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.

Executive dysfunction and long-term outcomes of geriatric depression.

BACKGROUND: This study investigated the relationship of executive and memory impairment to relapse, recurrence, and course of residual depressive symptoms and signs after remission of geriatric major depression. METHODS: Fifty-eight elderly subjects remitted from major depression received continuation nortriptyline treatment (plasma levels 60-150 ng/mL) for 16 weeks and then were randomly assigned to either nortriptyline maintenance therapy or placebo for up to 2 years. Diagnosis was made using the Research Diagnostic Criteria and the DSM-IV criteria after an interview using the Schedule for Affective Disorders and Schizophrenia. Executive dysfunction and memory were assessed with the Dementia Rating Scale, disability and social support were rated with the Philadelphia Multiphasic Instrument, and medical burden was assessed with the Cumulative Illness Rating Scale. RESULTS: Abnormal initiation and perseveration scores, but not memory impairment, were associated with relapse and recurrence of geriatric depression and with fluctuations of depressive symptoms in the whole group and in subjects who never met criteria for relapse or recurrence during the follow-up period. Memory impairment, disability, medical burden, social support, and history of previous episodes did not significantly influence the outcome of depression in this sample. CONCLUSIONS: Executive dysfunction was found to be associated with relapse and recurrence of geriatric major depression and with residual depressive symptoms. These observations, if confirmed, will aid clinicians in identifying patients in need of vigilant follow-up. The findings of this study provide the rationale for investigation of the role of specific prefrontal pathways in predisposing or perpetuating depressive syndromes or symptoms in elderly patients.

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.

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.

Stigma as a barrier to recovery: The extent to which caregivers believe most people devalue consumers and their families.

OBJECTIVE: The extent to which 461 caregivers of persons with serious mental disorders believed that most people devalue consumers and their families was assessed, and the magnitude of the relationships between these beliefs and the diagnostic status of consumers was estimated. METHODS: Caregivers of 180 consumers with schizophrenia, major depression, or bipolar disorder and caregivers of 281 consumers with bipolar disorder or schizoaffective disorder, manic type, completed a 15-item instrument comprising two scales: eight of the 15 items operationally defined the devaluation of individual consumers, and seven items operationally defined the devaluation of consumers' families. RESULTS: No significant differences were observed between the two samples on the two devaluation scales or on 14 of the 15 items that constituted the scales. About 70 percent of all caregivers indicated a belief that most people devalue consumers, and 43 percent expressed a belief that most people also devalue the families of consumers. CONCLUSIONS: Strong evidence from previous research indicates that the caregiving role is very demanding, is frequently distressing, and may be harmful to health and injurious to one's quality of life. The addition of a community that is perceived to be rejecting makes life even more difficult for the caregivers and families of people with serious mental disorders. The development and implementation of effective interventions to create more supportive and understanding communities would be a challenging and worthwhile endeavor.

Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence.

OBJECTIVE: Major depression is undertreated despite the availability of effective treatments. Psychological barriers to treatment, such as perceived stigma and minimization of the need for care, may be important obstacles to adherence to the pharmacologic treatment of major depression. The authors examined the impact of barriers that were present at the initiation of antidepressant drug therapy on medication adherence in a mixed-age sample of outpatients with major depression. METHODS: A two-stage sampling design was used to identify adults with a diagnosis of major depressive disorder, as determined by the Structured Clinical Interview for Diagnosis, who sought mental health treatment at outpatient clinics. Additional instruments were administered to 134 newly admitted adults who had been taking a prescribed antidepressant medication for at least a week to assess perceived stigma, self-rated severity of illness, and views about treatment. The patients were reinterviewed three months later and were classified as adherent or nonadherent on the basis of self-reported estimates of the number and frequency of missed doses. RESULTS: Medication adherence was associated with lower perceived stigma, higher self-rated severity of illness, age over 60 years, and absence of personality pathology. No other characteristics of treatment or illness were significantly related to medication adherence. CONCLUSIONS: Perceived stigma associated with mental illness and individuals' views about the illness play an important role in adherence to treatment for depression. Clinicians' attention to psychological barriers early in treatment may improve medication adherence and ultimately affect the course of illness.

Stigma as a barrier to recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder.

OBJECTIVE: The purpose of this study was to evaluate the effect of concerns about stigma on social adaptation among persons with a diagnosis of bipolar affective disorder. METHODS: The sample comprised 264 persons who were consecutively admitted to a psychiatric inpatient or outpatient service at a university-affiliated hospital and who met research diagnostic criteria for bipolar I disorder, bipolar II disorder, or schizoaffective disorder, manic type. Patients were evaluated with use of the Schedule for Affective Disorders and Schizophrenia, Lifetime Version (SADS-L), the Brief Psychiatric Rating Scale (BPRS), and a measure of perceived stigma. Social adjustment was measured at baseline and seven months later with the Social Adjustment Scale (SAS). RESULTS: As predicted, patients who had concerns about stigma showed significantly more impairment at seven months on the social leisure subscale but not on the SAS extended family subscale, after baseline SAS score and symptom level had been controlled for. More refined models using SAS-derived factors as dependent variables indicated that concerns about stigma predicted higher avoidance of social interactions with persons outside the family and psychological isolation at seven-month follow-up, after baseline SAS and BPRS scores had been controlled for. CONCLUSIONS: Concerns about the stigma associated with mental illness reported by patients during an acute phase of bipolar illness predicted poorer social adjustment seven months later with individuals outside the patient's family. Greater attention to patients' concerns about stigma is needed from both researchers and clinicians.

Depressive mood and obesity in US adults: comparison and moderation by sex, age, and race.

OBJECTIVE: Sustained depressive mood is a gateway symptom for a major depressive disorder. This paper investigated whether the association between depressive mood and obesity differs as function of sex, age, and race in US adults after controlling for socio-economic variables of martial status, employment status, income level and education level. METHODS: A total of 44,800 nationally representative respondents from the 2001 Behavioral Risk Factor Surveillance Survey were studied. Respondents were classified as having experienced a depressive mood if they felt sad, blue, or depressed at least for 1 week in the previous month. The depressive mood was operationalized in terms of duration and sustenance, both defined based on number of days with depressive mood: 7+ and 14+ days. Age groups were classified as young (18-64 years) and old (65+ years). Obesity status was classified as: not overweight/obese (BMI<25); overweight (25or=30). RESULTS: Prevalence of prior-month depressive mood was 14.3 and 7.8% for 7+ and 14+ days, respectively. Controlling for race and socio-economic variables, both young overweight and obese women were significantly more likely to have experienced depressive mood than nonoverweight/nonobese women. Young overweight, but not obese, men were significantly more likely to have experienced depressive mood than nonoverweight/nonobese men. Young obese women were also significantly more likely to have a sustained depressive mood than nonoverweight/nonobese women. For old respondents, depressive mood and its sustenance were not associated with obesity in either sex. DISCUSSION: The relationship between the depressive mood and obesity is dependent upon gender, age, and race. Young obese women, Hispanics in particular, are much more prone to depressive mood than nonobese women. Future studies testing associations between depression and obesity should be sensitive to the influence of these demographic and socio-economic variables.