Severity of depression and anxiety are predictors of response to antidepressant treatment in Parkinson's disease.

BACKGROUND: Antidepressants have appeared to be more effective than placebo treatment in treating depressive syndromes in patients with Parkinson's disease (PD). OBJECTIVE: To identify factors that predict improvement in depressive symptoms during antidepressant treatment in depressed PD patients. METHODS: A secondary analysis was performed on the dataset of the Randomized Placebo-controlled Study of Antidepressants in PD (SAD-PD), in which 76 patients received active treatment with either paroxetine or venlafaxine extended release (XR), and 39 patients received placebo treatment. Backward stepwise regression analyses were conducted with change in 24-item Hamilton Depression Rating Scale (HAMD-24) score between assessments at baseline and week 12 as the main outcome measure, and sex, age, baseline HAMD-24 score, Unified Parkinson's Disease Rating Scale section III (UPDRS-III) score, Mini-Mental State Examination (MMSE), and the Clinical Anxiety Scale (CAS) as independent variables. RESULTS: In both the active treatment and placebo groups, higher baseline HAMD-24 score and lower UPDRS-III score were associated with greater reduction in HAMD-24 score. Higher anxiety scores predicted less response in the active treatment group. Higher MMSE scores predicted greater response only in the placebo-treated group. Sex and age were no predictors of response. CONCLUSIONS: Higher pre-treatment depression scores and lower pre-treatment anxiety scores are the two most important predictors for improvement during antidepressant treatment in depressed PD patients, which is in line with those found in treatment studies of depressed non-PD patients. Furthermore, our results indicate the requirement for different or more intensive treatment for depressed PD patients with more severe anxiety symptoms.

A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease.

OBJECTIVE: To evaluate the efficacy and safety of a selective serotonin reuptake inhibitor (SSRI) and a serotonin and norepinephrine reuptake inhibitor (SNRI) in the treatment of depression in Parkinson disease (PD). METHODS: A total of 115 subjects with PD were enrolled at 20 sites. Subjects were randomized to receive an SSRI (paroxetine; n = 42), an SNRI (venlafaxine extended release [XR]; n = 34), or placebo (n = 39). Subjects met DSM-IV criteria for a depressive disorder, or operationally defined subsyndromal depression, and scored >12 on the first 17 items of the Hamilton Rating Scale for Depression (HAM-D). Subjects were followed for 12 weeks (6-week dosage adjustment, 6-week maintenance). Maximum daily dosages were 40 mg for paroxetine and 225 mg for venlafaxine XR. The primary outcome measure was change in the HAM-D score from baseline to week 12. RESULTS: Treatment effects (relative to placebo), expressed as mean 12-week reductions in HAM-D score, were 6.2 points (97.5% confidence interval [CI] 2.2 to 10.3, p = 0.0007) in the paroxetine group and 4.2 points (97.5% CI 0.1 to 8.4, p = 0.02) in the venlafaxine XR group. No treatment effects were seen on motor function. CONCLUSIONS: Both paroxetine and venlafaxine XR significantly improved depression in subjects with PD. Both medications were generally safe and well tolerated and did not worsen motor function. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that paroxetine and venlafaxine XR are effective in treating depression in patients with PD.

Effects of psychotherapy and other behavioral interventions on clinically depressed older adults: a meta-analysis.

OBJECTIVES: The goal of the present study was to assess the effects of psychotherapy and other behavioral interventions on depressive symptoms in clinically depressed older patients. METHODS: We used meta-analysis to examine the effects of 57 controlled intervention studies. RESULTS: On average, self-rated depression improved by d=0.84 standard deviation units and clinician-rated depression improved by d=0.93. Effect sizes were large for cognitive and behavioral therapy (CBT) and reminiscence; and medium for psychodynamic therapy, psychoeducation, physical exercise and supportive interventions. Age differences in treatment effects were not observed. Weaker effects were found in studies that used an active control group and in studies of physically ill or cognitively impaired patients. Studies of samples comprised exclusively of patients suffering from major depression (versus other mood disorders) also yielded weaker intervention effects. On average, 18.9% of participants did not complete the intervention, with higher dropout rates reported in group (versus individual) interventions and in longer interventions. CONCLUSIONS: We conclude that cognitive-behavioral therapy and reminiscence are particularly well-established and acceptable forms of depression treatment. Interventions with 7-12 sessions may optimize effectiveness while minimizing dropout rates. For physically and cognitively impaired patients, modifications in treatment format and/or content might be useful, such as combining psychotherapy with social work interventions and pharmacotherapy.

Religious involvement and depressive symptoms in primary care elders.

BACKGROUND: Multiple lines of evidence indicate relationships between religious involvement and depression, although the specific nature of the relationships is yet to be clarified. Moreover, there appear to be no well controlled longitudinal studies to date examining this issue in primary care elders. METHOD: The authors assessed the linear and non-linear relationships between three commonly identified types of religious involvement and observer-rated depressive symptoms in 709 primary care elders assessed at baseline and 1-year follow-up. RESULTS: Cross-sectional analyses revealed a curvilinear, U-shaped association between depressive symptoms and organizational religious activity, an inverse linear relationship of depressive symptoms with private religious involvement, and a positive relationship of depressive symptoms with intrinsic religiosity. Longitudinal analyses revealed a U-shaped association between depressive symptoms and private religious involvement, such that those reporting moderate levels of private religiosity at baseline evidenced lower levels of depressive symptoms at 1-year follow-up than those reporting either high or low levels of private religious activity. CONCLUSIONS: The relationships between religious involvement and depression in primary care elders are complex and dependent on the type of religiosity measured. The authors found the strongest evidence for an association of non-organizational, private religious involvement and the severity of depressive symptoms, although further study is warranted using carefully controlled longitudinal designs that test for both linear and curvilinear relationships.

Profile of discrete emotions in affective disorders in older primary care patients.

PURPOSE: This research examined whether the frequencies of specific emotions are associated with major and minor depression in older primary care patients. DESIGN AND METHODS: Older primary care patients (N = 146), prescreened with a depression questionnaire, completed a diagnostic interview and an emotions questionnaire. RESULTS: Controlling for age, sex, and other psychiatric and medical illnesses, major depressives differed from nondepressed controls in nine emotions; minor depressives differed from controls in four emotions. Major depressives differed from the controls more in sadness, joy, and interest--but not anger, fear, or guilt--than in comparison sets of emotions. Minor depressives differed from the controls more in sadness and inner-directed hostility--but not guilt, anger, fear, joy, or interest--than in comparison sets of emotions. IMPLICATIONS: The frequencies of discrete emotions are differentially associated with major and minor depression; future research is needed to determine their specific diagnostic and treatment implications.

Depression and self-reported functional status in older primary care patients.

OBJECTIVE: The authors' goal was to examine whether depression is associated with overreporting of functional disability. METHOD: The subjects were 304 patients 60 years old or older who were recruited from primary care settings. Measures included examiner ratings of depression diagnosis and medical burden and self-reported and examiner-rated functional assessments. Multiple regression techniques were used to determine the independent association of depression with self-reported function after examiner-rated function was added to the analysis as a covariate. RESULTS: Depression diagnosis was associated with poorer self-reported role functioning, whether the patient attributed the disability to physical or emotional causes. Depression was not independently associated with poorer self-reported physical functioning. CONCLUSIONS: Clinicians and researchers should recognize that depression can confound the self-reporting and attribution of functional disability.

Stress, medical illness, and depression.

In this review, we present potential pathways through which medical illness may act as a stress-related catalyst of major depression. We will consider available evidence and discuss biological, psychological, and psychosocial theories, individually and in their interplay, in an attempt to better understand the potential roles of stress in mediating the relationships between medical illness and mood disorder. We will use the specific example of major depression occurring after acute myocardial infarction to illustrate the application of our theoretical framework.

Depression, medical illness, and interleukin-1beta in older cardiac patients.

OBJECTIVE: A model has been proposed in which atherosclerosis contributes to depression in later life by the effects of cytokines on central monoamine systems. We collected pilot data to test the hypothesis that interleukin-1beta (IL-1beta) is associated with depression in a cardiac patient group. METHOD: Thirty-seven subjects completed research evaluations that included depression diagnosis (Structured Clinical Interview for DSM-III-R), depressive symptom severity (Hamilton Rating Scale for Depression), medical illness burden (Cumulative Illness Rating Scale), and serum IL-1beta level measured by enzyme linked immunosorbent assay. RESULTS: Serum IL-1beta level was not significantly associated with depressive symptom severity or depression diagnosis, whether or not controlled for medical illness burden, age, and gender. IL-1beta level was significantly correlated with medical illness burden. CONCLUSIONS: We did not confirm our study hypothesis. The correlation of IL-1beta level with medical illness burden likely reflects its release as part of the "sickness response" in a wide variety of disease states. Further research using a larger sample size and a non-cardiac comparison group is warranted.

Cerebrovascular risk factors and 1-year depression outcome in older primary care patients.

OBJECTIVE: A model in which cerebrovascular disease contributes to the pathogenesis of depression in later life was the basis of the authors' hypothesis that cerebrovascular risk factors at intake are independently associated with depression at 1-year follow-up. METHOD: The subjects were 247 patients aged 60 years or older in primary care practices. The study measures were completed at intake and 1-year follow-up. Multiple regression techniques were used to determine the independent association of initial cerebrovascular risk factors with depressive symptoms and diagnoses at 1 year. RESULTS: The authors found that the severity of initial cumulative cerebrovascular risk factors was significantly independently associated with 1-year depressive symptoms and diagnoses, but not after also controlling for overall medical burden. CONCLUSIONS: The results lend some support to the cerebrovascular model of depression.

Completed suicide among older patients in primary care practices: a controlled study.

OBJECTIVE: To determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not. DESIGN: A case-control study using data collected by psychological autopsies of suicides and prospective patient interviews for controls. SETTING: Primary care practices in Monroe County, NY. PARTICIPANTS: Forty-two suicides aged 60 years and older who visited a primary care provider within 30 days of death and 196 patients aged 60 years and older from a group practice of general internal medicine (n = 115) or family medicine (n = 81). MEASUREMENTS: Psychiatric diagnosis; depressive symptom severity; physical health and function; psychiatric treatment history. RESULTS: Completed suicides had more depressive illness (P = .001), physical illness burden (P = .0002), and functional limitations (P = .0001) than controls and were more likely to be prescribed antidepressants (P = .004), anxiolytic agents (P = .0001), and narcotic analgesics (P = .022). Among depressed subjects, affective symptom severity (P< .0001) and emotional dysfunction (P<.0001) distinguished suicide completers. However, physical health, overall function, and treatments received did not differ between groups. CONCLUSIONS: The primary care setting is an important venue for late life suicide prevention. Primary care providers should be well prepared to diagnose and treat depression in their older patients. Additional research is needed concerning the interactions of physical health, functional status, and depressive symptoms in determining suicide risk.

Anxiety and functional status in older primary care patients.

OBJECTIVE: The aim of this study was to test the hypothesis that anxiety in older primary care patients is associated with functional impairment after controlling for depression and medical comorbidity. METHOD: Primary care patients (n = 303), aged sixty or older were interviewed with a series of instruments designed to measure psychiatric symptoms including anxiety, depression, medical illness burden, and both examiner-rated and self-reported functional status. Anxiety was measured by the anxiety item of the Hamilton Rating Scale for Depression and the anxiety items of the Medical Outcomes Study Short Form SF-36. Multiple regression techniques were used to examine the association of anxiety with functional status after controlling for age, gender, education, medical burden, and depression. RESULTS: When controlled for depression and medical morbidity, increased anxiety predicted poorer social function. Anxiety was not independently associated with more basic activities of daily living. CONCLUSIONS: Further studies with more comprehensive measures of anxiety are warranted to clarify the relationships between anxiety and functional status.

Age and suicidal ideation in older depressed inpatients.

Age-related patterns of symptom presentation may complicate the recognition of suicide risk. The authors sought to determine whether there is a relationship between age and reported suicidal ideation in depressed suicide attempters (DSAs) and depressed nonattempters (DNs) 50 years of age and over. Regression analyses revealed that increasing age is significantly associated with the absence of suicidal ideation in both DSAs and DNs. Because of their lower rates of depressed mood and suicidal ideation, the depressions of older adults may more readily escape detection. Preventive or treatment measures initiated after the onset of the suicidal state may be insufficient, and other preventive strategies ought to be considered.

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.

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. METHODS: Subjects were 224 patients, aged 60 years and older, recruited from private internal medicine offices or a family medicine clinic. Validated measures of psychopathology, medical burden, and functional status were used. The subsyndromal depression group was defined by a score of more than 10 on the Hamilton Rating Scale for Depression and by the absence of major or minor depressive disorder. Analyses included multiple regression techniques to determine the presence of group differences adjusted for demographic covariates. RESULTS: Subsyndromal depression was common (estimated point prevalence of 9.9% compared with 6.5% for major depression, 5.2% for minor depression, and .9% for dysthymic disorder), associated with functional disability and medical comorbidity to a degree similar to major or minor depression, and often treated with antidepressant medications. CONCLUSIONS: Although depressive conditions are common and are associated with considerable functional and medical morbidity in older primary care patients, many patients with clinically significant depressive symptoms are not captured by criteria-based syndromic diagnostic categories. Future work should include intervention studies of subsyndromally depressed older persons as well as attention to the course and biopsychosocial concomitants of diagnosable and subsyndromal depressions in this population.

Psychiatric disorders in older primary care patients.

OBJECTIVE: 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.

Medical illness burden, trait neuroticism, and depression in older primary care patients.

OBJECTIVE: The authors tested the hypotheses that medical illness burden is independently associated with depression and that this association is moderated by neuroticism. METHOD: Multiple regression techniques were used to determine the independent associations of medical burden and neuroticism with depression in a group of 196 subjects, 60 years of age and older, recruited from primary care settings. RESULTS: Medical burden and neuroticism were independently associated with major depression, depressive symptoms, and psychiatric dysfunction. CONCLUSIONS: These findings support models in which medical disorders may contribute directly to depression. At the same time, the role of neuroticism in later-life depression warrants further study.

Quantitative and qualitative differences in the verbal learning performance of elderly depressives and healthy controls.

We compared the verbal learning and memory performance of 57 inpatients with unipolar major depression and 30 nondepressed control participants using the California Verbal Learning Test. The effect of age within this elderly sample was also examined, controlling for sex, educational attainment, and estimated level of intelligence. Except for verbal retention, the depressive had deficits in most aspects of performance, including cued and uncued recall and delayed recognition memory. As well, there were interactions between depression effects and age effects on some measures such that depressives' performance declined more rapidly with age than did the performance of controls. The results are discussed in the context of recent contradictory reports about the integrity of learning and memory functions in late-life depression. We conclude that there is consistent evidence, from this and other studies, that elderly depressed inpatients have significant deficits in a range of explicit verbal learning functions.

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.

Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale.

BACKGROUND: Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations. METHODS: One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics. RESULTS: Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis. CONCLUSIONS: The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.

Late-life suicide and depression in the primary care setting.

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.