Risk factors for major depression in older medical inpatients: a prospective study.

OBJECTIVE: To determine risk factors for major depression in older medical inpatients. METHOD: In a prospective cohort study, 86 older medical inpatients without depression or antidepressant medication were assessed 3, 6, and 12 months after enrollment. Incident major depression was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Potential predictive variables included sociodemographic variables, physical state, cognition, depressive symptoms, medication use, prior depressive episode, social network, support, and bereavement. Cox proportional hazards analysis (with backward variable elimination) was used to determine the best set of predictors. RESULTS: Twenty-six patients (30.2%) met criteria for incident major depression. Predictors of major depression included the following: prior depressive episode, birth outside Canada, low comorbidity, inadequate emotional support, fewer children seen, depressed mood, and diurnal variation. The risk of depression increased with the number of risk factors present. CONCLUSION: The seven identified risk factors may guide efforts to prevent major depression in older medical inpatients.     

Major depression in older medical inpatients predicts poor physical and mental health status over 12 months

OBJECTIVE: The aim of this study was to determine the 12-month effects upon physical and mental health status of a diagnosis of major or minor depression among older medical inpatients. METHODS: Patients 65 years and older, admitted to the medical wards of two university-affiliated hospitals, with at most mild cognitive impairment, were screened for major and minor depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria). All depressed patients and a random sample of nondepressed patients were invited to participate. The physical functioning and mental health subscales of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were measured at baseline and at 3, 6 and 12 months. RESULTS: Two hundred ten patients completed the SF-36 at baseline and at one or more follow-ups. In multiple linear regression analysis for longitudinal data, adjusting for baseline level of the SF-36 subscale outcome, severity of physical illness, premorbid disability, age, sex and other covariates, patients with major depression at baseline had lower SF-36 scores at follow-up, in comparison to patients with no depression [physical health, 9.22 (95% CI -15.52 to -2.93); mental health, 6.28 (95% CI -11.76 to -0.79)]. CONCLUSION: A diagnosis of major depression in cognitively intact older medical inpatients is associated with sustained poor physical and mental health status over the following 12 months.     

An exploratory study of diagnostic criteria for delirium in older medical inpatients

The poor prognosis of delirium in older medical inpatients has generated controversy about the diagnostic criteria for delirium in this population. The goal of the present study was to explore the presenting symptoms of delirium among older medical inpatients who did or did not recover from delirium. Patients 65 years or older admitted from the emergency department to medical services were screened with the Confusion Assessment Method (CAM). Patients with delirium were assessed at enrollment, several times during the first week, then weekly for 4 weeks using the Delirium Index (DI). Measures at baseline included demographics, dementia and severity of physical illness. Recovery was defined as a decline of three points or more on the DI and a final DI score of less than 5 or 4 points in patients with or without dementia, respectively. Of 290 patients who met DSM-IV criteria for delirium, 65 recovered and 225 did not. Three symptoms (orientation to person, hyperactivity, and inattention) were associated with recovery from delirium in older medical inpatients. These results suggest it may be necessary to place increased emphasis on these presenting symptoms when diagnosing delirium in this population.     

Dopaminergic function in panic disorder: comparison with major and minor depression.

Several lines of evidence suggest that dopamine might be involved in anxiety states. In this study, we assessed the growth hormone (GH) response to apomorphine (a dopaminergic agonist) 0.5 mg SC in nine drug-free inpatients meeting Research Diagnostic Criteria (RDC) for panic disorder who were age-matched and gender-matched with nine major depressive, and nine minor depressive inpatients. The three groups differed significantly in their mean GH peak response: 5.29 +/- 2.75 ng/ml in major depressives, 26.27 +/- 12.71 ng/ml in minor depressives, and 37.28 +/- 10.58 ng/ml in panics, with a significantly higher response in panic than in either minor or major depressive patients. These results support dopaminergic overactivity in panic disorder as compared with major and minor depression.     

The prognosis of minor depression in the general population: a systematic review

Minor depression is common in the general population. There is no consensus about prognostic indicators that can identify people at high and low risk of chronicity. We systematically reviewed the available literature on the prognosis of minor depression in the general population and identified five studies. Two of these were considered to be of relatively high methodological quality. There was a wide variety among the studies in the definitions of minor depression, the characteristics of the study population, length of follow-up and type of outcome measure. The results show that the majority of people with minor depression have a favorable prognosis; 46–71.4% achieve remission after a follow-up of 1–6 years. However, 16–62.3% still have a minor depression after 5 months to 1 year of follow-up, suggesting that for many people minor depression is chronic or recurrent; 12.7–27% develop a more severe form of depression; they were diagnosed with dysthymia or major depression after 1–6 years of follow-up. There was inconsistent evidence regarding mortality and functional impairment. No study presented results of prognostic factors, so it remains unclear which people have a more favorable course than others. The results of our review need to be interpreted with caution because of the small number of studies and the large heterogeneity among studies.     

The course of depression in adult outpatients. Results from the Medical Outcomes Study.

OBJECTIVE--To compare the course of depression during a 2-year period in adult outpatients (n = 626) with current major depression, dysthymia, and either both current disorders ("double depression") or depressive symptoms with no current depressive disorder. METHODS--Depressed patients visiting 523 clinicians (mental health specialists and general medical providers) were identified using a two-stage screening procedure including the Diagnostic Interview Schedule. The course of depression was assessed in 2 follow-up years with a structured telephone interview based on the format of the Diagnostic Interview Schedule. RESULTS--Baseline severity of depressive symptoms was greatest in patients with double depression, but initial functional status was poor in those with dysthymia with or without concurrent major depression. Patients with dysthymia had the worst outcomes, those with current major depression alone had intermediate outcomes, and those with subthreshold depressive symptoms had the best outcomes. Even the latter group, however, had a high incidence (25%) of major depressive episode over 2 years. Initial depression severity and level of functional status accounted for more explained variance in outcomes than did type of depressive disorder. CONCLUSIONS--The findings emphasize the poor prognosis associated with dysthymia even in the absence of major depression; the prognostic significance of subthreshold depressive symptoms; and the clinical significance of assessing level of severity of symptoms as well as functional status and well-being, regardless of type of depressive disorder.     

Recovery and major depression: factors associated with twelve-month outcome.

OBJECTIVE: In spite of the prevalence and chronicity of major depression, there is no consensus regarding which clinical and psychosocial variables are associated with recovery. The authors examined the probability of recovery from a major depressive episode 12 months after hospital discharge, the factors most closely associated with recovery, and the patterns of improvement distinguishing patients who recovered from those who did not. METHOD: Seventy-eight inpatients with a DSM-III diagnosis of major depression were assessed at hospitalization and at monthly intervals for 12 months after discharge on a variety of clinical and psychosocial factors. Recovery status at 12-month follow-up was then used as a basis for comparing acute-phase patient characteristics and change in symptoms over time. RESULTS: By the 12th month of follow-up, 34 (48.6%) of 70 patients met criteria for recovery. The five most important factors related to recovery were shorter length of hospital stay, older age at onset of depression, better family functioning, fewer than two previous hospitalizations, and absence of comorbid illness. The majority of patients who had recovered by 12 months had done so within 6 months of discharge; the average length of time to recovery was 4.9 months. CONCLUSIONS: Patients hospitalized for major depression have less than a 50-50 chance of recovering by 1 year. Some variables associated with nonrecovery (e.g., comorbid illness, poor family functioning) are amenable to clinical intervention; however, findings also suggest that there may be two distinct types of depressive illness with respect to recovery, one that remits quickly and the other with a more prolonged course of illness.     

The prognosis of depression in old age: outcome six to eight years after clinical treatment

Previous studies suggest that the short-term outcome in severely depressed elderly in The Netherlands is worse compared to other studies in the Western world. The present study examines the long-term prognosis of hospitalized elderly patients with major depressive disorder and possible predictors of outcome. One hundred and five elderly inpatients with unipolar major depression, admitted by regional mental health services in a geographically delimited area, were evaluated six to eight years after index episode by trained residents using a structured diagnostic interview (C.I.D.I.) The GP was interviewed using a standard questionnaire. At follow-up 40% of the original sample had died. Of the survivors 33% had fared well, 24% had a relapsing course, 22% had residual symptoms, 11% were continuously ill, and 9% had probable dementia. With respect to prognostic factors, personality disorder predicted a worse outcome. All patients with a major depressive disorder at follow-up received specialised care and used antidepressants. None of the patients received ECT. The mortality rate in clinically treated elderly with major depressive disorder is high. Among survivors the long-term prognosis in The Netherlands is comparable with other studies to date. The presence of a personality disorder predicts worse outcome. Though the accessibility of services seems to be good, more vigorous treatment was not applied.     

Substituting nonsomatic for somatic symptoms in the diagnosis of depression in elderly male medical patients

The authors examined the sensitivity and specificity of a modified version of the Research Diagnostic Criteria (RDC) for major, minor, and intermittent depressive disorder in 150 elderly male medical inpatients. Four somatic RDC symptoms were replaced with four nonsomatic symptoms. The sensitivity of the modified criteria was 87%, the specificity was 97%, and 96% of patients were correctly classified. Misclassifications were of mildly depressed patients. These results provide empirical support for the use of alternative, nonsomatic depressive symptoms when somatic symptoms are ambiguous indicators of depression.     

Assessment of depression in older medical inpatients: Practice,attitudes and the effect of teaching

The objective of this study was to determine the extent to which junior doctors assess depression in older medical inpatients and how much this could be influenced by a teaching session and the availability of a depression rating scale; also to determine the attitudes to depression of hospital doctors and senior nurses involved in the medical care of older people. Case note scrutiny was used on two occasions before and after a teaching session and distribution of depression rating scales, together with administration of the Depression Attitude Questionnaire. Participants were medical inpatients over 65 years old at a district general hospital and medical and senior nursing staff involved in their assessment and care. No patient had a documented mental state assessment at admission. This was unchanged following intervention. The questionnaire suggested that the problem lay not with knowledge, but with willingness to be involved in managing depression. In conclusion, the management of depression in older medical inpatients was unsatisfactory. The questionnaire suggested that future interventions to improve care should focus on encouraging 'ownership' of depression management rather than providing 'one-off' teaching.     

Twelve-month course of depressive symptoms in older medical inpatients

BACKGROUND: The study aimed: (1) to describe the 12-month course of depressive symptoms among medical inpatients aged 65+, and (2) to investigate predictors of a more severe course that could be identified easily by non-psychiatric staff. METHODS: Patients were recruited at two Montreal hospitals. Inclusion criteria were: aged 65+, admitted to medical service, at most mild cognitive impairment. Patients were screened for major and minor depression (DSM-IV criteria). All depressed patients and a random sample of non-depressed patients were invited to participate in the prospective study. The Hamilton Depression Scale (HAMD) was administered at admission, 3, 6, and 12 months. Individual patient trajectories of depressive symptoms over time were grouped using hierarchical clustering into three patient groups with a minimal, mild, and moderate/severe course of symptoms, respectively. The baseline predictors of a more severe clinical course were identified using ordinal logistic regression. RESULTS: Two hundred and thirty-two patients completed baseline and one or more follow-up interviews. Baseline patient characteristics that independently predicted a more severe symptom course included higher initial HAMD score, depressive core symptoms lasting 6 months or more, and female sex. CONCLUSION: The 12-month course of depression symptoms in this medically ill older sample was generally stable. Patients who will experience a more severe course can be identified by non-psychiatric staff at admission to hospital.     

Minor and major depression and the risk of death in older persons.

BACKGROUND: The association between depression and mortality in older community-dwelling populations is still unresolved. This study determined the effect of both minor and major depression on mortality and examined the role of confounding and explanatory variables on this relationship. METHODS: A cohort of 3056 men and women from the Netherlands aged 55 to 85 years were followed up for 4 years. Major depression was defined according to DSM-III criteria by means of the Diagnostic Interview Schedule. Minor depression was defined as clinically relevant depression (defined by a Center for Epidemiologic Studies Depression score > or = 16) not fulfilling diagnostic criteria for major depression. RESULTS: After adjustment for confounding variables (sociodemographics, health status), men with minor depression had a 1.80-fold higher risk of death (95% confidence interval, 1.35-2.39) during follow-up than nondepressed men. In women, minor depression did not significantly increase the mortality risk. Irrespective of sex, major depression was associated with a 1.83-fold higher mortality risk (95% confidence interval, 1.09-3.10) after adjustment for sociodemographics and health status. Health behaviors such as smoking and physical inactivity explained only a small part of the excess mortality risk associated with depression. CONCLUSION: Even after adjustment for sociodemographics, health status, and health behaviors, minor depression in older men and major depression in both older men and women increase the risk of dying.     

Characteristics and course of major depression in older primary care patients

OBJECTIVE: Identify the morbidity patterns displayed by older primary care patients experiencing depressive symptomatology who do and do not meet criteria for a major depression. METHOD: Patients ages sixty and older presenting at two ambulatory internal medicine centers were administered the CES-D. Among those scoring > or = 11, 104 completed a comprehensive assessment of their psychiatric symptomatology, medical illness, and functional abilities. The assessment battery was again administered six months later. RESULTS: The point prevalence of major depression in older primary care patients is estimated at 9 percent based on SCID interviews. Patients meeting criteria for this diagnosis compared to those who are symptomatic but not experiencing a major depression described more extensive psychopathology but also significantly more limitations in performing social and functional roles. At six-month follow-up, only 11.5 percent of those initially diagnosed with a major depression were considered fully recovered. CONCLUSIONS: Major depression is a prevalent disorder in older primary care patients which affects their ability to perform expected social and physical roles. Mechanisms for delivering efficacious treatments in routine medical practice are of a high priority.     

Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients

Objective: To determine the independent effects of depressed mood and markers of medical disease severity on mortality in consecutive medical inpatients. Methods: Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study endpoint was mortality from all causes at 1 year. Results: The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. In multivariate analyses, physicians' rating of prognosis was the best predictor of mortality [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI), 2.5–5.4]. Other independent predictors included a principal diagnosis of hemato-oncological disease, comorbidity scores, and HADS depression (adjusted OR 1.75; 95% CI, 1.10–2.79). Conclusion: Our data demonstrate an independent prognostic effect of depressed mood on mortality in general medical inpatients. Screening for depression may improve risk stratification in these patients over and above that obtained by routinely available physical parameters and physicians' clinical judgement.     

The clinical significance of subsyndromal depression in older primary care patients.

OBJECTIVE: Many seniors experience depressive symptoms not meeting standard diagnostic criteria. The authors sought to examine the clinical correlates of older primary care patients with "subsyndromal depression" (SSD), hypothesizing that SSD subjects have greater symptoms and functional impairment than nondepressed patients, but not as severe as those with major or minor depression, and to explore the characteristics of subjects captured by three different definitions of SSD used in prior published work. METHODS: The authors conducted a cross-sectional case comparison study that enrolled 662 primary care patients age >or=65 years. Outcomes were validated measures of psychopathology, medical illness burden, and functional status. RESULTS: All three SSD groups captured patients with greater symptoms and functional impairment than the nondepressed group. SSD subjects were as ill as those with minor or major depression on some measures (e.g., medical burden). Each SSD group definition captured some subjects unique to that group. CONCLUSIONS: Subsyndromal depression is common and associated with symptoms or impairments of clinical importance. Sole reliance on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions of major or minor depression omit a substantial proportion of seniors with clinically significant depressive symptoms. Longitudinal study is needed to help clinicians identify those at greatest risk for poor outcomes, while researchers testing mechanistic models should include patients with SSD to determine whether they share pathogenetic underpinnings with more severe mood disorders.     

The specificity of epidemiological correlates of major depression

Some of the variables associated with major depression in community samples may be nonspecific correlates of mental ill-health. The study objective was to evaluate this hypothesis by comparing two groups of psychiatric patients with the general population. Subjects were recruited from psychiatric inpatients at a general hospital in Calgary, Alberta, Canada, by dissemination of a consent form. Consenting subjects completed the mood disorders section of the Composite International Diagnostic Interview (CIDI). All subjects were interviewed to evaluate a set of variables that may be risk factors for major depression. The measurement instruments were identical to those used in a national survey so that comparisons to population-based data were possible. The psychiatric inpatients differed dramatically from community subjects in terms of stress, traumatic life events, recent life events, and social support. However, differences were not observed between inpatients with major depression (according to the CIDI) and inpatients without major depression. Associations between certain variables and major depressive disorders in community populations may reflect nonspecific associations with mental ill-health. This may occur because of nonspecific impacts of these variables on the etiology or prognosis of mental disorders or some nonspecific impact of mental illness itself.     

卒中后抑郁状态的发生率及相关因素研究

目的 了解卒中后抑郁状态（PSD） 的发生率及其相关因素。方法 采用Hamilton抑郁量素和自制一般情况调查表,对520例脑卒中患者进行调查评分,并用逐步Logistic回归统计方法对各相关因素进行分析。结果 PSD总发生率为34．2％,其中轻度20．2％,中度10．4％,重度3．7％。对PSD影响最大的相关因素是既往抑郁病史,其次是性别、家庭 和睦情况、合并疾病种类、神经功能缺损严重程度和卒中后病程。结论 上述因素是本组PSD患者的主要预测因素,为预防PSD提供参考依据。     

抑郁症的自杀未遂及其危险因素分析

为了获得抑郁症病人的自杀未遂发生率及其危险因素，采用自制的抑郁症与自杀的关系登记表和Ｈａｍｉｌｔｏｎ抑郁量表，分别对符合中国精神疾病分类方案与诊断标准第２版修订本的２１２例住院的抑郁症病人进行调查评分，然后用ＳＰＳＳ和ＰＥＭＳ软件包进行统计分析。结果：在２１２例抑郁症病人中发生自杀观念１５８例（７４．５％），自杀未遂６７例（３１．６％）。在自杀未遂组中的自杀方式以过量服药为主（４７．８％），自杀地点多在室内（７７．６％）。自杀未遂组的抑郁症状评分高于无自杀行为组（ｔ＝７．２７，Ｐ＜０．０１）。自杀与绝望感、抑郁情绪、自卑感、自知力等呈正相关。逐步回归分析发现，绝望感对自杀的影响最大，其次是抑郁情绪，再次是自卑感和自知力。提示抑郁症与自杀的关系密切，频繁出现≥３次自杀观念的抑郁症病人发生自杀行为的可能性较大。