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.     

Depression without sadness: functional outcomes of nondysphoric depression in later life

OBJECTIVES: We hypothesized that depressive symptoms not meeting full standard criteria for Major Depression would be associated with significant functional impairment among older adults over the course of a 13-year follow-up interval. Specifically, we developed criteria for a form of depression whose core symptoms did not include sadness or dysphoria. DESIGN: Population-based 13-year follow-up survey. SETTING: Community-dwelling adults living in East Baltimore in 1981. PARTICIPANTS: Subjects were the 1612 participants of the Baltimore sample of the Epidemiologic Catchment Area Program aged 50 years and older at the initial interview in 1981. MEASUREMENTS: The subjects were sorted into four categories based on their responses at baseline: (1) persons meeting standard criteria for Major Depression; (2) persons meeting alternative criteria for depression with dysphoria or (3) without dysphoria; and (4) a comparison category of persons not meeting any criteria for depression ("noncases"). The mortality and functional status of each group were compared after a 13-year follow-up interval. RESULTS: Compared with non-cases, participants aged 50 years and older who reported depressive symptoms but who denied sadness or dysphoria (nondysphoric depression) were at increased risk for death (relative risk (RR) = 1.70; 95% confidence interval (CI) (1.09, 2.67)), impairment in activities of daily living (RR = 3.76; 95% CI (1.73, 8.14)), impairment in instrumental activities of daily living (RR = 5.07; 95% CI (2.24, 11.44)), psychologic distress (RR = 3.68; 95% CI (1.47, 9.21)), and cognitive impairment (RR = 3.00; 95% CI (1.31, 6.89)) after a 13-year follow-up interval. The findings were not wholly explained by potentially influential baseline characteristics such as age, education, selected comorbid medical conditions, and functional status. CONCLUSION: Among adults aged 50 years and older, nondysphoric depression may be as important as Major Depression in relation to the development of functional disability and other long-term outcomes.     

Social support: some pragmatic implications for health care professionals

BACKGROUND: Depression affects a significant proportion of the expanding elderly population in the UK. Reports of a poorer prognosis for older than for younger adult patients have been challenged by recent papers. METHOD: The casenotes of 56 adults (mean age 47.8 years) and 54 elderly (mean age 72.9 years) patients with primary depression were assessed one year after receiving hospital treatment. Outcome measures were compared with earlier reported findings and factors possibly influencing outcome were explored. RESULTS: The pattern of outcome in both age groups was broadly similar, thus: adults v. elderly: recovered 44.6% v. 44.4%; relapsed and recovered 23.2% v. 24%; residual symptoms 19.6% v. 13% and chronic depression 7.1% v. 5.5%. In the adults there were two natural deaths and one suicide. In the elderly there were two cases of dementia and five natural deaths, which was double the expected death rate. Predictors of poor outcome were melancholic depression in adults and longer duration of illness at intake and an increasing number of previous episodes of affective disorder in the elderly. CONCLUSION: The outcome of treated depressive illnesses appears similar in elderly and adult patients. Associated physical ill health did not adversely affect outcome in the elderly group.     

Disability in geriatric depression

OBJECTIVE: The authors' purpose was to identify the relationship of disability to clinical measures that are part of a comprehensive psychiatric examination of depressed elderly patients. METHOD: The disability of 75 elderly inpatients and outpatients with major depression whose cognitive function ranged from normality to mild dementia was assessed with the Philadelphia Multilevel Assessment Instrument. Age at onset of depression, chronicity of depression, severity of depression, cognitive impairment, medical burden, social support and living environment were assessed with standardized instruments. RESULTS: Impairment in instrumental activities of daily living was significantly associated with advanced age, severity of depression, and medical burden. The relationship of depressive symptoms to impairment in instrumental activities of daily living was not influenced by age or medical burden. Anxiety and depressive ideation as well as retardation and weight loss were significantly associated with impairment in instrumental activities of daily living. Interviewer-rated global disability was associated with advanced age at onset of depression, medical burden, and overall cognitive impairment. Specifically, a disturbance in initiation and perseveration was significantly related to global disability. CONCLUSIONS: Impairment in instrumental activities of daily living appears to be a relatively independent dimension of health status that is related to depressive symptoms, particularly anxiety and depressive ideation as well as retardation and weight loss. Global disability may be associated with impairment in initiation and perseveration and with late onset of depression. These findings provide a basis for studies investigating whether psychotherapy aimed at depressive ideation and rehabilitation efforts focused on instrumental activities of daily living can improve the outcome of geriatric depression.     

Candida parapsilosis fungemia associated with implantable and semi-implantable central venous catheters and the hands of healthcare workers

Hypertension in the elderly features differently from its younger counterpart in terms of diagnosis, associated condition, atypical manifestation, management and complication. Epidemiological study in this increasing age group in the community is, therefore, needed. 334 elderly subjects living in various parts of Bangkok were randomly recruited by appointment at 7 geriatric day centers situated in local health offices of Bangkok Metropolitan Authority. Each subject received blood tests before being interviewed and measured by digital sphygmomanometer. Blood pressure and heart rate changes were recorded during lying, sitting and standing. The prevalence of hypertension was 36.5 per cent, 33.2 per cent were already aware of its existence while 3.3 per cent were newly detected by the survey. Isolated systolic hypertension, a unique subtype found in the elderly, was 4.5 per cent of all or 37.5 per cent among the hypertensive group. The associated medical conditions among the case group were diabetes mellitus 22.9 per cent, hyperlipidemia 13.9 per cent, hyperuricemia 33.3 per cent and heart disease 18.0 per cent. As far as postural hypotension is concerned, 14.8 per cent of case group whereas 11.3 per cent of the control group were affected. On the other hand, the symptom of postural dizziness was found to be 31.1 per cent and 55.2 per cent in the case and control group respectively. Following the statistical logistic regression analysis, the independent associated factors in the hypertension group were: history of hyperlipidemia, increased serum uric acid and poor heart rate response after standing. These findings, as parts of the multiple pathology and potential complications prevalent among this group, should be of concern by any physician looking after the elderly.     

Psychiatric disorders in Nigerian nursing home residents

BACKGROUND: The prevalence of psychiatric disorders in nursing homes, which has not been studied before in Nigeria, is the subject of this cross-sectional study. METHOD: Psychiatric disorders were assessed in 23 of the 29 residents of the two nursing homes in Lagos and diagnoses based on DSM-III-R criteria (APA, 1987) and AGECAT (Copeland et al., 1986) were made independently. RESULTS: The commonest diagnoses were dementia in 11 out of 23 residents and depression in four residents. Overall prevalence rate of psychiatric disorders was 74%. CONCLUSION: The present prevalence rate of psychiatric disorders is similar to those reported in similar institutions in the industrialized societies. This has implications for the care of the elderly in a non-industrialized society.     

Reliability and validity of depressive personality disorder

OBJECTIVE: Depressive personality disorder was introduced into DSM-IV's appendix amid controversy. While that disorder appears to be a reliable and valid one, the authors offer new data about its relationship to major depression, dysthymic disorder, and other personality disorders. METHOD: The authors assessed 54 subjects with early-onset, long-standing mild depressive features for depressive personality disorder, axis I and axis II disorders, family history, and treatment history; they conducted follow-up interviews 1 year after the baseline assessment. Subjects with (N=30) and without (N=24) depressive personality disorder were characterized and compared in terms of those variables. RESULTS: Although depressive personality disorder and dysthymia co-occurred in some subjects, 63% of subjects with depressive personality disorder did not have dysthymia, and 60% did not have current major depression. Although subjects with depressive personality disorder were more likely than the mood disorder comparison group to have another personality disorder, 40% had no such disorder. Contrary to study hypotheses, mood disorder was not more common in first-degree relatives of subjects with depressive personality disorder than in relatives of the comparison group. Subjects with and without depressive personality disorder had similar rates of past treatment with medication and psychotherapy; however, the duration of psychotherapy was significantly longer for subjects with than for those without depressive personality. The depressive personality diagnosis was relatively stable over the 1-year follow-up period. CONCLUSIONS: Depressive personality disorder appears to be a relatively stable condition with incomplete overlap with axis I mood disorders and personality disorders. Further studies are needed to better characterize its treatment response and relationship to axis I mood disorders.     

Cognitive-behavioral group therapy for panic disorder in the general clinical setting: a naturalistic study with 1-year follow-up

BACKGROUND: Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder. As most investigators have studied selected patients without comorbid disorders, it is less clear how well the treatment will perform in the usual clinical setting for patients with comorbid disorders and with physicians who do not have training in CBT. During the last 6 years, we have offered CBT in outpatient groups for patients with panic disorder and agoraphobia. The purpose of this prospective study was to assess the outcome of group treatment and compare the results with those of studies that used individual treatment. We wanted to identify variables that might predict outcome at follow-up and to assess the number and characteristics of dropouts. METHOD: Eighty-three consecutive patients with DSM-III-R panic disorder (56 women and 27 men; mean age = 34.5 years) were studied. Mean duration of panic disorder was 7.5 years. There was a high degree of comorbid major depression, social phobia, and psychoactive substance abuse/dependence. Treatment consisted of 4-hour group sessions conducted once a week for 11 weeks. More than half of the patients used antidepressant drugs. Degree of phobic avoidance, bodily sensations, anxiety cognitions, and depression were assessed at pretreatment, baseline, and end of treatment and at follow-up after 3 and 12 months. RESULTS: There was a large decrease in scores from start to end on all assessments. Sixty-three (89%) of 73 completers responded (> or = 50% reduction in Phobic Avoidance Rating Scale scores). Gains were maintained and even improved upon at follow-up. The results are comparable with studies that used individual therapy. A high depression score at the end of treatment predicted poor outcome at 1-year follow-up. Twelve (14%) of 83 did not complete the program. The presence of severe personality disorders and ongoing alcohol or substance abuse or dependence was associated with poor outcome and high dropout rate. CONCLUSION: CBT appears to be effective in the usual clinical setting, even in the hands of therapists without formal competence. Group therapy is a feasible arrangement, and the results from group treatment are comparable to those of individual approaches. Precise diagnosis and treatment of comorbid depression are of utmost importance. Patients with additional substance abuse or dependence, as well as severe personality disorders, may find this treatment modality less helpful.     

Severe deep white matter lesions and outcome in elderly patients with major depressive disorder: follow up study

OBJECTIVE: To determine the difference in outcome among elderly people with major depression who do and do not have severe white matter lesions on magnetic resonance imaging. DESIGN: Follow up study. SETTING: Two psychiatric and two general hospitals in Melbourne, Australia. SUBJECTS: 60 depressed subjects aged over 55 referred to hospital psychiatric services with major depressive disorder meeting American Psychiatric Association (DSM-IIIR) criteria. MAIN OUTCOME MEASURE: Proportion with good outcome as determined by full recovery from initial illness and no evidence of depressive relapse or cognitive decline during follow up among those with and without lesions. RESULTS: Mean (SD) follow up was 31.9 (9.9) months. Survival analysis showed a significant effect of severe lesions on time to poor outcome (P=0.04), with median survival 136 days in those with severe lesions compared with 315 days in those without. CONCLUSION: Severe white matter change on magnetic resonance imaging is associated with poor outcome in elderly depressed subjects.     

Nonadherence in tuberculosis treatment among HIV patients attending Bamrasnaradura Hospital, Nonthaburi

OBJECTIVE: To determine the clinical manifestations, outcome and nonadherence, in tuberculosis (TB) among HIV patients in Bamrasnaradura Hospital, Nonthaburi. DESIGN: A retrospective cohort study; hospital record files were reviewed over 11 months. A total of 200 consecutive HIV patients were entered and followed for a 6 months period of their TB treatment. Sociodemographic data, symptoms and signs and results of investigation tests were recorded at the time of presentation, while diagnosis, and clinical outcome were done at the end of the follow-up time. RESULTS: Extrapulmonary tuberculosis (58%) was more common than pure pulmonary involvement (42%). Lymphadenopathy (52%) was the commonest sign on physical examination. Chest X-rays were positive in 55 per cent cases, while AFB examination was positive in 48.5 per cent from the sputum and 46 per cent from lymph node aspirate specimens. After 6 months of treatment, 30 per cent patients were still alive, 12 per cent had died, and 50 per cent were lost to follow-up. Factors such as low socioeconomic status (p < 0.001), being newly diagnosed with TB (p < 0.001), past history of TB (p < 0.003), etc., were statistically significant in predicting the likely nonadherence in TB treatment among HIV patients. CONCLUSION: In HIV-infected individual, tuberculosis presents more often with extrapulmonary involvement, and the diagnosis is not difficult. While treatment of tuberculosis is successful, patients' compliance is the biggest problem in managing them.     

Major depression in the elderly: a population study in Helsinki

The aim of the study was to estimate the prevalence of major depression and to evaluate associated features in random age cohorts of 75, 80, and 85 years (N = 651). A clinical examination was made by experienced health center physicians, and major depression was diagnosed according to DSM-III criteria. The prevalence increased with age and was 1% to 4% in the age groups of 75 and 80 years, but 13% at the age of 85 years. No sex difference was found. The frequency of major depression was fourfold among institutionalized patients (16%) as compared to those living at home (4%). Major depression was strongly associated with objective health, intellectual functioning, and functional capacity. Depression was most common in subjects suffering from poor vision, urinary incontinence, or Parkinson's disease (odd ratios 4.2 to 4.9). Depression was also correlated with musculoskeletal disorders, coronary heart disease, and cerebrovascular diseases (odd ratios 2.5 to 3.4). The survey suggests that major depression is quite rare in healthy elderly people but common in disabled institutionalized patients.     

Recombinant allergens for diagnosis of allergic bronchopulmonary aspergillosis

PURPOSE: The investigation aimed at assessing the prevalence of depression among residents in a nursing home. METHODS: In a rural area of Germany a representative sample was examined by means of the "Brief Assessment Interview" (BAI). RESULTS: 17% had a depressive disorder without dementia, 9% had a mild dementia syndrome and a depressive disorder; a total of 47% suffered from symptoms of dementia without depression. Most of the patients were treated by general practitioners or internists. 11% of the patients with depression were treated with antidepressants, 19% with neuroleptics, 17% with minor tranquillizers, and 17% with hypnotics. Only 20% of the depressive patients had ever been examined by a psychiatrist, 4% underwent an actual psychiatric therapy. CONCLUSION: Elderly patients with depressive disorders living in nursing homes need a more specific psychiatric treatment.     

Functional status, symptoms of depression, and the outcomes of hospitalization in community-dwelling elderly patients

OBJECTIVE: To assess the relationship between symptoms of depression at admission and postdischarge medical outcomes in hospitalized elderly patients. DESIGN: Prospective cohort study. METHODS: Patients screened for symptoms of depression at admission using the Geriatric Depression Scale underwent assessment 1 month after discharge to determine outcomes of hospitalization. SETTING: A 370-bed, acute care, community hospital. PATIENTS: A sample of 197 cognitively intact, community-dwelling elderly patients, aged 70 years and older, hospitalized with medical diagnoses, with expected lengths of stay of 48 hours or more. MAIN OUTCOME MEASURE: The Medical Outcomes Study Short-Form instrument was used to obtain data on 1-month postdischarge medical outcomes with respect to physical functioning, health status, and mental status. RESULTS: On admission, a total of 23.9% had symptoms of depression (Geriatric Depression Scale score, > or = 11) that were significantly related to preadmission functional status. In multivariate analyses, depressive symptoms at admission were significantly related to 1-month medical outcomes, independent of functional status. CONCLUSIONS: Findings suggest that depressive symptoms in hospitalized elderly may be reactive to physical disability and characterize a group of patients who have poorer functional status prior to admission. The effect of depressive symptoms on 1-month postdischarge medical outcomes, however, appears to be independent of and in addition to the effects of preadmission functional status.     

Lung cancer--management and outcome in Glasgow, 1991-92

Current practice and outcome for patients with lung cancer were determined by retrospective case note review of a random sample of all lung cancer cases registered for a calendar year and augmented by review of all surgical and radical radiotherapy cases. A total of 262 patients - 231 patients less than 75 years of age and 31 patients more than 75 years of age - represented 83% of the random sample. Eighty-three per cent of patients were seen within 2 weeks of referral. One-third reported symptoms occurring for less than 1 month and one-third had experienced symptoms for more than 3 months. The median time interval from first hospital contact until the making of a management decision was 18 days. The median interval from first contact to surgery was 63 days, and to starting radical radiotherapy 70 days. Histological confirmation was obtained in 69% of patients. Ten per cent of all lung cancer patients were calculated to have received chemotherapy. Five per cent of the whole cohort had definitive surgery and 64% of these were judged to be free of the disease at 3 years. Overall survival was 9% at 3 years, with no differences relating to cell type or area of residence. Many areas of good practice have been identified, but the lack of tumour staging or performance status data, the low proportion receiving chemotherapy or definitive surgery and the poor outcome after radical radiotherapy indicate the need for prospective audit and feedback of results. The long time interval from management decision to surgery and radiotherapy suggests organizational issues which need attention.     

Prospective randomized controlled trial of preservation of the intercostobrachial nerve during axillary node clearance for breast cancer

OBJECTIVE: The authors' goal was to determine whether cognitive behavioral treatment of residual symptoms of depression might have a significant effect on relapse rate. METHOD: A 6-year follow-up assessment was conducted of 40 patients with primary major depressive disorder who had been successfully treated with antidepressants and were randomly assigned to either cognitive behavioral treatment of residual symptoms or standard clinical management. RESULTS: Ten of the patients (50%) in the cognitive behavioral treatment group and 15 (75%) in the standard clinical management group relapsed. The difference did not attain statistical significance. When multiple relapses were considered, patients in the cognitive behavioral treatment group had a significantly lower number of depressive episodes than those in the standard clinical management group. Patients responded to the same antidepressant drug used in the index episode; in two cases (4%), resistance occurred. CONCLUSIONS: The protective effects of cognitive behavioral treatment that were evident at 4-year follow-up faded afterward. Cognitive behavioral treatment of residual symptoms, however, improved the long-term outcome of major depression in terms of total number of episodes during the follow-up period.     

Systematic review of the outcome of anxiety and depressive disorders

BACKGROUND: Although there have been many changes in the diagnosis of anxiety and depressive disorders in the past 20 years there have been few comparative enquiries into the clinical outcome of greater diagnostic categories. We therefore compared the outcome of all studies which compared the outcome of specific anxiety and depressive disorders using the standard procedures of systematic review. METHOD: A Medline search was carried out of all studies comparing the outcome of anxiety and depressive disorders or mixed anxiety--depressive disorders in which information was available separately for each disorder. RESULTS: Eight studies satisfied the search criteria (all involving a period of observation of two years or greater); only one of these included randomisation of treatment and comparison between specific anxiety disorder outcome. There was a somewhat better outcome in patients with depressive disorders compared with anxiety ones, and strong evidence that both anxiety and depressive disorders singly had better outcomes than comorbid mixed disorders. CONCLUSION: Comorbid anxiety--depressive disorders have a poor outcome compared with single anxiety and depressive disorders, and there is some evidence that anxiety disorders have a worse outcome than depressive ones.     

A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents

Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.     

Anxious children in adulthood: a prospective study of adjustment

OBJECTIVE: To prospectively examine psychosocial functioning in young adulthood for children and adolescents with anxiety disorders. METHOD: This 8-year prospective study compared psychosocial functioning in young adults (mean age 22 years) who had histories of early-onset anxiety disorders, comorbid anxiety and depressive disorders, or no history of psychiatric illness (NPI). Follow-up interviews assessed subjects' residential, educational, occupational, and marital status; utilization of mental health services; and psychological status RESULTS: Anxious subjects without histories of depression were less likely than NPI controls to be living independently. Anxious-depressed subjects were less likely than controls to be working or in school; more likely than purely anxious subjects to utilize mental health services; and more likely than both anxious and control subjects to report psychological problems, most frequently depression. CONCLUSIONS: Overall, results suggest that children with anxiety disorders are relatively well adjusted in young adulthood. However, a history of comorbid depression is prognostic of a more negative outcome.     

Anxiety and depression as a hidden problem in primary health care. Only one case in four identified

Of 374 unselected primary care patients assessed with the Hospital Anxiety and Depression (HAD) scale, 11.8 per cent rated themselves as suffering from anxiety, and 3.7 per cent as depressed. Clinically, 8 per cent were diagnosed as cases of anxiety, and 4 per cent as cases of depression, but agreement was very poor between these cases and those elicited with the HAD scale, only 25 per cent of the latter being identified by the primary care physicians. One third of the patients with a clinical diagnosis of anxiety and 47 per cent of those with diagnosed depression were offered appropriate treatment, usually medication with a selective serotonin re-uptake inhibitor (SSRI) and consultation with a medical social worker. The results were consistent with the expected prevalences, thus indicating anxiety and depression to be markedly under-diagnosed and under-treated, and suggest that there is a manifest need of consultation facilities and of further education among primary care physicians.