Gary J. Kennedy

The emergence of depressive symptoms in late life: The importance of declining health and increasing disability

Despite considerable progress in the epidemiology of late life depressive disorders, the determinants and course of late life depressive symptoms remain unclear. The apparent reciprocal relationship between depression and disability, a consistent finding in cross-sectional studies further confounds efforts to estimate the importance of depressive symptoms in the elderly. In a longitudinal study of 1457 aged community residents who completed the Center for Epidemiologic Studies Depression scale at baseline and 24 months later, a significant level of depressive symptoms emerged in 163 respondents (11%), while 1080 (74%) remained symptom free. Unlike other studies, we found that the number of medical conditions, social support, life events, and demographic characteristics contributed little to distinguish those with emerging symptoms from those who remained symptom free. However, increasing disability and declining health preceded the emergence of depressive symptoms and accounted for seventy percent of the variance explained by discriminant analysis. These findings have etiologic implications for both the course and determinants of depression in late life.

Major and Subthreshold Depression Among Older Adults Seeking Vision Rehabilitation Services

OBJECTIVE Authors examined the potential risk factors of major and subthreshold depression among elderly persons seeking rehabilitation for age-related vision impairment. METHODS Participants (N=584), age 65 and older, with a recent vision loss, were new applicants for rehabilitation services. Subthreshold depression was defined as a depressive syndrome not meeting criteria for a current major depression (i.e., minor depression, major depression in partial remission, dysthymia) or significant depressive symptomatology. RESULTS Seven percent of respondents had a current major depression, and 26.9% met the criteria for a subthreshold depression. Poorer self-rated health, lower perceived adequacy of social support, decreased feelings of self-efficacy, and a past history of depression increased the odds of both a subthreshold and major depression, versus no depression, but greater functional disability and experiencing a negative life event were significant only for a subthreshold depression. Only a history of past depression was significant in increasing the odds of having a major versus a subthreshold depression. CONCLUSION Results highlight similarities in characteristics of, and risk factors for, subthreshold and major depression. Future research is needed to better understand both the trajectory and treatment of subthreshold depression, relative to major depressive disorders.

Neuropsychological strategies for detecting early dementia

As new and more effective treatments for Alzheimers disease (AD) emerge, the development of efficient screening strategies in educationally and racially diverse primary care settings has increased in importance. A set of candidate screening tests and an independent diagnostic assessment were administered to a sample of 318 patients treated at a geriatric primary care center. Fifty-six subjects met criteria for dementia. Exploratory analysis led to the development of three two-stage screening strategies that differed in the composition of the first stage or Rapid Dementia Screen, which is applied to all patients over the age of 65. The second stage, applied to those patients who screen positively for dementia, is accomplished with the Free and Cued Selective Reminding Test to detect memory impairment. Using clinical diagnosis as a gold standard, the strategies had high sensitivity and specificity for identifying dementia and performed better for identifying AD than non-AD dementias. Sensitivity and specificity did not differ by race or education. The strategies provide an efficient approach to screening for early dementia.

AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry was formed after Hurricane Katrina devastated New Orleans to identify and address needs of the elderly after the disaster that led to excess health disability and markedly increased rates of hopelessness, suicidality, serious mental illness (reported to exceed 60% from baseline levels), and cognitive impairment. Substance Abuse and Mental Health Services Administration (SAMHSA) outlines risk groups which fail to address later effects from chronic stress and loss and disruption of social support networks. Range of interventions recommended for Preparation, Early Response, and Late Response reviewed in the report were not applied to elderly for a variety of reasons. It was evident that addressing the needs of elderly will not be made without a stronger mandate to do so from major governmental agencies (Federal Emergency Management Agency [FEMA] and SAMHSA). The recommendation to designate frail elderly and dementia patients as a particularly high-risk group and a list of specific recommendations for research and service and clinical reference list are provided.

Suicide and Aging: International Perspectives

From Durkheim to Kraepelin, suicide has been recognized as a social and psychiatric ill. Among clinical scientists in the United States, interest in suicide grew substantially in the 1980s as rates among older adults increased. However, major advances in the science of mental health seem unlikely to reduce the prevalence of suicide as long as case recognition at the community level continues to be problematic. Public policy promoted to reduce social risk factors coupled with greater attention to psychopathology is the logical outgrowth from the most recent data. Differences in suicide rates by nation add weight to the argument.

9 – Religion and depression

Publisher Summary This chapter explores the relation of depressive symptoms to attendance at services and religious affiliation. The greater prevalence and incidence of depression has been accompanied by greater use of mental health services, psychotropic medications, and greater prevalence of cognitive impairment. Regarding religious practice, depression is more frequent among all respondents not attending religious services suggesting that the hypothesized preventive model may apply particularly to Catholics. The regression analysis indicated that social supports did not substitute for failure to attend services in the variance of depression. Neither the problems with activities of daily living which might have explained the relationship for respondents too disabled to attend services. Among Eastern European-born Jewish respondents, the stress deterrent model may be a better fit in that depression and greater attendance at services are significantly associated. Finally, differences in sociodemographics, disability and illness, immigrant status, and social supports may not account for the relation of lack of attendance at religious services and Jewish religious preference to symptoms of depression at baseline. Although failure to attend services has been associated with the emergence and persistence of depression at 24 months, only Jewish religious preference remained significant once age, disability, and social support controlled.

Use of antidepressants in older patients with co-morbid medical conditions : Guidance from studies of depression in somatic illness

Advanced age and medical complexity are characteristics not often associated with participation in randomised, placebo-controlled trials of antidepressants. Thus, evidence for the efficacy of antidepressant treatment among typical seniors with somatic illness and advanced age is scant. Furthermore, there appears to be no clear empirically based delineation between depressive symptoms and depressive disorders among very old, physically ill adults. The increasing numbers of antidepressants and adjunctive medications add to the practitioner’s perplexity when confronted with a very old, very depressed patient. Nonetheless, a growing body of evidence from antidepressant studies in the context of age-related somatic illnesses allows reasonable inferences to guide diagnosis and treatment. Once the practitioner and patient agree upon an antidepressant trial, the benefits of prescribed medication should be assessed within the first days rather than first weeks of treatment. The patient and practitioner should expect to escalate the antidepressant to the established therapeutic range rather than seek the lowest dose that is effective. Patients who experience no benefit whatsoever within the first weeks of treatment despite being within the therapeutic range should be offered an alternative promptly. With the results of studies of depression in co-morbid disorders and analyses of treatment response trajectory, the practitioner can be assured that advanced age, physical illness and depression need not go hand in hand.

The Emerging Problems of Alcohol and Substance Abuse in Late Life

Treatment of substance abuse among older adults will become increasingly important as the number of aged Americans increases. The abuse of psychoactive substances is a major contributor to excess morbidity, mortality, and homelessness among persons of all ages and socioeconomic strata regardless of race or ethnicity. Alcohol and tobacco account for the majority of substance abuse-related death and disability in the United States; the former through cerebrovascular and hepatic disease, accidents and violence, the latter through chronic pulmonary disease and malignancy. Patterns of substance abuse in late life are substantially different from those observed among younger adults. However, treatment may be less challenging. Effective diagnosis and treatment requires a nonpunitive, supportive, but persistent approach. This means the capacity to collect a substance intake history and the ability to formulate a treatment plan or referral strategy to an addiction specialist or residential treatment setting. It is also important for the practitioner to manage negative feelings toward patients who decline treatment or who are chronic abusers.

Healthcare Use Among Older Primary Care Patients With Minor Depression

OBJECTIVE To determine the rate of healthcare utilization for older primary care patients by depression status. DESIGN Cross-sectional data analysis. SETTING Primary care practices, western New York state. PARTICIPANTS 753 patients aged 65 years and older. MEASURES Diagnostic depression categories were determined using the Structured Clinical Interview for DSM-IV (SCID). The Cornell Services Index (CSI) measured outpatient medical visits. Demographic, clinical, and functional variables were obtained from medical records and interview data. RESULTS 41.23% had subsyndromal or minor depression (M/SSD) and 53.15% had no depression. The unadjusted mean number of outpatient medical visits was greater in those with M/SSD (3.96 visits within 3 months) compared to those without depression (2.84), with a significant difference after adjusting for demographic, functional, and clinical factors. CONCLUSION Those with M/SSD had higher rates of healthcare utilization compared with those without depressive symptoms. Future research should examine whether interventions for older adults with M/SSD reduce healthcare utilization.

The interface of depression and dementia

The interface of depression and dementia is an enduring, difficult problem in psychogeriatrics. Cognitive impairment is one of the secondary criteria for major depression; and major depression may well be a risk factor for Alzheimers disease. The influence of vascular disease on dementia and late-onset major depression is also compelling. However, depressive symptoms more often appear to be a prodrome of Alzheimers disease or a complication of vascular dementia. Major depression and stroke may both accelerate the dementia process, but seem unlikely on the basis of single episodes to be a sufficient cause of dementia. The heterogeneity of signs, symptoms and neuropathology in both depression and dementia remain substantial obstacles to a clear understanding of the interface.