Late life depression: challenge or curse for the general practitioner (GP). A cohort study

The aim of this study was to examine specificity of GP's care for elderly depressed patients. Among 17,000 examinees (10 GP-Offices) were extracted 231 patients with diagnosis of depressive episode (F32) and 152 with diagnosis of recurrent depressive disorder (F33) classified according to ICD-10. Older than 65 years were 134 depressed patients. Data were tracked longitudinally and obtained retrospectively for a 1-year period from 1st January to 31st December 2008. Questionnaire was designed for this study to estimate the care delivered to depressed patients. Logistic regression analysis showed that GP more often diagnosed depression in older patients, provided medical care for them and changed their therapy. The main therapy for up to 80% of elderly with diagnosis of recurrent depressive disorder was combination of pharmacotherapy and GP's support and psychiatrist psychotherapy, while more than 20% of elderly with diagnosis of depressive episode took only pharmacotherapy. In comparison with younger age group, elderly less frequently received psychotherapy and GP's support. GP has an important role in older depressed patient care, so improvement efforts could focus on GP's clinical skills of depression treatment, as well as therapy effectiveness and depression outcome for understanding treatment specificity within elderly.     

Clinical Interventions for Late-Life Anxious Depression

Anxiety symptoms are frequently present in patients with late-life depression. The designation “anxious depression” has been used to describe major depressive disorder (MDD) accompanied by clinically significant but subsyndromal anxiety symptoms. MDD may also present comorbid with diagnosable anxiety disorders, although this presentation is less common in late life. Diagnosis of anxious depression in the elderly is complicated by several factors (eg, their tendency to experience and report psychiatric symptoms as somatic illness) and is associated with a more severe clinical presentation, increased risk for suicidal ideation, increased disability, and poorer prognosis. Standard pharmacotherapy for depression may be sufficient but for many patients must be modified or augmented. Psychosocial interventions may also be an important component in the treatment of these patients, although no specific psychosocial treatments have been developed for late-life anxious depression.     

Depression and physical illness in the elderly.

The authors' study confirmed the high prevalence of depressive symptoms in elderly medical inpatients but found no relationship between the diagnosis of or symptoms of depression and mortality or hospital use. Other studies examining the impact of depression on outcome for elderly patients may not have adequately controlled for the severity of the accompanying physical illness, which may perhaps have been responsible for the reported adverse effects of depression on outcome. An alternative explanation is that the authors' study involved a 1-year follow-up and a longer period of time may be necessary. The study demonstrated that routine screening for depression in acute elderly medical inpatients may be a useful way of detecting coexisting psychiatric morbidity. The routine screening measures were acceptable to patients and may be of considerable potential value in alerting staff to accompanying psychological distress. This study also illustrated the high prevalence of depression in patient samples and the importance and usefulness of screening geriatric inpatients. There are, however, several questions that remain unanswered both in studies reviewed in this article and in the authors' own work. The etiology and mechanism of the association between physical illness and depression are unknown, and there has been a dearth of studies assessing the feasibility and utility of specific treatments for depression in the elderly physically ill.     

Perfusion deficits,inflammation and aging precipitate depressive behaviour

Major depressive disorder (MDD) is a severe psychiatric illness that is associated with significant morbidity and mortality. Despite advances in the treatment of major depression, one-third of depressed patients fail to respond to conventional antidepressant medication. One pathophysiologic mechanism hypothesized to contribute to treatment resistance in depression is inflammation. Inflammation has been linked to depression by a number of putative mechanisms involving perfusion deficits that can trigger microglial activation and subsequent neuroinflammation in the elderly. However, the pathophysiological mechanisms remain to be further elucidated. This review focusses on recent studies addressing the complex relationships between depression, aging, inflammation and perfusion deficits in the elderly. We expect that a better understanding of neuroinflammatory mechanisms associated with age-related diseases may lead to the discovery of new biomarkers of MDD and development of new therapeutic interventions.     

Descriptive epidemiology and risk factors of depression in the elderly

Depressive symptoms are frequent among the elderly, and seriously impair their quality of life. The prevalence of depressive symptoms is difficult to evaluate on account of several epidemiological problems, such as the various definitions of "depression", which often prevent comparisons between studies. The second major difficulty is related to the selection bias due to differences in populations studied, and to the high risk of refusal to participate among the depressed subjects. Nevertheless, the prevalence has been estimated, in general population, from 1 to 4% for major depression according to the DSM-IV criteria, and from 8 to 16% for depressive symptoms which may require treatment. The heterogeneity of the symptomatology of depression in the elderly, with atypical clinical feature, leads to underestimate its diagnosis and lack of proper medical care. However, effective treatments exist and most cases of depression among elderly are treatable. In the literature, many risk factors of depression among the elderly have been identified : female sex, low socio-economical level, bereavement, prior depression, co-morbidities, disability, cognitive deterioration and vascular factors. To decrease the consequences of depression and to improve the quality of life of the elderly, the screening and treatment of depression should be strengthened in the general elderly population.     

Prevalence of depressive disorders in men and women enrolled in cardiac rehabilitation

PURPOSE: Epidemiological studies have demonstrated that depression is an independent risk factor for the development and recurrence of coronary heart disease (CHD). The prevalence of depressive disorders, however, is not well documented in CHD patients enrolled in cardiac rehabilitation (CR). The purpose of this study was to estimate the prevalence of current and lifetime depressive disorders in the CR setting. METHODS: One hundred ten men and women diagnosed with CHD and enrolled in a phase II CR program were screened via a psychiatric, structured interview to assess current and lifetime history of major depressive disorder, minor depression, and dysthymic disorder. RESULTS: A total of 17 (15.5%) individuals screened positive for a current depressive disorder at entry into the CR program, with 10 (9.1%) individuals screening positive for major depressive disorder, 7 (6.4%) for minor depression, and 6 (5.5%) for dysthymic disorder. With respect to lifetime prevalence of mood disorders, 29 (26.4%) individuals met the diagnostic criteria for at least one depressive disorder during their lifetime. The lifetime prevalence of major depressive disorder, minor depression, and dysthymic disorder was 11.8%, 14.5%, and 10.9%, respectively. Female CR participants evidence significantly higher current and lifetime prevalence rates for depressive disorders compared to their male counterparts. CONCLUSIONS: The results of this study suggest that a substantial number of CHD patients enrolled in CR report a clinically significant history of depression. Efforts to assess and treat depression are needed in the CR setting and may be associated with better adherence to lifestyle modification programs.     

Surprisingly high prevalence of anxiety and depression in chronic breathing disorders

STUDY OBJECTIVES: The objectives of this study were to assess the prevalence, screening, and recognition of depression and anxiety in persons with chronic breathing disorders, including COPD. DESIGN: Cross-sectional study. SETTING: The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC). PARTICIPANTS: A large sample of 1,334 persons with chronic breathing disorder diagnoses who received care at the MEDVAMC. MEASUREMENTS: The prevalence of anxiety and depression was measured in a large sample of persons with a chronic breathing disorder diagnosis who received care at the MEDVAMC, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions. The positive predictive value of the PRIME-MD questions was then determined. The prevalence of anxiety and depressive diagnoses in patients determined to have COPD was then measured, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). RESULTS: Of patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The predictive value of a positive phone screen for either depression or anxiety was estimated to be 80%. In the subsample of patients who had COPD and received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety. CONCLUSIONS: It is troubling that a mere 31% of COPD patients with depression or anxiety are being treated, particularly given their high prevalence in this population. Practical screening instruments may help increase the recognition of anxiety and depression in medical patients, as suggested by the excellent positive predictive value of the PRIME-MD in our study.     

Evaluation of the depressive symptomatology in the elderly

Depressive symptoms are frequent in old age. They are associated with several types of mental disorders : major depression, bipolar disorder, dysthymia, organic mood disorder, mixed anxious and depressive disorder. Various types of assessment tools can help to evaluate depressive symptomatology in the elderly: self administered questionnaires, observer ratings, standardised interviews. All are helpful in the clinical approach of depressive states. Self-administered questionnaires are the best tools for a systematic brief screening for depression, while observer ratings will be used for a quantification of depressive symptomatology in the follow up or to evaluate the efficacy of therapeutic interventions. Lastly, standardised interview are mostly used in research protocols, taking advantage of their high specificity. For the assessment of depression as one of the behavioural and psychological symptoms of dementia, multidimensional tools like the NPI, or unidimensional instruments like the Cornell scale for depression will be preferred.     

Epidemiology of geriatric affective disorders.

Recent Epidemiologic Catchment area studies found the prevalence of major depression to be only about 1% in community-dwelling elders; other less severe depressive disorders, however, may be present in over 25% of this population. Furthermore, at least 8000 persons over age 60 commit suicide each year, making up nearly one quarter of the total number reported, a rate much higher than expected given the proportion of elderly in the US population. Bipolar disorder, on the other hand, is much less common than unipolar depression at a rate of about 0.1% in the community; in nursing homes, however, as many as 10% of residents may have this condition. Sociodemographic correlates of depression in late life include female sex, divorced or separated marital status, low income or educational level, inadequate social support, and recent negative and unexpected life events. In particular, physical health has a major impact on mood and well-being; consequently, rates of major depressive disorder in elders hospitalized with medical illness are over 10 times that reported in the community.     

The impact of depression on the course and outcome of coronary artery disease: review for cardiologists

Epidemiological research over the past decade indicates that major depression and depressive symptomatology are common among patients with coronary artery disease (CAD) and postmyocardial infarction. Major depression is a serious, debilitating comorbid disorder that can significantly increase risk for and complicate recovery from cardiac events (eg, myocardial infarction). Unfortunately, major depression is rarely detected or treated in the cardiology setting. However, it is a disorder that can be successfully and safely treated in the majority of cases. Although the mechanisms that may be mediating the depression-CAD link are less well understood, there are several plausible mechanisms by which depression may influence the course and outcome of CAD. This review examines the literature linking major depression and depressive symptomatology to CAD course and outcome, and makes recommendations for improving assessment and treatment of depression in the cardiology setting.     

老年冠心病患者与抑郁障碍的相关性研究

目的 探讨抑郁障碍是否为老年冠心病的危险因素并观察冠心病伴抑郁障碍患者炎性标记物水平变化.方法 对188例入选者进行临床情况调查、汉密顿抑郁量表评分和血清炎性标记物水平测定,分析冠心病伴抑郁障碍患病率及影响冠心病发病的危险因素.结果 冠心病患者87例,其抑郁障碍患病率为29.9%(26例),非冠心病入选者101例,患病率为11.9%(12例),抑郁障碍在两组间差异有统计学意义(P＜0.01).年龄、高血压、糖尿病、脂代谢异常和抑郁障碍是冠心病的危险因素之一.冠心病伴抑郁障碍组和冠心病不伴抑郁障碍组入选者在突发生活事件、心功能分级差异有统计学意义(均P＜0.05).两组入选者在冠状动脉病变、冠状动脉病变治疗差异无统计学意义(P＞0.05).冠心病伴抑郁障碍组和冠心病不伴抑郁组外周血炎性标记物水平比较显示,伴抑郁障碍组血清单核细胞趋化因子-1水平增高,高敏C反应蛋白和肿瘤坏死因子α差异无统计学意义.结论 老年冠心病患者伴抑郁障碍患病率高于老年非冠心患者群.抑郁障碍是影响冠心病发病的危险因素之一.老年冠心病患者抑郁障碍与炎性标记物之间可能存在一定关系.

Abstract：

Objective To explore whether depressive disorder is one of risk factors for coronary artery disease (CAD) in enrolled patients and observe the level of inflammation markers in coronary artery disease patients with depression. Methods In all patients, we recoded clinical information and data from Hamilton Depression Rating Scale for Depression( HRSD)and measured concentration of monocyte chemoattractant protein-1 (MCP-1), tumour necrosis factor α (TNFα) and hypersensitive C-reaction protein (hsCRP). Results Among 87 patients with coronary artery disease, depressive disorder was diagnosed in 26 patients, the prevalence of depressive disorder was 29. 9%. Among 101 patients without coronary artery disease, 12 patients were suffering from depressive disorder, the prevalence of depressive disorder was 11.90%. The prevalence of depressive disorder in coronary artery disease group was statistically higher than that in non-coronary heart disease group (29.8% vs.11.9%, P<0. 01). The incidence of coronary artery disease was associated with age, hypertension,diabetes mellitus, hypercholesterolemia and depression. Life events and stage of heart function occurred differently between CAD patients with and without depression (P<0. 05). There were no differences in the degree of coronary artery stenosis and the type of treatment (P>0. 05) between the two groups. There were higher concentration of MCP-1 in coronary artery disease patients with depression, but no remarkable difference in hsCRP and TNFa. Conclusions There is high prevalence of depressive disorder, which is one of risk factor for coronary artery disease. The depressive disorder may be associated with inflammation biomarker in patients with coronary artery disease.     

Frontal function, disability and caregiver burden in elderly patients with major depressive disorder

Caregivers of patients with late-life major depressive disorder experience a significant level of general caregiver burden. Disability in patients is possibly one of the origins of caregiver burden. Frontal lobe dysfunction might be the source of disability. This study investigated if frontal lobe dysfunction (body level) of patients with late-life major depressive disorder was associated with their disability (individual level), and if it led to a high level of caregiver burden (societal level). Thirty-four unselected pairs of caregivers and their family members with late-life major depressive disorder were recruited. Frontal Assessment Battery and Timed Instrumental Activities of Daily Living (TIADL) were used to assess patients' frontal function and disability, and Caregiver Burden Inventory was used to measure caregiver burden. Frontal Assessment Battery correlated with TIADL (r= -0.47; p<0.006). TIADL score was also associated with two subscales of the Caregiver Burden Inventory: social (r = 0.38, p=0.026) and time-dependent (r= 0.37, p= 0.033). This study supported the hypothesis that frontal lobe dysfunction in elderly patients with depression is associated with their disability in instrumental activities of daily living. Disability is related to social and time-dependent aspects of caregiver burden. Further studies to examine proposed cognitive interventions are suggested to reduce patient disability and caregiver burden.     

The Presentation, Recognition and Management of Bipolar Depression in Primary Care

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.     

Effect of Care Setting on Evidence-based Depression Treatment for Veterans with COPD and Comorbid Depression

Background Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients. Objective To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting. Design Retrospective cohort study. Patients A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder. Measurements and Main Results Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (≥3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only. Conclusions Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings. This study was funded by the VA Health Services Research & Development Service.     

Reducing Excess Disability in Dementia Patients

This study investigated the relationships between depressed mood and pleasant activities in patients with dementia and major depressive disorder, a cause of excess disability in patients. Four patients and their caregivers participated in a behavioral treatment program designed to improve patient depression. Caregivers were taught (1) to track patients' mood, duration and frequency of pleasant activity, (2) to increase pleasant activities for the patient and (3) to decrease behavioral disturbances that interfered with engagment in these pleasant activities. Caregivers of all patients successfully increased the frequency and duration of pleasant events, and decreased the patient's depression as measured by the Beck Depression Inventory and the Hamilton Depression Rating Scale. Further, increased frequency and duration of activity was significantly associated to decreased levels of depression in each of the patients. implications for using such methods with demented elderly patients who also present with depression, in rehabilitation settings are discussed.     

Structural abnormality on brain magnetic resonance imaging in late-onset major depressive disorder

The purpose of this study was to examine the structural abnormalities of patients with late-onset major depressive disorder using brain magnetic resonance imaging (MRI) and to assess clinical correlates of these structural abnormalities. Thirty-seven elderly patients with DSM-IV major depressive disorder that first occurred after the age of 50 years, and 18 control subjects without depression were recruited. All participants underwent comprehensive psychiatric assessment and cerebral MRI. Brain ventricular and sulcal sizes and white matter hyperintensities were assessed visually. Relative to control subjects, patients with late-life major depressive disorder showed more severe brain atrophy (p = 0.043) and white matter hyperintensities (p = 0.024), especially in the periventricular area (p = 0.012). Over 60% of the patient group had significant brain MRI hyperintensities. White matter hyperintensity was correlated with later onset of depressive illness (r = 0.49, p = 0.002) among patients. Brain atrophy and white matter hyperintensities are prevalent in patients with late-onset major depressive disorders. These two abnormalities may represent different pathophysiologic processes of depressive disorders. White matter hyperintensities may be predisposing factors for late-onset major depressive disorder.     

Depression in Frail Dutch Elderly

All elderly (75-90) living at home and in the two old people's homes in the municipality Sittard (The Netherlands) were assessed on physical vulnerability by means of oral interviews. In this way we were able to identify 222 frail elderly and collect data about demographic variables and depressive complaints. In this article the internal consistency of the Zung depression scale (Zung 1965) was tested for frail elderly. Relations between depression and demographic variables are discussed. The depression scale was internally consistent with a Cronbach's α of .82. Factor analysis resulted in 6 factors with a high percentage of explained variance on the first factor, indicating that the instrument is midimensional. The stability of the depression scale was not influenced by physical vulnerability. Of all frail elderly 28% had depressive complaints. Women scored somewhat higher on the depression index than men. A slight relation was found between depression and old age. This study shows that frail elderly living alone and residents of old people's homes have significantly more depressive complaints than respectively frail elderly living with others and independently living frail elderly.     

Effective low dose tricyclic antidepressant treatment for depressed geriatric rehabilitation patients. A double-blind study

The efficacy of low doses (10 to 20 mg daily) of doxepin in the treatment of depressive disorders in elderly inpatients was assessed by a double-blind study in 24 patients. The patients were treated for a three-week period to test for an early response. The Hamilton Depression Scale and the Geriatric Depression Scale were used to quantify symptoms of depression. The patients treated with doxepin had a significantly greater reduction in depressive symptoms than did those who received a placebo. No side effects were found and there were no major differences in the degree of physical dependency between the doxepin and placebo groups. A depressive disorder is a common occurrence among elderly inpatients and the effectiveness of low dose doxepin therapy without demonstrable side effects argues for the active treatment for this condition.     

Individuelle Therapieziele bei Patienten mit Diabetes und Depression

Nearly 25% of patients with diabetes have at least an impairing subclinical depression and 10% suffer from a depressive disorder. This affects the quality of life, the disease symptoms and the course of the diabetic disease. The diabetes-oriented therapy targets must be adapted for depressive patients because they are limited in coping with the daily routine due to the depression. Situations of inadequate coping can perpetuate the depression. A screening for depression must be integrated into the therapy. The treatment of depression is particularly important for patients with diabetes because of the multiple interactions between the diabetic disease and the depression.     

Odor identification in Alzheimer's disease and depression

BACKGROUND AND AIMS: In Alzheimer's disease (AD) olfactory deficits are common and depression is a difficult differential diagnosis. We therefore investigated the usefulness of an odor identification test to differentiate both conditions. METHODS: Twenty patients with probable Alzheimer's disease (AD), twenty elderly patients with a depressive disorder, and thirty healthy elderly subjects performed a German odor identification test. RESULTS: AD patients had significantly lower odor identification scores, compared with both depressive patients and control subjects (F=121.96, df=2, 67, p<0.001). With a cut-off score of 10/11, the sensitivity of the identification test to differentiate AD patients from depressive patients was 100%, and specificity was 95%. CONCLUSIONS: The odor identification test used in this study is able to reveal olfactory deficits in AD. It also seems to be a useful instrument to differentiate AD from depression.