M.L. Stek

Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication

BACKGROUND Severe depression can be a life-threatening disorder, especially in elderly patients. A fast-acting treatment is crucial for this group. Electroconvulsive therapy (ECT) may work faster than medication. AIMS To compare the speed of remission using ECT v. medication in elderly in-patients. METHOD The speed of remission in in-patients with a DSM-IV diagnosis of major depression (baseline MADRS score ≥20) was compared between 47 participants (mean age 74.0 years, s.d. = 7.4) from an ECT randomised controlled trial (RCT) and 81 participants (mean age 72.2 years, s.d. = 7.6) from a medication RCT (nortriptyline v. venlafaxine). RESULTS Mean time to remission was 3.1 weeks (s.d. = 1.1) for the ECT group and 4.0 weeks (s.d. = 1.0) for the medication group; the adjusted hazard ratio for remission within 5 weeks (ECT v. medication) was 3.4 (95% CI 1.9-6.2). CONCLUSIONS Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.

Depression in systemic lupus erythematosus, dependent on or independent of severity of disease.

Objectives To estimate the prevalence of depression in subjects with systemic lupus erythematosus (SLE) in relation to the general population and to unravel the relation between depression and SLE disease characteristics. Methods One hundred and two subjects with SLE (mean age 44.4 years) were studied using the Beck Depression Inventory (BDI) score to estimate the prevalence of depression. The BDI scores in subjects with SLE were compared with BDI scores from a pan-European population based study (Outcome in Depression International Network (ODIN) study, n = 7934), i.e. the general population. Results The mean BDI score was higher in SLE subjects (10.1 points) compared with the BDI scores derived from the general population (10.1 versus 5.6 points, respectively, p < 0.001). This corresponds to a prevalence of depression of 16.6% and 6.7%, respectively. There was no association between disease activity or organ damage and BDI scores in subjects with SLE (p > 0.1). Only 7% of SLE subjects with high BDI scores used antidepressants. Conclusion The mean BDI score and prevalence of depression are significantly higher in SLE subjects compared with the general population. No association was found between SLE disease characteristics and BDI scores. The number of depressed SLE subjects treated with antidepressants is low, suggesting inadequate recognition and treatment of depression in SLE.

Insulin-like growth factor-1 and risk of late-onset Alzheimer's disease: findings from a family study

Insulin-like growth factor-1 (IGF-1), part of an evolutionary conserved signaling pathway in both mammalian and non-mammalian species, is inferred in neurodegenerative disorders including Alzheimers disease (AD). A murine model for AD shows that reduced IGF-1 signaling prevents AD-like characteristics. However, variation in serum levels of IGF-1 and risk of AD in humans has yet to be determined. We used a proven family design, comparing middle-aged offspring with and without a parental history of AD. The offspring under study carry an increased risk of AD but do not yet experience cognitive impairment. A total of 206 offspring from 92 families with a parental history of AD were compared with 200 offspring from 97 families without a parental history of AD. Apolipoprotein-E (APOE) genotypes and serum IGF-1 levels were compared in subjects with and without a parental history of AD using linear regression, adjusted for APOE genotype and other possible demographic and clinical confounders. Offspring with a parental history of AD were more likely to be an APOE ε4 allele carrier (46.5% vs. 21%, p = 0.001) than were offspring without such a parental history. Offspring with a parental history of AD had higher IGF-1 levels than subjects without such a history, in both unadjusted and adjusted analyses (18.3 mmol/L vs. 16.7 mmol/L, p = 0.001). In conclusion, higher serum IGF-1 levels in middle age are associated with risk of AD disease in older age, independent of APOE genotype.

The implication of selection bias in clinical studies of late life depression: an empirical approach

It is supposed that selection bias precludes the extrapolation of results of studies carried out in a clinical setting to the general population. There is little empirical evidence demonstrating the degree to which those depressed in the community are different from those treated in clinical settings. This study compared elderly patients with major depression admitted to a psychiatric hospital with those living in the community.

Pulling out all the stops: what motivates 65+ year olds with depressive symptoms to participate in an outreaching preference-led intervention programme?

Objectives: Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme. Methods: From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme). Results: Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people. Conclusion: Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults’ illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Cognitive Impairment and Electroconvulsive Therapy in Geriatric Depression, What Could be the Role of Rivastigmine? A Case Series.

Electroconvulsive therapy (ECT), albeit highly effective in treating depression, is frequently associated with cognitive impairment, either temporary or more persistent. Especially in older patients, who generally respond even better, serious cognitive impairment during the course of ECT may lead to premature termination of ECT. Treatment of this cognitive impairment is of utmost importance. In this case series report, we present the effect of rivastigmine, an acetylcholinesterase inhibitor, on cognitive impairment in three older, severely depressed patients during or after a course of ECT. An improvement of cognitive functioning, in particular a decline of confusional symptoms, was observed in two patients with structural brain alterations associated with aging. In the other patient, who suffered primarily from amnesia, no effect of rivastigmine was observed. These preliminary results emphasize the need for detailed profiling of cognitive impairment when developing a research design to study the potential benefits of rivastigmine in the prevention or treatment of cognitive impairment in severely depressed patients treated with ECT.

Gastric rupture after electroconvulsive therapy.

We report on a rare complication, gastric rupture, which developed during electroconvulsive therapy (ECT) under general anesthesia. The patient developed symptoms of gastric rupture immediately after recovery from the first ECT session. An x-ray confirmed the clinical diagnosis, and an emergency laparotomy was conducted. The patient recovered without further complications. We review the literature and discuss ECT and potential risk factors relevant to the pathophysiology of gastric rupture. Furthermore, recommendations are proposed for clinical management.

The course of apathy in late-life depression treated with electroconvulsive therapy; a prospective cohort study

Apathy, a lack of motivation, is frequently seen in older individuals, with and without depression, with substantial impact on quality of life. This prospective cohort study of patients with severe late‐life depression treated with electroconvulsive therapy (ECT) aims to study the course of apathy and the predictive value of vascular burden and in particular white matter hyperintensities on apathy course.

SAT0229 Depression in systemic lupus erythematosus, dependent or independent of severity of disease?

Background Depression is one of the most commonly reported neuropsychiatric symptoms in systemic lupus erythematosus (SLE) patients. However, the prevalence of depression in relation to the general population and its relationship with SLE disease characteristics are still largely unkown. Objectives To estimate the prevalence of depression in subjects with SLE in relation to the general population and to unravel the relation between depression and SLE disease characteristics. Methods We studied 102 patients with SLE (mean age 44.4 yrs, 88% female, mean disease duration 7.8 yrs), all fulfilling the ACR classification criteria for SLE. Severity of SLE was determined with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Systemic Lupus International Collaborative Clinics Damage Index (SDI), representing disease activity and organ damage. We used the Beck Depression Inventory score (BDI), a validated screening instrument able to detect major depression and to estimate the prevalence of depression. A BDI score of more than 13 points was considered a high score. As a proxy for treatment of depression we assessed the number of patients using anti-depressants. Results The mean BDI score was higher in SLE patients (n=102) compared to the BDI scores derived from a European population based study (ODIN study, n=7934), (10.1 points in patients with SLE vs 5.6 points in subjects from ODIN, p<0.001). This corresponds with a prevalence of depression of 16.6% in SLE patients vs 6.7% in the general population. Only 7% of the SLE patients with a high BDI score used anti-depressant medication. There was no difference in disease characteristics, disease activity score (SLEDAI) and organ damage index (SDI) between SLE patients with and without depression (all p>0.1). The number of years of education was significantly lower in SLE patients with a depression compared to those without a depression (9.5 yrs. vs 12.2 yrs, p=0.004). Conclusions The mean BDI score, i.e. a proxy for prevalence of depression, is almost doubled in SLE patients compared to the mean BDI score from a large pan European population based study. Surprisingly, we found no association between disease characteristics or severity of SLE and presence of depression, determined with the BDI. Finally, we found that a small part of SLE patients with a high depression score were treated with anti-depressant medication, suggesting that depressed SLE patients might not be adequately recognized and treated for depression. For depressed SLE patients, this study provides clues that screening for depression in SLE patients should be done routinely, and that psychiatric counseling for these patients should be readily available. References Veerman JL, Dowrick C, Ayuso-Mateos JL, et al. Population prevalence of depression and mean Beck Depression Inventory score. Br J Psychiatry. 2009;195:516-9. Disclosure of Interest None Declared