Predicting 6-week treatment response to escitalopram pharmacotherapy in late-life major depressive disorder

OBJECTIVE: Approximately half of older patients treated for major depressive disorder (MDD) do not achieve symptomatic remission and functional recovery with first-line pharmacotherapy. This study aims to characterize sociodemographic, clinical, and neuropsychologic correlates of full, partial, and non-response to escitalopram monotherapy of unipolar MDD in later life. METHODS: One hundred and seventy-five patients aged 60 and older were assessed at baseline on demographic variables, depression severity, hopelessness, anxiety, cognitive functioning, co-existing medical illness burden, social support, and quality of life (disability). Subjects received 10 mg/d of open-label escitalopram and were divided into full (n = 55; 31%), partial (n = 75; 42.9%), and non-responder (n = 45; 25.7%) groups based on Hamilton depression scores at week 6. Univariate followed by multivariate analyses tested for differences between the three groups. RESULTS: Non-responders to treatment were found to be more severely depressed and anxious at baseline than both full and partial responders, more disabled, and with lower self-esteem than full responders. In general partial responders resembled full responders more than they resembled non-responders. In multivariate models, more severe anxiety symptoms (both psychological and somatic) and lower self-esteem predicted worse response status at 6 weeks. CONCLUSION: Among treatment-seeking elderly persons with MDD, higher anxiety symptoms and lower self-esteem predict poorer response after six weeks of escitalopram treatment.     

Major depressive disorder in the elderly: The relationship between age of onset and cognitive impairment

In order to determine if later age of onset of depression in the elderly is associated with increased cognitive impairment, the scores on the Mini-Mental State Examinations of 41 elderly depressed patients were correlated with the ages of onset of depression. All subjects, average age 74.7, were referred to a psychiatric day hospital for treatment of a major depressive disorder, and all scored at least 14 on the 17-item Hamilton Depression Rating Scale. The ages of first mental health contact and symptom onset were significantly negatively correlated with Mini-Mental State scores (p =0.021 and 0.035 respectively) after the confounding effect of age was adjusted for using partial correlations. The relation between late-onset depression and cognitive impairment lends support to the hypothesis that late-onset depressive disorders in the elderly may be associated with occult brain disease.     

A community needs assessment: the care needs assessment pack for dementia (CarenapD)—its development,reliability and validity

Objective. To develop and evaluate a multidisciplinary needs assessment tool for people with dementia living in the community and their carers. Design. The measure was developed through applying a theory of need, generating content, consultation with potential users and refinement and evaluation. Validity was established incrementally through the development process. Setting. The development and evaluation was conducted in a variety of settings, including multidisciplinary dementia community care teams, social work departments, day hospitals, and inpatient and residential care. Patients. The evaluation included community patients with a formal diagnosis of dementia (N=34) and consultation with a multidisciplinary group of potential users (N=23). The development process included inpatients with a formal diagnosis of dementia (N=157) and consultation with potential users (N=170) from a range of professions including both health and social care. Measures. Interrater reliability was assessed using the kappa statistic. Social validity was estimated using a measure developed for this purpose as part of the development process. Results. The evaluation of interrater reliability demonstrated that three-quarters of assessors agreed on at least 85% of items in the CarenapD. The kappa statistic demonstrated that agreement for 76.2% of items in the CarenapD was ‘good’ or better (ie kappa>0.75), for 12.4% of items it was ‘fair’ or ‘moderate’ (ie kappa 0.35–0.60) and for the remaining 12 (11.4%) items for which kappa could not be calculated there was low intra-item variance and high agreement (>90%). There was good evidence for social validity. Conclusions. The CarenapD is a reliable and valid multidisciplinary assessment of need for people with dementia living in the community and their carers. © 1998 John Wiley & Sons, Ltd.     

Categorical and dimensional perspectives on depression in elderly primary care patients – Results of the AgeMooDe study

An accurate diagnosis is essential for the management of late‐life depression in primary care. This study aims to (1) provide information on the agreement on depression diagnoses between general practitioners (GPs), dimensional tools (Geriatric Depression Scale [GDS], Hospital Anxiety and Depression Scale [HADS]) and a categorical tool (Structured Clinical Interview for DSM‐IV criteria [SCID]) and (2) identify factors associated with different diagnoses. As part of the multicenter study “Late‐life depression in primary care: needs, health care utilization and costs (AgeMooDe)” a sample of 1113 primary care patients aged 75 years and older was assessed. The proportion of depression was 24.3% according to GPs, 21.8% for the GDS, 18.9% for the HADS and 8.2% for the SCID. Taking GDS, HADS and SCID as reference standards, recognition of GPs was 47%, 48% and 63%. Cohen's Kappa values indicate slight to moderate agreement between diagnoses. Multinomial logistic regression models showed that patient related factors of depression were anxiety, intake of antidepressants, female gender, a low state of health, intake of medication for chronic diseases and functional impairment. GPs performed better at ruling out depression than ruling in depression. High levels of disagreement between different perspectives on depression indicate that they may be sensitive to different aspects of depression.     

Impacting late life depression: integrating a depression intervention into primary care

Care for depression in late life is often less successful in primary care than in carefully controlled clinical trials. Collaborative care models attempt to integrate mental health services into primary care. The authors conducted two focus groups and semi-structured individual interviews with all Depression Clinical Specialists (DCSs) working with Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a study testing a collaborative care intervention for late life depression, to examine integration of the intervention model into primary care. DCSs described key intervention components, including supervision from a psychiatrist and a liaison primary care provider, weekly team meetings, computerized patient tracking, and outcomes assessment tools as effective in supporting patient care. DCSs discussed details of protocols, training, environmental set-up, and interpersonal factors that seemed to facilitate integration. DCSs also identified research-related factors that may need to be preserved in the real world. Basic elements of the IMPACT model seem to support integration of late life depression care into primary care. Research-related components may need modification for dissemination.     

Diagnosis of late life depression: the view from primary care.

In the typical primary care practice, in which patients with a wide range of diseases and symptoms present with numerous needs, concerns, and requests, a chronic disease that lacks quantitative, biologically based diagnostic testing, such as depression, can present a daunting diagnostic challenge to even the best and most dedicated primary care physician. Depression does not compete well for patient and physician time and energy with other medical problems and medical co-morbidity in patients who seek care from their primary care physician. Primary care patients may be more comfortable with and accepting of depression being framed as a "normal" chronic disease rather than a psychiatric "brain" disease subject to cultural and generational stigmas, nihilism, and prejudice. Insurance parity in mental health care would make depression and other mental illness more legitimate in the eyes of patients, family members, employers, and physicians. Of particular value would be new and creative approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of psychiatric consultation in primary care, because elderly depressed patients often see the care of their depression as part of the integrated care of multiple chronic medical diseases, rather than a separate psychiatric problem to be referred for specialty care.     

Felt age and cognitive-affective depressive symptoms in late life

Objectives: This study examined both cross-sectional and longitudinal relationships between felt age and cognitive-affective symptom dimensions of depression in late life.

Method: Data for this study came from two interview waves (T1 and T2) of the National Health and Aging Trend Study. Sample persons (n = 6680) who resided in their own or another's home at T1 were included. At T2 (one year later), 5414 of the original 6680 were interviewed and depressive symptom data were available for 5371 sample persons. The associations between felt age and depressive symptoms were analyzed using stepwise linear regression analyses.

Results: At T1, (1) more than 70% of the sample felt younger and 7% felt older than their chronological age; and (2) younger felt age was associated with lower depressive symptoms, and older felt age was associated with higher depressive symptoms. Controlling for T1 depressive symptoms and health conditions, older felt age at T1 also predicted higher depressive symptoms at T2; however, chronological age and felt age explained only a small amount of variance in depressive symptom scores.

Conclusion: The self-enhancement or self-protection function of younger felt age at T1 does not appear to extend longitudinally to T2, while the negative depressive effect of older felt age at T1 extends to T2.     

Unmet care needs,care provision and patient satisfaction in patients with a late life depression: a cross-sectional study

Background: Research has shown that some 30% of total care needs in people with late-life depression (LLD) are unmet. It is not known to what extent patients actually don't receive any care for these needs or consider the care to be insufficient and their satisfaction with the provided care.

Aim: The aim of this study is to obtain insight into the care provided in relation to the reported unmet care needs and satisfaction with the total care provided is examined.

Method: A cross-sectional study of 99 people with LLD in an ambulatory setting.

Results: In 67% of patients, at least one unmet need was ascertained. In most cases (80%) care was actually provided for those needs by professionals and/or informal caregivers. Patients were satisfied with the care delivered for 81% of the reported care needs. Satisfaction was lowest for social care needs (67%). For six specific care needs it was demonstrated that dissatisfied patients were significantly more depressed than satisfied patients.

Conclusion: Even though patients might receive care for certain needs, this does not mean that their needs are met. A substantial proportion of patients with LDD feel that they need additional help for unmet needs.     

Major depressive disorder in Parkinson's disease: a register-based study

OBJECTIVE: To investigate whether patients with Parkinson's disease (PD) were at an increased risk of developing major depression compared with patients having other medical illnesses with a comparable degree of disability. METHOD: Case register linkage study of Danish Psychiatric Central Register (DPCR)and Danish National Hospital Register (DNHR). Three study cohorts were identified: all patients with PD, osteoarthritis, and diabetes. The rate of discharge diagnosis of depression on re-admission was estimated using competing risks models in survival analyses. The rates for patients with PD were compared with those of patients with osteoarthritis, and diabetes. RESULTS: The study sample identified 211 245 patients in the hospital registers with one of the index diagnoses. An increased incidence of developing depression was found for women and men throughout their lifetime when this incidence was compared with the control groups. CONCLUSION: The findings support the hypothesis that depression in patients with PD is a consequence of brain dysfunction.     

A randomized study on the effect of modified behavioral activation treatment for depressive symptoms in rural left-behind elderly

Objective: To evaluate the effectiveness of a modified behavioral activation treatment (MBAT) intervention on reducing depressive symptoms in rural left-behind elderly.

Method: This is a randomized study registered in Chinese Clinical Trial Registry (ChiCTR-IOR-17011289). Eighty rural left-behind elderly people who had a Geriatric Depression Scale (GDS) score between 11 and 25 were randomly assigned to the intervention (n?=?40) and control group (n?=?40). The intervention group received both MBAT and regular treatment for 8 weeks while the control group received regular treatment. Both groups were assessed with the GDS, Beck Anxiety Inventory (BAI), and Oxford Happiness Questionnaire (OHQ) at baseline, immediately post-intervention, and at 3 months post-intervention.

Results: There were a total of 73 participants that completed the intervention. The scores of GDS and BAI decreased significantly, but the scores of OHQ increased significantly in the intervention group after 8 sessions of MBAT (P?<?.01). The reduction in depression symptoms after the intervention was maintained at the 3-month follow-up. Significant differences in GDS, BAI, and OHQ scores were observed between the intervention group and the control group (P?<?.01).

Conclusion: MBAT produced a significantly greater reduction in depressive symptoms than regular care in rural left-behind elderly.

Clinical or methodological significance of this article: A modified behavioral activation (BA) psychotherapy can significantly reduce the recurrence and seriousness of depression symptoms in the left-behind elderly with mild to moderate depression. This study also suggests that further study of the MBAT as an intervention will provide a direction for the management of mental health in rural left-behind elders.     

Major depressive disorder is associated with elevated monocyte counts

One of the most consistently reported findings in depression has been leucocytosis. In 33 in-patients with major depressive disorder, we assessed white blood cell count (WBC) and lymphocyte subsets four times over a period of 6 weeks. The control group consisted of 44 healthy subjects. Shortly after admission, we detected significant increases in the numbers of leucocytes, granulocytes, platelets and monocytes in the depressed patients. Patients who recovered well during hospitalization showed a decrease in monocyte counts, whereas those with slower clinical improvement had significantly higher monocyte counts than the control group. This longitudinal study demonstrates that monocytes may play a role in the acute phase of depression and could provide an explanation for immunological dysfunction in depressive states.     

Major depressive disorder (MDD) from the patient's perspective: overcoming barriers to appropriate care

Major depressive disorder is a highly stigmatized condition which, despite its prevalence in primary care, is broadly unrecognized and consistently poorly treated. Epidemiological studies reveal a disconcerting lack of understanding about depression within the general population, and this invariably affects patients' attitudes to treatment. Public opinion polls have found a widespread distrust of antidepressant medications, and most members of the public would prefer a psychosocial or alternative approach to treatment to a pharmacological one. Public awareness initiatives such as the UK's Defeat Depression Campaign have helped to positively shift public attitudes towards depression and its treatment, but misconceptions about antidepressant medications appear especially entrenched. The landmark DEPRES study found that over 40% of patients did not consult their doctors for their depression, and only 30% of consulters received an antidepressant. Six clearly differentiated patient clusters were also identified in this study, suggesting that treatment might be selected on the basis of individual symptom profiles and other key differentiating factors. By understanding our patients' perspectives on depression and its management, it should be possible to improve rates of consultation and overcome resistance to antidepressant treatment. Only by achieving both of these goals in parallel will we really be making progress towards optimal management of major depression. ( Int J Psych Clin Pract 2001; 5 (Suppl 1): S37-S42)     

Screening for Depression on Continuing Care Psychogeriatric Wards

The performance of the Depressive Signs Scale (DSS), completed by the nursing staff, in detecting significant clinical depression among continuing care psychogeriatric inpatients was examined. A cutoff score of 5/6 gave the best sensitivity (70%) and specificity (72%) in the whole sample. The same cutoff value gave the best sensitivity (62%) and specificity (72%) in the dementia subsample. © 1997 by John Wiley & Sons, Ltd.     

Zinc in depressive disorder

Plasma zinc levels were measured in 14 patients with primary affective disorder on admission to hospital; they were compared with plasma zinc levels in group of 14 age- and sex-matched controls. A significant difference in zinc levels was found between the 2 groups. Plasma zinc levels of 9 of the depressed patients on admission to hospital and at the point of discharge were compared; a significant increase in zinc levels was detected.     

Psychiatric morbidity among continuing care geriatric inpatients

This study examines the point prevalence of psychiatric morbidity among continuing care geriatric inpatients and the performance of screening questionnaires in detecting such morbidity. From a sample of 74 patients it was possible to carry out complete dementia ratings in 53 patients and depression ratings in 52 patients. Eighty-three per cent of the patients assessed had dementia and 48% had significant depressive symptoms. Screening for dementia with the Mini Mental State Examination (MMSE) had 100% sensitivity and 78% specificity. The Geriatric Depression Scale (GDS) had 80% sensitivity and 64% specificity at the conventional cutoff of 10/11. Receiver operating characteristics curve analysis suggested that a 12/13 cutoff gave the best sensitivity (75%) and specificity (73%) values for depressive symptoms. Among patients with dementia a cutoff score of 12/13 on the GDS also gave optimal sensitivity, specificity and positive predictive values. The GDS revealed good test–retest stability in the whole sample (tau = +0.55, p < 0.001) and the demented subgroup (tau = +0.52, p < 0.001).