Pre-oedipal phenomena, affect disorders, and biological psychiatry.

With the emergence of biological psychiatry as a major political, conceptual, and treatment force, the diagnosis of endogenous depression is being applied across a broad range of clinical conditions. In such a climate, controversy surrounding the diagnostic enterprise, the somatic treatment of affect disorders, and the conceptualization of psychopathology poses important and exciting challenges to psychoanalytic psychologists practicing in medical settings. These issues are examined through a clinical illustration involving an 18-year-old adolescent girl diagnosed and treated as a "major affect disorder." Her Rorschach protocol is highlighted with a view toward describing and coming to understand the patient's experience of depression, significant others, and herself. The role of psychoanalytic object relations theory, developmental psychoanalysis, and self-psychology in providing a phenomenologically based, "experience near," unified view of the whole person is advanced as one possible corrective measure for slowing down and critically evaluating the movement toward an exclusively biological view of psychopathology and treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A symptom profile of hospitalization-requiring depression among the elderly related to clinical subgroups. A way to improve diagnostics

The objectives were to study clinical symptoms of major depression in later life by using relevant assessment scales of psychopathology, behavioural disorders, and physical functioning. The evaluations on admission and at discharge were based on interdisciplinary observations and interview of patients. The study was carried out during twelve months in a psychogeriatric university department and encompassed 202 patients. All (N = 80) (40%) patients who had a principal diagnosis of major depression are accounted for. Mean age was 79.5 years. Results of the assessments all showed significant improvements (p = 0.0000-0.0024). The overall results of the assessments show that the key symptom of sadness is often missing, muted, or overshadowed by other symptoms, and that behavioural disturbancies and functional disability may be important symptoms in geriatric depression. In conclusion: adequate treatment of major depression in the elderly significantly improves psychopathology, behavioural disorders and physical functioning. When dealing with mental disorders in this age group, awareness of the five clinical presentations in major geriatric depression, i.e. dementoform, somatoform neurotiform, eretic and classic geriatric depression, may target the diagnostic procedure.     

Clinical judgment of major depression in AIDS patients: The effects of clinician complexity and stereotyping.

This clinical judgment study found an overshadowing bias that existed in the treatment of major depression in AIDS patients. Two clinician individual differences—cognitive complexity about AIDS issues and attitudes toward AIDS victims—were investigated for possible moderating effects of the treatment overshadowing bias. Cognitive complexity about AIDS issues had a significant moderating effect, as more complex clinical and counseling psychologists were more likely to recommend antidepressant medication. Attitudes toward AIDS victims, measured by the Attitudes Towards AIDS Victims scale (Larsen, Serra, & Long, 1990), did not moderate clinician's treatment judgments. Results from a second set of exploratory analyses suggest that the diagnostic overshadowing occurred, but as a function of the presence of a terminal illness (AIDS or cancer) and not as a bias unique to AIDS issues. Implications for research and practice are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The course of geriatric depression with "reversible dementia": a controlled study

OBJECTIVE: The goals of this longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement of depression and 2) to compare it with that of depressed, never-demented patients. METHOD: The subjects were 57 elderly patients consecutively hospitalized for major depression. At entry into the study, 23 subjects also met criteria for "reversible dementia," while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months. RESULTS: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43%) than in the group with depression alone (12%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented. CONCLUSIONS: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group of patients with early-stage dementing disorders. Therefore, identification of a reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders.     

Prognostic value of ECG changes detected by Holter monitoring in silent ischemic heart disease in the aged

Ischemic Cardiomiopathy (IC) is the main cause of morbidity and mortality in the elderly and its incidence increases progressively with age. Holter monitoring (HM) is used to study IC which reveals asymptomatic ischemic episodes identifiable with the depression of the ST tract. It has been demonstrated that these electric manifestations have the same unfavourable diagnostic value as those accompanied by pain. In order to evaluate the prevalence and prognostic significance of episodes of silent myocardial ischemia in the elderly patient, we examined 99 consecutive patients with stable clinical symptoms of myocardial ischemia and a positive ergometric test (ET). The patients were randomly divided according to age (< or = 65 years, >65 years) into two groups with homogeneous clinical feature, except for a higher prevalence of women in the second group. The HM analysis, carried out for 24 hours during common every day activities and after suspending anti-ischemic therapy, showed that 62 patients (63%) had 289 episodes of electric ischemia; 216 (75%) of these were asymptomatic, and, in the group of elderly there was a higher incidence of ST depression unaccompanied by pain (A vs B = 86 vs 132 episodes, p < 0.001). Comparing the patients with and without anamnestic evidence of myocardial infarction it was found that the first group presented a higher prevalence of ST depression both asymptomatic and symptomatic (147 vs 71 silent episodes, p < 0.001, and 49 vs 24 symptomatic episodes, p = 0.015 respectively), while no statistically significant differences were found between the two age groups. Electric alterations of the asymptomatic ischemic kind were more often found in subjects with stable angina, above all if elderly; this is important from a prognostic point of view as few elderly patients are capable of performing a maximal TE and it is thus significant of reduced coronary reserve. From our data we observed that in patients with stable angina, especially if elderly, Holter revealed asymptomatic ST depression analyzed considering both its length and magnitude, is able to give prognostic evidence of subsequent coronary events.     

Depression of young and elderly patients

OBJECTIVE: To compare the presentation and outcome of depression between young and elderly patients. DESIGN: The clinical presentation, treatment and outcome of 47 young patients (21 to 64 years) were compared with 58 elderly (65 years and older) patients admitted to a general hospital psychiatric ward for the treatment of depressive disorders (based on ICD-10). SUBJECTS: There was no significant difference between the sexes in each age group. The majority of the elderly were either widowed (36%) or married (53%) while 45% of the young were single and 51% married. Seventy per cent of the elderly had retired while 64% of the young were in full-time employment. Most patients lived with their families (87% young and 96% elderly). All but one elderly suffered at least one physical disorder with two-thirds having two or more physical disorders; this contrasts greatly to young patients who were physically healthier (p < 0.001). RESULTS: In clinical presentation and symptomatology, the young patients had significantly more suicide ideation (p < 0.003) and psychomotor retardation (p < 0.001) but there was no difference in suicidal attempt, delusion, hallucination or agitation. More young patients (36%) had a past psychiatric illness (often depressive disorders) than elderly patients (8%) (p < 0.001), more elderly patients (88%) were treated with antidepressants than the young patients (62%) (p < 0.002). At one year follow-up, more elderly patients (46%) recovered compared with the young patients (23%) (p < 0.05). CONCLUSION: There were some differences in the symptomatology of depression between young and elderly patients, but the prognosis was better for elderly patients.     

Paroxetine. A review of its pharmacology, therapeutic use in depression and therapeutic potential in diabetic neuropathy

Paroxetine is a selective serotonin reuptake inhibitor effective in a once-daily administration regimen in the treatment of depression. In elderly patients (aged > or = 60 years) with major depression, short term (6 weeks) treatment with paroxetine produces clinical improvements significantly superior to those seen with placebo and similar to those with tricyclic antidepressant agents, mianserin and fluoxetine. There is evidence that paroxetine has positive effects on co-existing anxiety and does not precipitate agitation. Paroxetine has also shown potential in the symptomatic treatment of diabetic neuropathy; however, further clinical experience is needed to confirm this preliminary result. Short term paroxetine therapy is associated with fewer anticholinergic and CNS adverse effects, but generally more gastrointestinal disturbances, than tricyclic antidepressants and mianserin. Unlike the tricyclic agents, paroxetine does not significantly affect cardiovascular function or impair psychomotor performance. This tolerability profile should be particularly beneficial in elderly patients, who are generally more susceptible than younger patients to the anticholinergic and CNS adverse events associated with tricyclic antidepressant drugs, and in whom there is a higher prevalence of pre-existing cardiovascular disease. It also suggests an important potential advantage over tricyclic antidepressants in the setting of overdosage. Thus, primarily because of its better tolerability profile and potentially lower toxicity in overdosage and in patients with cardiovascular disease, paroxetine appears to be a more attractive option than tricyclic antidepressants for the treatment of depression in late life. Future research should attempt to define more fully the efficacy of paroxetine as long term prophylactic therapy for recurrent depression and to assess how its overall therapeutic profile compares with other selective serotonin reuptake inhibitors in the elderly.     

Consequences of major and minor depression in later life: a study of disability, well-being and service utilization

BACKGROUND: The consequences of major depression for disability, impaired well-being and service utilization have been studied primarily in younger adults. In all age groups the consequences of minor depression are virtually unknown. In later life, the increased co-morbidity with physical illness may modify the consequences of depression, warranting special study of the elderly. With rising numbers of elderly people, excess service utilization by depressed elderly represents an increasingly important issue. METHODS: Based on a large, random community-based sample of older inhabitants of the Netherlands (55-85 years), the associations of major and minor depression with various indicators of disability, well-being and service utilization were assessed, controlling for potential confounding factors. Depression was diagnosed using a two-stage screening design. Diagnosis took place in all subjects with high depressive symptom levels and a random sample of those with low depressive symptom levels. The study sample consists of all participants to diagnostic interviews (N = 646). RESULTS: As in younger adults, associations of both major and minor depression with disability and well-being remained significant after controlling for chronic disease and functional limitations. Adequate treatment is often not administered, even in subjects with major depression. As the vast majority of those depressed were recently seen by their general practitioners, treatment could have been provided in most cases. Bivariate analyses show that major and minor depression are associated with an excess use of non-mental health services, underscoring the importance of recognition. In multivariate analyses the evidence of excess service utilization was less compelling. CONCLUSIONS: Both major and minor depression are consequential for well-being and disability, supporting efforts to improve the recognition and treatment in primary care. However, controlled trials are necessary to assess the impact this may have on service utilization.     

Diagnosis and treatment of depression by general practitioners in England

This paper describes a preliminary study of diagnosis and treatment of depression by general practitioners in England. They regarded primary care depression as a reactive mood disorder with both physical and psychological symptoms and associated with those groups who are most vulnerable to life stressors. Four groups were seen as at risk from depression: elderly persons, menopausal women, young mothers, and those in early adulthood. The practitioners relied primarily on their experience to diagnose depression rather than following any official diagnostic criteria. Although they were in favour of nondrug therapy in treating depression, they mainly practised drug therapy due to time pressure and limited availability of resources.     

Variations in the reported age of a patient: A source of bias in the diagnosis of depression and dementia.

The presence of bias in assessing organic vs depressive pathology in the elderly psychiatric population has been clinically observed in the apparent tendency to overattribute cognitive deficits to senile dementia. In the present study, 21 male and 15 female 26–49 yr old clinical psychologists were presented with a taped interview in which the age of a 64-yr-old male with depressive pseudodementia was varied (either 55 or 75 yrs). It was assumed that the ambiguity involved in determining the etiology of the patient's cognitive deficits would elicit a social or diagnostic bias related to his age. Results show the presence of a bias, with a greater attribution of organic symptoms reflective of senile dementia and fewer judgments of depression when the patient was described as elderly rather than middle-aged. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults.

The efficacy of the Center for Epidemiologic Studies Depression Scale (CES-D) as a screener for clinical depression was examined in a sample of 1.005 community-residing adults (age range?=?50–96). Presence of a depressive disorder was determined by diagnostic interview. Analyses revealed that neither age, gender, cognitive impairment, functional impairment, physical disease, nor social desirability had a significant negative effect on the psychometric properties or screening efficacy of the CES-D. These results indicate that there was no significant degradation in the ability of the CES-D to screen for depression among community-residing elderly adults. This conclusion must be tempered by the fact that the sample did not include participants with the more disabling forms of cognitive or functional impairment and physical illness. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Age bias in the diagnostic decision-making behavior of clinicians.

Using a statistical design commonly used in decision-making research, the author investigated the ways in which psychologists formulate diagnoses of elderly patients with depressive symptoms. 55 psychologists and trainees made diagnostic decisions for 96 case vignettes representing a complete factorial combination of 5 diagnostic cues. Age bias was less evident in the diagnosis of depression or another psychiatric disorder than in the determination of prognosis. Ss failed to use configural decision rules that would have combined age-relevant cues for optimal diagnostic policies. Ss' reliabilities were highly variable, ranging from poor to excellent. Most Ss were unable to describe accurately the decision policies that they used. Results have implications for training clinicians to assess and diagnose elderly clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary care physicians' medical decision making for late-life depression

OBJECTIVE: To describe primary care physicians' clinical decision making regarding late-life depression. DESIGN: Longitudinal collection of data regarding physicians' clinical assessments and the volume and content of patients' ambulatory visits as part of a randomized clinical trial of a physician-targeted intervention to improve the treatment of late-life depression. SETTING: Academic primary care group practice. PATIENTS/PARTICIPANTS: One-hundred and eleven primary care physicians who completed a structured questionnaire to describe their clinical assessments immediately following their evaluations of 222 elderly patients who had reported symptoms of depression on screening questionnaires. INTERVENTIONS: Intervention physicians were provided with their patient's score on the Hamilton Depression rating scale (HAM-D) and patient-specific treatment recommendations prior to completing the questionnaire regarding their clinical assessment. MAIN RESULTS: Those physicians not provided HAM-D scores were just as likely to rate their patients as depressed, as determined by specific query of these physicians regarding their clinical assessments. A physician's clinical rating of likely depression did not consistently result in the formulation of treatment intentions or actions. Treatment intentions and actions were facilitated by provision of treatment algorithms, but treatment was received by fewer than half of the patients whom physicians intended to treat. Barriers to treatment appear to include both physician and patient doubts about treatment benefits. CONCLUSIONS: Lack of recognition of depressive symptoms did not appear to be the primary barrier to treatment. Recognition of symptoms and access to treatment algorithms did not consistently result in progression to subsequent stages in treatment decision making. More research is needed to determine how patients and physicians weigh the potential risks and benefits of treatment and how accurately they make these judgments.     

Comorbid panic disorder and major depression: Implications for cognitive–behavioral therapy.

Panic disorder and major depression frequently coexist, yet the implications of comorbidity for psychological treatments have rarely been studied. The objective of this study was to evaluate whether pretreatment comorbidity of major depression affects the outcome of cognitive–behavioral treatment (CBT) of panic disorder. Thirty-seven clients who met diagnostic criteria for both panic and major depression participated in 10 sessions of individual CBT for panic. Treatment outcome was contrasted with the outcome of 53 clients having only panic disorder who received the same treatment. The cooccurrence of depression did not adversely affect CBT for panic. These results have implications for clinical practice and theoretical implications for the nature of the relationship between panic and depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting negative spousal attitudes toward depressed persons: A test of Coyne's Interpersonal Model.

The utility of Coyne's (1976a) interactional model in predicting negative spousal attitudes toward depressed patients was examined. Eighty-nine couples with at least 1 member in treatment for depression were selected on the basis of semistructured diagnostic interviews. Overall, spouses living with a depressed patient reported significantly more distress than population norms. Consistent with prediction, patients' reassurance seeking and spouse' mood contributed to negative spousal attitudes. Additional analyses demonstrated that these effects persisted even after controlling for spouse marital adjustment, suggesting that negative spousal attitudes were more than a simple reflection of marital maladjustment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ageism revised and the provision of psychological services.

Advances in research on attitudes toward older adults can productively be applied to the problem of "professional ageism." Thus, it is suggested that professional psychologists may not hold global negative attitudes toward the aged. Instead they may have specific treatment biases: Some of these biases are based on negative misconceptions (e.g., psychotherapy for depression is inefficient for the elderly), and others are based on positive misconceptions (e.g., memory lapses in the aged do not have to signify anything pathological and, therefore, do not need to be referred to a mental health professional for evaluation). A recent pervasive bias is overestimation of Alzheimer's disease, an emphasis that threatens to overwhelm other stereotypes. Education about normal lifespan development and attention to how the public climate affects service delivery are recommended. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of patient age and gender on clinical decisions.

Examined the effect of patient age and gender on clinical decisions of 209 licensed clinical psychologists. Ss read vignettes describing a patient with symptoms of depression. Age and gender of the patient were varied in a between-Ss design. Ss made decisions regarding the diagnosis, treatment mode, treatment setting, and prognosis. Ss were also asked to list information that was influential in their decision regarding treatment setting. Age had a significant effect on diagnostic and treatment decisions, whereas the sex of the patient affected only diagnostic decision. As predicted, the age and sex of the patient had an impact on the information clinicians focused on in making their decisions. Discussion focuses on the theoretical rationale and implications of these findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

MRI signal hyperintensities in geriatric depression

OBJECTIVE: The authors rated periventricular and subcortical signal hyperintensities on magnetic resonance imaging (MRI) scans in elderly patients with depression and in normal subjects with similar demographic features to examine whether such changes discriminate patients with depression from normal subjects and whether they are associated with any clinical variables. METHOD: Two established hyperintensity rating systems were used to compare the MRI brain scans of 48 elderly patients with depression diagnosed according to DSM-III-R with the scans of 39 normal elderly subjects. RESULTS: Elderly depressed patients manifested significantly more severe hyperintensity ratings in the subcortical gray matter than age-matched comparison subjects. Significant differences were not identified between patients with similar current ages and cerebrovascular disease risk who had early-onset or late-onset depression. CONCLUSIONS: These findings support those of neuroimaging studies implicating the basal ganglia in depression and geriatric depression. The data suggest that the relationship observed in some reports between late-onset depression and MRI hyperintensities is most likely a function of cerebrovascular disease risk and age.     

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.     

Current Issues in Anxiety and Depression: Comorbid, Mixed, and Subthreshold Disorders.

Recent attention has been given to the high frequency of coexisting anxiety and depressive symptoms that has served to challenge the more traditional view that these two disorders are typically discrete syndromes. Furthermore, research suggests that less severe states of anxiety and depression continue to be overlooked, despite their capacity to produce significant psychosocial impairment. Given the implications for diagnostic and treatment outcome, psychologists need to be aware of the epidemiology, clinical presentations, and treatment strategies surrounding comorbid and subthreshold anxiety and depression. We review the literature, present issues related to these syndromes, and discuss the implications for diagnostic and clinical activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)