A. Hind Rifai

The Use of the Hamilton Rating Scale for Depression in Elderly Patients With Cognitive Impairment and Physical Illness

The authors performed a prospective study to assess the impact of cognitive impairment and medical burden on the Hamilton Ratingh Scale for Depression (Ham-D) scores in older psychiatric inpatients. Over 1 year, all patients admitted to an acute-care geriatric psychiatry unit were assessed with an instrument that includes an anchored version of the 17-uten Ham-D. Ham-D scores of 72 patients who met DSM-III-R criteria for a major depressive episode were compared with the scores of 31 patients who did not. The scores of a depressed and nondepressed patients were significantly different on admission but not at discharge. By contrast, the Ham-D scores of 11 depressed patients with a primary dementia did not differ either on admission or at discharge from the scores of 61 depressed patients without dementia. Controlling for psychiatric diagnosis, cognitive impairment had no significant effect on Ham-D scores. Medical burden accounted for less than 6% of the variance in admission Ham-D yields valid ratings of the severity of depressive symptoms in elderly patients with a broad range of cognitive impairment and physical illness.

Longitudinal Analysis of Nortriptyline Side Effects in Elderly Depressed Patients

Forty-five depressed elderly patients were closely monitored in a research setting during treatment with nortriptyline and interpersonal psychotherapy for 7 consecutive months of acute and continuation treatment. Overall, nortriptyline was efficacious and well tolerated in this group. The frequency of somatic complaints measured by the Rating Scale for Side Effects declined by 50% during the acute phase of treatment, suggesting that many somatic complaints that may be attributed to side effects of nortriptyline are actually somatic symptoms of depression. The authors discuss the implications of these findings and offer practical advice for the treating clinician. (J Geriatr Psychiatry Neurol 1991;4:226-230).

Personality Disorders in Elderly Inpatients With Major Depression

We studied 154 patients with major depression, with and without personality disorder (PD), consecutively admitted to a geriatric unit and compared their characteristics and responses to acute inpatient treatment. Thirty-seven patients (24%) met DSM-III-R criteria for PD. PD not otherwise specified and dependent PD were the most frequent PD diagnoses, whereas dramatic cluster PDs were rare. Patients with PD were significantly more likely to have had 1) recurrent depression, 2) an earlier age at first episode, and 3) a concurrent anxiety disorder. There was a higher proportion of patients with PD to have 1) never married, 2) separated or divorced, or 3) attempted suicide. During inpatient stays of similar lengths, both groups received similar treatment and improved to a similar and significant extent.

A Naturalistic Study of Trazodone in the Treatment of Behavioral Complications of Dementia

Altered serotonin transmission has been associated with behavioral complications of degenerative dementia. This study examined whether trazodone, a serotonergic antidepressant, may be useful in treating behavioral syndromes associated with dementia. Twenty-two dementia patients with behavioral problems were treated with trazodone (mean daily dose 172 ± 107 mg; mean duration 20 days). Seventy of cognitive impairment and behavioral symptoms were rated using the Mini-Mental State Examination (MMSE), the Global Assessment Scale, the Hamilton Rating Scale for Depression, and the Brief Psychiatric Rating Scale. A global assessment of improvement was made by chart review. Mean scores, with the exception of the MMSE, improved modestly but significantly between admission and discharge. Chart review of target symptoms revealed that 82% of the patients showed moderate-to-marked improvement on discharge, with most able to return to their preadmission residence. Trazodone was generally well tolerated except for occasional mild sedation effects. Results suggest that trazodone may be a useful alternative to neuroleptics or benzodiazepines in treating behavior problems in some demented patients.

Chronic Medical Illness in Patients With Recurrent Major Depression

The authors treated 115 elderly patients (ambulatory and without dementia) with recurrent major depression, by means of combined nortriptyline and interpersonal psychotherapy. They contrasted Cumulative Illness Rating Scale-Geriatric (CIRS-G) scores (for medical burden) in recovered and nonrecovered patients and generated a Cox proportional-hazards model of time-to-remission. The authors found no association between pretreatment chronic medical burden and acute treatment outcome in recovered (83 of 115) and nonrecovered patients and no relation of pretreatment CIRS-G scores with time-to-recovery. Findings support recent recommendations that practitioners be optimistic in treating elderly depressed, ambulatory patients whether or not significant medical burden coexists.

Nortriptyline and weight change in depressed patients over 60.

Weight change in pounds and body mass index was documented in 29 geriatric patients with recurrent depression successfully treated with nortriptyline over a 30-week period of acute and continuation therapy (925 patient-weeks of nortriptyline treatment). Weight before index episode as documented by physician records, and weight at three points (beginning of treatment, end of acute therapy, and end of continuation therapy) were recorded. Weight changes over the interval between these times and net weight change over the entire interval were then calculated. Only five patients (17.2%) gained a clinically significant (greater than 10 lb) amount of weight during treatment, ranging from 10 to 43 lb above premorbid weights. Seven of 29 patients (24.1%) showed a net weight loss below premorbid levels (maximum loss 12.5 lb), and 6 patients (20.7%) showed no weight change. The pattern of weight gain was variable; no correlations were found between initially high body mass index and weight gain over the entire interval. These data suggest that nortriptyline is apparently not a potent weight promoter in this group.

Premorbid History of Major Depression and the Depressive Syndrome of Alzheimer's Disease

To test the hypothesis that primary degenerative dementia of the Alzheimer type (PDD-AT) may increase the likelihood of expression of a lifetime vulnerability to the development of depression, the authors compared the premorbid rates of major depression in psychiatric inpatients with dementia, with or without a concurrent syndrome of depression. A premorbid history of major depression was four times more common in patients with the depressive syndrome of PDD-AT than in PDD-AT patients without depression. The authors discuss the significance of these findings for pathophysiologic models and estimates of comorbidity of depression in PDD-AT.

A Study of Elderly Suicide Attempters Admitted to an Inpatient Psychiatric Unit

The authors distinguish demographic and clinical characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit within 4 weeks of a suicide attempt. Of 560 patients admitted, 28 (5%) were recent attempters, 32 (6%) had a past history of suicide attempt, and 500 (89%) were nonattempters. Of the 28 recent attempters, 21 (75%) were diagnosed with a mood disorder, 4 (14%) with an organic mental disorder, and 3 (11%) with other mental disorders. Among the nonattempters, the distribution among the three diagnostic categories was 188 (38%), 251 (50%), and 61 (12%), respectively. Of 166 patients with a diagnosis of major depression, 18 (11%) were recent attempters, 14 (8%) were past attempters, and 134 (71%) were nonattempters. Recent attempts were significantly associated with alcohol abuse. This study confirms earlier reports of high rates of major depression in elderly attempters.

Nortriptyline Side Effects During Double-Blind, Randomized, Placebo-Controlled Maintenance Therapy in Older Depressed Patients

The authors assessed the severity of nortriptyline side effects in older patients with major depression during 12 months of double-blind therapy. Data were from 40 patients completing 1 year of maintenance therapy: 26 were on nortriptyline and 14 were on placebo. The authors detected significant time-by-treatment interactions for various side effects (all greater in treated patients), but not for overall side effects score. Clinically, these differences were judged to be minor and correctable. On the other hand, total side effect scores, physical tiredness, and subjective sleep disturbance covaried significantly with Hamilton Depression scores regardless of treatment assignment. Somatic worry, tiredness, and sleep complaints appeared to reflect residual depression rather than treatment assignment.

Phenomenology and Prevalence of Neuroleptic-Induced Akathisia in Late Life

The authors examined 115 patients totaling 127 admissions to an acute care geriatric psychiatry inpatient unit using the Barnes Akathisia Scale. Subjective complaints of akathisia were associated with a diagnosis of major depression and correlated with Hamilton Rating Scale for Depression scores but were not associated with current neuroleptic treatment. Objective evidence of akathisia was strongly associated with current neuroleptic use. Patients from 45 admissions were receiving neuroleptics at the time of assessment. By using the presence of objective akathisia to define the syndrome, the authors identified 8 patients from these 45 (17.8%) as having neurolepticinduced akathisia (NIA). The presence of MA was associated with a lower rate of antiparkinsonian agent use. NIA contributed to the presenting complaints on admission in 7 patients, comprising 5.5% of all 127 admissions.