19. Persistent physical symptoms and excessive preoccupations for these symptoms were measured 8 to 10 months after the onset of COVID-19. The combination of the Patient Health Questionnaire-15 and the Somatic Symptom Disorder-B Criteria Scale was used to identify the individuals likely to present with SSD. Two linear regression models were performed to identify sociodemographic and medical risk factors of SSD.
Results:
Among the 377 patients with a laboratory-confirmed diagnosis, 220 (58.4%) completed the questionnaires. Sixty-five percent of the 220 included patients required hospitalization, 53.6% presented at least one persistent physical symptom and 10.4% were considered to present SSD. Female sex, older age, infection during the second wave and having probable PTSD were significantly associated with the severity of SSD and SSD was associated with a significantly higher healthcare use.
Conclusions:
The identification of SSD should encourage clinicians to move beyond the artificial somatic/psychiatric dualism and contribute to a better alliance based on multi-disciplinary care.
... Depression is a common, but under-diagnosed and under-treated condition in elderly people, particularly in non-psychiatric settings (23) . The prevalence in previous data varied. ...
... The prevalence in previous data varied. It depended on the setting, community or hospital, the methodology in approximating, and the questionnaire or interview process used (23,24) . The prevalence of depression in the elderly Thai community dwelling sample was 13% (25) by using the Thai Geriatric Depression Scale (TGDS). ...
Objective: Investigate the prevalence and the characteristics of mental illness in elderly outpatients at Songklanagarind Hospital, a university hospital in southern Thailand. Material and Method: This was a cross-sectional study. We extracted the medical records of the outpatients aged over 65 years old diagnosed with a category (F) mental disorder in the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) over the periods between July 1 and December 31, 2014, from all outpatient medical records. We used R program for analyzing descriptive data. Results: There were 31,329 patients, aged over 65 years, who visited the outpatient clinic. We found that 752 patients in this group had been diagnosed with mental disorders; the prevalence was 2.4%. The most common diagnoses were: mood disorders (0.89%), organic mental disorders (0.85%), and neurotic-somatoform disorders (0.51%). Most patients (85.5%) received some form of medication. For each visit, the average medical fee for these patients was 3,431.30 Baht (96.80 US dollar). Conclusion: The prevalence of geriatric mental disorders, among the outpatients of Songklanagarind Hospital was much lower than the inpatient and community setting. This could be a reflection that some were under-diagnosed for these disorders in the outpatient clinics. One of these factors was the limited time available for each patient. We need some interventions and policies to detect these abnormalities early and thoroughly, so the patients would be receiving appropriate treatments, which in turn would provide them with a better quality of life.
... On the other hand, in adolescents and adults, the incidence is approximately twice as high in women, and is the highest in the 22 to 44 year old age group [4]. In the elderly aged 65 years or older, the male to female ratio becomes similar again [6]. ...
... It is known that MDD is not associated with socioeconomic status (SES) and it is not well correlated with education level [1,9]. MDD has been reported to occur more frequently in rural than urban areas [6]. The risk factors for MDD are slightly different from that for bipolar disorder. ...
Major depressive disorder (MDD) is one of the most common psychiatric disorders.
In general, 10% to 25% of women and 5% to 10% of men are at risk for having MDD once
in their lifetime. In addition, 5% to 10% of the population suffers from MDD, while 3% to
5% of the population is estimated to have severe MDD that requires treatment [1].
According to the Global Burden of Disease (published by the World Health Organization),
which considers both mortality and morbidity, MDD ranked fourth place among all
diseases. It is expected to rise to second place by 2020 following ischemic heart disease
[2]. The most effective way to reduce the burden of MDD is to prevent its onset by first
identifying high-risk individuals rather than treating MDD that has already started. MDD
prevention includes efforts to remove or reduce MDD risk factors. However, MDD is
thought to have multidimensional causes and pathogenesis in terms of bio-psycho-social
variables, thus risk factors are complicated. In this paper, the bio-psycho-social risk factors
for MDD are summarized.
... Approximately 15% community-dwelling older adults aged 65 and above endorsed clinically significant depressive symptoms (Blazer, 2003) and 1% to 5% were diagnosed with major depressive disorder (MDD) (Hasin, Goodwin, Stinson, & Grant, 2005). Despite its high prevalence, geriatric depression is not always recognized and remains untreated (Cahoon, 2012;Mulsant & Ganguli, 1999;Rodda, Walker, & Carter, 2011). This could, at least in part, be due to the atypical presentation of the depressed elderly (Brodaty, 1993;McCullough, 1991) who show less sadness and loss of hope (Avery & Silverman, 1984;Brown & Lewinsohn, 1984) and more cognitive impairment, apathy, lack of interest and motivation, anxiety, somatic complaints, and loss of insight (Kivelä, Pahkala, & Eronen, 1989;Mulsant & Ganguli, 1999;Butters et al., 2004;Rodda et al., 2011; recently summarized in Aizenstein et al., 2016). ...
... Despite its high prevalence, geriatric depression is not always recognized and remains untreated (Cahoon, 2012;Mulsant & Ganguli, 1999;Rodda, Walker, & Carter, 2011). This could, at least in part, be due to the atypical presentation of the depressed elderly (Brodaty, 1993;McCullough, 1991) who show less sadness and loss of hope (Avery & Silverman, 1984;Brown & Lewinsohn, 1984) and more cognitive impairment, apathy, lack of interest and motivation, anxiety, somatic complaints, and loss of insight (Kivelä, Pahkala, & Eronen, 1989;Mulsant & Ganguli, 1999;Butters et al., 2004;Rodda et al., 2011; recently summarized in Aizenstein et al., 2016). ...
A 56-year old Chinese female was referred to an academic medical center with atypical, treatment-resistant depression that continued for approximately 3 years after her sister’s death. Comprehensive evaluation including neurocognitive testing, EEG, spinal tap, HIV testing and brain MRI revealed behavioral variant of fronto-temporal dementia (bvFTD) with significant frontal and temporal lobe atrophy. This patient’s unusual clinical presentation emphasizes the overlap between depression and bvFTD, and underlines the importance of prompt, accurate diagnosis to minimize often ineffective pharmacological interventions and caregiver burnout.
... I n late life, depression is one of the reversible disorders that increased healthcare expenses and decreased quality of life [1]. In 1999, a systematic review reported only 13.5% of the depression prevalence in elderly people aged 55 and older, but depressive symptoms had proliferated over time [2,3]. Since population dynamic is one of the most important factors to determine health care needed in society, the growing trend of the elderly population can convert depression into one of the economic, social, and health challenges of the 21st century [4,5]. ...
The elderly population has extensively increased globally, so depression like a common problem in late life may convert to one of the economic, social, and health challenges of the 21st century. Due to the high cost of clinical diagnosis of depression, it is necessary to provide effective questionnaires like the 15-item Geriatric Depression Scale (GDS-15) for screening. But, the measurement invariance of GDS-15 is still unknown in the general population. In our study, 1473 participants of all Iran's ethnic groups were asked to answer GDS-15 and demographic factors such as human settlements, employment, disease, marital status, age, gender, homebound, financial status, and ethnicity. Then, the lordif package in R 3.1.3 was used to assess differential item functioning (DIF) items that behave unevenly across demographic factors. Our findings reveal that women, homebound patients, poorer, and non-Persian mother tongue score classic psychological symptoms higher than peoples of the same depression score in other groups. Since, psychologists have to remove or replace these items before using this questionnaire for screening geriatric depression.
... Thus, many factors contribute to the low level of MBI research being performed with this population. This oversight is unfortunate as LTCF residents have higher rates of physical and emotional concerns such as pain (Centers for Medicare & Medicaid Services, 2015) and depression (Ell, 2006;Mulsant & Ganguli, 1999). Further, LTCF residents are more likely to be prescribed high-risk medications to alleviate these concerns (Stevenson et al., 2014), including barbiturates, benzodiazepines, and anticholinergics (Campanelli, 2012). ...
Mindfulness-based interventions (MBIs) have received increased clinical attention in recent years. While some MBI research has focused on healthy older adults, research with more emotionally and physically vulnerable populations, such as residents of long-term care facilities (LTCFs), is lacking. The current paper presents quantitative and qualitative results from a pilot study of an individual MBI designed for residents of LTCFs. Participants included 8 residents from two skilled nursing facilities in the southeastern United States. Data were collected between October 2016 through June 2017. A modified MBI is proposed with specific adaptations for LTCF residents. Recommended adaptations for LTCFs include a shift from a group to an individual format, individual weekly instructor–participant meetings, removal of the yoga and full-day silent retreat and shortening the duration of the formal practices. The current study found that these adaptations result in an individual MBI that is accessible to most LTCF residents while still providing the associated benefits of traditional group MBIs.
... The World Health Organization identified depression as the leading cause of disability worldwide, citing a 20% increase over the last decade (21). Approximately 15-27% of older adults experience depressive symptoms (22), and the burden is higher for more marginalized older adults who receive social services (23). Late-life depression has been associated with reduced quality of life and function, poor self-rated health, excess service utilization, and increased disability, morbidity, and mortality, including suicide (24)(25)(26)(27). ...
Social isolation is an important public health issue that has gained recognition during the COVID-19 pandemic because of the risks posed to older adults based on physical distancing. The primary purposes of this article are to provide an overview of the complex interconnectedness between social isolation, loneliness, and depression while introducing the COVID-19 Connectivity Paradox, a new concept used to describe the conflicting risk/harm continuum resulting from recommended physical distancing. In this context, examples will be provided for practical and feasible community-based models to improve social connectivity during COVID-19 by adjusting the processes and modalities used to deliver programs and services to older adults through the aging social services network. The COVID-19 pandemic has highlighted the need for clinical and community-based organizations to unite and form inter-sectorial partnerships to maintain the provision of services and programs for engaging and supporting older adults during this difficult time of physical distancing and shelter-in-place and stay-at-home orders. The aging social services network provides a vital infrastructure for reaching older underserved and/or marginalized persons across the U.S. to reduce social isolation. Capitalizing on existing practices in the field, older adults can achieve distanced connectivity to mitigate social isolation risk while remaining at safe physical distances from others.
... In a study of depressive geriatric patients with congestive heart failure, functional capacity of depressive individuals was not associated with the severity of congestive heart failure. Although individuals with depression tend to report worse physical functioning than other individuals, daily energy expenditure has been shown to be the same as for non-depressive individuals (26,27). Troosters et al. showed that elderly individuals who did not have chronic degenerative diseases and had no history of admission walked an average of 631 meters (29). ...
Research Problem: To investigate the relationship between depression, functional capacity, swallowing and quality of life in patients over 65 years of age in a nursing home. Method: A sample of this cross-sectional and descriptive study. After demographic data of 60 individuals over the age of 65 were recorded, Standardized Mini Mental Test (SMMT), Geriatric Depression Scale (GDS), 6 minutes walking test, and Bedhead Water Drinking Evaluation Test with Eat 10 test were applied. Findings: 71% of the patients were female and 28% were male. The mean age of males is 71.83 and the average age of females is 69 years. There was no significant difference in the relationship between depression and functional capacity (p> 0.05). There was a significant difference between depression and social functioning of SF36 and social health perception (p <0.05). Conclusion: Even though anatomical differences are observed in elderly individuals, they can function as functional swallowing. Extended English summary is in the end of Full Text PDF (TURKISH) file. Özet Amaç: Huzurevinde kalan 65 yaş üstü hastaların depresyon ile fonksiyonel kapasite,yutma ve yaşam kalitesi arasındaki ilişkiyi araştırmak. Metod: Karşılaştırmalı tanımlayıcı bir çalışma olup; 65 yaş üstü bireylerin demoğrafik verileri kaydedildi ve hastalara Standartize mini mental test, Geriyatrik depresyon skala, 6dk yürüme testi, yatak başı su yutma testi yapıldı. Bulgular: Hastaların %71’i kadın, %28’i erkek idi. Erkek hasta yaş ortalaması 71.83 kadınların ise 69 idi.Depresyon ile fonksiyonel kapasite arasında anlamlı bir fark bulunamadı.Ancak depresyon ile SF-36nın sosyal fonksiyonu,sağlık algısı arasında anlamlı fark bulundu. (p <0.05). Sonuç: Yaşlı bireylerde gençlere göre anatomik olarak farklılıklar görülse bile fonksiyonel olarak yutma işlevini yerine getirebilmektedirler.
... Notably, with the progression of AD the expression of depressive syndromes change, resulting in an under-recognition of late-life depression due to clinical and nosological ambiguities (Forsell et al., 1993;Mulsant & Ganguli, 1999). However, the declining prevalence of depression in more advanced AD stages may be the consequence of assessment difficulties due to the advanced cognitive decline (Lee & Lyketsos, 2003;Olin et al., 2002a). ...
Die sozialen und wirtschaftlichen Kosten sowie die persönlichen Folgen der zunehmenden Prävalenz von Demenz und ihrer neuropsychiatrischen Symptomen, unterstreichen die Notwendigkeit für ein besseres Verständnis der Risikofaktoren und die Identifizierung und Entwicklung von effektiveren und langanhaltenden Interventionen. Neuropsychiatrische Symptome, wie Apathie und Depression, sind in mehr als 80% der Mild Cognitive Impairment (MCI) und Alzheimer Demenz (AD) Fällen vorhanden. Forstmeier und Maercker (2008) zeigten, dass hohe motivationale Fähigkeiten im mittleren Lebensalter mit geringeren kognitiven Beeinträchtigungen einhergehen. Diese kumulative Dissertation begutachtet die nosologische Stellung von Apathie in der Demenz (Paper 1); evaluiert in einer Querschnittsstudie ob motivationale Fähigkeiten im mittleren Lebensalter ein Prädiktor von Apathie und Depression in MCI und früher AD sind (Paper 2); und untersucht in einer Längschnittsstudie ob motivationale Fähigkeiten des mittleren Lebensalters den Fortschritt von Apathie und Depression in MCI und AD beeinflussen (Paper 3). Diese Doktorarbeit demonstriert insbesondere die Anwendbarkeit von Forstmeier und Maerckers (2008) Modell der motivationalen Fähigkeiten für Apathie und Depression in der Demenz. Es zeigt, dass Apathie und Depression getrennte Syndrome sind, dass Forstmeier und Maerckers (2008) Modell der motivationalen Fähigkeiten für Apathie und Depression bei MCI und AD angewendet werden kann, und dass motivationale Fähigkeiten ein Prädiktor und schützender Faktor für Apathie und Depression in Fällen von MCI und AD sind. Diese Erkenntnisse sind besonders wichtig, da motivationale Fähigkeiten ein modifizierbares Konstrukt sind, die durch Training und Intervention eine kosteneffektive Prävention und Intervention für kognitive Beeinträchtigung und deren assoziierten neuropsychiatrischen Symptomen bieten. The social and economic costs and personal consequences of the increasing prevalence of dementia and its neuropsychiatric symptoms emphasize the need for better understanding of risk factors and the identification and development of more effective and long-lasting interventions. Neuropsychiatric symptoms of apathy and depression accompany more than 80% of Mild Cognitive Impairment (MCI) and Alzheimer’s Disease (AD) cases. Forstmeier and Maercker (2008) have shown that high midlife motivational abilities predict lower levels of cognitive impairment. This cumulative PhD thesis assesses the nosological position of apathy in dementia in a critical review (Paper 1); evaluates midlife motivational abilities as a predictor of apathy and depression in MCI and early AD in a cross-sectional study (Paper 2); and examines midlife motivational abilities as a predictor of the progression of apathy and depression in MCI and AD in a longitudinal study (Paper 3). Specifically, this PhD thesis establishes the applicability of Forstmeier and Maercker’s (2008) motivational abilities model to apathy and depression in dementia. It provides evidence that apathy and depression are two separate syndromes, concludes that Forstmeier and Maercker’s (2008) motivational abilities model is applicable to apathy and depression in individuals with MCI and AD and demonstrates midlife motivational abilities to be a predictor and protective factor for apathy and depression in MCI and AD. These findings are important as motivational abilities are modifiable constructs which, with increased training and intervention, may provide an inexpensive and effective prevention and intervention for not only cognitive decline but also the presence of highly disabling neuropsychiatry symptoms.
... Although late-life depression is a chronic and disabling illness, there is a common misconception that it is a normal feature of aging. Depression at old age is therefore under-recognized and severely under-treated, especially in very old age with high somatic comorbidity [22]. Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. ...
... On the other hand, mood disorders are widespread: it has been estimated that 1/7 of the general population is affected over the whole lifetime [12]. Among elderly people, the prevalence of depressive symptoms and major depressive disorder (MDD) is 15% and 1-3%, respectively [13]. Female gender, alcohol and substance or drug abuse, family history, and medical conditions are factors associated with depression in the elderly. ...
Depression and dementia represent frequent clinical presentations in the elderly population. Both diseases are interlinked. Indeed, depression in the elderly may reflect an increased risk for the later development of dementia. Worldwide, about 47 million people are affected by dementia, which represents about 10% of the general population over 65 years of age. On the other hand, among elderly people, the prevalence of depressive symptoms and major depressive disorder (MDD) is 15% and 1–3%, respectively. Female gender, alcohol and substance or drug abuse, family history, and medical conditions are factors associated with depression in the elderly.
... 9 Because of the seriousness of these consequences, geriatric depression has been identified as a major public health problem, yet it is undiagnosed in 50% of the cases. 10 Surprisingly, unipolar major depression was the fourth leading cause of disorders among ten leading specific causes of global disability adjusted life years (DALYs) lost in the Global Burden of Disease (GBD) Study in 1990 and 2000 accounting for 3.7% and 4.4% of total disability adjusted life years (DALYs) lost respectively. 1,11 The stigma of mental illness is perhaps the most fundamental reason why older people do not seek treatment often. ...
BACKGROUND
As the population is ageing, many of the older adults will experience depressive disorders. Projections are that, by the year
2020, depression will be second only to heart disease in its contribution to the global burden of disease. In older adults, several
environmental challenges can potentially trigger the onset of depression. The depressive symptoms in the elderly are often
wrongly thought to be a part of the normal ageing process. Depression if left unidentified, can worsen the physical comorbidities;
again, the physical co-morbidities can lead to depression or worsen already existing un-identified depression. They
do not often seek the help of a psychiatrist due to lack of awareness and the associated stigma. Hence, the General Medicine
Outpatient department of a Hospital provides an important setting for the detection of depression in the older adults.
The objectives of the study were 1) To identify the presence of depression among the patients aged 60 years and above
coming to a General Medicine OPD as their first point of contact. 2) To assess the severity of the depression in such elderly. 3)
To correlate the depressive symptoms in the said elderly with the existing medical co-morbidities.
MATERIALS AND METHODS
The elderly subjects aged 60 years and above, visiting the general medicine OPD of MVJ Medical College and Research Hospital
were recruited for the study. One hundred consecutive elderly meeting the inclusion criteria were included after excluding those
meeting the exclusion criteria. A detailed history was taken, physical and mental state examination was done. Details were
collected in the socio-demographic and medical co-morbidity schedule after cross-verifying with a reliable and adequate
informant. The Geriatric Depression Scale-15 was then administered. Results were calculated using the SPSS 11.0 version.
Results were recorded in the form of means, standard deviations, frequencies, percentages, chi square, p value, t test and oneway
ANOVA where applicable.
RESULTS
62% of the elderly were found to have significant depressive symptoms which is a large number. When we looked at the severity
of depression; 58.06% had mild, 25.80% had moderate and 16.12% had severe, depressive symptoms. Considering that the
majority had mild depression, it could easily be overlooked and go undiagnosed. There was no statistical significance between
both the groups of depressive symptoms (present/absent) with regards to number of medical co-morbidities. However, when
multiple co-morbidities were present, the mean GDS-15 score was found to be higher when compared to none and single comorbidity.
CONCLUSION
A significant number of elderly attending the general medicine OPD had depressive symptoms. Majority of these cases had mild
depression followed by moderate and severe deppression. Elderly with multiple co-morbidities were found to have higher mean
GDS-15 score indicating more severe symptoms. This study not only throws light on the high proportion of geriatric depression
but also on the fact that the General Medicine OPD is an important locus for geriatric depression identification and screening.
... Several potential risk factors for depression have been reported in the literature, such as age, 26 sex, 27 smoking, 28 functional and health status, 29,30 personality characteristics, 25 and social functioning and support. 31 The differential role of these risk factors remains largely unknown because the risk factors were rarely studied simultaneously. ...
Elderly patients with somatic illness are at increased risk of depression. The authors studied the prevalence and persistence of depressive symptoms during the first year after the events of myo-cardial infarction, congestive heart failure, fall-related injury, and the diagnosis of cancer and their putative pre-event risk factors. The GLAS study contains data from 614 patients who experienced post-baseline myocardial infarction, cancer, heart failure, or fall-related injury of the extremities within 5 years after the baseline assessment. Follow-up was conducted 8 weeks, 6 months, and 1 year after the somatic event. The authors studied the relative importance of 21 baseline risk factors for experiencing significant depressive symptoms during follow-up and the persistence of depression. Depressive symptoms were prevalent in 38.3% of the subjects during the post-event year; in about 19.1%, symptoms were mild. For a majority of patients (67.5%), symptoms persisted until the next assessment. Significant pre-event risk factors were depressive symptoms at baseline, age, smoking, poor general health, poor well-being, and neuroticism. Within the depressed group, only neuroticism was related to the persistence of symptoms. Neurot-icism increases the risk of experiencing post-event depressive symptoms and is related to their persistence, which suggests the existence of a depression-prone personality. (
... Although late-life depression is a chronic and disabling illness, there is a common misconception that it is a normal feature of aging. Depression at old age is therefore under-recognized and severely under-treated, especially in very old age with high somatic comorbidity (24) . Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. ...
Background
Mental disorders in old age are frequent.
Objective
To determine the diagnostic pattern of mental disorders in elderly patients aged ≥ 60 years, attending the Old Age Psychiatry Unit, Ibn-Rushed Psychiatric Teaching Hospital, Baghdad, Iraq.
Methods
A retrospective study to all attendees to the Old Age Psychiatry Unit between January 2009 and November 2011 was carried out. Data collected included diagnoses, comorbid disorders, treatment received, and socio demographic characteristics.
Results
Analysis of 907 patients was done; the mean age 68 ± 6.3 years, 67.5% age range 60 – 69 years, 70% married, 50% without income (unemployed and housewives), 52% illiterate, and 98.5% live with their families. Depression was 46.9%, schizophrenia 23.2%, and 20.7% dementia. 48% of clients had comorbid illness. All patients had at least one pharmacological medication. Diagnoses high statistical significant association with gender (P=0.000), marital status (P=0.001), occupation (P=0.000), and education level (P=0.000).
Conclusion
Mental disorders in old age are frequent. Many old age people were with limited access to mental health services. Mental health services must be designed to meet the needs of older people at all points of the mental health continuum.
... Brain volume changes due to depression in older adults may be modified by a number of confounding factors. First, female gender (Mulsant and Ganguli, 1999) and past history of depression seem to increase the risk of LLD (Cole and Dendukuri, 2014). Second, magnitude of brain volume reduction has been associated with the severity of the depressive episode (Lorenzetti et al., 2009;Vakili et al., 2000). ...
Background:
Structural neuroimaging studies revealed a consistent pattern of volumetric reductions in both hippocampus (HC) and anterior cingulate cortex (ACC) of individuals with major depressive episode(s) (MDE). This study investigated HC and ACC volume differences in currently depressed individuals (n = 150), individuals with a past lifetime MDE history (n = 79) and healthy controls (n = 287).
Methods:
Non-demented individuals were recruited from a cohort of community-dwelling older adults (ESPRIT study). T1-weighted magnetic resonance images and FreeSurfer Software (automated method) were used. Concerning HC, a manual method of measurement dividing HC into head, body, and tail was also used. General Linear Model was applied adjusting for covariates.
Results:
Current depression was associated with lower left posterior HC volume, using manual measurement, in comparison to healthy status. However, when we slightly changed sub-group inclusion criteria, results did not survive to correction for multiple comparisons.
Conclusions:
The finding of lower left posterior HC volume in currently depressed individuals but not in those with a past MDE compared to healthy controls could be related to brain neuroplasticity. Additionally, our results may suggest manual measures to be more sensitive than automated methods.
... Both ageing and institutionalization in aged care homes are associated with significant risk of developing chronic neurological and mental health conditions such as depression, anxiety, Parkinson's disease and epilepsy [7][8][9][10][11][12][13][14] . Central nervous system (CNS) medications are used to manage these conditions. ...
Background/aims:
Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes.
Methods:
The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM).
Results:
CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores.
Conclusion:
Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.
... In addition, patients may often present with somatic complaints that mimic those of a diagnosed medical condition, hence complicating the diagnosis of a mental disorder. This is evident in the case of diagnosing depression among elderly, where the similarity of symptoms of depression to those of dementia, or the presence of a medical condition may override the symptoms of depression [9]. A mental health literacy study among psychiatrically and generally trained nurses employed in a psychiatric hospital has also revealed that despite the training received, the depression vignette was commonly defined as "stress" instead of a psychiatric diagnosis [10]. ...
Background
The current study aimed to explore the correct recognition of mental disorders across dementia, alcohol abuse, obsessive compulsive disorder (OCD), schizophrenia and depression, along with its correlates in a nursing student population. The belief in a continuum of symptoms from mental health to mental illness and its relationship with the non-identification of mental illness was also explored.
Methods
Five hundred students from four nursing institutions in Singapore participated in this cross-sectional online study. Respondents were randomly assigned to a vignette describing one of the five mental disorders before being asked to identify what the person in the vignette is suffering from. Continuum belief was assessed by rating their agreeableness with the following statement: “Sometimes we all behave like X. It is just a question of how severe or obvious this condition is”.
Results
OCD had the highest correct recognition rate (86%), followed by depression (85%), dementia (77%), alcohol abuse (58%) and schizophrenia (46%). For continuum belief, the percentage of respondents who endorsed symptom continuity were 70% for depression, 61% for OCD, 58% for alcohol abuse, 56% for dementia and 46% for schizophrenia. Of concern, we found stronger continuum belief to be associated with the non-identification of mental illness after controlling for covariates.
Conclusions
There is a need to improve mental health literacy among nursing students. Almost a quarter of the respondents identified excessive alcohol drinking as depression, even though there was no indication of any mood symptom in the vignette on alcohol abuse. Further education and training in schizophrenia may need to be conducted. Healthcare trainees should also be made aware on the possible influence of belief in symptom continuity on one’s tendency to under-attribute mental health symptoms as a mental illness.
... In addition, patients may often present with somatic complaints that mimic those of a diagnosed medical condition, hence complicating the diagnosis of a mental disorder. This is evident in the case of diagnosing depression among elderly, where the similarity of symptoms of depression to those of dementia, or the presence of a medical condition may override the symptoms of depression [9]. A mental health literacy study among psychiatrically and generally trained nurses employed in a psychiatric hospital has also revealed that despite the training received, the depression vignette was commonly defined as "stress" instead of a psychiatric diagnosis [10]. ...
Background
The current study aimed to explore the correct recognition of mental disorders across dementia, alcohol abuse, obsessive compulsive disorder (OCD), schizophrenia and depression, along with its correlates in a nursing student population. The belief in a continuum of symptoms from mental health to mental illness and its relationship with the non-identification of mental illness was also explored.
Methods
Five hundred students from four nursing institutions in Singapore participated in this cross-sectional online study. Respondents were randomly assigned to a vignette describing one of the five mental disorders before being asked to identify what the person in the vignette is suffering from. Continuum belief was assessed by rating their agreeableness with the following statement: “Sometimes we all behave like X. It is just a question of how severe or obvious this condition is”.
Results
OCD had the highest correct recognition rate (86%), followed by depression (85%), dementia (77%), alcohol abuse (58%) and schizophrenia (46%). For continuum belief, the percentage of respondents who endorsed symptom continuity were 70% for depression, 61% for OCD, 58% for alcohol abuse, 56% for dementia and 46% for schizophrenia. Of concern, we found stronger continuum belief to be associated with the non-identification of mental illness after controlling for covariates.
Conclusions
There is a need to improve mental health literacy among nursing students. Almost a quarter of the respondents identified excessive alcohol drinking as depression, even though there was no indication of any mood symptom in the vignette on alcohol abuse. Further education and training in schizophrenia may need to be conducted. Healthcare trainees should also be made aware on the possible influence of belief in symptom continuity on one’s tendency to under-attribute mental health symptoms as a mental illness.
... Dans leur étude, Camara et Ka [2] avaient retrouvé des expressions cliniques diverses allant de la tristesse classique de l'humeur, à d'autres manifestations comme des expressions somatiques, cognitives, délirantes et comportementales. Ceci explique les difficultés de diagnostiquer une dépression de la personne âgée avec comme conséquences une méconnaissance, une prise en charge insuffisante et un réel problème de santé publique [2,8,15]. ...
Résumé
Malgré une population plutôt jeune, le Sénégal est confronté à une augmentation du nombre de personnes âgées. Cette situation impose une plus grande vigilance par rapport à la politique sanitaire, ce qui passe par une meilleure connaissance du profil épidémiologique. Pour ce faire, nous avions réalisé une étude rétrospective et descriptive. Elle couvrait une période de dix ans, allant de la période du 1er janvier 2004 au 31 décembre 2014, portant sur les nouveaux cas de patients âgés d’au moins 60 ans et intéressant un effectif de 1490 personnes. La moitié des patients de cette étude avait comme diagnostic une démence (34,6 %) ou une dépression (19,8 %). Près des deux tiers (73 %) souffraient d’une comorbidité somatique essentiellement représentée par : l’hypertension artérielle, le diabète et les pathologies neurologiques. Les patients étaient adressés en consultation par la famille (77 %) ou référés par les centres de soins médicaux (17 %). Il y avait une légère prédominance des femmes qui représentaient 56 %, soit un sex-ratio de 1,26. La moitié des patients était mariée, le tiers veuf. La famille reste la principale ressource en psychogériatrie, étant à l’origine de l’essentiel des demandes. En matière de sensibilisation, le message devra donc plus être centré sur elle. La formation s’impose également pour permettre aux autres acteurs de soins d’être plus attentifs par rapport à la démence et à la dépression de la personne âgée, afin de faciliter un dépistage et une prise en charge précoces.
... In Anbetracht der epidemiologischen Daten zur Häufigkeit von Depressionen im Alter (Helmchen ea 1996, Djernes 2006 wird diese Diagnose zu selten gestellt (Mulsant und Ganguli 1999). Das hat vermutlich verschiedene Ursachen. ...
Die Diagnostik der Altersdepression ist ein anspruchsvolles Thema, das deutlich über das Abarbeiten diagnostischer Algorithmen, wie sie z. B. in der ICD-10 oder dem DSM-V ausgeführt sind, hinausgeht. Das klinische Bild der Patienten wird durch zahlreiche Faktoren gefärbt und kontrastiert: durch die Symptome der häufig gleichzeitig vorhandenen körperlichen Erkrankungen, durch mehr oder weniger ausgeprägte altersgemäße oder das Altersgemäße überschreitende kognitive Veränderungen, durch über die Jahrzehnte stattgehabte Reifungsprozesse, Persönlichkeitsentwicklungen und Traumatisierungen sowie durch Kohorteneffekte in Folge von Sozialisierungsprozessen unter historischen sozialen, kulturellen und politischen Rahmenbedingungen. All diesen Aspekten soll die Diagnostik depressiver Störungen im Alter Rechnung tragen und darüber hinaus auch eine Einschätzung der Prognose erlauben sowie die Auswahl angemessener Behandlungs- und Versorgungsnotwendigkeiten leiten.
... 6,7 Depression affects more women than men. [8][9][10] Chang et al 11 reported that the overall incidence of depression was 21.9 per 1,000 personyears among participants aged 65þ years in the Nurses Health Study. ...
Abstract
Objective: To assess the prevalence of, and factors associated with, moderate-to-severe depressive symptoms in
community-dwelling older Australian women.
Methods: A questionnaire-based, cross-sectional study was conducted amongst community-dwelling older
women. Participants were recruited between April and August 2014 from a national database based on the electoral
roll. Depressive symptoms were assessed by the Beck Depression Inventory-II (BDI-II) tool. Vasomotor symptoms
(VMS), vulvovaginal atrophy (VVA), and pelvic floor symptoms were assessed using validated questionnaires.
Women were provided a comprehensive list of psychotropic medications (antidepressants, benzodiazepines,
antipsychotics, and mood stabilizers) to identify their use over the preceding month.
Results: In all, 1,534 women completed the BDI-II. Overall, 34.2% (95% confidence interval [CI] 31.8%-36.7%)
of women had VMS, 6.3% (95% CI 5.2%-7.7%) had moderate-to-severe depressive symptoms (BDI-II score �20),
26.8% (95% CI 24.6%-29.1%) had used any psychotropic medication in the previous month, and 17.5% (95%CI:
15.6-19.5%) had taken an antidepressant.
Moderate-to-severe depressive symptoms were more common among women using antidepressants
compared with nonusers (16.6% vs 4.3%; P<0.001). Obesity (adjusted odds ratio [AOR] 2.18, 95% CI
1.17-4.04), living in financially insecure housing (AOR 3.84, 95% CI 2.08-8.08), being a caregiver to another
person (AOR 2.39, 95% CI 1.36-4.19), being a smoker (AOR 2.28, 95% CI 1.12-4.66), having VMS (AOR
1.67, 95% CI 1.03-2.62), having pelvic floor dysfunction (AOR 1.78, 95% CI 1.08-2.94), and having vaginal
dryness during intercourse (AOR 1.84, 95% CI 1.06-3.22, P<0.05) were positively and independently
associated with moderate-to-severe depressive symptoms. Being currently partnered (AOR 0.57, 95% CI
0.33-0.97) and employed (AOR 0.38, 95% CI 0.16-0.92) were associated with a lower likelihood of
depressive symptoms.
Conclusions: In older women, depressive symptoms are common and are associated with social and financial
insecurity, and with VMS.
... [1,2] Prevalence estimates for depressive symptoms are at least 2-4 times higher than for major depressive disorder (MDD). [3,4] In addition, depressive symptoms have been associated with cognitive decline, [5,6] greater medical comorbidities, [7] decreased quality of life, [8] and increased health care cost. [3,9] Furthermore, subsyndromal depressive symptoms confer a risk factor for new-onset mood disorders. ...
Altered cortical thickness has been observed in aging and various neurodegenerative disorders. Furthermore, reduced hippocampal volume has been reported in late-life depression. Even mild depressive symptoms are common in the elderly. However, little is known about the structural MRI measures of depressive symptoms in normal cognitive aging. Thus we sought to examine the association between depressive symptoms with cortical thickness and hippocampal volume as measured by brain MRI among community-dwelling participants. We conducted a cross-sectional study derived from the ongoing population-based Mayo Clinic Study of Aging, involving cognitively normal participants (N = 1,507) aged≥70 years. We observed that depressive symptoms were associated with lower global cortical thickness and lower thickness in specific prefrontal and temporal cortical regions, labeled by FreeSurfer software, version 5.3. As expected, the strength of correlation was very small, given that participants were community-dwelling with only mild depressive symptoms. We did not observe associations between hippocampal volume and depressive symptoms. These findings may provide insight into the structural correlates of mild depressive symptoms in elderly participants.
... 6,7 Depression affects more women than men. [8][9][10] Chang et al 11 reported that the overall incidence of depression was 21.9 per 1,000 personyears among participants aged 65þ years in the Nurses Health Study. ...
... The prevalence of major depressive disorder (MDD) in the elderly is estimated at 1% to 3%. Recognition of depression is complex because of patients that often deny depression as a psychological dimension, presenting somatic complaints, anxiety or cognitive impairments (Mulsant and Ganguli, 1999;Wohlreich et al., 2004). ...
Depressive disorders are fairly common among older adults. These disorders can cause significant morbidity and mortality among older people. Unfortunately, depressive disorders are often misdiagnosed or underdiagnosed in this population. A detailed history, a comprehensive mental status examination, a focused physical examination, screening laboratory studies, and appropriate use of neuropsychological testing can assist with the diagnosis of depression among older adults. Available data indicates that both psychotherapy and pharmacotherapy are beneficial in the treatment of depression among older individuals. Electroconvulsive therapy (ECT) is highly effective in the treatment of depressive disorders with psychotic features, catatonic features, and agitation and among individuals who are refractory to other treatments and in situations where there is urgent need for treatment response either due to suicidal or homicidal behaviors or failure to thrive. Evidence also indicates benefits of ketamine, repetitive transcranial magnetic stimulation (rTMS), and collaborative care approaches for the treatment of depression among older adults.
Neuromodulation (or neurostimulation) therapies are of particular importance in geriatric psychiatry, as older adults are often unable to tolerate adequate pharmacotherapy of depressive disorders. Among neurostimulation treatments, electroconvulsive therapy (ECT) remains the principal and usually most definitive alternative to medications. However, newer treatments such as repetitive transcranial magnetic stimulation (rTMS) and deep brain stimulation (DBS) are emerging. rTMS involves stimulation of the brain using a magnetic coil applied to the scalp surface and is administered without anesthetic or loss of consciousness. It is very well-tolerated by most patients and has a high degree of acceptability. Its efficacy for treating depressive disorders is more modest than that of ECT, and early evidence suggested that it was less effective in older patients. However, more recent rTMS treatment protocols involving longer treatment courses and higher intensity of treatment parameters are showing promise in treating depressive disorders in older adults, with response rates of 30–60% and remission rates of 10–30%. rTMS is a useful addition to the armamentarium of treatments in geriatric psychiatry; its place in treatment algorithms will evolve with emerging research and increased availability for routine clinical use. Its uses for other indications (e.g., for anxiety disorders), or to improve cognition in major neurocognitive disorder, are also being explored in current research. DBS via direct bilateral stimulation of Brodmann area Cg25 with implanted electrodes showed some promise in open trials, but subsequent randomized controlled trials failed to demonstrate its efficacy; it remains an investigational treatment.
Apathy and depression are the most prevalent neuropsychiatric symptoms in Alzheimer’s disease and mild cognitive impairment. Despite much research on apathy and depression in dementia, the nosological position of apathy as a separate syndrome from depression remains debated. This literature review provides a critical analysis of the areas of clinical manifestation, symptomatology, assessment, prevalence and neuropathology. Evidence does not provide a clear view of the nosological position of apathy in dementia for symptoms and neuropathology. However, the ambiguity of the evidence may be attributed in large part to a lack of clarity in definition and etiology, clinical criteria and assessment overlap. Given the evidence, it is concluded that the argument in favor of apathy as a separate syndrome from depression in dementia is persuasive. Reaching a consensus on the definition and nosological position of apathy within dementia is vital to provide patients and caregivers with the support they require, increase understanding of risk factors, and enable comparisons across research and practice.
The World Mental Health Surveys were established by the World Health Organization in 2000 to provide valuable information for physicians and health policy planners. These surveys have shed light on the prevalence, correlates, burden, and treatment of mental disorders in countries throughout the world. This volume focuses on the epidemiology of coexisting physical and mental illness around the world. This book includes surveys from 17 discrete countries on six continents, covering epidemiology, risk factors, consequences, and implications for research, clinical work, and policy. Many physical and mental illnesses share a relationship with one another and often occur simultaneously. Clinicians from the disciplines of both psychiatry and medicine are increasingly faced with both challenges on a daily basis, making this an ideal book for a wide range of health professionals. This is the first book devoted to this topic on such a wide-ranging scale.
Mindfulness-based interventions (MBIs) have been adapted for use with a variety of populations, but empirical research on their use with residents of long-term care facilities (LTCFs) is lacking. This case report demonstrates successful implementation of an individual MBI with a Native American male who participated in an 8-week study at a LTCF. Measures of mindfulness, depression, rumination, and pain were administered at pre- and posttreatment. The participant showed improvements on all measures, particularly depression. Follow-up interviews indicated that the participant was still engaging in the mindfulness techniques and found them to be helpful 1 month and 1 year following completion of the program. Recommendations for implementing the program in LTCFs are provided. Despite the limitations of an individual MBI (I-MBI) approach in LTCF populations (e.g., understaffing), several positive implications exist, including greater access for LTCF residents with physical and other limitations, as well as flexibility in tailoring the I-MBI to meet each resident’s unique needs.
p>This thesis examines the psychiatric and physical morbidity of elderly life and indeterminate sentence prisoners. It explores contributory factors to their ill health, their prison experiences and access to the provision of current primary and secondary healthcare. A total of 181 prisoners aged 55 years and above were interviewed at two Category B prisons, HMP Kingston and HMP Albany. Prisoners' physical health was assessed by self-report and from the prison medical record. Three reliable and validated screening instruments were used to assess their cognitive status and functional ability, and in a small subset, (N=121) depressive symptoms were recorded. Current healthcare delivery is assessed using the principles and standards as defined in the National Service Framework for Older People, together with the efficacy of Clinical Governance. Qualitative data gathered at interview details prisoners' views on their overall experiences of health at different stages of sentencing, including access to and the provision of healthcare. Changes in criminal justice policy over the last decade have resulted in a significant increase in the number of elderly life/indeterminate sentence prisoners in England and Wales whilst the proposed partnership between the Prison Service and National Health Service (NHS) was to be fully operational from April 2006. Contemporary studies of elderly prisoners and their health care needs are limited in number and since psychiatric and physical morbidity regardless of type or origin is usually more common with increasing age, an ageing prison population should demonstrate a high incidence of multiple-pathology and morbidity. The results clearly indicate that elderly lifers demonstrate high levels of multiple physical health pathology and high rates of depressive illness although cognitive function is similar to age matched controls. Length of prison sentence, as a proxy for exposure to the prison environment, does not appear to relate to the burden of ill health. Ill health appears to be a characteristic of this population's demographics. As the Prison Service now embarks upon un-chartered territory having reached maximum population capacity policymakers will have to address the specific needs of those prisoners who will spend the remainder of their lives in prison as well as those who will be released in old age.</p
Introduction
Many of the assessment tools used to study depression amongst older people in low- and middle- income countries (LMICs) are adaptations of instruments developed in other cultural settings. There is a need to validate those instruments in LMICs.
Methods
721 men and women aged 55–80 years from the Mysore Birth Records Cohort underwent standardised assessments for sociodemographic characteristics, cardiometabolic risk factors, cognitive function and mental health. Sensitivity, specificity and level of agreement of EURO-D diagnosis of depression with diagnosis of depression derived by the Geriatric Mental State (GMS) examination were calculated. To validate the EURO-D score against GMS depressive episode, we used maximum Youden's index as the criterion for each cut-off point. Concurrent validity was assessed by measuring correlations with the WHO Disability Assessment Schedule (WHO DAS II).
Results
Of the 721 (408 men and 313 women) who participated in this study, 138 (54 men and 84 women) were diagnosed with depression. Women had higher depression scores on the EURO-D scale and disability on the WHO DAS II scale. A maximum Youden's Index of 0.60 was observed at a EURO-D cut-off of 6, which corresponded to 95% sensitivity, 64% specificity, kappa value of 0.6 and area under the curve (AUC) of 80%. There was significant and positive correlation between EURO-D and WHO DAS II scores.
Limitations
Future independent validation studies in other settings are required.
Discussion
This study supports the use of the EURO-D scale for diagnosing depression amongst older adults in South India.
Late life depression is a significant public health problem as well as a burden on patients, their families, and caregivers. There are significant associations of late life depression with medical disorders and cognitive impairment, the latter due to effects of the depression itself or association with dementia. Diagnostic criteria and screening tests have continued to evolve and provide structure and guidelines for assessment. Accurate diagnosis and treatment are of utmost importance to improve quality of life, alleviate suffering, and prevent suicide. A number of effective antidepressant medications are available; combination therapy with these medications and cognitive behavioral therapy appear most efficacious, and maintenance therapy can decrease the chances of remission. A sequence for treatment of late life depression is provided, with strategies for treatment-resistant depression. The relationship of dementia to depression and the interaction of depression with mechanisms of aging are major foci of research.
Objectives: The increase in the aging population along with a variety of diseases and problems threatening their health and, on the other hand, socio-economic developments and changes in individual and family lifestyles, has increased the number of nursing homes. Considering the importance of the impact of living environment on various aspects of mental health, this study aimed to compare stress, anxiety and depression of the elderly living in nursing homes and those living at home. Methods & Materials: This is a descriptive comparative study with a cross-sectional design conducted in 2017. Using a convenience sampling method, 436 elderly people in Tehran including 218 home dwellers and 218 nursing-home residents were selected. Participants were evaluated through interview by the short-form version of Depression Anxiety Stress Scale (DASS-21). Comparisons between the two groups were made using independent t-test in SPSS v.20 software. Results: Mean and standard deviation of the DASS-21 score in elderly residents of nursing homes (37.75±11.34) was higher than in home dwellers (26.68±5.64). There were statistically significant differences in stress, anxiety and depression between the two groups (P≤0.05). Conclusion: Stress, anxiety and depression in the elderly living in nursing homes are more than in those living at home. Family participation in providing welfare and mental health care, supporting with appropriate insurance coverage, establishing day care centers, and supporting family caregivers can be very helpful to enhance their mental health.
Psychosis in the elderly represents a frequent and challenging feature, with a prevalence of psychotic symptoms that may reach 10-63% in the hospitalized population. However, both the diagnosis and the treatment of psychotic symptoms in the elder population may present many problems. In the present chapter, we debate the differential diagnosis between the causes of psychosis in the elderly and how to deal with them. The first cause of psychosis in this population is represented by dementia. Psychiatric symptoms may be present not only in the last phases of neurodegenerative disorders but also in the early stages or at onset, more frequently in specific subtypes of dementia, such as frontotemporal dementia. The second most common cause of psychosis in the geriatric population is depression, while delirium is the third. Delirium, differently from the other described diagnoses, is characterized by an acute change in mental status, disturbances of consciousness, and clouded sensorium and may be caused by several circumstances, ranging from infections to inappropriate medication use. Considering the background of the present literature, we report the case of a 66-year-old man who was referred to our inpatient clinic for a manic episode with delusions. We investigated the differential diagnostic processes, which encompass a comprehensive clinical evaluation, a very accurate anamnestic interview, blood tests, and eventually brain imaging. Another major issue of concern is treatment, which might be guided by a multidisciplinary endeavor, including pharmacological and non-pharmacological interventions. © Springer International Publishing AG, part of Springer Nature 2019. All rights reserved.
Objective:
The present study investigated the prevalence of depression using PHQ-9 across general and occupational characteristics in older Koreans and identified associations between depression and occupational factors.
Methods:
This cross-sectional study used Korean National Health and Nutrition Examination Survey and analyzed 2,426 participants (>50 years older). Complex sample logistic regression analysis was performed after adjusting general characteristics.
Results:
Using KNHANES data we identified the employment status and occupational factors (working hours per week, working status, occupation type, working schedule) are associated with the prevalence of late-life depression after adjusting general characteristics among older Korean men.
Conclusions:
The occupational environment associated with mental health is an important social issue for increasingly aging workers. There is a need for appropriate occupational environments and high-quality occupations enabling older people to work with public interest and collaborative effort of social and governmental institutions.
Somatic therapies are of particular importance in geriatric psychiatry, as older adults are often unable to tolerate adequate pharmacotherapy of depression. Among neurostimulation treatments, ECT remains the principal alternative to medications. However, newer treatments such as rTMS (repetitive transcranial magnetic stimulation) and DBS (deep brain stimulation) are emerging. rTMS involves stimulation of the brain using a magnetic coil applied to the scalp surface and is administered without anesthetic or loss of consciousness. It is very well tolerated by most patients and has a high degree of acceptability. Its efficacy for treating depression is more modest than that of ECT, and early evidence suggested that it was less effective in older patients. However, more recent rTMS treatment protocols involving longer treatment courses and higher intensity of treatment parameters are showing promise in treating depressive disorders in older adults, with response rates of 30–60% and remission rates of 10–30%. rTMS is a useful addition to the armamentarium of treatments in geriatric psychiatry; its place in treatment algorithms will evolve with emerging research and increased availability for routine clinical use. Its uses for other indications (e.g., for anxiety disorders), or to improve cognition in major neurocognitive disorder, are also being explored in current research. Direct bilateral stimulation of Brodmann area Cg 25 with implanted electrodes showed some promise in open trials, but subsequent randomized controlled trials failed to demonstrate its efficacy; it remains an investigational treatment.
Objectives:
Prevalence and risk factors for protein-energy wasting (PEW) are poorly studied in the nondialysis, older population with advanced chronic kidney disease (CKD). Our aim was to evaluate the prevalence of PEW in advanced stage CKD patients aged greater than 65 years. Furthermore, we aimed to describe risk factors for PEW in the overall study population and among obese individuals.
Design:
Prospective observational cohort study.
Methods:
The EQUAL study, a European Quality Study on treatment in advanced chronic kidney disease, is a multicenter prospective observational cohort study in six European countries. We included patients aged ≥65 years with incident glomerular filtration rate <20mL/min/1.73m2not on dialysis attending nephrology care. PEW was assessed by 7-point Subjective Global Assessment (7-p SGA).
Results:
In general, the study cohort (n = 1,334) was overweight (mean body mass index [BMI] 28.4 kg/m2). The majority of the patients had a normal nutritional status (SGA 6-7), 26% had moderate PEW (SGA 3-5), and less than 1% had severe PEW (SGA 1-2). Muscle wasting and loss of fat tissue were the most frequent alterations according to the SGA subscales, especially in those aged >80 years. The prevalence of PEW was higher among women, increased with age, and was higher in those with depression/dementia. PEW was the most common in those with underweight (BMI <22 kg/m2), 55% or normal weight (BMI 22-25 kg/m2), 40%. In obese individuals (BMI >30 kg/m2), 25% were diagnosed with protein wasting. Risk factors for SGA ≤5 in obese people were similar to those for the overall study population.
Conclusion:
This European multicenter study shows that the prevalence of PEW is high in patients with advanced CKD aged >65 years. The risk of PEW increases substantially with age and is commonly characterized by muscle wasting. Our study suggests that focus on nutrition should start early in the follow-up of older adults with CKD.
Depressive disorders are a common cause of emotional suffering, increased disability, premature mortality, increased healthcare utilization costs, and cognitive decline in the elderly. There appear to be multiple unique pathophysiological pathways to late-life depression. This chapter seeks to review the research performed in this field over the last several decades, describing disturbances in fronto-subcortical function, genetic polymorphisms, chronic stress and inflammation, as well as vascular pathology. We also discuss structural and functional neuroimaging studies of late-life depression. Future research must explore outcomes of early intervention strategies combined with a personalized approach to the depressed elderly patient.
La sindrome cortico-basale (SCB) rappresenta a tutt’oggi, dopo la pubblicazione del primo caso da parte di Rebeiz e coll. nel 1967, un quadro clinico di infrequente riscontro nella pratica clinica. Accanto alla degenerazione cortico-basale (DCD) che ne rappresenta la causa più frequente, altre patologie neurodegenerative possono manifestarsi con una SCB. Tra queste la malattia di Alzheimer (AD). CASO CLINICO Un soggetto di sesso m, di a. 68, destrimane, viene all’osservazione del Centro Demenze del distretto sanitario 51, ASL NA 3 sud nel giugno del 2012 per la comparsa di distonia lentamente ingravescente all’arto superiore di sinistra accompagnata a mioclono ipsilaterale, lievi turbe mnesiche ( specie a carico della memoria a breve termine e procedurale), depressione del tono dell’umore. Assumeva Eutirox 25 mcg/die (per pregresso nodulo solitario benigno alla tiroide, asportato chirurgicamente) e Ticlopidina (una compressa/die) per ateromasia carotidea non emodinamicamente significativa. L’esame obiettivo evidenziava marcato ipertono dell’arto superiore sinistro con iperelicitabilità dei riflessi bicipitale e tricipitale ipsilaterali, più modesto ipertono degli arti inferiori ; eloquio congruo ma lento e con pause tra una parola e la successiva ; mioclono segmentario a carico dell’arto superiore sinistro; bradicinesia. Le manovre semeiologioche per la valutazione della motilità oculare risultavano perfettamente nella norma. Veniva sottoposto a MMSE (23/30, totale acalculia, aprassia visuosostruttiva, minimo deficit nel ricordo delle tre parole, assenza di disorientamento spazio-temporale), FAB sec. Dubois et at. (15/18); valutazione neurologica (parkinsonismo in fase iniziale ); visita psichiatrica (umore depresso, apatia). Punteggio ADL = 6/6, IADL (considerando soltanto gli items applicabili al sesso M) = 4/4 ; CIRS = 1.23 con indice di comorbidità complessa pari a 0. Le analisi di laboratorio risultavano nella norma ; una RMN encefalo mostrava “Non si rilevano alterazioni della morfologia e del segnale del parenchima cerebrale sovra- e sottotentoriale…lieve dilatazione degli spazi pericerebrali della convessità da iniziali segni di atrofia, più evidente a destra”; una tomoscintigrafia cerebrale con Tc99 mostrava “deficit corticale di perfusione in sede parieto-occipitale di destra. Asimmetrica la perfusione dei nuclei della base. Assenza di significativi deficit in sede cerebellare”. Posta diagnosi di SCB (Cambridge criteria) in corso di AD, veniva proposta terapia con Rivastigmina (dapprima in compresse fino a 3 mg bis in die, e successivamente in cerotto fino a 9.5 mg/ die) associata a levo-dopa 25/250 mg tre volte al giorno. A distanza di un anno e mezzo il paziente (valutato periodicamente prima mensilmente e poi ogni sei mesi) mostrava mantenimento del punteggio a MMSE e a FAB con mancata risposta della distonia e della rigidità alla levo-dopa, poi sospesa dopo tre mesi. Nel corso del follow-up, non venivano riferite cadute da parte del paziente e l’esame obiettivo confermava assenza di deficit del movimento oculare. All’ultimo controllo (gennaio 2013), rimaneva in terapia con Eutirox 25 mcg, Ticlopidina 250 mg/die, Exelon cerotto 9.5 mg/die. Veniva confermato l’iniziale orientamento diagnostico di SCB-AD. DISCUSSIONE La AD rappresenta, dopo la DCB, la causa più frequente di SCB. In uno studio di 12 casi autoptici (Shelley et al, 2009), la DCB rappresentava il 50% delle forme di SCB diagnosticate in vita e l’AD il restante 50%. Ma anche in altre casistiche, la percentuale di soggetti diagnosticati in vita come DCB che in realtà all’esame autoptico avevano una AD è molto alta (Ling H et al, 2010). A tutt’oggi non esistono criteri di certezza nella diagnosi differenziale.tra la SCB in corso di AD e la SCB-DCB e stabilire in vita se una SCB sia espressione di DCB o di AD è praticamente impossibile (Hassan A. et al., 2011; Ling E. et al., 2010; Mathew R et al., 2012). Alcuni elementi clinici sembrano rivestire un ruolo diagnosticamente impattante : è il caso del mioclono che quando presente orienterebbe maggiormente verso la diagnosi di SCB-AD (Hu WT et al, 2009). Il deterioramento cognitivo è parte integrante della SCB e la presenza di demenza di per sé non esclude la diagnosi di DCB, anche se la perdita iniziale di memoria episodica sembra avere un ruolo predittivo maggiore per AD versus DCB. Particolarmente significative, poi, le informazioni fornite dal neuroimaging: il riscontro di un ipoperfusione temporoparietale e di una atrofia cerebrale diffusa sono, nell’esperienza di diversi gruppi di studio, elementi fortemente a favore della diagnosi di SCB-AD. Tutte queste considerazioni ci hanno indotto a considerare il paziente che abbiamo osservato come affetto da SCB-AD.
Bipolare wie auch unipolare Depressionen sind durch eine hohe Rate kurzfristiger Rückfälle und durch große Häufigkeit von Rezidiven gekennzeichnet. 75-85% aller unipolar depressiven Patienten haben mindestens 2 Episoden während ihres Lebens (FRANK et al. 1990, MUELLER et al. 1999), und 30-50% der Patienten, und mit steigendem Lebensalter sogar noch mehr, erleiden einen Rückfall innerhalb der ersten 6 Monate nach Beendigung der Behandlung einer depressiven Episode (THASP. 1999). Dabei erhöht sich mit jedem Rückfall auch die Wahrscheinlichkeit und Schwere weiterer Episoden, gleichzeitig kommt es zu einer Verkürzung des beschwerdefreien Intervalls (GREDEN 1993, THASE 1992). Als besondere Prädiktoren für häufige Rezidive kristallisierten sich anhand einer großen Untersuchung des NIMH weibliches Geschlecht, früher Krankheitsbeginn und die Zahl vorausgegangener Episoden heraus. Nicht auch zuletzt wegen der hohen Suizidgefährdung sollte also eine konsequente Weiterbehandlung und ggf. Rezidivprophylaxe nach mehreren Episoden die Regel darstellen.
Available evidence suggests that antidepressants, antipsychotics, lithium, and antiepileptic drugs can increase the risks for falls and fractures in older adults. However, the relationship between falls and psychotropic medications is complex because the mental disorders treated with these psychotropic medications and their comorbidities are themselves significant and independent risk factors for falls. Thus, fall risk by itself is not a contraindication for the use of psychotropic medications in an older frail patient. Nevertheless, clinicians need to prescribe these medications judiciously and to follow principles of conservative prescribing to minimize the risk for falls. While some psychotropic medications may have a direct effect on balance, most falls and fractures are related to other side effects, in particular, orthostatic change in blood pressure, pro-arrhythmogenic effects, extrapyramidal symptoms (including Parkinsonism and akathisia), sedation, and cognitive impairment. Thus, careful selection of specific medications based on their differential side effect profile and monitoring of adverse effects is mandatory. Close monitoring is particularly important during the first few days or weeks after starting a new psychotropic medication or after a dose increase.
This study was aimed to evaluate the cross-sectional and longitudinal associations between various perceived-stress and depressive symptoms in old Taiwanese men and women aged 50 years and over. Data were derived from the Taiwan Longitudinal Study on Aging. Stress for health, finance, and family members’ related issues were all cross-sectionally associated with concurrent depressive symptoms for men and women (all P < 0.05). Increased/constant-high health stress was positively associated with subsequent depressive symptoms in both genders (all P < 0.05). Constantly high job stress and increased stress over family members’ problems were associated with higher likelihood of subsequent depressive symptoms in men (P < 0.05). Constantly high/increased financial stress and relationship strain with family members were positively associated with subsequent depressive symptoms in women (all P < 0.05). The results suggest that stress for health, job, finance, and family members-related issues are unequally associated with depressive symptoms among Taiwanese men and women aged 50 years and over. Changes of health stress even reduced are significantly associated with subsequent depressive symptoms. Long-term job stress and increased stress over family members’ problems increase occurrences of men’s depressive symptoms, while increased/long-term financial stress and relationship-strain with family members increase occurrences of women’s depressive symptoms. Long-term high health stress has more impacts on men’s depressive symptoms than women’s, while long-term high relationship strain with family members has more impacts on women’s depressive symptoms than men’s.
Mood disorders are common and often under-recognised in older people whereby, together with the general ageing of the population, they are becoming a significant and growing public health problem worldwide. However, the need to address the problem of late life mood disorders in a real world setting is met with a surprising lack of strong evidence in this field. RCTs which focus on elderly mood disorders are not very common and the majority of them focus on pharmacological treatment of major depression. Comorbidity as well as polypharmacy, cognitive decline, unpredictable placebo response, and uncertainty on optimal duration of trials are some of the challenges the investigator has to address. Moreover, some methodological limitations of RCTs reduce the applicability of the results of such studies to common clinical practices and have encouraged some authors to investigate the existence of possible alternative research designs such as pragmatic RCTs.
Context.—
Depression and ischemic heart disease often are comorbid conditions
and, in patients who have had a myocardial infarction, the presence of depression
is associated with increased mortality. Patients with heart disease need a
safe and effective treatment for depression.Objective.—
To compare the efficacy, cardiovascular effects, and safety of a specific
serotonin reuptake inhibitor, paroxetine, with a tricyclic antidepressant,
nortriptyline hydrochloride, in depressed patients with ischemic heart disease.Design.—
Two-week placebo lead-in followed by a double-blind randomized 6-week
medication trial.Setting.—
Research clinics in 4 university centers.Patients.—
Eighty-one outpatients meeting Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition criteria for major depressive
disorder and with documented ischemic heart disease.Interventions.—
Treatment with either paroxetine, 20 to 30 mg/d, or nortriptyline targeted
to a therapeutic plasma level, 190 to 570 nmol/L (50-150 ng/mL), for 6 weeks.Main Outcome Measures.—
For effectiveness of treatment, a decline in the score of the Hamilton
Rating Scale for Depression by 50% and final score of 8 or less; for cardiovascular
safety, heart rate and rhythm, supine and standing systolic and diastolic
blood pressures, electrocardiogram conduction intervals, indexes of heart
rate variability, and rate of adverse events.Results.—
By intent-to-treat analysis, 25 (61%) of 41 patients improved during
treatment with paroxetine and 22 (55%) of 40 improved with nortriptyline.
Neither drug significantly affected blood pressure or conduction intervals.
Paroxetine had no sustained effects on heart rate or rhythm or indexes of
heart rate variability, whereas patients treated with nortriptyline had a
sustained 11% increase in heart rate from a mean of 75 to 83 beats per minute
(P<.001) and a reduction in heart rate variability,
as measured by the SD of all normal R-R intervals over a 24-hour period, from
112 to 96 (P<.01). Adverse cardiac events occurred
in 1 (2%) of 41 patients treated with paroxetine and 7 (18%) of 40 patients
treated with nortriptyline (P<.03).Conclusions.—
Paroxetine and nortriptyline are effective treatments for depressed
patients with ischemic heart disease. Nortriptyline treatment was associated
with a significantly higher rate of serious adverse cardiac events compared
with paroxetine.
THE NEED to find a safe and effective treatment for depressed patients
with cardiac disease has intensified because of 2 relatively recent findings,
one that emphasizes the potential importance of treatment and the other that
emphasizes the potential risks. Frasure-Smith et al1
reported compelling new evidence that patients who develop depression following
a myocardial infarction (MI) are at significantly greater risk for death than
medically comparable post-MI patients who are not depressed.1
In their study, 222 patients were evaluated approximately 1 week after MI
and 16% of the sample met criteria for major depression. Over the next 6 months,
the depressed patients had a 3.5 times greater risk of cardiac death than
patients not diagnosed as depressed. Subsequently, this finding was extended
to establish that depression was a significant predictor of post-MI cardiac
mortality at 18 months. Intriguingly, the risk associated with depression
is greatest in patients who have 10 or more ventricular premature depolarizations
(VPDs) per hour.2 This observation is compatible
with other findings that suggest that the association of depression and sudden
cardiac death involves an arrhythmic mechanism. It is unknown whether treatment
of the depressive episode will reduce the associated increase in cardiac mortality.
However, before one can consider studying this question, it needs to
be established that there is a safe and effective antidepressant treatment
for the post-MI depressed patient. The tricyclic antidepressants (TCAs) have
been the most systematically studied with respect to cardiovascular effects,
and it has been documented that the tricyclics (1) increase heart rate, (2)
induce orthostatic hypotension, (3) slow intraventricular cardiac conduction,
and (4) suppress VPDs.3 Although TCAs can cause
significant complications in depressed patients with cardiac disease, their
robust efficacy combined with knowledge that forewarns the clinician as to
when problems are likely to occur had led to the belief that, in most cases,
the use of TCAs in patients with heart disease was a "relatively" safe procedure
with a favorable risk-benefit ratio.
However, the results of the cardiac arrhythmia suppression trials (CAST)
suggest that this conclusion be revised.4- 5
The hypothesis of the CAST studies was that suppression of post-MI VPDs would
decrease mortality. Contrary to expectations, patients treated with drugs
with class 1C (encainide hydrochloride or flecainide acetate) or class 1A
(moricizine) antiarrhythmic activity had an increased mortality rate compared
with placebo-treated patients. The mechanism by which the antiarrhythmics
induce this increased mortality rate has not been definitively established.
To date, most evidence points to an interaction between drugs with class 1
antiarrhythmic activity and ischemic myocardium, which results in an increased
vulnerability to ventricular fibrillation.6- 8
Thus, patients with ischemic heart disease treated with a class 1A or 1C antiarrhythmic
drug may be at risk when their next ischemic episode occurs. Because TCAs
are class 1A antiarrhythmic drugs, similar in effect to quinidine and moricizine,
it is both reasonable and prudent to assume that TCA treatment carries a similar
risk.9
Given the probable risk associated with TCA treatment in patients with
ischemic heart disease, the obvious question is whether the selective serotonin
reuptake inhibitors (SSRIs) are a safe and effective alternative. The available
data on the cardiovascular effects of the SSRIs are quite limited.10- 14
It has been reported that the SSRIs slightly decrease heart rate, do not routinely
slow intracardiac conduction, do not affect supine or standing systolic or
diastolic blood pressure, and do not induce orthostatic hypotension. However,
these findings are compromised by methodological problems in data collection
and their applicability is limited because the sample studied consisted of
predominantly medically healthy patients with depression and, specifically,
patients free of cardiac disease.
To date, there is only one study of the cardiovascular effects of an
SSRI, fluoxetine, in the treatment of depressed patients with significant
cardiac disease.15 In that study, 27 patients
with major depression and left ventricular impairment and/or conduction disease
and/or ventricular arrhythmia were treated openly with fluoxetine for 7 weeks
at a maximum dose of 60 mg/d. Fluoxetine induced a small reduction in heart
rate, but did not have a statistically significant effect on blood pressure,
ejection fraction, ventricular arrhythmia, or conduction intervals. However,
the study included patients with multiple types of cardiac disease and did
not specifically address the issue of risk in depressed patients with ischemic
heart disease.
In this article, we report the first prospective double-blind study
comparing the safety and efficacy of an SSRI, paroxetine, with a TCA, nortriptyline
hydrochloride, in depressed patients with ischemic heart disease.
We estimated clinicians' awareness of depression for patients with current depressive disorder (N = 650) who received care in either a single-specialty solo or small group practice, a large multispecialty group practice, or a health maintenance organization in three US sites. Depressive disorder was determined by independent diagnostic assessment shortly after an office visit. Detection and treatment of depression were determined from visit-report forms completed by the treating clinician. Depending on the setting, from 78.2% to 86.9% of depressed patients who visited mental health specialists had their depression detected at the time of the visit, compared with 45.9% to 51.2% of depressed patients who visited medical clinicians, after adjusting for case-mix differences. Among patients of mental health specialists, there were no significant differences by type of payment in the likelihood of depressive disorder being detected or treated. Among patients of medical clinicians, however, those receiving care financed by prepayment were significantly less likely to have their depression detected or treated during the visit than were similar patients receiving fee-for-service care.
The Cornell Scale for Depression in Dementia is introduced. This is a 19-item clinician-administered instrument that uses information from interviews with both the patient and a nursing staff member, a method suitable for demented patients. The scale has high interrater reliability (kw = 0.67), internal consistency (coefficient alpha: 0.84), and sensitivity. Total Cornell Scale scores correlate (0.83) with depressive subtypes of various intensity classified according to Research Diagnostic Criteria.
The purpose of these analyses was to test the hypothesis that depressive symptomatology affects the risk of onset of physical disability in high-functioning elderly adults.
The data come from the MacArthur Study of Successful Aging, a community-based cohort of high-functioning adults aged 70 through 79 years who were assessed twice at a 2.5-year interval. Physical and cognitive status was assessed by performance as well as by self-report measures.
In gender-stratified logistic regression models, high depressive symptoms as measured by the depression subscale of the Hopkins Symptom Checklist were associated with an increased risk of onset of disability in activities of daily living for both men and women, adjusting for baseline sociodemographic factors, physical health status, and cognitive functioning.
Joined with evidence that physical disability is a potential risk factor for depression, these findings suggest that both depressive symptoms and physical disability can initiate a spiralling decline in physical and psychological health. Given the important impact of activities-of-daily-living functioning on utilization of medical services and quality of life, prevention or reduction of depressive symptoms should be considered an important point of intervention.
Evidence is accruing that older individuals receive little attention for mental health problems and that any attention that is given is most often within the primary care setting. A randomized clinical trial was carried out at a primary care clinic of The Johns Hopkins University, Baltimore, testing the ability of feedback of the results of a screening instrument (the General Health Questionnaire) to increase awareness in clinicians of the emotional and psychological problems of their patients. This report contrasts those aged 65 years and older with younger patients. Detection and management of mental morbidity were lower for older individuals, but the feedback intervention increased the likelihood of attention to these problems. This was not true for younger patients. Detection was significantly higher for older patients when screening data were made available, as was management, although the latter difference was not statistically significant. There was evidence as well that the intervention moved clinicians to greater congruence with their older patients in the perception that current mental health problems existed. These findings have important implications for primary care.
(JAMA 1987;257:489-493)
The authors assessed the severity of nortriptyline side effects in older patients with major depression during 12 months of double-blind therapy. Data were from 40 patients completing 1 year of maintenance therapy: 26 were on nortriptyline and 14 were on placebo. The authors detected significant time-by-treatment interactions for various side effects (all greater in treated patients), but not for overall side effects score. Clinically, these differences were judged to be minor and correctable. On the other hand, total side effect scores, physical tiredness, and subjective sleep disturbance covaried significantly with Hamilton Depression scores regardless of treatment assignment. Somatic worry, tiredness, and sleep complaints appeared to reflect residual depression rather than treatment assignment.
A considerable body of knowledge now exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of “competing demands” derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated “domains,” representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of “face validity” for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.
Evaluated the presence of depression in 50 outpatients (mean age 71.6 yrs) with dementia using the self-rated Geriatric Depression Scale (GDS) and the clinician-rated Cornell Depression Scale (COR). Impaired insight, as manifested by unawareness of dementia, correlated with dementia severity and discriminated a group of patients in whom the GDS failed to show evidence of depression. Discrepancy between the 2 types of scales occurred among mildly as well as moderately demented patients when insight was impaired. Recognition of this discrepancy suggests that reliance on self-ratings may underestimate the presence and degree of depression among patients with dementia. Clinician-rated scales such as the COR may be the most useful and widely applicable type of scale for the whole spectrum of patients who present to an outpatient dementia clinic. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The relationship of "somatic worry" to age, actual medical illness, and depression severity was examined in 91 psychiatric inpatients with unipolar major depression. Multiple regression analysis was used to determine the independent contributions of demographic, psychopathologic, and medical illness variables to the measures of somatic worry. Increased age and higher Ham-D scores were significantly and independently associated with greater somatic concern in the sample as a whole, but medical illness was not. Therefore somatic worry in depressed inpatients cannot be conceptualized as a direct consequence of poor physical health; age and the depressed state itself play important, though poorly understood, roles.
Copyright (C) 1993 American Association for Geriatric Psychiatry
To test the hypothesis that primary degenerative dementia of the Alzheimer type (PDD-AT) may increase the likelihood of expression of a lifetime vulnerability to the development of depression, the authors compared the premorbid rates of major depression in psychiatric inpatients with dementia, with or without a concurrent syndrome of depression. A premorbid history of major depression was four times more common in patients with the depressive syndrome of PDD-AT than in PDD-AT patients without depression. The authors discuss the significance of these findings for pathophysiologic models and estimates of comorbidity of depression in PDD-AT.
To test the hypothesis that primary degenerative dementia of the Alzheimer type (PDD-AT) may increase the likelihood of expression of a lifetime vulnerability to the development of depression, the authors compared the premorbid rates of major depression in psychiatric inpatients with dementia, with or without a concurrent syndrome of depression. A premorbid history of major depression was four times more common in patients with the depressive syndrome of PDD-AT than in PDD-AT patients without depression. The authors discuss the significance of these findings for pathophysiologic models and estimates of comorbidity of depression in PDD-AT.
Copyright (C) 1996 American Association for Geriatric Psychiatry
Copyright (C) 1996 American Association for Geriatric Psychiatry
We examined physician characteristics associated with the recognition of depression and anxiety in primary care. Fifty-five physicians treating a total of 600 patients completed measures of psychosocial orientation, psychological mindedness, self-rating of sensitivity to hidden emotions, and a video test of sensitivity to nonverbal communication. Patients were classified as cases of psychiatric distress based on the CES-D scale and the Diagnostic Interview Schedule. Physician recognition was determined by notation of any psychosocial diagnosis in the medical charts over the ensuing 12 months. Of 192 patients scoring 16 or above on the CES-D, 44% (83) were recognized as psychiatrically distressed. Three findings were central to this study: 1) Physicians who are more sensitive to nonverbal expressions of emotion made more psychiatric or psychosocial assessment of their patients and appeared to be over-inclusive in their judgments of psychosocial problems; 2) Physicians who tended to blame depressed patients for causing, exaggerating, or prolonging their depression made fewer psychosocial assessments and were less accurate in detecting psychiatric distress; 3) False positive labeling of patients who had no evidence of psychiatric distress was rare. Surprisingly, more severe medical illness increased the likelihood of labeling and accurate recognition. Physician factors that increased recognition may indicate a greater willingness to formulate a psychiatric diagnosis and an ability notice nonverbal signs of distress.
(C) Lippincott-Raven Publishers.
The clinical and neurobiological literature of geriatric depression which focuses on the relationship between depression and dementia is reviewed. The hypothesis that depression of late life and dementia are linked by a spectrum of underlying ageing-associated brain changes is presented, and the implications for future research are discussed.
The authors found that among 228 general hospital patients, minor tranquilizers were prescribed most often and with the least justification and that major tranquilizers were prescribed sparingly and by and large judiciously. Antidepressants were given less often than would be justified by the incidence of depressive illness among these patients. Nonrecognition of depression in patients with somatic complaints and autonomic signs of depression contributed to this lack of treatment.
To determine primary care physicians' attitudes and practice patterns concerning the diagnosis and treatment of depression in elderly outpatients.
Survey of primary care physicians' attitudes using a 22-item questionnaire. Current practice patterns were identified from a computerized medical record system.
Academic primary care group practice at an urban ambulatory care clinic.
Thirty-five faculty general internists and 118 resident internal medicine physicians who had cared for 2,759 patients 65 years of age and older in the previous year.
Attitudes: Eighty percent of all physicians considered the diagnosis and treatment of depressed elderly patients to be their responsibility. Fifty-five percent of the internists felt confident in accurately diagnosing depression, and 35% felt confident in prescribing antidepressants for this population. Residents reported more difficulties in dealing with depressed elderly patients than did faculty. Practice patterns: Of patients greater than or equal to 65 years old, 8% were prescribed antidepressants, 5.4% had current diagnoses of depression, and 2% were seen for evaluation by psychiatry professionals. Age was negatively correlated with depression diagnosis, antidepressant drug use, and psychiatry evaluation.
Internists in this primary care group practice accept responsibility for the treatment of depressed elderly patients but perceive their clinical skills as inadequate and are frustrated with their practice environment. Interventions aimed at improving the diagnosis and treatment of depressed elderly patients may be more effective if they are able to improve knowledge, attitudes, and the practice environment.
This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care).
Although psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions.
We studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology. At base line we determined the type and quantity of drugs received by all residents (n = 823), and a blinded observer performed standardized clinical assessments of the residents who were taking psychoactive medications. After the five-month program, drug use and patient status were reassessed.
Scores on an index of psychoactive-drug use, measuring both the magnitude and the probable inappropriateness of medication use, declined significantly more in the nursing homes in which the program was carried out (experimental nursing homes) than in the control nursing homes (decrease, 27 percent vs. 8 percent; P = 0.02). The use of antipsychotic drugs was discontinued in more residents in the experimental nursing homes than in the control nursing homes (32 percent vs. 14 percent); the comparable figures for the discontinuation of long-acting benzodiazepines were 20 percent vs. 9 percent, and for antihistamine hypnotics, 45 percent vs. 21 percent. In the experimental nursing homes residents who were initially taking antipsychotic drugs showed less deterioration on several measures of cognitive function than similar residents in the control facilities, but they were more likely to report depression. Those who were initially taking benzodiazepines or antihistamine hypnotic agents reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups.
An educational program targeted to physicians, nurses, and aides can reduce the use of psychoactive drugs in nursing homes without adversely affecting the overall behavior and level of functioning of the residents.
Forty-five depressed elderly patients were closely monitored in a research setting during treatment with nortriptyline and interpersonal psychotherapy for 7 consecutive months of acute and continuation treatment. Overall, nortriptyline was efficacious and well tolerated in this group. The frequency of somatic complaints measured by the Rating Scale for Side Effects declined by 50% during the acute phase of treatment, suggesting that many somatic complaints that may be attributed to side effects of nortriptyline are actually somatic symptoms of depression. The authors discuss the implications of these findings and offer practical advice for the treating clinician.
To determine the prevalence rates of major depressive disorder and of depressive symptoms and their relationship to mortality in nursing homes, research psychiatrists examined 454 consecutive new admissions and followed them up longitudinally for 1 year. Major depressive disorder occurred in 12.6% and 18.1% had depressive symptoms; the majority of cases were unrecognized by nursing home physicians and were untreated. Major depressive disorder, but not depressive symptoms, was a risk factor for mortality over 1 year independent of selected physical health measures and increased the likelihood of death by 59%. Because depression is a prevalent and treatable condition associated with increased mortality, recognition and treatment in nursing homes is imperative.
Caregivers play a critical role in providing the social support that allows impaired elders to remain at home. The demands of caregiving, however, may stretch the physical and psychological resources of the caregiver, thus jeopardizing the elder. The social support available to the caregiver may help buffer or mitigate the ill effects of caregiving. The purpose of this review is to examine the effect of social support on the development of depression in the caregiver, with a consideration of the components and measurement of social support. The practical as well as the research implications are discussed. Although the anticipated difficulty of caregiving depends on assessment of the elder's mental and functional disability as well, the clinician must not neglect to consider the caregiver's appraisal of the social support available. This assessment need not be elaborate and might include inquiring (1) whether the caregiver has someone in whom to confide; (2) who visits the caregiver, how often, and whether the caregiver is happy with these relationships; (3) what aspects of caregiving are most disturbing; and (4) whether there are symptoms of depression.
Aged nursing home and congregate apartment residents were screened for symptoms of depression and cognitive impairment. of
708 survey respondents, 12.4% met DSM-IIIR criteria (33) for major depression; about half this group also displayed significant
cognitive deficits. Another 30.5% of the total sample reported less severe but nonetheless marked depressive symptoms. Such
“minor” depressive syndromes were much more common among congregate housing than nursing home residents. Possible major depression
was more prevalent among newly admitted residents of both housing components. Comparison of cognitively impaired vs intact
respondents revealed that the two groups' self-reports of depression were equally internally consistent, and bore equivalent
correlations with observer ratings made by interviewers and direct care staff. Checks of medical records of a group of survey
nonrespondents (n = 203) indicated that, excepting the extremely demented, the active sample of 708 accurately represents
institution residents as a whole. Finally, comparison with clinical diagnoses made by facility psychology and psychiatry department
staff indicated good concurrent validity of research screening measures and methods.
Although more than 30% of ambulatory medical patients are depressed, little is known about how their depression is managed in the primary care setting. We surveyed 282 primary care physicians at two internal medicine and four family medicine programs. We asked these physicians to describe how they actually managed depression in their depressed medical patients and how they would manage ten hypothetical depressed medical patients. Demographic and attitudinal data were also obtained. Physicians reported that they utilized a wide variety of treatments for their depressed patients. They indicated that they would recommend counseling twice as many depressed patients as they would recommend medicating or referring. Over 30% of the variance in self-reported preferences to recommend particular treatments for depression was accounted for by physician characteristics. Prior experience with a treatment strategy was a significant factor in predicting a recommendation for future use of a treatment independent of other considerations such as endorsement of positive attitudes about the efficacy or benefits of a treatment. Prior experience was also more important than physician sociodemographics as a predictive variable. The clinical and educational implications of these findings for psychiatrists and primary care physicians are discussed.
Despite the large number of elderly patients in nursing homes and the intensity of medication use there, few current data are available on patterns of medication use in this setting. We studied all medication use among 850 residents of 12 representative intermediate-care facilities in Massachusetts. Data on all prescriptions and patterns of actual use were recorded for all patients during one month. On average, residents were prescribed 8.1 medications during the month (interquartile range, 7.4 to 8.8) and actually received 4.7 (range, 4.2 to 5.4) medications during this period. More than half of all residents were receiving a psychoactive medication, with 26% receiving antipsychotic medication. Twenty-eight percent of patients were receiving sedative/hypnotics during the study month, primarily on a scheduled rather than an as-needed basis. Of patients receiving a sedative/hypnotic, 26% (range, 14% to 41%) were taking diphenhydramine hydrochloride, a strongly anticholinergic hypnotic. Of those receiving one of the benzodiazepines, 30% were receiving long-acting drugs, generally not recommended for elderly patients. The typical benzodiazepine dose was equivalent to 7.3 mg per patient per day of diazepam. The most commonly used antidepressant was amitriptyline hydrochloride, the most sedating and anticholinergic antidepressant in common use. These data indicate that despite growing evidence of the risks of psychoactive drug use in elderly patients, the nursing home population studied was exposed to high levels of sedative/hypnotic and antipsychotic drug use. Suboptimal choice of medication within a given class was common, and use of standing vs as-needed orders was often not in keeping with current concepts in geriatric psychopharmacology. Additional research is needed to assess the impact of such drug therapy on cognitive and physical functioning, as well as to determine how best to improve patterns of medication use in this vulnerable population.
Sixty-two elderly depressives were located one year after discharge. Eight patients (13%) had died, 2.6 times higher than the expected mortality rate. Patients dying were more likely to have had a diagnosis of cardiovascular disease (P less than 0.001).
In this study we conducted a resurvey at 33 months of elderly general medical clinic outpatients previously classified as depressed or not using the Zung Self-Rating Depression Scale. Resurvey results and review of medical records permitted characterization of the point prevalences of depression at the time of the initial and follow-up surveys, and identification of physical illness factors associated with depression. The point prevalences of depression were approximately equal (20%), although only about 10% were depressed at both occasions. Among the initially nondepressed, the number of new physical diagnoses during follow-up was the best predictor of depression at retest. Other factors associated with depression at one or both occasions were: alcohol abuse, obstructive pulmonary disease, and a relatively greater number of medical diagnoses. Thus, among elderly outpatients, depression appears common with roughly equal rates of remission and incidence; also, new medical illness may precipitate depression.
General practice (GP) depressives prescribed an antidepressant were compared with those given other treatment, and with antidepressant-treated psychiatric out-patient depressives. GP depressives were considerably less severely ill than out-patients, with fewer depressive symptoms and shorter illness, as well as less primary and less endogenous depression. The two groups of GP depressives differed less, but those receiving other treatment tended to have less severe depression than those receiving antidepressants and were less likely to satisfy diagnostic criteria for depression. Depressives in GP differ considerably in clinical characteristics from psychiatric out-patient depressives, and clinical features influence the GP's decision to treat with antidepressants.
Recent epidemiological and family genetic studies in different countries using standardized diagnostic interviews for mental disorders have rather consistently demonstrated considerably lower current (e.g. ECA Study: 0.9%) and lifetime (1.4%) prevalence estimates of Major Depression in the elderly (older than 65 years of age) as compared to younger age groups (e.g. 30-44 years: 1 year, 3.9%; lifetime, 7.5%). Some investigators have questioned the validity of these data and suggested alternative interpretations. One possibility is that the complex standardized symptoms and clinical probe questions, and the required judgmental process inherent in diagnostic interviews exceed the cognitive capacity of older adults. This may result in systematic response bias. This paper examines the degree to which the lower prevalence estimates of depression in the elderly are biased due to specific characteristics of the assessment strategy. Analyses of epidemiologic data from the Munich Follow-up Study (MFS), based on the Diagnostic Interview Schedule, demonstrate that (1) older respondents report lifetime depressive symptoms with the same frequency as younger respondents. The additional probe questions designed to identify the degree to which symptoms were caused by factors other than psychological revealed that (2) the elderly more often attribute such symptoms to physical illnesses or conditions. This results in (3) the exclusion of the reported symptoms as a basis for diagnosing depression. A laboratory study demonstrated that "working memory capacity" was a good predictor of this response behavior, indicating that the complexity of the formalized questions exceeds the cognitive capacity of the elderly. Attributing symptoms to a physical illness or condition might be a heuristic strategy to simplify complex recall and judgment processes; the resulting answer is plausible but incorrect. We recommend that the symptom and probe questions of standardized diagnostic interviews be simplified, especially for use with the elderly.
Synopsis
While the relationship of life events to depression onset has occupied researchers for almost a quarter of a century, few studies have attempted to account for either the temporal patterning of events relative to episode onset, or, the effect of multiple events in a study period. In this report, we attempt to address the issues of timing of events, multiple events (both positive and negative) and multiple aspects (both positivity and negativity) of single events on latency time to depression onset, while simultaneously accounting for possible decay in the effects of events over time. We use the proportional hazards approach to model the effects of life events and consider modelling the change in impact of events with the passage of time.
After interviewing 142 recurrent unipolar patients using the Life Events and Difficulties Schedule, we rated severity and positivity of life events reported during the 6-month period prior to onset. As we hypothesized, additional life events occurring after an initial provoking agent level event significantly alter the risk of illness onset. Additional severely threatening events decrease the time to onset, but positive events do not appear to delay onset. Interestingly, seemingly neutral events had a highly significant effect in shortening the time to onset. We note the many limitations imposed on the interpretation of these findings related to the selected group of subjects studied and encourage those who have more generalizable data to apply these methods of analysis.
To describe primary care physicians' clinical decision making regarding late-life depression.
Longitudinal collection of data regarding physicians' clinical assessments and the volume and content of patients' ambulatory visits as part of a randomized clinical trial of a physician-targeted intervention to improve the treatment of late-life depression.
Academic primary care group practice.
One-hundred and eleven primary care physicians who completed a structured questionnaire to describe their clinical assessments immediately following their evaluations of 222 elderly patients who had reported symptoms of depression on screening questionnaires.
Intervention physicians were provided with their patient's score on the Hamilton Depression rating scale (HAM-D) and patient-specific treatment recommendations prior to completing the questionnaire regarding their clinical assessment.
Those physicians not provided HAM-D scores were just as likely to rate their patients as depressed, as determined by specific query of these physicians regarding their clinical assessments. A physician's clinical rating of likely depression did not consistently result in the formulation of treatment intentions or actions. Treatment intentions and actions were facilitated by provision of treatment algorithms, but treatment was received by fewer than half of the patients whom physicians intended to treat. Barriers to treatment appear to include both physician and patient doubts about treatment benefits.
Lack of recognition of depressive symptoms did not appear to be the primary barrier to treatment. Recognition of symptoms and access to treatment algorithms did not consistently result in progression to subsequent stages in treatment decision making. More research is needed to determine how patients and physicians weigh the potential risks and benefits of treatment and how accurately they make these judgments.
A multidisciplinary diagnostic evaluation was performed for 868 older psychiatric inpatients during a 46-month interval. A total of 402 (46%) met DSM-III-R criteria for organic mental disorders, 329 (38%) had mood disorders, 90 (10%) had psychotic disorders, and 47 (5%) had other mental disorders or conditions. Concurrent medical problems were systematically assessed and classified according to ICD-9-CM criteria. The patients suffered from a mean of 5.6 +/- 3.1 (SD) active medical problems (range 0-18). This level of medical comorbidity was significantly greater than that of older psychiatric outpatients and comparable to that of elderly inpatients in general medical hospitals. When the effects of age and education were controlled for, there were no significant differences in mean numbers of medical problems among the four groups of psychiatric inpatients. An association of major depression with diseases of the digestive system was observed and may be related to peripheral autonomic dysregulation.
To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.
A 4-year prospective cohort study.
Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash.
A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Non-participants were somewhat older and had a higher level of chronic medical illness.
Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO.
In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness.
Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.
To determine how primary care physicians treat patients with major depression in the course of routine practice and the degree to which such practice produces outcomes anticipated with interventions recommended by the Agency for Health Care Policy and Research Depression Guideline Panel.
Prospective cohort study.
Academically affiliated ambulatory family practice centers and internal medicine clinics in urban neighborhoods of Pittsburgh, Pa.
Ninety-two patients who were seen in primary care practices and who met criteria for a current major depression as determined by the Diagnostic Interview Schedule and a psychiatrist's assessment.
Physicians were informed of the patient's psychiatric diagnosis, and were urged to treat it in whatever manner and for whatever duration they deemed appropriate (ie, with "usual care").
The treatments that were provided, the patients' clinical course, and the relationship between the type of treatment and clinical course.
Health center records indicated that 67 patients (73%) received a depression-specific treatment in the 8 months following study entry. A majority of the total cohort were prescribed an antidepressant drug. Of the 92 patients, 18 (20%) were asymptomatic at 8 months (Hamilton Rating Scale for Depression score, < or = 7). The treatment pattern was not clearly related to the clinical course.
The recovery rates for the patients with major depression who were treated with usual care in routine primary care practices were lower than those anticipated from treatments consistent with the Agency for Health Care Policy and Research guidelines. Further studies of the caregiving elements that influence the effectiveness of depression-specific treatments of patients in primary care settings are needed.
To reexamine the conclusions of the 1991 National Institutes of Health Consensus Panel on Diagnosis and Treatment of Depression in Late Life in light of current scientific evidence.
Participants included National Institutes of Health staff and experts drawn from the Planning Committee and presenters of the 1991 Consensus Development Conference.
Participants summarized relevant data from the world scientific literature on the original questions posed for the conference.
Participants reviewed the original consensus statement and identified areas for update. The list of issues was circulated to all participants and amended to reflect group agreement. Selected participants prepared first drafts of the consensus update for each issue. All drafts were read by all participants and were amended and edited to reflect group consensus.
The review concluded that, although the initial consensus statement still holds, there is important new information in a number of areas. These areas include the onset and course of late-life depression; comorbidity and disability; sex and hormonal issues; newer medications, psychotherapies, and approaches to long-term treatment; impact of depression on health services and health care resource use; late-life depression as a risk factor for suicide; and the importance of the heterogeneous forms of depression. Depression in older people remains a significant public health problem. The burden of unrecognized or inadequately treated depression is substantial. Efficacious treatments are available. Aggressive approaches to recognition, diagnosis, and treatment are warranted to minimize suffering, improve overall functioning and quality of life, and limit inappropriate use of health care resources.
Panic disorder, a psychiatric disorder characterised by frequent panic attacks, is the most common anxiety disorder, affecting 2 to 6% of the general population. No one line of treatment has been found to be superior, making a risk-benefit assessment of the treatments available useful for treating patients. Choice of treatment depends on a number of issues, including the adverse effect profile, efficacy and the presence of concomitant syndromes. Tricyclic antidepressants (TCAs) are beneficial in the treatment of panic disorder. They have a proven efficacy, are affordable and are conveniently administered. Adverse effects, including jitteriness syndrome, bodyweight gain, anticholinergic effects and orthostatic hypotension are commonly associated with TCAs, but can be managed successfully. Selective serotonin (5-hydroxytryptamine; 5HT) reuptake inhibitors are also potential first line agents and are well tolerated and effective, with a favourable adverse effects profile. There is little risk in overdose or of anticholinergic effects. Adverse effects include sedation, dyspepsia and headache early in treatment, and sexual dysfunction and increased anxiety, but these can be effectively managed with proper dosage escalation and management. Benzodiazepines are an effective treatment, providing short-term relief of panic-related symptoms. Patients respond to treatment quickly, providing rapid relief of symptoms. Adverse effects include ataxia and drowsiness, and cognitive and psycho-motor impairment. There are reservations over their first-line use because of concerns regarding abuse and dependence. Monoamine oxidase inhibitors, because of their adverse effects profile, potential drug interactions, dietary restrictions, gradual onset of effect and overdose risk, are not considered to be first-line agents. They are effective however, and should be considered for patients with refractory disease. Valproic acid (valproate sodium), while not intensively studied, shows potential for use in panic disorder. More studies are needed in this area before the available data can be confirmed. As a supplement to drug therapy, cognitive behavioural therapy is effective. It is well tolerated, and may be beneficial in certain clinical situations. Its main drawback is the time commitment and effort needed to be made by the patient.
The temporal relationship between the appearance of depressive symptoms and the clinical onset of dementia and Alzheimer disease was evaluated in a community sample.
An original sample of 1366 subjects aged 65 years or older, selected randomly from a rural Pennsylvania community, was cognitively screened at study entry and every 2 years thereafter. A subset of 954 survivors of this cohort without dementia was screened for depressive symptoms at the second and subsequent data-collection waves. A "depression cluster" was identified by the presence of 5 or more depressive symptoms, including depressed mood, at the time of screening. Cognitively impaired subjects and a sample of unimpaired controls underwent standardized clinical evaluation to determine the presence of incident dementia (by DSM-III-R criteria) and probable or possible Alzheimer disease (by criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and to estimate the clinical onset of dementia symptoms.
A highly increased probability of the depression cluster developing existed among subjects following the onset of dementia (15.4% [6/39]) and Alzheimer disease (17.6% [6/34]) compared with subjects without dementia (3.2% [23/712]). The odds ratios, after adjustment for age, sex, education level, and self reported memory loss, for the development of depression were 6.5 (95% confidence interval, 2.2-19.1) in subjects with Alzheimer disease and 5.2 (95% confidence interval, 1.8-15.2) in subjects with overall dementia. Depressive symptoms did not confer a significantly increased relative risk of dementia (1.27; 95% confidence interval, 0.55-2.93) or Alzheimer disease (1.28; 95% confidence interval, 0.51-3.20).
Depressive symptoms appeared to be early manifestations, rather than predictors, of Alzheimer disease in this community sample.
Epidemiologic data are used as a framework to discuss the pharmacologic and cognitive-behavioral management of anxiety disorders in late life. Generalized anxiety disorder (GAD) and phobias account for most cases of anxiety in late life. The high level of comorbidity between GAD and major depression, and the observation that the anxiety usually arises secondarily to the depression, suggests that antidepressant medication should be the primary pharmacologic treatment for many older people with GAD. Most individuals with late-onset agoraphobia do not have a history of panic attacks and the illness often starts after a traumatic event. Exposure therapy is the treatment of choice for agoraphobia without panic. It is uncommon for obsessive-compulsive disorder (OCD) and panic disorder to start for the first time in old age, but these disorders can persist from younger years into late life. Case reports and uncontrolled case series suggest that elderly people with OCD or panic disorder can benefit from pharmacologic and cognitive-behavioral treatments that are known to be effective in younger patients. However, it is not known whether the rate of response among elderly patients is adversely affected by the chronicity of these disorders. The prevalence and incidence of post-traumatic stress disorder in late life are not known. Uncontrolled data support the use of selective serotonin reuptake inhibitors in war veterans with chronic symptoms of post-traumatic stress disorder; other treatments for this condition await evaluation in the elderly.