Ipsit V. Vahia

A tune in “a minor” can “b major”: A review of epidemiology, illness course, and public health implications of subthreshold depression in older adults

BACKGROUND With emphasis on dimensional aspects of psychopathology in development of the upcoming DSM-V, we systematically review data on epidemiology, illness course, risk factors for, and consequences of late-life depressive syndromes not meeting DSM-IV-TR criteria for major depression or dysthymia. We termed these syndromes subthreshold depression, including minor depression and subsyndromal depression. METHODS We searched PubMed (1980-Jan 2010) using the terms: subsyndromal depression, subthreshold depression, and minor depression in combination with elderly, geriatric, older adult, and late-life. Data were extracted from 181 studies of late-life subthreshold depression. RESULTS In older adults subthreshold depression was generally at least 2-3 times more prevalent (median community point prevalence 9.8%) than major depression. Prevalence of subthreshold depression was lower in community settings versus primary care and highest in long-term care settings. Approximately 8-10% of older persons with subthreshold depression developed major depression per year. The course of late-life subthreshold depression was more favorable than that of late-life major depression, but far from benign, with a median remission rate to non-depressed status of only 27% after ≥1 year. Prominent risk factors included female gender, medical burden, disability, and low social support; consequences included increased disability, greater healthcare utilization, and increased suicidal ideation. LIMITATIONS Heterogeneity of the data, especially related to definitions of subthreshold depression limit our ability to conduct meta-analysis. CONCLUSIONS The high prevalence and associated adverse health outcomes of late-life subthreshold depression indicate the major public health significance of this condition and suggest a need for further research on its neurobiology and treatment. Such efforts could potentially lead to prevention of considerable morbidity for the growing number of older adults.

Exergames for Subsyndromal Depression in Older Adults: A Pilot Study of a Novel Intervention

OBJECTIVES Subsyndromal depression (SSD) is several times more common than major depression in older adults and is associated with significant negative health outcomes. Physical activity can improve depression, but adherence is often poor. The authors assessed the feasibility, acceptability, and short-term efficacy and safety of a novel intervention using exergames (entertaining video games that combine game play with exercise) for SSD in older adults. METHODS Community-dwelling older adults (N = 19, aged 63-94 years) with SSD participated in a 12-week pilot study (with follow-up at 20-24 weeks) of Nintendos Wii sports, with three 35-minute sessions a week. RESULTS Eight-six percent of enrolled participants completed the 12-week intervention. There was a significant improvement in depressive symptoms, mental health-related quality of life (QoL), and cognitive performance but not physical health-related QoL. There were no major adverse events, and improvement in depression was maintained at follow-up. CONCLUSIONS The findings provide preliminary indication of the benefits of exergames in seniors with SSD. Randomized controlled trials of exergames for late-life SSD are warranted.

Association Between Older Age and More Successful Aging: Critical Role of Resilience and Depression

OBJECTIVE There is growing public health interest in understanding and promoting successful aging. While there has been some exciting empirical work on objective measures of physical health, relatively little published research combines physical, cognitive, and psychological assessments in large, randomly selected, community-based samples to assess self-rated successful aging. METHOD In the Successful AGing Evaluation (SAGE) study, the authors used a structured multicohort design to assess successful aging in 1,006 community-dwelling adults in San Diego County, ages 50-99 years, with oversampling of people over 80. A modified version of random-digit dialing was used to recruit subjects. Evaluations included a 25-minute telephone interview followed by a comprehensive mail-in survey of physical, cognitive, and psychological domains, including positive psychological traits and self-rated successful aging, scaled from 1 (lowest) to 10 (highest). RESULTS The mean age of the respondents was 77.3 years. Their mean self-rating of successful aging was 8.2, and older age was associated with a higher rating, despite worsening physical and cognitive functioning. The best multiple regression model achieved, using all the potential correlates, accounted for 30% of the variance in the score for self-rated successful aging and included resilience, depression, physical functioning, and age (entering the regression model in that order). CONCLUSIONS Resilience and depression had significant associations with self-rated successful aging, with effects comparable in size to that for physical health. While no causality can be inferred from cross-sectional data, increasing resilience and reducing depression might have effects on successful aging as strong as that of reducing physical disability, suggesting an important role for psychiatry in promoting successful aging.

Successful Aging: Focus on Cognitive and Emotional Health

We review the definitions, predictors, and biobehavioral determinants of successful aging, as well as the evidence for and mechanisms of underlying selected interventions to enhance cognitive and emotional health in older adults. Defining successful aging has proven difficult, with discrepancies seen among biomedical, psychological, and lay perspectives. Although consensus is lacking, a number of studies have examined the genetic, lifestyle, and social determinants of operationalized determinants of successful aging; qualitative examinations of the meaning of the construct have also been conducted. The determinants coincide with fundamental aspects of aging. Recent clinical trials suggest that caloric restriction, physical activity, cognitive intervention, stress reduction, and social programs may enhance cognitive and emotional health in older people.

Subthreshold Depression and Successful Aging in Older Women

OBJECTIVES Subthreshold depression (StD) is common in older adults and is associated with poor self-rated health. However, the impact of StD on broader indicators of successful aging, such as positive psychological constructs, cognitive functioning, or quality of well-being, has not been assessed. The authors compared persons with scores above and below a predetermined threshold on the Center for Epidemiological Studies Scale for Depression (CES-D) with nondepressed (ND) persons on measures of multiple domains associated with successful aging. DESIGN Cross-sectional survey-based psychological assessments. PARTICIPANTS A total of 1,979 community-dwelling older women participating in the Womens Health Initiative study. MEASUREMENTS ND was defined as a CES-D score below 8, StD as a score between 8 and 15, and CES-D Depression (CD) as a score of 16 or above. The study questionnaire consisted of multiple self-reported measures of positive psychological functioning (e.g., optimism and resilience), cognitive functioning and complaints, and quality of well-being. The authors also obtained a history of diagnosis, treatment, and hospitalization related to mental health problems. RESULTS Overall 20.2% of women met CES-D criteria for StD and 7% for CD. Women with StD had worse self-rated successful aging, worse physical and emotional functioning, lower optimism, more negative attitudes toward aging, lower personal mastery and self-efficacy, and greater anxiety and hostility than ND women but scored better on all these measures than women with CD. Subjects with StD also had higher self-reported rates of previous diagnosis, treatment, and hospitalization for mental health problems than the ND group. Subjects with StD with depressed mood and/or anhedonia were largely similar to those without these symptoms. CONCLUSIONS Mild-moderate levels of depressive symptoms that likely fall under a general category of StD were common and were associated with worse functioning on virtually every component of successful aging that the authors examined. StD represents a clinical entity that may affect the longitudinal course of successful aging for large numbers of persons and is a potential target for clinical intervention.

Focus on geriatric psychiatry: schizophrenia in later life: clinical symptoms and social well-being.

The number of persons aged 55 and older with a diagnosis of schizophrenia is projected to double over the next 20 years. A tripartite classification system of early-onset schizophrenia, late-onset schizophrenia, and very-late-onset schizophrenia-like psychosis has been proposed. This column reviews recent findings on the outcome and associated features of clinical symptom and social well-being categories for older adults with early-onset schizophrenia.

Is late‐onset schizophrenia a subtype of schizophrenia?

Vahia IV, Palmer BW, Depp C, Fellows I, Golshan S, Kraemer HC, Jeste DV. Is late‐onset schizophrenia a subtype of schizophrenia?

Comparison of the conceptualization of wisdom in ancient Indian literature with modern views: focus on the Bhagavad Gita.

The study of wisdom has recently become a subject of growing scientific interest, although the concept of wisdom is ancient. This article focuses on conceptualization of wisdom in the Bhagavad Gita, arguably the most influential of all ancient Hindu philosophical/religious texts. Our review, using mixed qualitative/quantitative methodology with the help of Textalyser and NVivo software, found the following components to be associated with the concept of wisdom in the Gita: Knowledge of life, Emotional Regulation, Control over Desires, Decisiveness, Love of God, Duty and Work, Self–Contentedness, Compassion/Sacrifice, Insight/Humility, and Yoga (Integration of Personality). A comparison of the conceptualization of wisdom in the Gita with that in modern scientific literature shows several similarities, such as rich knowledge about life, emotional regulation, insight, and a focus on common good (compassion). Apparent differences include an emphasis on control over desires and renunciation of materialistic pleasures. Importantly, the Gita suggests that at least certain components of wisdom can be taught and learned. We believe that the concepts of wisdom in the Gita are relevant to modern psychiatry in helping develop psychotherapeutic interventions that could be more individualistic and more holistic than those commonly practiced today, and they aim at improving personal well–being rather than just psychiatric symptoms.

Association Between Higher Levels of Sexual Function, Activity, and Satisfaction and Self-Rated Successful Aging in Older Postmenopausal Women

OBJECTIVES: To determine whether measures of successful aging are associated with sexual activity, satisfaction, and function in older postmenopausal women.

A case-controlled study of successful aging in older HIV-infected adults.

OBJECTIVE There is a growing public health interest in the aging human immunodeficiency virus (HIV)-infected (HIV+) population, although there is a dearth of research on successful aging with HIV. This study aimed to understand the risk and protective factors associated with self-rated successful aging (SRSA) with HIV. DESIGN Cross-sectional, case-controlled. SETTING HIV Neurobehavioral Research Program and the Stein Institute for Research on Aging at University of California, San Diego. PARTICIPANTS Eighty-three community-dwelling HIV+ and 83 demographically matched HIV-uninfected (HIV-) individuals, enrolled between December 1, 2011, and May 10, 2012, mean age of 59 years, primarily white men, 69% with acquired immune deficiency syndrome (AIDS), who had been living with an HIV diagnosis for 16 years. Diagnostic criteria for HIV/AIDS were obtained through a blood analysis. MEASUREMENTS Participants provided ratings of SRSA, the primary outcome measure, as part of a comprehensive survey that included measures of physical and emotional functioning and positive psychological traits. Relationships between how the different variables related to SRSA were explored. RESULTS While SRSA was lower in the HIV+ individuals than their HIV- counterparts, 66% of adults with HIV reported scores of 5 or higher on a 10-point scale of SRSA. Despite worse physical and mental functioning and greater psychosocial stress among the HIV+ participants, the 2 groups had comparable levels of optimism, personal mastery, and social support. Higher SRSA in HIV+ individuals was associated with better physical and emotional functioning and positive psychological factors, but not HIV disease status or negative life events. CONCLUSIONS Successful psychosocial aging is possible in older HIV+ individuals. Positive psychological traits such as resilience, optimism, and sense of personal mastery have stronger relationship with SRSA than duration or severity of HIV disease. Research on interventions to enhance these positive traits in HIV+ adults is warranted.