Association of Obesity and Frailty in Older Adults: NHANES 1999-2004.

OBJECTIVES: Body composition changes with aging can increase rates of obesity, frailty and impact function. Measuring adiposity using body fat (%BF) or central adiposity using waist circumference (WC) have greater diagnostic accuracy than traditional measures such as body mass index (BMI). DESIGN: This is an observational study. SETTING: This study focused on older community-dwelling participants. PARTICIPANTS: We identified individuals age ≥ 60 years old using the 1999-2004 cross-sectional National Health and Nutrition Survey (NHANES). INTERVENTION: The primary analysis evaluated the association between frailty and %BF or WC. Frailty was the primary predictor (robust=referent) and %BF and WC were considered continuous outcomes. Multiple imputation analyses accounted for missing characteristics. MEASUREMENT: Dual energy x-ray absorptiometry was used to assess %BF and WC was objectively measured. Frailty was defined using an adapted version of Fried's criteria that was self-reported: (low BMI<18.5kg/m2; slow walking speed [<0.8m/s]; weakness [unable to lift 10lbs]; exhaustion [difficulty walking between rooms on same floor] and low physical activity [compared to others]). Robust, pre-frail and frail persons met zero, 1 or 2, and ≥3 criteria, respectively. RESULTS: Of the 4,984 participants, the mean age was 71.1±0.2 (SE) years and 56.5% were females. We classified 2,246 (50.4%), 2,195 (40.3%), and 541 (9.2%) individuals as robust, pre-frail and frail, respectively. Percent BF was 35.9±0.13, 38.3±0.20 and 40.0±0.46 in the robust, pre-frail and frail individuals, respectively. WC was 99.5±0.32 in the robust, 100.1±0.43 in pre-frail, 104.7±1.17 in frail individuals. Compared to robust individuals, only frail individuals had greater %BF on average (ß=0.97±0.43,p=0.03); however, pre-frail and frail individuals had 2.18 and 4.80 greater WC, respectively (ß=2.18±0.64,p=0.002, and ß=4.80±1.1,p<0.001). CONCLUSION: Our results demonstrate that in older adults, frailty and pre-frailty are associated with a greater likelihood of high WC (as dichotomized) and a greater average WC (continuous).

Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011-2014.

OBJECTIVES: Sarcopenia is a gradual loss of muscle mass and strength that occurs with aging. This muscle deterioration is linked to increased morbidity, disability, and other adverse outcomes. Although reduced handgrip strength can be considered a marker of sarcopenia and other aging-related decline in the elderly, there is limited research on this physical health problem in at-risk groups with common biopsychosocial conditions such as depression. Our primary objective was to ascertain level of combined handgrip strength and its relationship with depression among adults aged 60 years and older. DESIGN: Unadjusted and adjusted linear regression models were conducted with a cross-sectional survey dataset. SETTING: Secondary dataset from the 2011-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: Community-dwelling, non-institutionalized adults ≥60 years old (n=3,421). MEASUREMENTS: The predictor variables included a positive screen for clinically relevant depression (referent=PHQ-9 score <10). The criterion variable of combined handgrip strength (kg) was determined using a dynamometer. RESULTS: Mean age and BMI were 69.9 years (51.5% female) and 28.8 kg/m2, respectively. Mean combined handgrip strength in the overall cohort was 73.5 and 46.6 kg in males and females, respectively. Three hundred thirty-six (9.8%) reported symptoms of depression. In unadjusted and fully adjusted models, depression was significantly associated with reduced handgrip strength (B = -0.26±0.79 and B = -0.19±0.08, respectively; p<0.001). CONCLUSION: Our findings demonstrate handgrip strength has a significant inverse association with depression. Future longitudinal studies should investigate the causal processes and potential moderators and mediators of the relationships between depression and reduced handgrip strength. This information may further encourage the use of depression and handgrip strength assessments and aid in the monitoring and implementation of health care services that address both physical and mental health limitations among older adult populations.

Poverty and psychiatric status. Longitudinal evidence from the New Haven Epidemiologic Catchment Area study.

We assessed the effect of poverty on psychiatric status using two waves of New Haven (Conn) Epidemiologic Catchment Area data. Poverty was defined using federal poverty guidelines; psychiatric status was assessed by the Diagnostic Interview Schedule (DIS). When examining the course of healthy respondents at the first interview, respondents in poverty had a twofold-increased risk (controlling for demographic factors) for an episode of at least one DIS/DSM-III Axis I psychiatric disorder. Rates of most specific psychiatric disorders were comparably higher for respondents meeting poverty criteria compared with those not in poverty, although these differences were not always statistically significant. The effects of poverty did not differ by sex, age, race, or history of psychiatric episodes.

Clinical determinants of suicidal ideation and behavior in geriatric depression.

BACKGROUND: The aim of this study was to find clinical characteristics that can identify elderly patients with depression at risk for suicidal ideation and to determine their prognosis. METHOD: Suicidal ideation, past suicidal behavior, severity of depression, cognitive impairment, medical burden, disability, and social support were studied in 354 patients with depression aged 61 to 93 years. The patients had in-person evaluations every 6 months and telephone evaluations for a mean of 1.8 years (SD, 2.2). RESULTS: During the index episode, suicidal ideation was predicted by previous suicide attempts with serious intent (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.37-5.80), severity of depression (OR, 1.09; 95% CI, 1.03-1.16), and poor social support (OR, 1.77; 95% CI, 1.18-2.65). Suicide attempts during the year prior to entry were reported by patients with a severe index episode (OR, 1.05; 95% CI, 1.00-1.11), impaired instrumental activities of daily living (OR, 0.78; 95% CI, 0.67-0.93), and limited impairment in activities of daily living (OR, 1.53; 95% CI, 1.10-2.14). At the initial evaluation, severity of depression, previous attempts, and seriousness of suicidal intent during previous attempts predicted the course of suicidal ideation (concordance correlation, 0.78). During follow-up, contemporaneous severity of depression was the most important determinant of suicidal ideation over time (concordance correlation, 0.88). CONCLUSIONS: Elderly individuals with severe depression, history of suicide attempts with serious intent, and poor social support are most likely to have suicidal ideation and should be targeted for appropriate interventions. Severity of depression is the strongest predictor of the course of suicidal ideation.

Factors associated with 1-year outcome of major depression in the community.

Evidence from outcome studies of major depression indicates a high rate of relapse and chronicity, and that prior chronicity, recurrent episodes, and the presence of psychosocial stressors are associated with a poor outcome. However, the generalizability of these findings is limited because most studies have focused on treated samples; thus, these studies may have been biased toward more chronic or severe illnesses. In prospectively surveying a large probability sample of the general population, the Epidemiologic Catchment Area program offers the opportunity to investigate prognosis without selection bias. In this study, the Epidemiologic Catchment Area subjects with a diagnosis of Major Depressive Disorder at first interview (n = 423) were categorized according to their diagnostic status 1 year later. The results confirmed a high rate of nonrecovery, with clinical features associated with a poor outcome that resembled those identified in previous clinical studies. Overall, clinical factors were more important prognostically than were sociodemographic characteristics. However, there was some evidence that a poorer outcome in older women may partially explain the greater female prevalence of depression in the community.

Differences in the effects of divorce on major depression in men and women.

OBJECTIVE: The authors examined the relationship between marital disruption and major depressive episodes. METHOD: The analyses were based on longitudinal, community-based data from the New Haven Epidemiologic Catchment Area (ECA) program on respondents 18-60 years old. The presence and history of major depression was assessed by using the National Institute of Mental Health Diagnostic Interview Schedule. RESULTS: Martial disruption was associated with higher prevalence rates of major depression in both men and women, but only men had a greater risk of a first-onset major depression. Differences between men and women in rates of major depression were observed only among married subjects. CONCLUSIONS: These findings suggest that the relationship between marital disruption and major depressive episode differs for men and women. They also provide further evidence that differences between men and women in rates of depression vary by marital status.

The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment.

Data from a survey of five U.S. communities showed that dysthymia affected approximately 3% of the adult population. It was more common in women under age 65, unmarried persons, and young persons with low income and was associated with greater use of general health and psychiatric services and psychotropic drugs. Dysthymia had a high comorbidity with other psychiatric disorders, particularly major depression; only about 25%-30% of cases occur over a lifetime in the absence of other psychiatric disorders. The findings suggest that although the onset and highest risk periods of major depression and bipolar disorder are in young adulthood, a residual state of dysthymia occurs in middle and old age.

Physical health, depressive symptoms, and managed care enrollment.

OBJECTIVE: This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs). METHOD: The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables. RESULTS: In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics. CONCLUSIONS: This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.

Depressive episodes and dysphoria resulting from conjugal bereavement in a prospective community sample.

Using three waves of interviews from the New Haven Epidemiologic Catchment Area Program, the authors contrast the extent and nature of depressive episodes and dysphoria between newly bereaved (N = 39) and married (N = 1,047) respondents age 45 and older. Bereavement greatly increased the risk of both conditions. This observation did not appear to be an artifact because psychosocial risk factors were similar for the bereaved and married groups. Bereavement increased the risk for a depressive episode more among respondents who reported no prior dysphoria than among those who did. Among those meeting criteria for depression, the bereaved reported symptoms similar to those of the married group except for significantly fewer reports of guilt.

Adverse life events and cognitive-personality characteristics in the prediction of major depression and antidepressant response.

OBJECTIVE: Stressful life events are known to precipitate major depression. However, it remains unclear why some individuals who experience adverse events develop depression whereas others do not, and how the occurrence of life events affects treatment outcome. Emerging models posit that the effect of adverse life events varies by cognitive-personality style. This study examines the direct and interactive effects of stressful life events and cognitive-personality style in predicting 1) episode onset in patients with DSM-IV unipolar depression versus community comparison subjects and 2) depressive symptom severity at the completion of a 6-week standard antidepressant regimen. METHOD: Multivariate models were used to test the effects of adverse life events, cognitive-personality style, and the congruence of event type (interpersonal versus achievement) with cognitive-personality style on depressive onset and treatment outcome in 43 patients with major depression and 43 healthy comparison subjects. Cognitive-personality characteristics were assessed by using Beck's measures of sociotropy (interpersonal dependency) and autonomy (need for independence and control). RESULTS: Adverse life events, sociotropy, and an autonomy factor need for control were each significantly related to depressive onset and predicted group status for 88% of the subjects. Event types affected outcome differently, and specific life event types interacted with cognitive-personality styles in predicting response to treatment. A multivariate model accounted for 65% of the variance in predicting outcome. CONCLUSIONS: Adverse life events are a potent factor in predicting depression. However, cognitive-personality characteristics also confer susceptibility to depression. Better outcome is associated with occurrence of adverse interpersonal events (e.g., death of a loved one) rather than adverse achievement events (e.g., loss of job) and occurs when the event type is congruent with cognitive-personality style.

Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study.

OBJECTIVE: This study examined the effects of nine axis I psychiatric disorders, as assessed by the Diagnostic Interview Schedule, on the risk of mortality over a 9-year period among a community sample of 3,560 men and women aged 40 and older. METHOD: The study identified the vital status as of Oct. 1, 1989, of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area study. Mortality risk by psychiatric status was estimated by using Cox proportional hazards models. RESULTS: Nine years after the baseline interview, it was confirmed that 1,194 (33.5%) of the respondents were deceased and 2,344 (65.8%) survived; the vital status of 22 (0.6%) remained unknown. When the relative risk of mortality was adjusted for age, several disorders--major depression, alcohol abuse or dependence, and schizophrenia--increased the likelihood of mortality. CONCLUSIONS: These data are further evidence of the negative outcome of some psychiatric problems even when assessed in community samples. The relatively high prevalence of depression and alcohol disorders indicates the far-reaching impact that these problems have on community health in general.

Predictors of antidepressant prescription and early use among depressed outpatients.

OBJECTIVE: The rates of antidepressant recommendation and use were determined in outpatients with major depression receiving services in mental health clinics. Site of service and the patients' sociodemographic and clinical characteristics were investigated as possible predictors. METHOD: Patients admitted to six outpatient clinics were recruited through a two-stage sampling procedure. Patients with major depressive disorder (N = 124) according to the Structured Clinical Interview for DSM-IV--Patient Edition were assessed at admission and 3 months later. RESULTS: Drug therapy was recommended for most patients (71%), and minimal use (at least 1 week) was recorded for 59% of the subjects. White patients were nearly three times as likely to receive a recommendation for antidepressants. Antidepressant recommendation was also associated with severity of depressed mood, recent medication use, and clinic type. Recent antidepressant use was the only variable that predicted whether the patient actually took the recommended medication. CONCLUSIONS: Many patients with depression seeking treatment at community mental health clinics do not receive antidepressant drug therapy. The offer of medication is predicted by patient ethnicity, clinic type, and symptom severity. Minority patients are less likely to be offered antidepressant treatment.

Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression.

OBJECTIVE: The authors' goal was to examine the extent to which perceived stigma affected treatment discontinuation in young and older adults with major depression. METHOD: A two-stage sampling design identified 92 new admissions of outpatients with major depression. Perceived stigma was assessed at admission. Discontinuation of treatment was recorded at 3-month follow-up. RESULTS: Although younger patients reported perceiving more stigma than older patients, stigma predicted treatment discontinuation only among the older patients. CONCLUSIONS: Patients' perceptions of stigma at the start of treatment influence their subsequent treatment behavior. Stigma is an appropriate target for intervention aimed at improving treatment adherence and outcomes.

The influence of psychological and social factors on accuracy of self-reported blood pressure.

The data reported here document levels of accuracy in reports of blood pressure and identify correlates of inaccurate reporting. The data come from a long-term follow-up of a cohort of African-American women who registered for antepartum care between September, 1967 and June, 1969. At the follow-up interview, these women were asked whether they had ever received a diagnosis of hypertension from a physician. The self-reports of hypertension were compared with information contained in the medical records of these women. Twenty-five percent reported having high blood pressure but 53% of these reports were unconfirmed by their medical records (overall misreporting rates was 15.9% with 2.5% underreporting and 13.4% overreporting). The factors related to misreporting included a psychiatric diagnosis (based on the Diagnostic Interview Schedule) of major depressive disorder or drug and/or alcohol abuse and a small social network. The conjunction of these three variables significantly affected accuracy of reporting (100% misreporting with all three variables). These results suggest that, using currently standard methodology, there is an unreliable subpopulation of respondents in health surveys that may require the collection of data on health status from a second source to confirm data from self-reported health measures.

Psychiatric status among the homebound elderly: an epidemiologic perspective.

OBJECTIVE: To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors. DESIGN: Survey. SETTING: Epidemiologic Catchment Area (ECA) project in New Haven, CT. PARTICIPANTS: 2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area. INTERVENTION: None MAIN MEASURES: Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination. RESULTS: Cognitive impairment (21.8% vs 11.0%, P less than 0.001), depression (2.3% vs 0.7%, P less than 0.01), dysthymia (3.9% vs 1.7%, P less than 0.01), and anxiety disorders (2.2% vs 0.4%, P less than 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P less than 0.01) was significantly more prevalent among elders confined to a bed or chair. CONCLUSIONS: The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.

Depression and medical illness in late life: report of a symposium.

The high comorbidity of medical illnesses and late life depression poses both challenges and opportunities. Challenges in assessment techniques, diagnosis, and specific prognosis affect clinical care and research methodology alike. However, investigations that turn this vexing "confound" into research questions may prove fruitful. For clinicians working with older persons, recognizing the prognostic import of comorbid medical illnesses in late-life depression is essential to treatment planning. This comorbidity also poses difficulties in diagnosing depression inasmuch as symptoms of the medical conditions may overlap with those of an affective disorder. Symptom assessments must strike a balance between overly inclusive (e.g., mistakenly treating the psychomotor slowing of Parkinson's disease as depression) and overly exclusive (e.g., erroneously dismissing the patient's mood symptoms as "understandable"). Clinicians also should be sensitive to the broad range of symptomatic presentations with varying severities of both mood and medical disorders, as exemplified by variability across treatment settings. For researchers, similar issues are of relevance in planning investigative strategies. Consideration should be given to the following: 1. Case identification is a crucial first step; the approach to depressive symptoms potentially confounded by medical illnesses must be defined explicitly. Choice of an inclusive approach avoids premature exclusion of relevant phenomena; exploratory analyses can examine the effects of other approaches to the relationships of interest. 2. The use of similar research instruments across sample sites would greatly facilitate comparisons of results. Each subject group offers its own "leverage" for answering particular questions. Psychiatric inpatients will highlight the contributions of severe psychopathology (useful, for example, in identifying biologic markers). Medical inpatients are well suited to studies examining validity of different approaches to case identification, investigating health service utilization, or highlighting the contribution of acute, severe, life-threatening medical disorders to affective illness. Long-term care residents lend themselves to issues that benefit from compression of health processes over time. Medical outpatients have many advantages regarding generalizability and public health significance. Community samples are needed to determine the biases of all the above groups, which are each defined by service utilization. 3. Study of the relationships between depression and medical illness may further understanding of pathogenic mechanisms in late life mood disorders. Research questions might be guided by the biopsychosocial conceptual context described above. On the one hand, this context demands multidimensional study methodology to identify the routes by which medical illness influences depression in particular patient groups. Multivariate models should examine direct and indirect effects of medical illness on depression while, at the same time, considering intervening variables such as functional disability, personality, and social support. Guided multiple regressions or structural equation modeling will allow for determination of strengths of associations. 4. At the same time, and of particular importance if complex multivariate analyses are used, specific theoretic models should help direct focused investigations. The development and testing of such models is a major challenge that should be addressed by current research. Finally, from a societal perspective, the comorbidity of depression and medical illness likely has a tremendous impact on both health and health care delivery for older adults. Further study is needed to identify more specific approaches to treatment. Yet existing data clearly support a policy of routine psychiatric assessment of older people in general medical settings...

Reliability of self-reported age at onset of major depression.

Reliability of self-reported age at onset of major depressive disorder was studied in a sample of 335 subjects who were ascertained from a large epidemiologic survey conducted in several U.S. communities and who were interviewed blindly at two different times. Reliability was generally good for these subjects who met DSM-III criteria for depression at two interviews. A large proportion of the variability in the difference of test-retest values can be accounted for by recency of last episode of depression and interactions of age with duration of illness, having been treated for a mental health problem, and comorbidity of other mental disorders. Interactions between duration and comorbidity and between geographic region and treatment were also significant. Contrary to previous studies which do not consider the interval between current age and age at onset and which suggest that reliability diminishes with age, our findings show that older respondents tend to systematically decrease and not increase age at onset across the two interviews. These findings do not support the hypothesis that recently reported secular changes in major depression, including a decreased age at onset and higher rates in younger as compared to older cohorts, can be explained by a differential reporting effect. Furthermore, the findings suggest that factors which contribute to variability in an individual's age at onset should be incorporated in genetic and clinical studies of major depression.

Marital dissatisfaction and incidence of major depressive episode in a community sample.

The association between marital dissatisfaction at baseline and 12-month incidence of major depressive episode (MDE) was examined in a community sample of married individuals from the New Haven Epidemiologic Catchment Area program (N = 904) who did not meet criteria for MDE at baseline. Results indicate that marital dissatisfaction was associated with increased incidence of MDE, with a significant risk ratio of 2.7 and an attributable risk of 29.5%. Thus, dissatisfied spouses were nearly 3 times more likely than nondissatisfied spouses to develop an MDE during the year, and nearly 30% of the new occurrences of MDE were associated with marital dissatisfaction. The association between marital dissatisfaction and risk of MDE (a) remained significant when controlling for demographics and depression history and (b) was not moderated by sex or by depression history. Findings suggest that marital dissatisfaction may be etiologically related to major depression.

The prevalence and correlates of untreated serious mental illness.

OBJECTIVE: To identify the number of people in the United States with untreated serious mental illness (SMI) and the reasons for their lack of treatment. DATA SOURCE/STUDY DESIGN: The National Comorbidity Survey; cross-sectional, nationally representative household survey. DATA COLLECTION: An operationalization of the SMI definition set forth in the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act identified individuals with SMI in the 12 months prior to the interview. The presence of SMI then was related to the use of mental health services in the past 12 months. PRINCIPAL FINDINGS: Of the 6.2 percent of respondents who had SMI in the year prior to interview, fewer than 40 percent received stable treatment. Young adults and those living in nonrural areas were more likely to have unmet needs for treatment. The majority of those who received no treatment felt that they did not have an emotional problem requiring treatment. Among those who did recognize this need, 52 percent reported situational barriers, 46 percent reported financial barriers, and 45 percent reported perceived lack of effectiveness as reasons for not seeking treatment. The most commonly reported reason both for failing to seek treatment (72 percent) and for treatment dropout (58 percent) was wanting to solve the problem on their own. CONCLUSIONS: Although changes in the financing of services are important, they are unlikely by themselves to eradicate unmet need for treatment of SMI. Efforts to increase both self-recognition of need for treatment and the patient centeredness of care also are needed.

Social functioning in community residents with depression and other psychiatric disorders: results of the New Haven Epidemiologic Catchment Area Study.

Social functioning was compared among 4913 community participants with current depression, past depression, other psychiatric disorders and no psychiatric history, from the New Haven Epidemiologic Catchment Area Wave I survey. Respondents with current major depressive disorder (1.5%) (based on the Diagnostic Interview Schedule) reported significantly poorer intimate relationships and less satisfying social interactions than respondents with past depression or other current disorders. Respondents with no psychiatric history (77%) reported significantly more active and satisfying social interactions than persons with any psychiatric disorder. These social functioning and depression associations were similar among males and females, and corroborated results from patient samples.