Deborah A. King

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability.

OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions.

Psychiatric Disorders in Older Primary Care Patients

AbstractOBJECTIVE: Most older people with psychiatric disorders are never treated by mental health specialists, although they visit their primary care physicians regularly. There are no published studies describing the broad array of psychiatric disorders in such patients using validated diagnostic instruments. We therefore characterized Axis I psychiatric diagnoses among older patients seen in primary care. DESIGN: Survey of psychopathology using standardized diagnostic methods. SETTING: The private practices of three board-certified general internists, and a free-standing family medicine clinic. PARTICIPANTS: All patients aged 60 years or older who gave informed consent were eligible. MEASUREMENTS AND MAIN RESULTS: For the 224 subjects completing the study, psychiatric diagnoses were based on the Structured Clinical Interview for DSM-III-R. Point prevalence estimates used weighted averages based on the stratified sampling method. For the combined sites, 31.7% of the patients had at least one active psychiatric diagnosis. Prevalent current disorders included major depression (6.5%), minor depression (5.2%), dementia (5.0%), alcohol abuse or dependence (2.3%), and psychotic disorders (2.0%). Dysthymic disorder and primary anxiety and somatoform disorders were less common and frequently comorbid with major depression. CONCLUSIONS: Mental disorders, particularly depression, are common among older persons seen in these primary care settings. Clinicians should be particularly vigilant about depression when evaluating older patients with anxiety or putative somatoform symptoms, given the relatively low prevalences of primary anxiety and somatoform disorders.

Stimulus and response contingencies in the misbehavior of rats.

Misbehavior by rats, in the form of unnecessary and species-typical pawing, nosing, carrying, chewing, and retrieving a rolling ball bearing, was produced by pairing the ball bearing with food (Pavlovian procedure, Experiments 1 and 2) or by requiring contact with the ball bearing for food (operant procedure, Experiments 4 and 5). Misbehavior occurred both before and after eating the food pellet. The frequency, complexity, and duration of pre-pellet misbehavior was increased by delay of food until after the ball bearing exited (or was programmed to exit) and by requiring contact with the bearing to obtain food. Alternative goal-directed behavior, in the form of nosing, gnawing, and licking the food tray, occurred in Pavlovian contingencies in which food was delivered before the bearing was programmed to exit. Post-pellet misbehavior tended to occur when food was delivered before the bearing was programmed to exit and, in the case of required contact, before the animal released the bearing. Omission of food delivery on contact reduced the duration, complexity, and frequency of misbehavior, though experienced animals continued to contact (Experiment 3). In general, misbehavior was affected by both stimulus- and response-reward contingencies but showed characteristic organization and topography under both types of contingency.

Social Support, Depression, and Functional Disability in Older Adult Primary-Care Patients

OBJECTIVE The authors asked whether social support and depression are independently associated with functional disability and examined the potential role of social support as a moderator in the depression-functional disability association. METHODS Subjects were 305 patients age 60 years and over. Predictor variables were social support, depressive symptoms, and depression diagnosis. Dependent variables were the Instrumental Activities of Daily Living Scale, the Physical Self-Maintenance Scale, and the Physical Functioning subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey. Authors used multiple-regression analyses. RESULTS Depressive symptoms and all dimensions of social support were independently associated with functional disability: the specifics of these relationships varied among types of social support and functional disability. Depression diagnosis was not independently associated with any functional disability measure. Social support (more instrumental help, more perceived satisfaction) moderated some depression diagnosis-functional disability associations, and one depressive symptom-functional disability association. CONCLUSIONS The study hypotheses were partially confirmed. Different dimensions of social support have important and varied roles in the depression-functional disability dynamic. Future research is needed to further specify the complex relationships among depression, social support, and functional disability.

Depressive Disorders and Symptoms in Older Primary Care Patients: One-Year Outcomes

Syndromically diagnosable and subsyndromal depressions have substantial prevalence and functional morbidity among older persons seen in primary care, but their naturalistic outcome is largely unknown. The authors describe depressive symptoms and syndromes and functional outcomes at 1-year follow-up and examine specific outcome predictors in a cohort study using psychopathological, medical, and functional assessments at intake and 1-year follow-up. Subjects were 247 patients over age 60, recruited from private internal medicine offices and a university-affiliated family medicine clinic. Multiple-regression techniques examined the independent association of intake variables to outcome measures. Of the 63 subjects with an active depression diagnosis at study intake, 36 (57%) still had an active depression diagnosis at 1 year. The outcome for major depression was worse than for minor or subsyndromal depression. Medical illness burden and neuroticism were independent predictors of outcome. Major depression and depressive symptom severity were independently associated with poorer social functioning at follow-up. Depressive conditions had considerable rates of persistence, yet the outcome was not uniformly poor. Longer-term naturalistic study is needed, as are treatment studies targeting those at highest risk of recurrence or chronicity.

Personality is associated with perceived health and functional status in older primary care patients.

Using data collected on 265 primary care medical patients 60 years of age and older, the authors examined the personality bases of subjective health (perceived health, functional status) after controlling for observer-rated depression and medical burden. Four hypotheses were tested: High Neuroticism is associated with poorer perceived health, low Extraversion is associated with poorer perceived health, low Openness to Experience is associated with worse functional status, and age moderates the relationships between personality and subjective health. Findings supported the notion that personality is associated with subjective health; moreover, this effect appeared to grow more pronounced with increasing age. This study underscores the conceptual and heuristic value of examining moderators of the links between personality variables and health.

Cerebrovascular Risk Factors and Later-Life Major Depression: Testing a Small-Vessel Brain Disease Model

The topic of vascular depression has received increasing prominence as a putative etiology of depression in later life. The authors examined one aspect of this model by comparing the burden of systemic cerebrovascular risk factors (CVRFs) in 130 psychiatric inpatients with major depression and 64 normal control (NC) subjects, all age > or = 50 years. Depressed subjects did not differ statistically from NCs on cumulative CVRF scores. Diabetes mellitus and atrial fibrillation were both associated with depression, but only atrial fibrillation retained an independent association after medical disability was statistically controlled. Among the depressed subjects, CVRF scores were not significantly associated with overall symptom severity, psychiatric disability, age at onset of depression, melancholic subtype, or psychotic depression. These data did not support the notion that a linear model of small-vessel disease might apply to the great majority of older inpatients with major depression.

Sex differences in subclinical depression: administration of the Beck Depression Inventory in public and private disclosure situations.

To test the idea that the preponderance of women depressives is due to a masculine tendency to avoid negative social consequences by reporting fewer depressive symptoms, two studies were conducted in which the Beck Depression Inventory (BDI) was administered to both sexes under conditions of public and private disclosure. It was hypothesized that men would score lower on the BDI than women in the public disclosure condition but not in the private disclosure condition. Despite procedural differences in the two experiments, the results of both studies failed to support the experimental hypothesis. However, in each case, analysis of variance revealed a significant interaction between sex of subject and sex of examiner (p less than .05). These results are discussed in terms of a willingness to admit more symptoms to a same-sex person due to fear of rejection by the opposite sex and in terms of gender-specific patterns of self-disclosure in first-encounter heterosexual situations. Results of both studies also suggest BDI scores of college students can be interpreted without regard to type of administration.

Cerebrovascular Risk Factors and Depression in Older Primary Care Patients: Testing a Vascular Brain Disease Model of Depression

The authors examined whether cerebrovascular risk factors (CVRFs) are associated with depressive diagnoses and symptoms in 303 primary-care patients age >/=60 years, as would be consistent with a small-vessel brain disease model of later-life depression. CVRFs were not significantly independently associated with major, minor, or subsyndromal depression, late-onset major depression, or overall depressive symptom severity. These data did not support the notion that a small-vessel brain disease model of depression might apply to the majority of older persons with depressive symptoms and syndromes in primary-care settings. Future work should include longitudinal study with larger sample sizes.

Trait Neuroticism, Depression, and Cognitive Function in Older Primary Care Patients

OBJECTIVE Prior studies on the association of trait neuroticism and cognitive function in older adults have yielded mixed findings. The authors tested hypotheses that neuroticism is associated with measures of cognition and that depression moderates these relationships. DESIGN Cross-sectional observational study. SETTING Primary care offices. PARTICIPANTS Primary care patients aged > or =65 years. MEASUREMENTS Trait neuroticism was assessed by the NEO-Five Factor Inventory. Major and minor depressions were determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and depressive symptom severity by the Hamilton Depression Rating Scale (Ham-D). Cognitive measures included the Mini-Mental State Examination (MMSE), Initiation-Perseveration subscale of the Mattis Dementia Rating Scale, and Trail-Making tests A and B. RESULTS In multiple regression analyses, neuroticism was associated with MMSE score independent of depression diagnosis (beta = -0.04, chi2 = 14.2, df = 1, p = 0.0002, 95% confidence interval [CI] = -0.07 to -0.02) and Ham-D score (beta = -0.04, chi2 = 8.97, df = 1, p = 0.003, 95% CI = -0.06 to -0.01). Interactions between neuroticism and depression diagnosis (chi2 = 7.21, df = 2, p = 0.03) and Ham-D scores (chi2 = 0.55, df = 1, p = 0.46) failed to lend strong support to the moderation hypothesis. CONCLUSION Neuroticism is associated with lower MMSE scores. Findings do not confirm a moderating role for depression but suggest that depression diagnosis may confer additional risk for poorer global cognitive function in patients with high neuroticism. Further study is necessary.