Quality-of-life impairment in depressive and anxiety disorders

OBJECTIVE: Previous reports demonstrating quality-of-life impairment in anxiety and affective disorders have relied upon epidemiological samples or relatively small clinical studies. Administration of the same quality-of-life scale, the Quality of Life Enjoyment and Satisfaction Questionnaire, to subjects entering multiple large-scale trials for depression and anxiety disorders allowed us to compare the impact of these disorders on quality of life. METHOD: Baseline Quality of Life Enjoyment and Satisfaction Questionnaire, demographic, and clinical data from 11 treatment trials, including studies of major depressive disorder, chronic/double depression, dysthymic disorder, panic disorder, obsessive-compulsive disorder (OCD), social phobia, premenstrual dysphoric disorder, and posttraumatic stress disorder (PTSD) were analyzed. RESULTS: The proportion of patients with clinically severe impairment (two or more standard deviations below the community norm) in quality of life varied with different diagnoses: major depressive disorder (63%), chronic/double depression (85%), dysthymic disorder (56%), panic disorder (20%), OCD (26%), social phobia (21%), premenstrual dysphoric disorder (31%), and PTSD (59%). Regression analyses conducted for each disorder suggested that illness-specific symptom scales were significantly associated with baseline quality of life but explained only a small to modest proportion of the variance in Quality of Life Enjoyment and Satisfaction Questionnaire scores. CONCLUSIONS: Subjects with affective or anxiety disorders who enter clinical trials have significant quality-of-life impairment, although the degree of dysfunction varies. Diagnostic-specific symptom measures explained only a small proportion of the variance in quality of life, suggesting that an individual's perception of quality of life is an additional factor that should be part of a complete assessment.     

Drug treatment in depressed elderly in the Dutch community

OBJECTIVES: In older people, a diagnosis of depression is frequently missed, and proper treatment is subsequently hampered. We investigated antidepressant and benzodiazepine use in an older community sample, and assessed possible risk factors associated with non-treatment in depressed elderly. METHODS: Data were used from the baseline measurements of the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified community sample of 3107 older Dutch people (55 to 85 years), respondents were screened on depression with the Center for Epidemiologic Studies Depression Scale (CES-D). In the depressed subsample depressive disorder according to DSM-III was assessed using the Diagnostic Interview Schedule (DIS). The use of antidepressants and anxiolytics (benzodiazepines) in the depressed subsample was measured, and associations with age, sex, cognitive impairment, physical health and anxiety symptoms were investigated. RESULTS: Only 16% of the respondents with a major depressive disorder used antidepressants. More than half of them used non-therapeutic dosages. Lower antidepressant use was associated with cognitive impairment. Benzodiazepine use was more likely than antidepressant use, which was especially evident in females in the major depressive disorder group. CONCLUSIONS: Depressed older people were undertreated, particularly when they were cognitively impaired. A high rate of benzodiazepine use was found, particularly in females.     

Randomized, double-blind, placebo-controlled trial of fluoxetine treatment for elderly patients with dysthymic disorder.

OBJECTIVE: The authors compared the efficacy and side effects of fluoxetine and placebo in elderly outpatients with dysthymic disorder. METHODS: Patients were randomly assigned to fluoxetine (20 mg-60 mg/day) or placebo for 12 weeks in a double-blind trial. RESULTS: Of 90 randomized patients, 71 completed the trial. In the intent-to-treat sample, random regression analyses of the Hamilton Rating Scale for Depression (Ham-D; 24-item) and Cornell Dysthymia Rating Scale (CDRS) scores at each visit produced significant time x treatment group interactions favoring the fluoxetine group. Analysis of percentage change in Ham-D scores yielded no effect for treatment group, but a similar analysis of percentage change in CDRS scores yielded a main effect for treatment group, favoring fluoxetine over placebo. In the intent-to-treat sample, response rates were 27.3% for fluoxetine and 19.6% for placebo. In the completer sample, response rates were 37.5% for fluoxetine and 23.1% for placebo. CONCLUSION: Fluoxetine had limited efficacy in elderly dysthymic patients. The clinical features of elderly dysthymic patients are typically distinct from those of dysthymic disorder in young adults, and the findings suggest that treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients. Further research is needed to identify efficacious treatments for elderly patients with dysthymic disorder, and investigative tools such as electronic/computerized brain scans and neuropsychological testing may help identify the factors that moderate antidepressant treatment response and resistance.     

Comorbidity in bipolar disorder among the elderly: results from an epidemiological community sample

OBJECTIVE: This study sought to determine psychiatric comorbidity among elderly individuals with bipolar disorder. METHOD: An epidemiological community survey identified 84 elderly (ages >/=65) respondents with bipolar disorder, 1,327 younger adults with bipolar disorder, and 8,121 elderly respondents without bipolar disorder. RESULTS: Elderly respondents with bipolar disorder reported lifetime and 12-month rates of comorbid alcohol use disorders (38.1%, 38.1%, respectively), dysthymia (15.5%, 7.1%), generalized anxiety disorder (20.5%, 9.5%), and panic disorder (19.0%, 11.9%) that were significantly higher than among elderly respondents without bipolar disorder. They had lower lifetime and 12-month rates of alcohol use disorders and lower 12-month rates of dysthymia and panic disorder than younger adults with bipolar disorder. Elderly men with bipolar disorder reported a greater prevalence of alcoholism; women reported a greater prevalence of panic disorder. CONCLUSIONS: Comorbid axis I disorders, including panic disorder, are common among elderly individuals with bipolar disorder.     

Mental disorder in elderly suicides: a case-control study

OBJECTIVE: The authors' goal was to study the importance of different psychiatric disorders in relation to suicide in individuals 65 years old or older. METHOD: The psychological autopsy approach was used to study 85 cases of suicide among subjects who were 65 years old or older; 153 living comparison subjects from the same age group who were randomly selected from the tax register were interviewed face-to-face. Retrospective axis I diagnoses were made according to DSM-IV on the basis of interview data and medical records. RESULTS: Ninety-seven percent of the suicide victims fulfilled criteria for at least one DSM-IV axis I diagnosis, compared with 18% of the living comparison subjects. Recurrent major depressive disorder was a very strong risk factor for suicide, as was substance use disorder. An elevated risk was also associated with minor depressive disorder, dysthymic disorder, psychotic disorder, single-episode major depressive disorder, and anxiety disorder. Comorbid axis I disorders were observed in 15 (38%) of the 39 elderly subjects with major depressive disorder who had committed suicide. CONCLUSIONS: Although recurrent major depressive disorder was the mental disorder most strongly associated with suicide, the findings of this study suggest that elderly individuals who commit suicide represent a heterogeneous group with regard to mental disorders, implying a need for differentiated prevention strategies.     

Clinical features of dysthymia and age: a clinical investigation.

A few authors have described the clinical picture of dysthymia in groups of elderly patients and pointed out differences from literature reports of dysthymia in younger adults. The present study, an attempt to analyze age effects on clinical characteristics of dysthymia throughout a lifetime, was performed in a sample of 106 patients, all aged > or =18 years, who were diagnosed according to DSM-IV. The patients were evaluated using: (1) a semistructured interview to assess clinical features, family history and previous treatments; (2) the Hamilton Depression Rating Scale; (3) the Interview for Recent Life Events; and (4) the Structured Clinical Interview for DSM-IV Disorders. Statistical analysis with stepwise logistic regression revealed that age was positively related to concomitant medical illnesses and to the total score of recent life events, but negatively related to the presence of avoidant or dependent personality disorders. The data suggested different etiologic pathways in older and younger patients. Dysthymia appeared to be associated in younger adults with abnormalities of personality; in the elderly, with a history of health problems and life losses.     

Outcome of dysthymic disorder at 5-year follow-up: the effect of familial psychopathology, early adversity, personality, comorbidity, and chronic stress.

OBJECTIVE: This study sought to identify predictors of course and outcome in dysthymic disorder. METHOD: Eighty-six outpatients with early-onset dysthymic disorder (before age 21) participated in a prospective 5-year follow-up study. Family history of psychopathology, early home environment, axis I and II comorbidity, social support, and chronic stress were assessed at baseline. The Longitudinal Interval Follow-up Evaluation and the Hamilton Depression Rating Scale were used in the follow-up assessments conducted at 30 and 60 months. RESULTS: Comorbid anxiety disorder, cluster C and depressive personality features, and chronic stress were associated with a lower rate of recovery from dysthymic disorder, while family history of bipolar disorder was associated with a higher probability of recovery. Family history of dysthymic disorder, poor childhood maternal and paternal relationships, childhood sexual abuse, cluster C features, neuroticism, a history of anxiety and eating disorders, and chronic stress predicted higher levels of depression at follow-up. Multivariate models indicated that almost all domains contributed to the prediction of course and outcome. CONCLUSIONS: The course and outcome of dysthymic disorder is best conceptualized within a multifactorial framework, with family history of psychopathology, early adversity, axis I and II comorbidity, and chronic stress all making important contributions.     

Cognition in dysthymia

Depression is named as one of the most prevalent Mental Health problem, affecting almost 10 % of the population. According to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) different subtypes are included. Dysthymic Disorder is characterized by a depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. The aim of this study was to investigate the neuropsychological profile of dysthymic disorder. Ninety three patients fulfilling criteria for dysthymia were examined on a variety of cognitive tasks, neurological exam and a semi-structured psychiatric interview. Forty one non-depressed individuals served as controls. Significant differences between groups were found in digit span; immediate and delayed recall of a story; and semantic and phonologic fluency. Logic memory was worse than serial learning task, and has a correlation with attention deficit and depressive features. Conclusions: This results indicate that the neuropsychological performance of patients with dysthymic disorder exhibit impairments in attention and memory. Attentional deficits appear to be the key of cognitive deficits in dysthymia.     

The guy's/age concern survey: Physical health and psychiatric disorder in an urban elderly community

The associations between physical health problems and cognitive impairment, depression, generalized anxiety and phobic disorders are described in a random community sample of 890 elderly people. 28.4% of the total sample reported one or more serious physical health problems, and increased rates of health problems were associated with cognitive impairment, depression, generalized anxiety and agoraphobia. Particular psychiatric disorders were associated with distinct patterns of specific physical health problems. Self-reports of physical health problems were associated with worry about physical health, but this did not account for the association between physical health problems and depression and agoraphobia.     

Comorbidity with depression in older people: The Islington Study

The coexistence of depression with other psychiatric disorders, which has been extensively studied in younger adults, has hardly been reported in older people. This study focuses primarily on comorbidity and other associations of depression in a community sample of older adults. A random sample of 700 older people in the inner London borough of Islington, and any other adults living with them, were interviewed at home using standardized instruments. Older people who were depressed were likely to have other comorbid physical and psychiatric pathology, namely general anxiety, phobic anxiety, physical disability, somatic symptoms, sleep disturbance and subjective memory impairment. The overwhelming majority of older people with depression were not receiving pharmacological treatment. Such lack of treatment may be because patients with physical or psychiatric comorbidity have presenting symptoms that obscure the diagnosis of depression. We conclude that while the majority of elderly people are psychiatrically well and do not require day to day help, those who are depressed have a significant rate of comorbidity. Health workers treating elderly people with depression should look for other physical and psychiatric conditions routinely. Comorbid depression should be considered in elderly people with subjective memory loss, sleep disturbance, somatic complaints, anxiety disorders or activities of daily living (ADL) limitation.     

Dysthymia among Substance Abusers: An Exploratory Study of Individual and Mental Health Factors

The purpose of this study was to examine the individual characteristics and mental health factors of dysthymic and nondysthymic substance abusers. Out of a total of 1,209 medical records reviewed to select cases of dysthymic and nondysthymic substance abusers attending a community drug treatment program, 183 medical records were selected, 48% of which were dysthymic substance abusers. Bivariate analyses indicated that dysthymic substance abusers were more likely to be male, older individuals, reported high levels of alcohol dependence, lower quality of life, and higher number of previous substance abuse treatment. Results from hierarchical multiple logistic regression analyses indicated that age, gender, and quality of life were significant predictor for having dysthymia. Implications for the mental health field are discussed, underlining the importance of developing and providing competent treatment for substance abusers with co-occurring disorders.     

Longitudinal study of the influence of life events and personality status on diagnostic change in three neurotic disorders

It has been known for many years that diagnosis within the neurotic spectrum of disorders is temporally unstable and also that life events can be major precipitants of change in symptoms. Reasons for this instability could include inherent inadequacy of current diagnostic practice, the influence of life events as an agent of diagnostic shift, and an innate course of disorder with features dependent on the stage at which disorder presents (e.g., development of panic to agoraphobia). These possibilities were examined in a prospective study that was initially a randomised controlled trial. Two hundred ten patients recruited from primary care psychiatric clinics with DSM-III diagnosed dysthymic, generalised anxiety, and panic disorders were randomly allocated to either drug treatment (mainly antidepressants), cognitive-behaviour therapy, or self-help therapy over a 2 year period, irrespective of original diagnosis. Life events were recorded by using a standard procedure over the period 6 months before starting treatment and at five occasions over 2 years; 181 (86%) of the patients had follow-up data and 76% maintained compliance with the original treatment allocated over the 2 years; and 155 of the 181 patients (86%) had at least one diagnostic change in this period. There was no difference in the number of diagnostic changes between the three original diagnostic groups, but dysthymic disorder changed more frequently to major depressive episode than did GAD or panic disorder (20; 11; 12) (%) and panic disorder changed more frequently to agoraphobia (with or without panic) than did dysthymia or GAD (18; 8; 6) (%). There was no relationship between loss events and depressive diagnoses or between addition events and anxiety diagnoses, but greater numbers of conflict events were associated with diagnostic change. More life events were associated with the flamboyant and dependent personality disorders, reinforcing other evidence that many life events are internally generated by personality characteristics and cannot be regarded as truly independent.     

The relationship between generalized anxiety disorder, depression and mortality in old age

BACKGROUND: The association between depression and an increased risk of death in elderly persons has been established in both clinical and community studies. Co-occurrence of depression and generalized anxiety has been shown to represent more severe and more chronic psychopathology. However, little is known about the relation between generalized anxiety disorder, mixed anxiety-depression (generalized anxiety disorder and depression) and excess mortality in the elderly. OBJECTIVE: To investigate whether generalized anxiety and mixed anxiety-depression are associated with mortality. METHOD: Generalized anxiety disorder, mixed anxiety-depression and depression were assessed in 4051 older persons with a ten-year follow-up of community death registers. The mortality risk of generalized anxiety, depression and mixed anxiety-depression was calculated after adjustment for demographic variables, physical illness, functional disabilities and social vulnerability. RESULTS: In generalized anxiety disorder and mixed anxiety-depression no significant excess mortality was found. In depression a significant excess mortality was found in men [HR 1.44 (1.09-1.89)] but not in women [HR 1.04 (0.87-1.24)] after adjustment for the different variables. CONCLUSIONS: In elderly persons depression increases the risk of death in men. Neither generalized anxiety nor mixed anxiety-depression are associated with excess mortality. Generalized anxiety disorder may even predict less mortality in depressive elderly people. The relation between generalized anxiety disorder and its possibly protective effect on mortality has to be further explored.     

抑郁症与心境恶劣障碍患者的甲状腺素水平

目的:测定抑郁症与心境恶劣障碍患者的甲状腺素水平,探讨其神经内分泌改变。方法:对抑郁症30例和心境恶劣障碍30例进行汉密尔顿抑郁量表(HAMD),艾森克人格问卷(EPQ)及生活事件量表(LES)评定。测血清三碘甲状腺原氨酸(T3)、甲状腺素(T4)及促甲状腺素(TSH)浓度。结果:两组间在HAMD总分及T4水平差异显著。抑郁症组T3与EPQ的内外向分及HAMD的迟缓因子分呈正相关;T4与HAMD总分、焦虑因子分及负性生活事件刺激量呈正相关;TSH与正性生活事件刺激量呈正相关。心境恶劣障碍组T3与认知障碍因子分呈负相关;T4与HAMD总分、负性生活事件及迟缓因子分呈正相关。结论:负性生活事件促进了抑郁发作,T4水平可预测抑郁症状的严重程度。     

A study of self-harm in older people: mental disorder, social factors and motives

Data was collected on seventy-six older people who presented to a specialist self-harm team. Data included: diagnosis, suicide intent, motives for self-harm, social contacts and life events and difficulties. The majority of elderly who harmed themselves had high suicide intent and 69% were depressed. Patients were frequently living alone with an isolated life-style and poor physical health. Depressed self-harm subjects had higher suicide intent scores than non-depressed and to gain relief from an unbearable state of mind was a frequently recorded motive for these patients. Other motives for self-harm appear to be similar between depressed and non-depressed self-harmers. It is important that older people who self-harm receive an appropriate assessment of both risk and need by an experienced mental-health professional skilled at recognising depression in later life. The need for adequate recognition and management of depression in older people in primary care is also highlighted.     

Comorbidity of the anxiety disorders in a community-based older population in The Netherlands

OBJECTIVE: The aim of the study was to investigate patterns of comorbidity among the anxiety disorders in a community-based older population, and the relationship of these disorders with major depression, use of alcohol and benzodiazepines, cognitive impairment and chronic somatic illnesses. METHOD: The data were derived from the Longitudinal Aging Study Amsterdam (LASA) study. A two-stage screening design was adopted to identify respondents with anxiety disorders. RESULTS: In total, 10% of the elderly with an anxiety diagnosis suffered from two or more anxiety disorders. Major depression (13% vs. 3%), benzodiazepine use (24% vs. 11%) and chronic somatic diseases (12% vs. 7%) were significantly more prevalent in respondents with an anxiety disorder than in respondents without anxiety disorders. Heavy or excessive alcohol intake (5% vs. 4%) and cognitive impairment (11% vs. 13%) were not significantly associated with any anxiety disorder. CONCLUSION: When anxiety disorders are diagnosed, in older people there is a relatively high probability of comorbid conditions being present.     

The clinical spectrum of so-called "minor" depressions.

Reviewing the recent literature on the overlapping spectrum of neurotic depressive and dysthymic conditions--unofficially referred to as "minor," "atypical" or "characterologic" depressives--the authors conclude that significant symptomatologic admixtures with anxiety disorders do not represent the prototypical features of these disorders as defined in DSM-III-R. It is long-standing anhedonia on an intermittent or chronic basis which appears to characterize the trait illness of dysthymia. The emerging data on dysthymia suggest that it begins early in life, is often complicated by major depressions, and pursues a chronic--often pernicious--course. The development of hypomanic switches during the prospective course of some of these patients further suggests some kinship to bipolar disorder. Although traditionally conceived as being largely "psychogenic," familial data and selected biologic indices--especially in the area of sleep--and thymoleptic responsiveness impart some credibility to the role of biologic factors in the origin of these disorders. Given the high prevalence of dysthymic conditions in clinical practice, new research strategies on their causes are needed as a precondition for more rational treatment approaches.     

Phenomenology, psychosocial correlates, and treatment seeking in major depression and dysthymia of adolescence

OBJECTIVE: To compare phenomenology, psychosocial correlates, and treatment seeking in DSM-Itt-R major depression and dysthymia among adolescents diagnosed as cases in a community-based study. METHOD: A self-report questionnaire, including psychosocial data, life events, eating behaviors, depressive symptoms, substance use, pathological behaviors, and family and school functioning was administered to a nonselected sample (N = 3,287, 93.2% of targeted population) of adolescents aged 11 to 20 years from several Haute-Marne communities in France in 1988-1989. Subgroups of subjects (n = 205, 84.7% of eligible subjects) were interviewed with a structured diagnostic schedule, and adolescents with major depression (n = 49), dysthymia (n = 21) and controls (n = 135) were compared. RESULTS: Nearly 30% of controls had at least one current symptom of depression. Patterns of affective symptoms were similar in major depression and dysthymia, but significant differences emerged in comorbid conditions (more anxiety disorders, suicidal behaviors, and alcohol intoxications associated with major depression) and stressor at onset (more severe in major depression). Experiences of loss during the prior 12 months were associated with both forms of affective disorder, while poor family relationships were specific correlates of dysthymia. In contrast, peer relationships and pathological behaviors did not differ between depressed subjects and controls. Although psychosocial functioning was significantly impaired in both groups of depressed adolescents, treatment seeking was limited to 34.7% for major depressive subjects and 23.8% for dysthymic subjects. CONCLUSION: The results provide evidence that major depression and dysthymia in adolescence are equally severe but may have distinct patterns in associated factors. Despite free access to health care, the rate of treatment seeking for mood disorders in France is similar to that reported in U.S. studies.     

The Zurich study

Dysthymia was assessed in the prospective Zurich Cohort Study of young adults. The 1-year prevalence rate was around 3% if no exclusion criteria were applied. Pure dysthymics without major or recurrent brief depression accounted for about 1%. Most cases of dysthymia met the symptom criteria for major depressive disorder (MDD) and were characterized by a more continuous course. However, evidence presented in this paper suggests that a diagnosis separate from MDD is not warranted. The family history of dysthymic subjects did not differ from major depressives. The smaller group of primary dysthymics, on the other hand, did not differ from controls as regards family history for treated depression. The low prevalence rates, taken together with methodological problems involved in assessing dysthymia and the lack of a distinct course, suggest that dysthymia does not constitute a valid subtype of depression in an age group of 20-30 years of the community. Dysthymia belongs to the wide spectrum of major depressive syndromes and represents only a subgroup characterized by specific course characteristics.     

Comorbid anxiety disorders in depressed elderly patients

OBJECTIVE: Anxiety disorders are common in adults with depressive disorders, but several studies have suggested a relatively low prevalence of anxiety disorders in older individuals with depression. This cross-sectional study measured current and lifetime rates and associated clinical features of anxiety disorders in depressed elderly patients. METHOD: History of anxiety disorders was assessed by using a structured diagnostic instrument in 182 depressed subjects aged 60 and older seen in primary care and psychiatric settings. Associations between comorbid anxiety disorders and baseline characteristics were measured. The modified structured instrument allowed detection of symptoms that met inclusion criteria for generalized anxiety disorder in a depressive episode. RESULTS: Thirty-five percent of older subjects with depressive disorders had at least one lifetime anxiety disorder diagnosis, and 23% had a current diagnosis. The most common current comorbid anxiety disorders were panic disorder (9.3%), specific phobias (8.8%), and social phobia (6.6%). Symptoms that met inclusion criteria for generalized anxiety disorder, measured separately, were present in 27.5% of depressed subjects. Presence of a comorbid anxiety disorder was associated with poorer social function and a higher level of somatic symptoms. Symptoms of generalized anxiety disorder were associated with a higher level of suicidality. CONCLUSIONS: Contrary to previous reports, the present study found a relatively high rate of current and lifetime anxiety disorders in elderly depressed individuals. Comorbid anxiety disorders and symptoms of generalized anxiety disorder were associated with a more severe presentation of depressive illness in elderly subjects.