Factors predicting the relapse of depression in old age

BACKGROUND: Studies in mixed-aged populations show differences between the predictors of a relapse and those of a long-term course of depression, supporting the hypothesis about similar differences among the aged. AIM: The aim was to identify the factors predicting or related to a relapse of depression among the Finnish elderly having recovered from depression during treatment. MATERIAL AND METHODS: The population consisted of 70 depressed (DSM-III criteria) elderly (60 yr-) Finns having recovered from depression during treatment as determined 15 months after baseline. By the 4-year follow-up after the recovery, 20 patients had relapsed and 50 persons were non-depressed. RESULTS: The logistic regression model showed major depression and psychomotor retardation to be independent predictors. Relapses were not related to stressors in life or physical illnesses occurring during the follow-up. CONCLUSIONS: Major depressive elderly patients have a high risk for relapses without the occurrence of the stressors or physical illnesses. In clinical practice, major depressive elderly patients should be followed up in order to detect and treat potential relapses as early as possible. Cooperation between psychiatrists and general practitioners is needed in the follow-up. Theoretically, the results suggest the assumption of a biochemical aetiology of major depression.     

The outcome of depression and dysthymia in a very elderly population: Results from a three-year follow-up study

Depression is a common disorder in the elderly. In population-based studies the rate of treatment is low. In spite of this most of the studies on the outcome of depression in the elderly are based on treated series. This study used data from a population of 1,101 very elderly persons. Of these, 7.2% (n=78) were diagnosed as having a major depression and 3.5% (n=39) as having a dysthymia at an initial examination. Both syndromes were over-represented in persons affected by dementia. Seventy-seven per cent of the depressed persons had consulted a physician recently and 17% were treated for depression. Three years later those who were depressed and had survived were re-examined. At the follow-up examination, 48.6% of the non-demented persons and 14.3% of the demented were depressed. In conclusion, the rate of treatment of depression in the very elderly is low and the course is chronic or relapsing in almost half of the cases.     

Predictors for Depression, Anxiety and psychotic symptoms in a very elderly population: data from a 3-year follow-up study

  Background: This study examined the predictors for Depression, Anxiety and psychotic symptoms in a population of very elderly persons. Methods: A total of 894 persons with a mean age of 84.5 years were examined twice using a 3-year interval. Physicians performed a structured psychiatric interview and persons with a current disorder or symptom were excluded. Results: Persons who had a history of psychosis, were affected with Dementia and had an insufficient social network had an increased frequency of psychotic symptoms. A history of Depression/Anxiety increased the frequency of having Anxiety and Depression. An insufficient social network was associated with Anxiety. Conclusions: In this study Anxiety, Depression and psychotic symptoms in the very elderly seem to be linked to a lifetime psychological vulnerability, since all were related to a previous psychiatric history. Additionally, psychotic symptoms seemed to emerge due to structural brain damage, as seen in Dementia. Accepted: 23 February 2000     

One-year prognosis of depressive illness in the elderly population in Japan

A 1-year prospective study of 43 elderly depressed residents (13 men and 30 women) in Nagai City in Japan is described. An initial survey was carried out in 1993 to find depressed residents. The subjects of the survey were 2056 residents of 65 years of age and older. The Japanese version of the Geriatric Depression Scale (GDS) was employed as a screening tool in the first phase of the survey. In the second phase, screened subjects and control subjects were interviewed by psychiatrists using the Structured Interview for DSM-III-R (SCID). The diagnosis of depression was made by the psychiatrists on the basis of the results of the SCID. Forty-three persons were judged to be depressed. At follow-up, 10 were still depressed and 15 were well. Four were demented. Fourteen dropped out due to death, hospitalization, absence from home or refusal. The results showed that approximately half of the elderly depressed persons seemed to recover by the time of the 1-year follow-up. One-year prognosis of dysthymia was the worst. Some types of depression seemed to be a precursor for dementia. The concern is with how the findings may be used as an aid in understanding and planning community mental health services strategies. The results indicate that it is very important to pay close attention to patients with depressive illness who do not meet the criteria for major depression.     

Depression in stroke patients 7 years following stroke

OBJECTIVE: To study the frequency of depression in stroke patients many years following stroke, most previous studies having concentrated on the first few years. METHOD: Participants of a previous study of post-stroke depression (99 stroke patients and 28 control subjects) were re-examined 7 years later. Depression was diagnosed using research diagnostic criteria. The test battery comprised the Mini Mental State Examination, the Raven Matrices A+B and Word Pair Learning. Subjective experience of changes in memory, concentration, mood, irritability and fatigue during the 7-year period was also examined. RESULTS: Twenty per cent of the stroke patients fulfilled the criteria for major or minor depression compared with 11% of the control subjects. No differences in cognitive function were found between depressed and non-depressed stroke patients. The stroke patients reported experiencing more lability of mood and irritability during the 7-year period following stroke than the control subjects. Depressed stroke patients experienced more impairment of concentration and memory function than non-depressed stroke patients. CONCLUSION: Affective symptoms are common among stroke patients 7 years following stroke.     

One-year outcomes of minor and subsyndromal depression in older primary care patients

BACKGROUND: Despite the high prevalence and morbidity of minor and subsyndromal depression in primary care elderly people, there are few data to identify those at highest risk of poor outcomes. The goal of this observational cohort study was to characterize the one-year outcomes of minor and subsyndromal depression, examining the predictive strength of a range of putative risks including clinical, functional and psychosocial variables. METHODS: Patients aged > or = 65 years were recruited from primary care medicine and family medicine practices. Of 750 enrollees, 484 (64.5%) completed baseline and one-year follow-up assessments of depression diagnosis (major depression vs. minor and subsyndromal depression vs. non-depressed) by the Structured Clinical Interview for DSM-IV, depressive symptom severity (Hamilton Rating Scale for Depression), and validated measures of other predictors. RESULTS: Patients with baseline minor and subsyndromal depression were more depressed than the non-depressed group at follow-up: They had a 7.0-fold (95% CI 4.5-10.8) risk of developing major depression, and a one-year adjusted Hamilton Depression Score of 11.0 (95% CI 10.2-11.8) compared with 7.8 (95% CI 7.1-8.5) for the non-depressed group; these outcomes were less severe than those of the major depression group. Independent predictors of depression outcomes included race, psychiatric and physical functioning, and social support. CONCLUSIONS: Minor and subsyndromal depression are likely to persist, and pose an elevated risk of worsening over one year. Clinicians and preventive interventions researchers should focus on modifiable risks, such as psychiatric functioning or social support, in elders suffering clinically significant depressive symptoms.     

Differences in heart rate variability between depressed and non-depressed elderly

OBJECTIVE: To determine whether older primary care patients with a Major Depressive Disorder (MDD) have lower heart rate variability (HRV) compared to non-depressed patients. HRV is a measure of cardiac autonomic functioning. METHOD: A cross-sectional comparison of 136 elderly persons with MDD and 136 non-depressed controls (matched for age and gender) recruited in family practices in the Netherlands. Depression was determined according to the DSM-IV criteria using the PRIME-MD. HRV was measured with an electrocardiogram (ECG) during a 5-minute supine rest. RESULTS: Multivariate analyses showed statistically significant decrease in HRV in MDD patients compared with controls. CONCLUSION: Older primary care patients with MDD have a reduced HRV. This may explain why depression is a risk factor for cardiovascular disease and mortality.     

Is depression related to subsequent diabetes mellitus?

OBJECTIVE: To compare the risk of developing diabetes mellitus (DM) in the general population between subjects who had a depression and subjects who never had a depression. METHOD: Retrospective cohort design. People with depression were diagnosed with a depression between 1975 and 1990; controls never had a depression. Both groups were followed for a diagnosis of type II diabetes until 2000. Data on 1334 depressed and 66 670 non-depressed subjects were available from a large general practice-based database. RESULTS: No overall relation was found, but among males below age 50 there was a 78% increase in the rate of development of DM compared with non-depressed patients (hazard ratio 1.78, 95% CI: 1.21-2.62). CONCLUSION: Depression in males between the age of 20 and 50 years is related to an increased risk of developing DM.     

Stronger symptoms of depression predict high coronary heart disease mortality in older men and women

BACKGROUND: Most cohort studies have found depressive symptoms to be associated with increased cardiovascular mortality in the elderly, but follow-up times have often been short and study populations small. OBJECTIVES: To describe associations between stronger symptoms of depression and the risk of death from coronary heart disease (CHD) or myocardial infarction (MI) in elderly Finnish subjects free of CHD at the baseline. METHODS: This study is a prospective population-based epidemiological and clinical twelve-year follow-up study in Lieto Health Centre, Finland. The basic population consisted of 1196 elderly (64 years of age or older) persons who lived in the municipality of Lieto in southwestern Finland in 1990. The occurrence of CHD was determined on the basis of electrocardiographic (ECG) findings, Rose questionnaire and the diagnoses in medical records. The persons with CHD were excluded from the study population. Symptoms of depression at the baseline were measured with the Zung Self-rating Depression Scale (ZSDS). Mortality was followed up for about 12 years. RESULTS: The Kaplan-Meier survival curves showed stronger symptoms of depression to be related to high risks of mortality from CHD or MI among men and women. According to the Cox model for men significant predictors for higher risk of CHD or MI mortality were stronger symptoms of depression, higher age and a large number of medications in use. When women were examined, significant predictors were stronger symptoms of depression and a large number of medications in use. CONCLUSIONS: Stronger symptoms of depression are an independent risk factor for high CHD or MI mortality in aged Finnish men and women free of CHD at baseline.     

Six-year survival of depressed elderly Finns: a community study

Background. The 6-year survival of depressed elderly (N = 290) Finns was assessed and compared to that of a non-depressed population (N = 982), and the factors related to high mortality were analysed. Method. Depression was determined according to the DSM-III criteria, and a majority of the depressed population suffered from dysthymic disorder. Survival distributions were represented as Kaplan-Meier survival curves. The Cox proportional hazards model was used to analyse the simultaneous relationships between mortality and certain variables. Results. The survival curves showed an increased mortality of the depressed elderly in both men and women. However, when the simultaneous relationships of age, marital status, education, smoking, functional abilities, somatic illnesses and depression were taken into account, depression did not predict mortality. The predictors of mortality were high age, a high number of medicines, smoking, disability, male sex and occurrence of somatic illnesses. Conclusions. Evidence of once measured depression is not predictive of increased mortality in an unselected elderly population (60+) when the other factors known to influence survival probability are taken into account. © 1997 John Wiley & Sons, Ltd.     

Serum cholesterol and depressive symptoms in elderly Finnish men

OBJECTIVE: Evidence from previous studies suggests that alterations in lipid levels may be associated with depression in old age. The objective of this study was to investigate the association between serum lipids and depressive symptoms in a population of elderly men. SUBJECTS AND METHODS: Altogether 470 men born between 1900 and 1919 were examined in the 30-year follow-up of the Seven Countries Study in 1989. Zung Self-Rating Depression Scale was used to determine the depressive status of the subjects. The depressive status was dichotomised and used as the dependent variable in the present study. RESULTS: The depressive status was available for 421 men aged 70 to 89 years in 1989. The prevalence of depression, defined as the Zung sum score equal to or greater than 48, was 15.2% (n = 64). A low serum total cholesterol (odds ratio (OR) 0.67, 95% confidence intervals (CI) 0.48-0.94, p = 0.022) and low low density lipoprotein cholesterol (OR 0.67, 95% CI: 0.46-0.98, p = 0.041) were independently associated with depression. No association with depression was found for high density lipoprotein (HDL) concentration or HDL/total cholesterol ratio after the adjustment for other putative correlates for depression. CONCLUSIONS: Our study of a well-documented population of elderly Finnish men confirms that low total serum cholesterol is associated with a high amount of depressive symptoms independently of weight change or chronic disease. Our study is the first to show an independent association of low LDL-cholesterol concentration with a high amount of depressive symptoms in the old-old.     

Validation and comparison of three brief depression scales in an elderly Chinese population

The study aimed to establish the diagnostic accuracy of the Geriatric Depression Scale (GDS), the Even Briefer Assessment Scale for Depression (EBAS DEP), and the single question test for depression in our elderly Chinese population, and to determine if any one instrument was to be preferred. Ninety-eight community-living, socially active and non-depressed elderly and 75 patients diagnosed with depression were administered the three depression scales. Receiver operating characteristics (ROC) were employed to determine the optimal cut-off scores for the GDS and EBAS DEP, and the diagnostic performance of all three instruments were then compared. ROC analysis indicated an optimal cut-off score of 4 and above for the 15-item GDS, with a sensitivity of 84.0% and a specificity of 85.7%, while the EBAS DEP had 77.3% sensitivity and 89.8% specificity at the optimal cut-off score of 3 and above. The sensitivity and specificity of the single question were 64.0% and 94.9%, respectively. The non-parametric test of the areas-under-the-curve showed no significant difference between the diagnostic performances of the GDS and the EBAS DEP; visually, however, the ROC plot of the GDS was superior. The GDS, the EBAS DEP, and the single question were all valid screening tools for depression in the elderly Chinese population. For busy physicians, there is rationale to first use the single-question test, supplemented where necessary with either the GDS or the EBAS DEP, as an efficient diagnostic strategy for identifying depression amongst older Chinese patients.     

Psychological status,life and social conditions: A study in a population of institutionalized elderly people

The relationship between social and life conditions on the one hand and the presence of depression on the other was analysed in a population of institutionalized elderly subjects. The influence of health status on psychological condition and the presence of endocrinological changes in hormones associated with chronic stress were investigated in depressed elderly people. One hundred and thirty-seven elderly people (mean age 82.4 ± 7.7) were studied and 60 of them underwent a thorough psychiatric examination. The overall prevalence of depression-not previously diagnosed in all but one patient—was 76.6%; 23.3% were severely depressed. Neither gender nor the presence of organic disease differentiated the depressed from the non-depressed. The only two life and social variables associated with depression among the many items analysed were the length of institutionalization and the period of retirement. It was observed that a higher cortisol level in the severely depressed group showed a positive correlation between plasma (and urine) cortisol level and Hamilton Rating Scale for Depression (HRSD) score. A relationship between immunological impairment and depression in old age has been reported elsewhere; it is suggested that these findings could be partly mediated by the observed endocrinological changes.     

Late-life depression symptom profiles are differentially associated with immunometabolic functioning

Growing evidence suggests immune and metabolic dysregulation among depressed persons, possibly restricted to specific subgroups. This study explores the association between depressive disorders and characteristics with immunometabolic functioning among older persons. Data are from the baseline assessment of the Netherlands Study of Depression in Older Persons, including 131 non-depressed and 358 depressed (6-month DSM-IV major depressive disorder) persons (60–93 years). Immune (C-reactive protein, interleukin [IL]-6) and metabolic (waist circumference, triglycerides, high-density lipoprotein cholesterol, blood pressure, fasting glucose) factors were measured. Depression characteristics included severity, age of onset, symptom profile (atypical/melancholic) and antidepressant use. Depressed persons showed lower IL-6 levels compared with non-depressed persons. Depressed persons, except those with atypical depression, had lower waist circumference, lower glucose levels and scored lower on an overall index including all immunometabolic factors. Low waist circumference was more pronounced among those with less severe depression and those with a later age of onset, whom also had lower blood pressure levels. Atypical depression was associated with higher triglyceride levels. Antidepressant use was not clearly associated with immunometabolic functioning. To conclude, contrary to our expectations, we found overall immunometabolic downregulation in older depressed persons, in particular among those with less severe symptoms and those with late-life onset. However, persons with atypical depression presented with metabolic upregulation compared with other depressed persons. Taking depression symptom profiles into account is important when examining biological dysregulation in late-life depression.     

Death wishes in the very elderly: data from a 3-year follow-up study

OBJECTIVE: The aim of this study was to study the 3-year outcome of death wishes in an elderly population. METHOD: 1099 very elderly people were examined extensively by physicians, including a structured psychiatric interview. Three years later those who had survived were re-examined (n = 683) using a similar procedure. RESULTS: Of the sample, 11.6% (n = 128) had death wishes at the first examination and 8.9% (n = 54) at the follow-up. Of the 54, 17 have had death wishes persistently during the 3-year period; all of them had psychiatric diagnoses. Of those having death wishes at one of the examinations 70% had psychiatric diagnoses. Attrition was more common in the group with death wishes than in the group without when age, gender, somatic disorders including dementia and disability in daily living were taken into account. CONCLUSION: This study shows that there is a need for a psychiatric examination when elderly people express death wishes.     

One-year severity of depressive symptoms: results from the NESDA study

The aim of this study was to simultaneously examine a wide range of risk factors and clinical characteristics in their predictive value for the 1-year severity of depressive symptoms. Data from 789 participants in the Netherlands Study of Depression and Anxiety (NESDA), a large psychiatric cohort study, with a major depressive disorder (MDD) at baseline were used. Depression severity at 1-year follow-up was studied using linear and multinomial logistic regression models. Results of the analyses showed that high neuroticism, no partner and older age were found predictive of a poorer outcome independent of baseline clinical characteristics. Further, comorbid anxiety disorder, first episode, having a moderate subtype (vs. melancholic), and higher baseline depression severity predicted poorer outcome. To conclude, both risk factors and clinical characteristics independently predicted 1-year severity of depressive symptoms. The findings indicate that the prediction of prognosis and identification of persons at risk of a poor outcome should not only be based on clinical characteristics, but on risk factors as well.     

Symptomatic and functional recovery in depression in later life

Objectives

Functional limitations give an indication of the total impact of diseases, such as depression, on individuals health and recovery. This study examines the change in several domains of functioning over 2 years in older persons depressed at baseline (non-remitted group and remitted group after 2 years) and in a non-depressed comparison group.

Methods

Data were used from a cohort study (Netherlands Study of Depression in Older persons [NESDO]) consisting of depressed older persons ≥?60 years (N?=?378) and a non-depressed comparison group (N?=?132) with 2 years of follow-up (attrition rate 24%). Functional limitations (outcome) were assessed with the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire every 6 months. Total scores and domain scores were used. Depression was classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria at baseline and at 2-year follow-up. Severity of depression (predictor) was assessed with the Inventory of Depressive Symptomatology (IDS) at 6-month intervals.

Results

Linear mixed models showed that the level of functional limitations differed between the three groups during 2 years of follow-up. The non-remitted group had the highest level of functional limitations during 2 years, followed by the remitted group. Stable low levels of functional limitations were found for the non-depressed group. Remission from depression was accompanied by improvements in functioning, however, compared to the non-depressed comparison group significant functional limitations remained. Higher severity of depression appeared as risk factor for a declining course of functioning, especially the social aspects of functioning.

Methodological considerations

Participants that were more severely depressed and more functionally impaired at baseline had higher attrition rates than the participants that were included in the analytical sample.

Conclusion

This study showed that depression in later life has long-term debilitating effects on functioning, enduring even after remission from depression. This implies that depression treatment in later life should aim broader than just symptomatic recovery, but also include functional recovery.

     

Depressive symptoms predicting six-year mortality in depressed elderly finns

The specific symptoms of depression associated with increased mortality in the depressed elderly are poorly known. The aim of this paper is to analyse the individual depressive symptoms measured by the Zung Self Rated Depression Scale (ZSDS) and the Hamilton Rating Scale for Depression (HRSD) in association with mortality among depressed elderly subjects. The population consisted of 169 depressed (DSM-III criteria) aged (65+ years) persons from a Finnish epidemiological research project. The follow-up for deaths continued for about 6 years. When age, sex, smoking, physical health and functional abilities were taken into account, dissatisfaction, weight loss and gastrointestinal symptoms (anorexia and constipation) predicted mortality together with high age and poor physical health. Weight loss was related to an increased risk of death, specifically in the depressed. Dissatisfaction and gastrointestinal symptoms were more general markers of increased mortality.     

A three-year follow-up of major depression, dysthymia, minor depression and subsyndromal depression: results from a population-based study

This study examined the 3-year outcome of major depression (MD)/dysthymic disorder (DD), minor depression (MinD), and subsyndromal symptomatic depression (SSD) in a population-based sample. The aims were to study the fluctuating nature of the symptoms of depression and to analyze the risk of fulfilling the criteria for MD/DD at the follow-up. An extensive questionnaire was sent out to persons ages 20-64 years registered in Stockholm County. Depression was assessed with the Major Depression Inventory. After 3 years the procedure was repeated, and 8,622 persons participated in both waves. Diagnoses of MD/DD, MinD, or SSD were made. Highest 3-year stability in fulfilling the criteria for a specific depressive category was found in MD/DD, and of those affected, only 35.9% had one or fewer symptoms of depression at the 3-year follow-up. The frequency of those with one or fewer symptom of depression was equal in MinD (58.9%) and in SSD (56.5%). The relative risk (RR) of fulfilling the criteria for MD/DD at Wave 2 was highest for those affected by MD/DD (RR=22.4) at Wave 1, whereas those fulfilling the criteria for MinD or SSD had similar rates (RR=4.8 and 5.0, respectively). This study supports the view that depression is a dimensional illness, with the affected persons moving in and out of diagnostic subtypes. The 3-year prognosis was severe in half of the affected persons in all three diagnostic depression categories.     

Motivational symptoms of depression mask preclinical Alzheimer's disease in elderly subjects

BACKGROUND: Althoughthe relationship between depressive disorders and Alzheimer's disease (AD) is debated, there is evidence that depression may be an early symptom of dementia. OBJECTIVE: To evaluate depression features prospectively in elderly subjects with a view to identifying a subgroup affected by preclinical AD. METHODS: We performed a cohort study on cognitive performances with a 12-month follow-up in out-patients referred to the local Neuropsychology Clinic complaining of memory problems. Two hundred and twenty-two consecutive non-demented subjects were studied using a neuropsychological battery and the Beck Depression Inventory (BDI) and assessed again 1 year later for the possible onset of cognitive impairment. Multivariate analysis was performed to detect independent predictors of dementia development among age, education, neuropsychological test scores and BDI scores and subscores. BDI subscores were obtained by dividing items into three domains corresponding to mood-related, somatic and motivation-related symptoms. RESULTS: At the time of the first evaluation, 124 of the 222 subjects were depressed according to DSM-III-R criteria. At 1 year, 31 of the 124 depressed subjects and 2 non-depressed ones had AD according to NINCDS-ADRDA criteria. Stepwise logistic regression analysis indicated that the subjects who went on to develop dementia had significantly higher total BDI scores and motivational BDI subscores. Among depressed subjects, the probability of being diagnosed with dementia during follow-up was significantly associated with a motivational BDI subscore > or = 7 (odds ratio: 3,885, 95% Cl 154-97,902). COMMENT: Close neuropsychological follow-up of depressed elderly subjects complaining of memory failure and showing apathy is recommended to detect the early stage of AD.