Advances in the treatment of depression in older adults

Depressive symptoms in older adults are common, but the minority of elderly meet criteria for major depressive disorder. This has led to confusion regarding the recognition of diagnosis, approach to treatment, and monitoring of outcomes in this needy population. Few depressed older adults are willing to seek treatment from psychiatrists or mental health specialists. Treatment approaches to the depressive spectrum of disorders in late life, which encompasses major and minor depressive disorder, dysthymic disorder, and mood disorders related to medical conditions, must include evidence-based algorithms that can be delivered in a variety of health care settings. Several recent multisite trials have advanced the use of collaborative care models and the systematic stepwise approach to the treatment of depression and anxiety states in older adults. This offers the ability to provide effective treatment of depression for older adults, consistent with current guidelines, in primary care and specialized health care settings.     

Symptoms of depression in older adults with multiple sclerosis (MS): comparison with a matched sample of younger adults

The study considered for the first time depression in older adults with multiple sclerosis (MS). Depression symptom scores of 27 persons aged over 65 years who were part of a large study of persons with MS (n = 529), were compared with those of a matched sample of younger adults from the same study. The association between cognitive (attitudinal) variables known to explain significant variance in depressive symptoms in younger adults with MS was then considered in the older adult sample. Consistent with findings from studies with general community samples, older adults with MS reported significantly fewer depressive symptoms than younger adults with MS. The relationship between cognitive variables and depressive symptoms found previously in younger adults was also evident for the older adults. Multiple sclerosis related helplessness was found to be significantly higher in older as opposed to younger adults with MS, the opposite of what was predicted given the differences between the groups in depression scores. Differences in the cognitive variables do not appear to explain the differences between older and younger adults with MS in terms of depressive symptoms. This finding offers support for the view that a decrease in emotional responsiveness may explain differences in depressive symptoms between younger and older adults with MS, rather than this being the result of differences in emotional control exerted via cognitive means.     

Latent subtypes of depression in a community sample of older adults: Can depression clusters predict future depression trajectories?

Identifying sources of heterogeneity in late life depression remains an important focus of psychiatric investigation. Community samples are particularly informative since many older adults have clinically significant depressive symptoms but fail to meet criteria for major depression and older adults generally do not seek treatment for their depressive symptoms. The primary data used for these analyses were those collected in a community-based survey of over 3000 adults age 65 or older followed for up to ten years. Depressive symptoms were measured by the Center for Epidemiologic Studies-Depression scale (CES-D). Latent class analysis was used to identify clusters of participants based on their symptom profiles at baseline. Mixed models were used to examine trajectories of CES-D scores based on cluster assignment.     

Changes in positive and negative peer influences and depressive symptoms from adolescence to young adulthood

IntroductionPeers are believed to continue as prominent sources of influence for young adults. However, having peers who use alcohol and drugs is associated with depressive symptoms in young adults and research on the effects of having peers who model positive activities beyond adolescence is scarce.MethodIn this 10-year study of 644 Canadian youth (52% female), we used multilevel modeling to examine the effects of within-person and between-person differences in the interplay of peer behaviours and changes in depressive symptoms between ages 14 and 25. Data were collected via face-to-face interviews and surveys for private topics.ResultsYouth with close friends who used drugs and alcohol consistently reported more depressive symptoms at each age, whereas having friends who engaged in positive activities was associated with fewer depressive symptoms, especially during adolescence. Moreover, at times when youth had more substance-using peers than usual (within person variation), they also reported more symptoms.ConclusionsSubstance-using peer contexts convey both short- and long-term risks for depressive symptoms. However, the protective effects of having peers who are engaged in positive activities, while generally protective, may be reduced in young adulthood. It is possible that older youth withdraw from peers and activities as their depression worsens, and prosocial activities become less supervised by parents, more optional, and more expensive.     

Medication use and nonadherence to psychoactive medication for mental health problems by community-living canadian seniors with depression

Objectives: To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada. Methods: Canadian Community Health Survey-Mental Health and Well-Being respondents aged 65 years and older (n = 7736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed. Results: In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence. Conclusion: All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low.     

Old age depression and its treatment

The Numbers of elderly people are gradually increasing in our society, and mood disorders are progressively increasing among older people. Old age depression may also occur after life events: the death of the significant other, economical reasons, health problems (neurological and/or cardiovascular diseases, arthritis, cancer, nutritional deficiency) and can develop into a depressive state. Old age depression is often mistreated, or undertreated, and also underdiagnosed, and this for several reasons: older people reduce their social relations, depression very often presents as a comorbidity with organic diseases (that cover and mask depressive symptoms); finally,the patient may believe that a depressive state is a normal course of life in older people. Recovering from depression is really feasible both in young/adults and in old people, but in older people we can find a higher frequency of admission to hospital, or mortality or suicidality. The depressive symptoms in old age depression is similar to those in adults, however the following aspects require special care, in order to ensure a correct diagnosis despite the presence of comorbidities: - the mood: in contrast with the young and adult, old people often do not complain about their low mood; - the psychotic simptoms: hypocondriacal and psychotic, including hallucinatory symptoms are often present; - the anxiety symptoms: these are often present together with neuro-sensory symptoms; - the somatic symptoms: the comorbidity with organic diseases can mask and overlap the depressive state; - reduction of congnitive functioning: in these cases, which are quite frequent, it is essential to make a differential diagnosis from "pseudodementia" and "dementia". In conclusion, several factors contribute to the onset of depression in old age, so that we can assert that it is a really a multifactorial disease.     

Genetic Liability for Depression,Social Factors and Their Interaction Effect in Depressive Symptoms and Depression Over Time in Older Adults

ObjectivesThe objectives of this study were to investigate the effect of genetic and social factors on depressive symptoms and depression over time and to test whether social factors moderate the relationship between depressive symptoms and its underlying genetics in later life.MethodsThe study included 2,279 participants with a mean follow-up of 15 years from the Longitudinal Aging Study Amsterdam with genotyping data. The personal genetic loading for depression was estimated for each participant by calculating a polygenic risk scores (PRS-D), based on 23,032 single nucleotide polymorphisms associated with major depression in a large genome-wide association study. Partner status, network size, received and given emotional support were assessed via questionnaires and depressive symptoms were assessed using the CES-D Scale. A CES-D Scale of 16 and higher was considered as clinically relevant depression.ResultsHigher PRS-D was associated with more depressive symptoms whereas having a partner and having a larger network size were independently associated with less depressive symptoms. After extra adjustment for education, cognitive function and functional limitations, giving more emotional support was also associated with less depressive symptoms. No evidence for gene-environment interaction between PRS-D and social factors was found. Similar results were found for clinically relevant depression.ConclusionGenetic and social factors are independently associated with depressive symptoms over time in older adults. Strategies that boost social functioning should be encouraged in the general population of older adults regardless of the genetic liability for depression.     

The association of a heart attack or stroke with depressive symptoms stratified by the presence of a close social contact: findings from the National Health and Aging Trends Study Cohort

Objective

The objective of the study is to examine whether the risk of having clinically significant depressive symptoms following a heart attack or stroke varies by the presence of a close social contact.

Methods

The National Health and Aging Trends Study is a nationally representative longitudinal survey of US Medicare beneficiaries aged 65 and older initiated in 2011. A total of 5643 older adults had information on social contacts at baseline and depressive symptoms at the 1‐year follow‐up interview. The two‐item Patient Health Questionnaire identified clinically significant depressive symptoms. Interview questions examined social contacts and the presence of self‐reported heart attack or stroke during the year of follow‐up.

Results

A total of 297 older adults reported experiencing a heart attack and/or stroke between their baseline and follow‐up interviews. In regression analyses accounting for sociodemographics, baseline depressive symptoms, medical comorbidity, and activities of daily living impairment, older adults with no close social contacts had increased odds of depressive symptoms at follow‐up after experiencing a heart attack or stroke, while those with close social contacts had increased odds of depressive symptoms at follow‐up after experiencing a stroke, but not a heart attack.

Conclusions

Older adults have increased odds of having depressive symptoms following a self‐reported stroke, but only those with no close social contacts had increased odds of depressive symptoms following a heart attack. Social networks may play a role in the mechanisms underlying depression among older adults experiencing certain acute health events. Future work exploring the potential causal relationships suggested here, if confirmed, could inform interventions to alleviate or prevent depression among at risk older adults. Copyright © 2017 John Wiley & Sons, Ltd.     

Anxiety, depression and disability across the lifespan

The authors examined the relationship between anxiety, depression and physical disability, after controlling for demographic and health variables, in a sample of 374 adults aged 18-94. Results indicate that anxiety, depression and comorbid anxiety and depression are associated with higher levels of disability, after controlling for factors such as age, gender, income, self-rated health, number of medical conditions and number of physician visits in the past year. Furthermore, anxiety, depression and comorbid anxiety and depression have a differential effect on disability according to age, with older adults with any of these symptoms reporting higher levels of disability than younger adults. These findings suggest that physicians working with older adults should assess for and treat anxiety as well as depressive symptoms.     

Religious denomination as a symptom-formation factor of depression in older Dutch citizens

OBJECTIVES: The type of symptoms in depression is likely to be influenced by cultural environment. As religion represents an important cultural resource for older adults, it is hypothesised that religious denomination represents a symptom-formation factor of depression in the older generation. Focusing on older Dutch citizens, it is expected that depressed Calvinists report: (1) less depressed affect, (2) more vegetative symptoms, and (3) more guilt feelings, than Roman Catholics and non-church members. METHODS AND PROCEDURES: The Center for Epidemiologic Studies Depression Scale (CES-D) was used to distinguish depressed (N=395) and non-depressed (N=2333) older adults, and to assess depressive symptom-profiles. The Diagnostic Interview Schedule (DIS) was used to assess major depressive episodes and criterion-symptoms of depression. RESULTS: Depressed Calvinists, especially males, had higher scores on the vegetative CES-D subscale. The same was found for non-church members with Calvinist parents. Among those who have had a major depressive episode in later life (N=84), support was found for all hypotheses. Feelings of guilt were also more prevalent among Roman Catholics. CONCLUSIONS: Religious denomination modified the type of symptoms in late-life depression. As a Calvinist background was associated with less depressive affect and more inhibition, there is a risk of underdiagnosis of major depression in older Calvinists in The Netherlands.     

Sociodemographic characteristics of the neighborhood and depressive symptoms in older adults: using multilevel modeling in geriatric psychiatry.

OBJECTIVE: Neighborhood sociodemographic characteristics may be important to the mental health of older adults who have decreased mobility and fewer resources. Our objective was to examine the association between neighborhood context and level of depressive symptomatology in older adults in a diverse geographic region of central North Carolina. METHODS: The sample included 2,998 adults 65 or older residing in 91 census tracts. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression scale (CES-D). Neighborhoods were characterized by five census-based characteristics: socioeconomic disadvantage, socioeconomic advantage, racial/ethnic heterogeneity, residential stability, and age structure. RESULTS: In ecologic level analyses, level of census tract socioeconomic disadvantage was associated with increased depressive symptoms. To determine whether neighborhood context was associated with depressive symptoms independently of individual characteristics, the authors used multilevel modeling. The authors examined the ability of each of five neighborhood (level 2) characteristics to predict a level 1 outcome (CES-D symptoms) controlling for the effects of individual (level 1) characteristics. Younger age, being widowed, lower income, and having some functional limitations were associated with increased depression symptoms conditional on census tract random effects. However, none of the neighborhood characteristics was significantly associated with depression symptoms, conditional on census tract random effects, either unadjusted or adjusted for individual characteristics. CONCLUSION: Any observed association between neighborhood sociodemographic characteristics and individual depressive symptoms in our sample may reflect the characteristics of the individuals who reside in the neighborhood rather than the neighborhood characteristics themselves. The use of multilevel modeling is important to separate these effects.     

Housing type and depressive symptoms among older adults: a test of sense of belonging as a mediating and moderating variable

Objectives: Higher levels of depression have been documented among older adults who reside in an assisted living facility, compared with those who remain in their own homes. The aims of the current study were to test whether the relationship between housing type and depressive symptoms was mediated by a sense of belonging and whether housing type and sense of belonging interact to influence the depressive symptoms among older adults (moderation model).Method: A sample of 257 older adults who lived in their own homes and 166 older adults who lived in an assisted living facility completed the psychological subscale of the Sense of Belonging Instrument and the Center for Epidemiologic Studies Depression Scale.Results: Results showed that a sense of belonging partially mediated the relationship between housing type and depressive symptoms, such that living in a nursing home was associated with lower levels of belonging, and lower levels of belonging were, in turn, associated with higher levels of depressive symptoms. Residing in an assisted living facility was associated with depressive symptoms at low and average levels of belonging.Conclusion: Results highlight the need for more research on the role of sense of belonging as an influencing factor on depressive symptoms among institutionalised older adults for both theoretical and treatment goals.     

The association between depressive disorders and health care utilization: results from the São Paulo Ageing and Health Study (SPAH)

Background

Although depressive disorders are associated with increased health care utilization in the elderly living in high-income countries, few studies have examined this relationship in Latin America.

Method

The present study is part of the São Paulo Ageing and Health Study, a population-based epidemiological study of mental disorders in 2072 low-income adults ≥ 65 years old living in São Paulo, Brazil. Depressive disorders defined as major depressive disorder (MDD) and clinically relevant depressive symptoms (CRDS) were assessed with the Geriatric Mental State and the Neuropsychiatric Inventory. We examined the association between depressive disorders/symptoms and health care utilization (outpatient visits, hospital admissions and medication use in the past 3 months) using count models.

Results

The prevalence of MDD and CRDS was 4.9% and 21.4%, respectively. In the fully adjusted model, older adults with MDD were 36% more likely to have one more outpatient visit (RM: 1.36, 95% CI: 1.11–1.67), while older adults with CRDS were 14% more likely to have one more outpatient visit (RM: 1.14, 95% CI: 1.02–1.28). Elderly individuals with MDD had a prevalence of hospital admissions in the previous 3 months that was twice that of those without depression (PR=2.02, 95% CI: 1.09–3.75). Significant differences were not found for medication use.

Conclusion

Among low-income older adults living in Brazil, those with MDD are more likely to have a recent hospital admission and outpatient service use than those without depression. Future studies are needed to examine the effectiveness of depression treatments for this population in order to both decrease the burden of illness as well as to minimize health care utilization related to depression.     

Linking depressive symptoms and functional disability in late life

We hypothesized that the relationship of depressive symptoms to functional disability might be mediated by cognitive processes such as memory and problem-solving. The study sample consisted of 147 community-dwelling older adults (mean age = 74.0 years, SD = 5.9). In regression models that included terms for age, gender, and years of education, depressive symptoms were significantly inversely associated with two performance-based measures of functioning: everyday problems test (beta = -0.15, p = 0.04) and observed tasks of daily living (beta = -0.14, p = 0.02). When memory and problem-solving ability were added to the model, the relationship of depressive symptoms with function was attenuated. A structural equation model based on our conceptual framework revealed that both memory and problem-solving abilities were important mediators in the relationship of depressive symptoms and functional disability. The results suggest that intervention studies intended to limit functional disability secondary to depression among older adults may need to consider the effect of depression on cognition.     

Comparison of depressive symptoms between homebound older adults and ambulatory older adults

Due to the social isolation imposed by chronic illness and functional limitations, homebound older adults are more vulnerable to depression than their mobility-unimpaired peers. In this study, we compared 81 low-income homebound older adults, aged 60 and older, with their 130 ambulatory peers who attended senior centers, with respect to their depressive symptoms, depression risk and protective factors, and self-reported coping strategies. Even controlling for sociodemographics, health problems, and other life stressors, being homebound, as opposed to participating in senior centers, was significantly associated with higher depressive symptoms. However, when the coping resources-social support and engagement in frequent physical exercise, in particular-were added to the regression model, the homebound state was no longer a significant factor, showing that the coping resources buffered the effect of the homebound state on depressive symptoms. In terms of self-reported coping strategies, even among the depressed respondents, only a small proportion sought professional help, and that was largely limited to consulting their regular physician and social workers, who may not have had professional training in mental health interventions.     

Treatment of late-life depression complicated by alcohol dependence.

OBJECTIVES: Among elderly patients, mental and physical illness are often present along with alcohol dependence. The interaction between alcohol use and concurrent physical or mental disabilities is complex and complicates treatment planning. The aim of this study was to test the efficacy of naltrexone combined with sertraline for the treatment of older adults with major depression and alcohol dependence. METHODS: The sample was 74 subjects, age 55 and older, who met criteria for a depressive disorder along with alcohol dependence. All subjects were randomly assigned to 12 weeks of naltrexone 50 mg/day or placebo. Also, all subjects received sertraline 100 mg/day and individual weekly psychosocial support. Treatment response for alcohol consumption and depression was measured during the 12 weeks of treatment. RESULTS: At baseline, the average age of subjects was 63.4, and subjects were drinking an average of 10.7 drinks per drinking day. The overall results are encouraging; 42% of the subjects had a remission of their depression and had no drinking relapses during the trial. There was no evidence for an added benefit of naltrexone in combination with sertraline, but there was significant correlation between any alcohol relapse during the trial and poor response to depression treatment. CONCLUSION: Patients with concurrent mental disorders, such as major depression and alcohol dependence, are increasingly prevalent in clinical practice and have been demonstrated to show poorer treatment response and higher treatment costs. The results of this trial underscore the importance of addressing alcohol use in the context of treating late-life depression.     

Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy

OBJECTIVE: To improve interventions for depressed older adults, data are needed on the comparative effects of pharmacotherapy versus psychotherapy. Given that most older adults with clinically significant depressive symptoms do not have major depression, data on treatments for minor depression and dysthymia are especially needed. METHOD: Meta-analysis was used to integrate the results of 89 controlled studies of treatments focused on acute major depression (37 studies) and other depressive disorders (52 studies conducted with mixed diagnostic groups, including patients with major depression, minor depression, and dysthymia). A total of 5,328 older adults received pharmacotherapy or psychotherapy in these studies. RESULTS: Clinician-rated depression scores improved, on average, by 0.80 standard deviation (SD) units; self-rated depression scores improved by 0.76 SD units. Clinician-rated depression improved by 0.69 SD units in pharmacotherapeutic studies and by 1.09 SD units in psychotherapeutic studies. Self-rated depression improved by 0.62 SD units and 0.83 SD units, respectively. An interesting finding was the stronger improvements in clinician-rated depression among control subjects participating in medication studies, compared to those in psychotherapeutic studies. CONCLUSIONS: Available treatments for depression work, with effect sizes that are moderate to large. Comparisons of psychotherapy and pharmacotherapy must be interpreted with caution, in part because medication studies are more likely to use a credible active placebo, which may lead to smaller adjusted effect sizes in medication studies. Given that psychotherapy and pharmacotherapy did not show strong differences in effect sizes, treatment choice should be based on other criteria, such as contraindications, treatment access, or patient preferences.     

Sleep complaints and depression in an aging cohort: A prospective perspective

OBJECTIVE: Most research on the association between sleep disturbances and depression has looked at cross-sectional data. The authors used two waves of data from a panel study of community residents aged 50 years or more to investigate this issue prospectively. METHOD: Data on symptoms of major depressive episodes and sleep problems were examined for a subgroup of the 1994 and 1995 surveys of the Alameda County (California) Study (N=2,370). The authors examined the effects of age, gender, education, marital status, social isolation, functional impairment, financial strain, and alcohol use. Depression was measured with 12 items that covered the DSM-IV diagnostic criteria for major depressive episodes, including insomnia and hypersomnia. RESULTS: The prevalences were 23. 1% for insomnia and 6.7% for hypersomnia in 1994. Sleep was a significant correlate of depression, as were being female, older age, social isolation, low education, financial strain, and functional impairment. When sleep problems and depression were examined prospectively, with controls for the effects of the other variables, sleep problems in 1994 predicted depression in 1995. However, other symptoms of major depressive episodes-anhedonia, feelings of worthlessness, psychomotor agitation/retardation, mood disturbance, thoughts of death-were much stronger predictors of future major depression. CONCLUSIONS: Sleep disturbance and other symptoms that are diagnostic for major depression are strongly associated with the risk of future depression. Sleep disturbance appears to be a less important predictor of depression. More epidemiologic research is needed on the relative contributions of the range of depressive symptoms to the risk of clinical depression.