Anosognosia and depression in patients with Alzheimer's dementia

Anosognosia refers to impaired awareness of patients to realize deficits related to a disorder and is a common symptom of dementia. Anosognosia has far-reaching consequences for diagnosis and treatment and is probably associated with unfavorable prognosis. This study examined the relationship between anosognosia and depression in patients with Alzheimer's dementia (AD). Assessment included interviews of patients and their caregivers. Depressive symptoms were evaluated with observer and self-rating instruments: the Geriatric Depression Scale (GDS), and the “mood” subscale of the Nurses Observation Scale for geriatric patients (NOSGER). Anosognosia was evaluated with the Anosognosia Questionnaire for Dementia (AQ-D). For the evaluation of behavioral and neuropsychological symptoms in dementia and the caregiver burden, the neuropsychiatric inventory (NPI) and the Cares of older People in Europe (COPE) Index were administered. A total of 47 patients were enrolled in the study at the department's geriatric psychiatry outpatient clinic. A considerable discrepancy was found between observer- and self-ratings of depressive symptoms. In 74.5% of the participants, caregiver ratings indicated secondary symptoms of depression as opposed to patient ratings. Thus, in AD, anosognosia may affect not only deficits in cognition and everyday functioning but also affective symptoms (“affective anosognosia”). Caregiver rating therefore is particularly important when assessing mood changes in AD patients.     

Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic

Caregiver burden has been associated with patient dementia. In this study we tested the hypothesis that caregiver burden and depression are related to patient cognitive impairment. We analyzed records of 127 elderly male patients from a Veterans hospital geriatrics referral clinic. The patients and their informal caregivers had been referred to the clinic because the complexity and multiplicity of their problems were beyond the treatment capability of other clinics. There was a high prevalence of dementia (73%) and depression (69%) in these patients according to Diagnostic and Statistical Manual (DSM-III) criteria. Quantitative measures of patient dementia and dependency in activities of daily living were not statistically associated with measures of caregiver depression or burden. In contrast, measures of patient depression were significantly correlated with measures of caregiver depression and burden. We hypothesize that caregivers of chronically ill, elderly men cope better with physical and cognitive incapacity than with affective symptoms. Because caregiver support is the most important factor in maintaining a disabled elder in the community, we suggest evaluating patients and caregivers for depression as part of standard practice in geriatric clinical settings.     

The relationship between caregivers' global ratings of Alzheimer's disease patients' quality of life, disease severity, and the caregiving experience

OBJECTIVES: To compare caregivers' ratings of Alzheimer's disease (AD) patients' global quality of life (QOL) using direct assessments and substituted judgments, and to identify qualities of the patients and their caregivers that are associated with these QOL assessments. DESIGN: Cross-sectional interviews. SETTING: A university-based Memory Disorders Clinic. PARTICIPANTS: Forty primary caregivers of AD patients. MEASUREMENTS: Direct scaling of overall quality of life (poor, fair, good, very good, or excellent) and measures of dementia severity, the caregiving experience, and patient and caregiver demographics. RESULTS: The majority of patients had mild (n = 20) or moderate (n = 11) AD. Caregivers' direct assessments of patient QOL were poor (5%, n = 2), fair (28%, n = 11), good (40%, n = 16), very good (20%, n = 8), and excellent (8%, n = 3). Twenty-one (52.5%) of the caregivers rated the patient's QOL the same as they thought the patient would; 12 (30.0%) rated the patient's QOL worse; and seven (17.5%) rated the patient's QOL better. Agreement between the two ratings was fair to moderate. Bivariate analyses showed that lower ratings of caregivers' direct assessments of patient QOL were associated with decreasing ratings of patient mental health and increasing dementia severity, caregiver burden, and caregiver depression. Multivariate models showed burden to be the significant predictor of caregivers' rating of patient QOL and the subscale measuring the caregivers' distress at controlling patient behavior had the strongest association with QOL. Lower ratings of substituted judgment assessments of patient QOL were associated with lower caregiver ratings of the patient's mental health. CONCLUSIONS: Nearly one-half of the caregivers of patients with predominantly mild to moderate AD assess a patient's QOL differently than they believe the patient would. Dementia severity and the caregiver's experiences of depression and burden negatively affect caregivers' assessments of QOL. These results provide a compelling reason why clinicians should take the time to screen for and address caregiver depression and burden and problematic patient behaviors.     

Non-cognitive outcomes in trials of disease-modifying drugs for Alzheimer's disease

Alzheimer's disease (AD) constitutes a major challenge for healthcare systems in countries with ageing populations. The clinical signs include the progressive loss of memory and other cognitive functions. However, AD also has non-cognitive features, such as decline in functional abilities, inducing a spectrum of psychological and behavioural symptoms. There is considerable clinical interest in non-cognitive abnormalities of AD, due to their high prevalence and because non-cognitive features complicate patient management, increasing the burden on caregivers and frequently leading to institutionalisation. Efforts are currently being made to investigate AD pathology and to develop appropriate treatment strategies. These strategies focus on the long-term preservation of cognitive and functional abilities and/or the slowing of disease progression, together with the attenuation of behavioural symptoms and the maintenance of quality of life for the patient and the caregiver. The non-cognitive features of AD are often neglected, but are important outcomes when evaluating the “real-life” benefits of disease-modifying treatments for dementia. We discuss the non-cognitive outcomes of interest, in particular, activities of daily living, nutritional parameters, mood and behavioural features, falls, patient's and caregiver's quality of life and use of health system; and the instruments that can be used to measure them.     

Behavioral correlates of computed tomographic (CT) scan changes in older psychiatric patients

Fifty psychiatric inpatients aged 50 and over, with no hard neurologic findings, and with a variety of DSM-III diagnoses (adjustment disorder, affective illness, and dementia), were rated for behavioral and psychiatric symptoms using the Geriatric Rating Scale and the Nurse's Assessment of Global Symptomatology-Elderly. These clinical ratings were correlated with computed tomographic (CT) scan assessments of various superficial cerebral regions as well as with linear measures of ventricular size. Behavioral deficits in activities of daily living (ADL) plus an interactional variable, inability to respond to requests, were correlated with superior temporal and inferior parietal CT abnormalities, particularly on the left side. Suspiciousness and peculiar thinking, mood lability and irritability, as well as impaired memory with confusion, perplexity, and disorientation were also associated with atrophy in these same regions. Prefrontal area defects correlated with mood lability and deficits in visual-interactional responsiveness. Statistically controlling for effects of age and alcohol abuse did not alter the basic nature of these results. Regional cerebral specialization in relation to these results are discussed using concepts developed by Luria.     

Role of depressive and cognitive status in self-reported evaluation of quality of life in older people: comparing proxy and physician perspectives

OBJECTIVE: To assess the quality of life (QOL) of older adults aged over 65 years, who were healthy or suffering from depressive syndrome (DS) and/or Alzheimer's disease (AD); to analyse agreement between participants' and proxies' QOL ratings; to evaluate the association between participants' depressive and cognitive symptoms and QOL rating; to correlate participants' health ratings and the severity of physician assessment. METHODS: 138 non-institutionalised older people of both genders and their respective caregiver and treating doctor were consecutively recruited (response rate 74.6%). Forty suffered from AD, 36 from DS, 35 from both conditions and 27 had neither. All participants were evaluated by Mini Mental State Examination, Geriatric Depression Scale and World Health Organization Quality of Life (WHOQOL) questionnaire. The caregiver filled out QOL-Proxy and the physician filled out the 'Health and Severity of Illness' form. RESULTS: The four groups scored significantly differently in all areas of WHOQOL-100 (WHOQOL questionnaire with 100 items). Participants with DS perceived their QOL as poorer than did healthy and AD subjects. Participants with AD and DS obtained intermediate scores. Severity of depression correlated with worsening QOL. Subjects with DS--but not those with AD, AD and DS, and, in some areas, healthy participants--had similar perception of their QOL to their proxies. Poor physical health ratings by the physician corresponded to poorly perceived QOL by the patient. CONCLUSION: Older people with AD perceive their own QOL similarly to and, in some areas, even better than healthy people of the same age. The opposite was observed among the depressed. Informants do not always evaluate QOL in the same way as healthy elders and those with AD, while there is more agreement with depressed patients. Informant evaluation may be helpful but is not necessarily reliable.     

Depression and dementia

Data from the literature devoted to the relationships between dementia and depression are controversial on account of numerous methodological biases (community studies or from neurological or psychiatric departments), categorical versus dimensional approaches and variability of assessment tools for depression, aim of the study (depression versus dementia or versus Alzheimer's disease, AD). The difficulty to discriminate depression from AD is largely overestimated due to the confusion between depression, depressive symptomatology and apathy. The distinction is greatly facilitated by taking into account the qualitative differences of the memory deficits and cerebral imagery. Distinction of depression from frontotemporal or subcortical dementias could be much more difficult. Relationships between depression and AD are controversial. Most reports of depression as a risk factor for AD in the subsequent years, actually describe depressed symptomatology linked to apathy in preclinical AD. However, some studies found a relationship between AD and depression occurring more than 10 years before the onset of AD symptomatology, suggesting some common risk factors. The so-called symptoms of depression in AD are more related to apathy and affective disturbances than to dysphoria. The frequency of major depressive episode (MDE), greatly varies according to studies, but the frequency of suicide is low. Depression in dementia is related to neurobiological factors as well as to psychological mechanisms. Therefore, its treatment should associate antidepressant drugs and psychological support directed to the patient and family.     

Assessment of cognitive, psychiatric, and behavioral disturbances in patients with dementia: the Neurobehavioral Rating Scale.

OBJECTIVE: To assess the validity of the Neurobehavioral Rating Scale (NRS) in patients with Alzheimer's disease (AD) or multi-infarct dementia (MID) and to characterize the cognitive, psychiatric, and behavioral disturbances that occur in these patients. DESIGN: Cross-sectional evaluation. SETTING: West Los Angeles VAMC Geropsychiatry Inpatient Unit, Neurobehavior Inpatient Unit, and Dementia Clinic; UCLA Alzheimer's Disease Clinic. PATIENTS: Convenience sample of 61 patients with AD and 22 patients with MID. MAIN OUTCOME MEASURE: The NRS, a 27-item observer-rated instrument that measures cognitive, psychiatric, and behavioral disturbances. RESULTS: The NRS demonstrated content and convergent validity in this patient group. Principal components analysis of the NRS ratings identified a six-factor solution, and each factor contained clinically related symptoms. The factors were Cognition/Insight, Agitation/Disinhibition, Behavioral Retardation, Anxiety/Depression, Verbal Output Disturbance, and Psychosis. Among the patients with AD, agitation, disinhibition, hostility, poor insight, poor motivation, suspiciousness, and delusions were more severe in patients with more advanced dementia. Depressive symptoms occurred with equal severity in patients with mild and advanced dementia, but depressed mood was more severe in patients with earlier age of onset of AD. CONCLUSION: The NRS is a useful instrument for structured assessment of a broad range of cognitive, psychiatric, and behavioral disturbances in patients with dementia.     

Effects of cognitive function and depressive mood on the quality of life in Chinese Alzheimer's disease patients in Hong Kong

Aim: In view of the paucity of data on the quality of life (QOL) in Chinese Alzheimer's disease (AD) patients, we investigated the effects of cognitive function and depressive mood on QOL among our Chinese AD patients in Hong Kong, using the Cantonese Chinese version of Quality of Life in Alzheimer's disease (QOL‐AD). Methods: This was a cross‐sectional study. The Cantonese Chinese version of QOL‐AD was adapted from the Mandarin Chinese and English versions of QOL‐AD, and was administered to 111 AD patients and their caregivers. Results: The Cantonese Chinese version of QOL‐AD showed good internal consistency, test–retest and inter‐rater reliability. The patients' and caregivers' reports of QOL‐AD were moderately correlated (r = 0.516, P < 0.001). Both QOL‐AD scores from patient and caregiver reports varied significantly in relation to the severity of cognitive impairment, being lowest in the subgroup with Mini‐Mental State Examination scores of 10 or less. The mean QOL‐AD scores from both patient and caregiver reports were also significantly lower in the depressed (Geriatric Depression Scale [GDS] scores ≥15) than non‐depressed groups (GDS scores ≤15) (QOL‐AD patient report 23.8 and 34.2, respectively, P < 0.001, Student's t‐test; QOL‐AD caregiver report 28.9 and 31.0, respectively, P < 0.05, Student's t‐test). General linear model analyses showed that only the MMSE and GDS scores were independent significant factors associated with the patient but not the caregiver reports of the QOL‐AD. Conclusion: Among Chinese AD patients in Hong Kong, depressive mood and low MMSE score adversely affect the QOL‐AD from the patient but not the caregiver perspectives. Geriatr Gerontol Int 2011; 11: 69–76.     

What causes grief in dementia caregivers?

Alzheimer's disease (AD) is the most prevalent neurodegenerative disease in the world. Most AD patients become dependent on their relatives, i.e. family caregivers. Providing care to a person with AD influences caregiver's life and leads to feelings of grief, which often precede caregiver depression. The purpose of the article was to evaluate the Meuser and Marwit Caregiver Grief Inventory (MM-CGI-50) for use in Polish family caregivers and to find out determinants of grief of family caregivers of AD individuals living in Poland. A sample of 151 spouse and adult child caregivers of community-dwelling AD patients (95 females and 56 males) was interviewed to determine the influence of such factors as caregiver's age, gender, family relation to the care recipient (CR) and caregiving-related changes in caregiver's working time, leisure time and material status to find out the impact of caregiving role on intensity of caregiver grief. Caregiver grief was measured by means of MM-CGI-50. Additionally, carers were administered a questionnaire including patient's and caregiver's demographics. Also, CR's dementia assessment was informant-based and determined with investigator-administered clinical dementia rating (CDR) scale. Of all analyzed factors, only caregiver's informant dementia rating significantly influenced caregiver grief. To conclude, the effect of caregiver's age, gender, family relation to the CR and caregiving-related changes in caregiver's working time; leisure time and material status could not be found. To add, MM-CGI-50 can be effectively used to assess grief in Polish family caregivers of AD patients.     

Psychopathology of stroke

The psychopathology of stroke encompasses several psychiatric and behavioral disorders that have high prevalence in the geriatric population, reduce the patient autonomy and increase the caregiver's burden. These disorders are usually associated with other cognitive and neurological deficits, and are labelled as neuropsychiatric when the whole clinical picture is consistent with the specific dysfunction of a neural system or brain region. Thus the neuropsychiatry of stroke comprises disorders of the perception/identification of the self and the environment (anosognosia of hemiplegia, misidentification syndromes, confabulations, visual hallucinations, delirium and acute confusional state), amotivational syndromes (apathy and athymhormia), disorders of emotional reactivity (blunted affect, emotional incontinence, irritability, catastrophic reactions), poor impulse or ideation control (mania) and personality changes. The clinical profile of the subcortical vascular dementia also points to specific brain dysfunction (frontal-subcortical pathways) that manifests with behavioral (depression, emotionalism, irritability) and cognitive symptoms (psychomotor retardation, attention, executive and memory deficits). However, post-stroke depression and anxiety, which have a more variable clinical presentation and might be assimilated, for several aspects, to post-traumatic or adaptive disorders, are disorders less characterized in their neural correlates.     

Behavioral and psychological symptoms, cognitive impairment and caregiver burden related to Alzheimer's disease patients treated in an outpatient memory clinic

AIM: The relationships among behavioral and psychological symptoms of dementia (BPSD), cognitive impairment of Alzheimer's disease (AD) patients and the caregiver burden of their caregivers were investigated in an outpatient memory clinic. METHODS: Forty-six pairs of AD patients and their family caregivers were involved in this study. Neuropsychiatry Inventory (NPI) was used to estimate BPSD, to which memory symptoms were added as a subcategory of BPSD. MMSE, word fluency, clock drawing test and category-cued memory test were used for cognitive measurement. Zarit burden interview (ZBI) and CES-D were used to assess caregiver burden. RESULTS: Among 11 BPSD subcategories, memory symptoms, apathy, depression, delusion, aggression and anxiety were prevalent BPSD was a strong determinant of caregiver burden. Among BPSD symptoms, anxiety, aggression and aberrant motor behavior were significantly related to ZBL In terms of the relationship between BPSD and cognitive impairment, the scores for delusion and apathy were significantly related to the cognitive decline. On the other hand, patients who showed symptoms related to memory and depression had higher cognitive function than those who did not. CONCLUSION: These analyses will contribute to better assessment of AD patients and their caregivers, hopefully resulting in better support for them.     

Management of psychosis in patients with Alzheimer’s disease: focus on aripiprazole

Psychosis of Alzheimer’s disease (AD) is characterized by delusions or hallucinations and may be associated with agitation, negative symptoms or depression. There are no psychotropic medications that are approved by the US FDA for the treatment of psychosis of AD. However, atypical antipsychotics have been widely used and recommended by geriatric experts in the management of psychosis of AD in view of the modest efficacy and relative safety until FDA warnings were issued in 2005 and meta-analytic studies showed no significant difference to placebo. The FDA warnings on the cardiac, metabolic, cerebrovascular, and mortality risks have caused serious concerns for the use of atypical antipsychotic agents in elderly patients with dementia. Only a few studies have evaluated prospectively the effects of aripiprazole in psychosis associated with AD. These studies show improvement in the symptoms of psychosis associated with AD with aripiprazole. The safety and tolerability profile of aripiprazole suggests a low potential for negative impact on dementia and overall patient health. Further studies comparing the efficacy and tolerability of aripiprazole vs other atypical antipsychotics in dementia are needed.     

An integrated program for dementia evaluation and care management.

The growth of the geriatric population and the emergence of managed care dictate new approaches to dementia care. Management of Alzheimer's disease (AD) is a critical issue for health care policy as well as quality of life for patients and caregivers. The Alzheimer's Disease Education Program (ADEP) seeks to improve the quality of care for individuals with AD and to reduce the burden of caregiving experienced by families. Objectives of ADEP include early detection of AD through dementia screening followed by caregiver education and support. This article outlines an effective method of dementia evaluation and management.     

Effects of rivastigmine on actigraphically monitored motor activity in severe agitation related to Alzheimer's disease: a placebo-controlled pilot study

Acetylcholinesterase inhibitors (AChEIs) are effective in the treatment of cognitive symptoms in Alzheimer's disease (AD). Because the behavioral and psychological symptoms of dementia (BPSD) have also been attributed to central cholinergic deficits, we examined whether the AChEI rivastigmine can reduce motor activity as measured in a rater-independent manner by wrist actigraphy in agitated AD patients. A total of 20 consecutive AD inpatients (13 females, 7 males, 80.4+/-9.1 years, S.D.) were included from our geriatric psychiatry unit, all of whom were exhibiting agitated behavior not attributable to delirium. Patients were assigned randomly and in a single-blinded fashion to rivastigmine 3mg or placebo for 14 days. Motor activity levels were monitored using an actigraph worn continuously on the wrist of the non-dominant hand. At the beginning and end of the study, patients were assessed using the Neuropsychiatric Inventory (NPI) and Nurses' Observation Scale for Geriatric Patients (NOSGER). Patients in the rivastigmine group exhibited less agitation than placebo recipients on the NPI-agitation subscale, but not on NOSGER. Actigraphic measurements showed a tendency towards reduced motor activity in the rivastigmine group. Because rivastigmine usually exerts its main effects after a longer period of time, the short-term effects seen in our study justify further controlled clinical trials examining the use of rivastigmine in BPSD by means of actigraphy.     

综合医院老年住院患者情感障碍的识别

目的探讨对综合医院老年病房住院老年患者进行老年综合评估与精神科医师会诊相结合的方式对情感障碍的识别作用。方法某三级甲等医院老年病房2011年8月至2013年3月收治的≥65岁老年住院患者,在人院时进行包括Zung抑郁自评量表（SDS）和老年抑郁量表（GDS）15项在内的老年综合评估,由老年科医师决定是否进行多学科团队查房及精神科医师会诊。精神科医师根据国际疾病分类第10版（ICD-10）标准诊断情感障碍。结果研究期间共收治≥65岁老年住院患者281例,年龄（75．2±6．8）岁,男：女为136：145,其中49例（17．4％）患者罹患情感障碍,年龄（73．5±6．0）岁,男：女为16：33,其中抑郁发作39例,恶劣心境障碍5例,双相情感障碍2例,复发性抑郁2例,未特定抑郁障碍（NOS）1例,情感障碍患病率17．4％。确诊的49例患者中,提请精神科会诊的第一位原因分别为：有相关病史7例,医师注意到患者有情绪问题23例,失眠2例,存在疾病不能解释的躯体症状5例,量表筛查阳性12例。结论情感障碍是老年住院患者常见的精神疾患,采用老年综合评估与精神科医师会诊相结合的方式有利于识别老年情感障碍,是一种值得推广的老年精神医学服务模式。     

Use of the Geriatric Depression Scale in dementia of the Alzheimer type

The Geriatric Depression Scale (GDS) has been shown to be an effective screening test for depression in selected geriatric populations. However, it has not been evaluated as a screening test for depression among elderly adults with dementia of the Alzheimer type. Over a two-year period 283 patients were seen in a geriatric assessment center and were screened for depression using the Geriatric Depression Scale. They also received a clinical psychiatric diagnosis by one of two geropsychiatrists. Patients with a Clinical Dementia Rating (CDR) of 0 (cognitively intact) (n = 70) and those with mild Alzheimer's disease (CDR of 1) (n = 72) were selected for comparison. The data were analyzed using Receiver Operating Characteristic Curves (ROCs) in order to compare the utility of the Geriatric Depression Scale in these two groups. ROC curves, which plot sensitivity against false positives, have come into increasing use as a method of examining the clinical performance of tests. The area lying beneath the curve (AUC) can be estimated and used as a quantitative measure of test performance (equivalent to the Wilcoxon rank sum). In the intact group, the Geriatric Depression Scale produced a ROC curve with an AUC of 0.85 (percent score = 1), which is significant (z = 7.28, P less than .0001). In the group composed of those with Alzheimer's disease, the Geriatric Depression Scale yielded a ROC curve with an AUC of 0.66, which was not significantly different from chance (z = 1.92, P = NS). This study provides empirical evidence that while the Geriatric Depression Scale is an accurate screening test for depression in cognitively intact geriatric populations, it does not maintain its validity in populations that contain large numbers of patients with dementia of the Alzheimer type.     

A comparison of caregivers for elderly stroke and dementia victims.

OBJECTIVE: To compare elderly co-resident caregivers of stroke and dementia patients on measures of burden and psychological morbidity. DESIGN: Cohort study. SETTING: Caregivers interviewed at home. SUBJECTS: Convenience sample, 99 co-resident caregivers of dementia and stroke patients registered with a community rehabilitation and geriatric service and who were 60 years or over. MAIN OUTCOME MEASURES: Caregiver burden as measured by self-administered questionnaire and subsequent interview, using the Relatives Stress Scale (RSS) and psychological morbidity as measured on the General Health Questionnaire (GHQ). RESULTS: Forty-six percent of caregivers had significant psychological morbidity (GHQ greater than 4). Mean RSS score was 12.2 (SD 5.4). No significant differences were found between stroke and dementia caregivers on these measures. Caregiver burden was significantly correlated with psychological morbidity in both caregiver groups. Behavior and mood disturbance in the patient was significantly correlated with burden (dementia caregivers r = 0.66; stroke caregivers r = 0.49, P less than 0.0001) and psychological morbidity (dementia caregivers r = 0.44, P less than 0.01; stroke caregivers r = 0.30, P less than 0.05). Caregiver's dissatisfaction with participation in life activities was correlated with burden (dementia caregivers r = 0.58; stroke caregivers r = 0.63, P less than 0.0001) and psychological morbidity (dementia caregivers r = 0.67, stroke caregivers r = 0.56, P, 0.0001). CONCLUSION: Elderly co-resident caregivers for stroke and dementia patients experience similar degrees of burden and high levels of psychological morbidity. Psychiatric aspects of chronic disability, rather than physical aspects, were found to be more stressful to caregivers. All assessments of the disabled elderly should include measures of caregiver burden and psychological distress.     

Depression associated with dementia

Depression and cognitive disorders, including dementia and mild cognitive impairment, are common disorders in old age. Depression is frequent in dementia, causing distress, reducing the quality of life, exacerbating cognitive and functional impairment and increasing caregiver stress. Even mild levels of depression can significantly add to the functional impairment of dementia patients and the severity of psychopathological and neurological impairments increases with increasing severity of depression. Depressive symptoms may be both a risk factor for, as well as a prodrome of dementia. Major depressive syndrome of Alzheimer’s disease may be among the most common mood disorders of older adults. Treating depression is therefore a key clinical priority to improve the quality of life both of people with dementia as well as their carergivers. Nonpharmacological approaches and watchful waiting should be attempted first in patients who present with mild to moderate depression and dementia. In cases of severe depression or depression not able to be managed through nonpharmacological means, antidepressant therapy should be considered.