Combined hearing and visual impairment and depression in a population aged 75 years and older

BACKGROUND: Depression is associated with both visual and hearing impairment. Little is known about the relationship between combined hearing and visual impairment and mood in this age group. The aim of this population-based study was to investigate the association between functional sensory impairment, especially combined sensory impairment and depressive symptoms and depression diagnosed according to the DSM-IV criteria. METHOD: The study group consisted of 470 adults, population-based sample, aged 75 years or older. We used the Snellen eye charts with E-letters and reading charts to evaluate the functional visual acuity. The ability to conduct a face-to-face conversation, the hearing aid use and the self-reported hearing problems were used to assess the functional hearing acuity. Depression was identified with two different methods. A geriatrician interviewed the subjects and the DSM-IV checklist was used to determine whether they met the criteria for major depression. The Zung Depression Status Inventory (DSI) was used to identify depressive symptoms. The cut off points of 40/80 and 48/80 in the DSI-score was used. RESULTS: Seventy-two persons (15%) of the study population had depression diagnosed according to the DSM-IV criteria. Twelve per cent of subjects in the Functional Hearing Impairment (FHI) group, twenty per cent in the Functional Visual Impairment (FVI) group, eighteen per cent in the Combined Sensory Impairment (CSI) group and fifteen per cent in the Adequate Sensory Function (ASF) group suffered major depression. The differences between these groups were insignificant. The occurrence rates of the DSI score equal or over 40 points was 50% in the FHI group, 53% in the FVI group, 70% in the CSI group and 45% in the ASF group. The difference between the ASF group and sensory impairment group including FHI, FVI and CSI groups was statistically significant (p = 0.03). CONCLUSIONS: Depressive symptoms, but not major depression, were common if elderly persons had combined sensory impairment.     

The role of cardiovascular disease in the identification and management of depression by primary care physicians.

OBJECTIVE: The objective of this study was to describe the influence of cardiovascular disease (CVD) on identification and management of depression by primary care physicians. METHOD: Three hundred fifty-five adults with and without significant depressive symptoms who were screened in primary care offices and invited to participate completed a baseline in-home assessment. CVD was assessed by self-report and psychologic status was assessed with commonly used, validated standard questionnaires. At the index visit, doctors' ratings of depression and reports of active management were obtained on 340 of the 355 patients who completed in-home interviews. RESULTS: Older adults who reported heart failure were more likely to be identified as depressed than were older adults who did not report heart failure (unadjusted odds ratio [OR]: 2.34; 95% confidence interval [CI]: 1.13-4.85; Wald chi(2) = 5.20, df = 1, p = 0.023). In multivariate models that controlled for potentially influential characteristics such as age, marital status, education, ethnicity, functional status, level of depression, cognitive impairment, attitudes about depression, use of medical care, and number of medications, the findings remained statistically significant. Among older adults identified as depressed, older adults with heart failure were significantly less likely to be actively managed for depression than were older adults without heart failure (unadjusted OR: 0.33; 95% CI: 0.14-0.76; Wald chi(2) = 6.73, df = 1, p = 0.009). After controlling for potentially influential covariates, these findings remained substantially unchanged. CONCLUSIONS: CVD, in particular heart failure, may influence the identification and management of depression among older patients by primary care physicians. The findings underlie the importance of developing interventions that integrate the management of depression and CVD in primary care settings.     

Major depression and associated impairment: same or different genetic and environmental risk factors?

OBJECTIVE: Impairment was added as a diagnostic criterion for many psychiatric disorders in DSM-IV. Does the addition of impairment influence only prevalence rates, or does it also introduce new etiological factors into psychiatric diagnoses? METHOD: A lifetime history of major depression and associated functional impairment was assessed by personal interview with 3,669 female and 4,377 male twins from the population-based Virginia Twin Registry. Structural equation modeling was used to estimate the correlation between risk factors for major depression and associated functional impairment. RESULTS: While the risk factors for major depression and associated functional impairment are substantially correlated, they are not identical. The most parsimonious model suggests that over a quarter of the variance in associated functional impairment is due to factors unrelated to risk for major depression. Of the variance unique to associated functional impairment, approximately one-third is familial. The relationship between associated functional impairment and major depression did not differ significantly between men and women. CONCLUSIONS: Risk factors for major depression and associated functional impairment are substantially but imperfectly correlated. The addition of associated functional impairment as a criterion for the diagnosis of major depression not only lowers prevalence estimates but also introduces a small set of new etiological factors into the diagnosis of major depression.     

Anxiety and functional status in older primary care patients

OBJECTIVE: The aim of this study was to test the hypothesis that anxiety in older primary care patients is associated with functional impairment after controlling for depression and medical comorbidity. METHOD: Primary care patients (n = 303), aged sixty or older were interviewed with a series of instruments designed to measure psychiatric symptoms including anxiety, depression, medical illness burden, and both examiner-rated and self-reported functional status. Anxiety was measured by the anxiety item of the Hamilton Rating Scale for Depression and the anxiety items of the Medical Outcomes Study Short Form SF-36. Multiple regression techniques were used to examine the association of anxiety with functional status after controlling for age, gender, education, medical burden, and depression. RESULTS: When controlled for depression and medical morbidity, increased anxiety predicted poorer social function. Anxiety was not independently associated with more basic activities of daily living. CONCLUSIONS: Further studies with more comprehensive measures of anxiety are warranted to clarify the relationships between anxiety and functional status.     

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

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

A qualitative exploration of depression in emerging adulthood: disorder, development, and social context

OBJECTIVE: One in four emerging adults will experience a depressive episode between the ages of 18-25. We examined the lived experience of emerging adults with a focus on their treatment seeking, development and the social context of their illness. METHOD: In-depth interviews were conducted with 15 participants with major or minor depression. Interviews were recorded, transcribed verbatim and analyzed using established qualitative methods. RESULTS: Emerging adults reported dynamic and complex interactions within and between thematic areas including identification as an individual with depression, interactions with the healthcare system, relationships with friends and family, and role transitions from childhood to adulthood. Depressed mood, concerns about self-identifying one's self as being depressed, the complexity of seeking care often without insurance or financial support, alienation from peers and family, and a sense of failure to achieve expected developmental milestones appeared to interact and exacerbate functional impairment. CONCLUSIONS: Further research is needed to better understand and intervene upon pathways that lead to poor outcomes such as delayed milestones among emerging adults with depression. Health care providers should be conscious of the unique vulnerabilities posed by depressive disorders in this age group.     

Cognitive function across manic or hypomanic, depressed, and euthymic states in bipolar disorder

OBJECTIVE: The study aims were to address neuropsychological functioning across different states of bipolar illness and to determine relationships among clinical features, neuropsychological performance, and psychosocial functioning. METHOD: Several domains of cognitive function were examined in 30 depressed bipolar patients (DSM-IV criteria for major depression, Hamilton Depression Rating Scale score > or = 17), 34 manic or hypomanic bipolar patients (DSM-IV criteria for manic or hypomanic episode, Young Mania Rating Scale score > or = 12), and 44 euthymic bipolar patients (6 months of remission, Hamilton depression scale score < or = 8, and Young Mania Rating Scale score < or = 6). The comparison group consisted of 30 healthy subjects without history of neurological or psychiatric disorders. A neuropsychological battery assessed executive function, attention, and verbal and visual memory. RESULTS: The three groups showed cognitive dysfunction in verbal memory and frontal executive tasks in relation to the comparison group. Low neuropsychological performance was associated with poor functional outcome. Impairment of verbal memory was related to the duration of illness and the numbers of previous manic episodes, hospitalizations, and suicide attempts. CONCLUSIONS: A poorer performance was observed in all bipolar groups regarding executive function and verbal memory in relation to the healthy comparison subjects. These cognitive difficulties, especially related to verbal memory, may help explain the impairment regarding daily functioning, even during remission. Further studies should focus on testing, whether optimizing prophylactic pharmacological treatment and psychoeducation might reduce cognitive impairment, and whether bipolar patients would benefit from neuropsychological rehabilitation in order to reduce the impact of cognitive impairment in their overall functioning.     

Social phobia symptoms, subtypes, and severity: findings from a community survey

OBJECTIVES: Our goals were (1) to ascertain the range of functional impairment attributable to social phobia in a community sample, and (2) to verify the existence of social phobia subtypes in the community, and report on their relative prevalence, severity, and levels of impairment. METHODS: Community surveys were conducted contemporaneously in Winnipeg, Manitoba, and in Alberta, with a total of 1956 respondents. Instruments included the Comprehensive International Diagnostic Interview-Version 2.1 module for DSM-IV social phobia, enhanced with 6 additional (for a total of 12) social phobic situational probes to provide a more comprehensive assessment of possible subtypes, and additional questions about specific functional impairment due to social phobia. RESULTS: Of those persons in the community surveyed, most had no (60.4%) or few (ie, 1-3) (27.8%) social fears; few persons (3.4%) had many (ie, >/=7). Among those with DSM-IV social phobia (7.2%), classification based on number (normally distributed with median of 3, mode of 5) or content (eg, speaking-only vs other fears; performance-only vs interactional fears) of social fears failed to yield a defensible subtyping solution. Impairment increased linearly as the number of social fears was increased, with no clear threshold evident. CONCLUSIONS: Social phobia is associated with substantial impairment in multiple functional domains. Support for subtyping based on the extent or pattern of social fears was not provided. Rather, social phobia in the community seems to exist on a continuum of severity, with a greater number of feared situations associated with greater disability.     

Personal characteristics and depression-related attitudes of older adults and participation in stages of implementation of a multi-site effectiveness trial (PRISM-E)

BACKGROUND: No study has assessed attitudes about depression and its treatment and participation at each step of recruitment and implementation of an effectiveness trial. Our purpose was to determine the association between personal characteristics and attitudes of older adults about depression with participation at each step of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) treatment effectiveness trial. METHODS: Information on personal characteristics and attitudes regarding depression and its treatment were obtained from all potential participants in PRISM-E. RESULTS: Persons who reported better social support were more likely to complete a baseline interview, but were less likely to meet with the mental health professional carrying out the intervention. Attitudes about taking medicines were significantly associated with uptake of the intervention, but not with earlier phases of recruitment. Persons were much more likely to have a visit with the mental health professional for treatment of depression if they were willing to take medicine for depression but did not endorse waiting for the depression to get better [odds ratio (OR) = 3.16, 95% confidence interval (CI) = 1.48-6.75], working it out on one's own (OR = 5.18, 95% CI = 1.69-15.85), or talking to a minister, priest, or rabbi (OR = 2.01, 95% CI = 1.02-3.96). CONCLUSION: Social support and other personal characteristics may be the most appropriate for tailoring recruitment strategies, but later steps in the recruitment and implementation may require more attention to specific attitudes towards antidepressant medications.     

Executive dysfunction and long-term outcomes of geriatric depression

BACKGROUND: This study investigated the relationship of executive and memory impairment to relapse, recurrence, and course of residual depressive symptoms and signs after remission of geriatric major depression. METHODS: Fifty-eight elderly subjects remitted from major depression received continuation nortriptyline treatment (plasma levels 60-150 ng/mL) for 16 weeks and then were randomly assigned to either nortriptyline maintenance therapy or placebo for up to 2 years. Diagnosis was made using the Research Diagnostic Criteria and the DSM-IV criteria after an interview using the Schedule for Affective Disorders and Schizophrenia. Executive dysfunction and memory were assessed with the Dementia Rating Scale, disability and social support were rated with the Philadelphia Multiphasic Instrument, and medical burden was assessed with the Cumulative Illness Rating Scale. RESULTS: Abnormal initiation and perseveration scores, but not memory impairment, were associated with relapse and recurrence of geriatric depression and with fluctuations of depressive symptoms in the whole group and in subjects who never met criteria for relapse or recurrence during the follow-up period. Memory impairment, disability, medical burden, social support, and history of previous episodes did not significantly influence the outcome of depression in this sample. CONCLUSIONS: Executive dysfunction was found to be associated with relapse and recurrence of geriatric major depression and with residual depressive symptoms. These observations, if confirmed, will aid clinicians in identifying patients in need of vigilant follow-up. The findings of this study provide the rationale for investigation of the role of specific prefrontal pathways in predisposing or perpetuating depressive syndromes or symptoms in elderly patients.     

Citalopram treatment of social anxiety disorder with comorbid major depression

Treatment of patients with both social anxiety disorder and major depression has been little studied although social anxiety disorder and depression frequently co-occur. Each disorder has been shown to respond to serotonin reuptake inhibitor treatment. Objectives of this study were to characterize a sample of these comorbid patients and to assess response to treatment with citalopram. Patients with primary DSM-IV generalized subtype of social anxiety disorder and comorbid major depression (N = 21) were assessed for symptoms of each disorder, including atypical depressive features, and functional impairment. Patients were treated with a flexible dose of open label citalopram for 12 weeks. Response rates for the intention-to-treat sample at week 12 were 14/21 (66.7%) for social anxiety disorder and 16/21 (76.2%) for depression. All continuous measures of social anxiety, depression, and functional impairment improved significantly with treatment, but depression symptoms responded more rapidly and more completely than social anxiety symptoms. Mean dose of citalopram at study endpoint was 37.6 mg/day. Only three patients (14.3%) fulfilled DSM-IV criteria for atypical features of depression, although 18 (85.7%) fulfilled the criterion for interpersonal rejection sensitivity. Citalopram treatment may benefit patients with primary social anxiety disorder and comorbid major depression, and it should be further studied in controlled trials. Improvement in social anxiety disorder symptoms lagged behind improvement in depression, and greater than 12 weeks of treatment may be required to assess full social anxiety response in patients with comorbid depression. The overlap of social anxiety disorder with atypical features of depression may primarily be due to the shared feature of rejection sensitivity.     

Correlates of knowledge and beliefs about depression among long-term care staff

CONTEXT: Despite the high prevalence of depression in long-term care (LTC), it often is unrecognized and inadequately treated. Thus, the goals of the present study were to evaluate LTC staff characteristics that are associated with knowledge and beliefs about depression. METHODS: A cross sectional study of 371 LTC staff members completed a knowledge and beliefs about depression questionnaire, a short demographic questionnaire, a burden measure, and a questionnaire about attitudes associated with working with depressed residents. RESULTS: Relative to nurses, social workers, and activity staff, paraprofessional caregivers had a lower score on the depression measure and a higher score on the burden measure. Paraprofessional caregivers were more likely to view depression as a normal phenomenon, held less accurate beliefs about signs and symptoms of depression, and were less familiar with the effectiveness of specific treatments of depression. CONCLUSIONS: Educational interventions about depression should be specifically geared to meet the needs of paraprofessional caregivers who provide the majority of care to LTC residents, yet possess less knowledge about depression and its treatments.     

Attitudes of hospital staff toward mentally ill patients in a teaching hospital,Turkey

The aim of this study was to examine the attitudes of hospital staff toward major mental diseases: schizophrenia and depression. Negative attitudes were common among all of the hospital staff, and were more common among academicians, resident physicians and nurses. Causes of attitude variations were discussed. BACKGROUND: Attitudes of hospital staff are important for admission, early diagnosis and treatment, and the rehabilitation process of mentally ill patients. AIMS: The main objective of this study was to investigate and compare hospital workers' attitudes toward and knowledge of schizophrenia and depression. METHODS: In 2001, a total of 160 hospital staff (40 academicians, 40 resident physicians, 40 nurses and 40 hospital employees) in a teaching hospital were interviewed with a questionnaire. The questionnaire included items about background information, a one-paragraph vignette, questions on social distance and expected burden, recognition of mental illness, hospitalization, prognostic outcome, and to whom and where the patient should be admitted. RESULTS: Although academicians, resident physicians, and nurses have sufficient knowledge about schizophrenia and depression, the frequency of their negative attitudes towards mentally ill subjects was more than that for uneducated hospital employees. CONCLUSIONS: It was commented that this difference might be as a result of negative effects of the medical education system.     

The construct of minor and major depression in Alzheimer's disease

OBJECTIVE: This study examined the frequency of major and minor depression in Alzheimer's disease and determined whether these types of depression have a different functional and psychopathological impact and whether there is a change in the prevalence of major and minor depression throughout the stages of Alzheimer's disease. METHOD: A consecutive series of 670 patients with probable Alzheimer's disease were assessed with the Structured Clinical Interview for DSM-IV; specific instruments to rate the presence and severity of depression, anxiety, apathy, irritability, delusions, pathological affective crying, performance of activities of daily living, and social functioning; and a standardized neuropsychological evaluation. Diagnoses of major and minor depression were generated from DSM-IV criteria. RESULTS: Twenty-six percent of the patients had major depression, 26% had minor depression, and 48% were not depressed. Major depression was significantly associated with sad mood in all three stages of the illness, although this association dropped significantly for minor depression in severe Alzheimer's disease. Both major and minor depression were significantly associated with more severe psychopathology, functional impairments, and social dysfunction. Depressive symptoms that most strongly discriminated between Alzheimer's disease patients with and without sad mood were guilty ideation, suicidal ideation, loss of energy, insomnia, weight loss, psychomotor retardation/agitation, poor concentration, and loss of interest. CONCLUSIONS: Our study demonstrates that DSM-IV criteria for major and minor depression identify clinically relevant syndromes of depression in Alzheimer's disease, mild levels of depression can produce significant functional impairment, and the severity of psychopathological and neurological impairments increases with increasing severity of depression.     

Executive dysfunction and disability in elderly patients with major depression.

The authors studied 126 elderly patients without dementia and with unipolar major depression. Impairment in instrumental activities of daily living (IADLs) was significantly associated with age (P<0.0001), gender (P<0.001), medical burden (P=0.013), severity of depression (P=0.01), initiation/perseveration (IP; P=0.035), and IP x depression (P=0.029). Depression was associated with IADL impairment mainly in patients with impaired IP. Among the cognitive impairments, IP-only contributed significantly to IADL impairment, whereas attention, construction, conceptualization, and memory did not. Attention to executive function and disability may guide clinical management and lead to development of innovative pharmacological and behavioral interventions.     

Adaptive, emotional, and family functioning of children with obsessive-compulsive disorder and comorbid attention deficit hyperactivity disorder

OBJECTIVE: The purpose of the study was to examine adaptive, emotional, and family functioning in a well-characterized group of children and adolescents with obsessive-compulsive disorder (OCD) and to evaluate the influence of comorbid attention deficit hyperactivity disorder (ADHD) on the levels of impairment in various functional domains. METHOD: The study group included 287 children and adolescents (191 boys, 96 girls) ages 7-18 years. Fifty-six subjects had a diagnosis of OCD only, 43 had both OCD and ADHD, 95 had ADHD, and 93 were unaffected comparison children. Best estimate DSM-IV diagnoses were assigned on the basis of structured interviews and clinical ratings. The children's functioning was evaluated with a comprehensive battery of well-established, standardized measures, including the Vineland Adaptive Behavior Scales, parents' ratings of social and family functioning, and children's self-reports of emotional adjustment. RESULTS: The children with OCD only were more impaired than were unaffected comparison subjects in most areas of adaptive functioning and emotional adjustment. Children with OCD plus ADHD had additional difficulties in social functioning, school problems, and self-reported depression. Impairment in daily living skills, reduced number of activities, and self-reported anxiety were uniquely associated with the diagnosis of OCD. Family dysfunction was associated with ADHD but not with OCD. CONCLUSIONS: Children and adolescents with OCD are impaired in multiple domains of adaptive and emotional functioning. When comorbid ADHD is present, there is an additional burden on social, school, and family functioning.     

The role of functional assessment as an outcome measure in antidementia treatment

Functional assessment refers to the evaluation of performance in basic activities of daily living, instrumental activities of daily living, professional duties, and hobbies. This assessment is particularly relevant in the evaluation of cognitive impairment. In fact, functional decline represents a core feature of dementia according to the DSM-IV criteria. Clinically, functional deterioration represents a diagnostic marker, can be used to chart the course of the disease, and as a prognostic marker as it contributes significantly to caregiver burden and institutionalization. For all these reasons, functional assessment has been widely used as an outcome measure in intervention trials of Alzheimer disease (AD). Appropriate function assessment scales have been developed for use in clinical trials of AD. Studies have shown that functional decline benefits from pharmacological interventions in AD and some other cognitive syndromes. This benefit translates into a stabilization ranging between 6 to 12 months compared to a gradual deterioration in the placebo group. There is rarely reversibility for IADL's lost. There are no functional scales specifically designed for assessment of subjects with non-AD cognitive impairment. Scales specifically developed for Mild Cognitive Impairment and other dementias are needed.     

Comorbid medical conditions among depressed elderly patients discharged home after acute psychiatric care.

OBJECTIVE: The authors examined physical illness among elderly patients hospitalized for treatment of major depression, the impact of comorbidity on functional status, and the burden of comorbidity on post-discharge service needs. METHODS: Data for this cross-sectional study were derived from patient interviews and abstracted from hospital charts. The sample comprised 195 older adults hospitalized for treatment of depression on the geropsychiatric unit of a large urban teaching hospital and discharged to home. Medical comorbidity was measured with the Cumulative Illness Rating Scale for Geriatrics. A psychiatrist confirmed DSM-IV for Axis I diagnosis of depression, and the Geriatric Depression Scale measured depression severity. Unit nurses administered the Mini-Mental State Exam. They assessed functional dependency via the OARS Multidimensional Functional Assessment Questionnaire. Service needs post-discharge were measured from physician discharge orders and patient scores on standardized tests. RESULTS: Almost three-fourths of depressed elderly patients had at least one comorbid condition requiring first-line treatment; nearly half had two, and one-fourth had three or more. Comorbid physical illness and cognitive impairment was significantly and negatively associated with elderly patients' functional impairment at discharge. Depressed patients with higher medical comorbidity had significantly more needs for services after they left acute care. CONCLUSION: Medical comorbidity needs to be assessed and considered in planning for post-acute care for depressed elderly patients discharged home.     

Assessing disturbed thinking and cognition using the Ego Impairment Index in older schizophrenia patients: paranoid vs. nonparanoid distinction.

OBJECTIVE: We compared thought-disturbance via the Rorschach-derived Ego Impairment Index (EII) between DSM-IV paranoid vs. nonparanoid (undifferentiated and disorganized) subtypes of older schizophrenia patients. METHODS: 44 DSM-IV medically stable outpatients with schizophrenia (27 paranoid, 17 nonparanoid) and 45 normal comparison participants aged 45-100 years were assessed using the EII, a Rorschach-derived cognitive-based measure of disturbed thinking. Group differences on the EII and the relation of this measure to key demographic and clinical variables were examined. RESULTS: Nonparanoid schizophrenia patients demonstrated significantly greater impairment on the EII than their paranoid counterparts. The EII performance of paranoid patients was similar to normal comparison participants. Furthermore, the paranoid patients displayed better premorbid intellectual functioning, less negative symptoms, and better global cognitive performance than nonparanoid patients. Finally, greater impairment on the EII was correlated with poor performance on a global measure of cognitive ability. CONCLUSIONS: The present findings substantiate previous work suggesting that nonparanoid patients have a form of the illness characterized by worse premorbid functioning and greater disturbed thinking and cognition than their paranoid counterparts.     

Major depression in elderly home health care patients

OBJECTIVE: Despite the growth of geriatric home health services, little is known about the mental health needs of geriatric patients seen in their homes. The authors report the distribution, correlates, and treatment status of DSM-IV major depression in a random sample of elderly patients receiving home health care for medical or surgical problems. METHOD: Geriatric patients newly admitted to a large, traditional visiting nurse agency were sampled on a weekly basis over a period of 2 years. The 539 patients ranged in age from 65 to 102 years; 351 (65%) were women, and 81 (15%) were nonwhite. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to interview patients and informants. The authors reviewed the results of these interviews plus the patients' medical charts to generate a best-estimate DSM-IV psychiatric diagnosis. RESULTS: The patients had substantial medical burden and disability. According to DSM-IV criteria, 73 (13.5%) of the 539 patients were diagnosed with major depression. Most of these patients (N=52, 71%) were experiencing their first episode of depression, and the episode had lasted for more than 2 months in most patients (N=57, 78%). Major depression was significantly associated with medical morbidity, instrumental activities of daily living disability, reported pain, and a past history of depression but not with cognitive function or sociodemographic factors. Only 16 (22%) of the depressed patients were receiving antidepressant treatment, and none was receiving psychotherapy. Five (31%) of the 16 patients receiving antidepressants were prescribed subtherapeutic doses, and two (18%) of the 11 who were prescribed appropriate doses reported not complying with their antidepressant treatment. CONCLUSIONS: Geriatric major depression is twice as common in patients receiving home care as in those receiving primary care. Most depressions in patients receiving home care are untreated. The poor medical and functional status of these patients and the complex organizational structure of home health care pose a challenge for determining safe and effective strategies for treating depressed elderly home care patients.