Generalizability of pharmacologic and psychotherapy trial results for late-life unipolar depression.

OBJECTIVES: Despite evidence of low representativeness of clinical trial results for depression in adults, the generalizability of clinical trial results for late-life depression is unknown. This study sought to quantify the representativeness of pharmacologic and psychotherapy clinical trial results for late-life unipolar depression. METHOD: Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults from the United States population. To assess the generalizability of clinical trial results for late-life depression, we applied a standard set of eligibility criteria representative of pharmacologic and psychotherapy clinical trials to all individuals aged 65 years and older in NESARC with a DSM-IV diagnosis of MDE and no lifetime history of mania/hypomania (n = 273) and in a subsample of individuals seeking help for depression (n = 78). RESULTS: More than four of ten respondents and about two of ten respondents would have been excluded by at least one exclusion criterion in a typical pharmacologic and psychotherapy efficacy trial, respectively. Similar results (i.e.41.1% and 25.9%, respectively) were found in the subsample of individuals seeking help for depression. Excess percentage of exclusion in typical pharmacologic studies was accounted for by the criterion "significant medical condition". We also found that populations typically included in pharmacologic and psychotherapy clinical trials for late-life unipolar depression may substantially differ. CONCLUSION: Psychotherapy trial results may be representative of most patients with late-life unipolar depression in routine clinical practice. By contrast, pharmacologic clinical trials may not be readily generalizable to community samples.

Comorbidity of late-life depression in the United States: a population-based study.

OBJECTIVES: This study sought to determine the clinical and sociodemographic correlates and the treatment-seeking rate of major depressive disorder (MDD), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, among older adults and its association with comorbid psychiatric disorders and perceived health status. METHODS: Data were drawn from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey (N = 43,093) representative of the US population. RESULTS: Compared with participants aged 65 years and older without a 12-month diagnosis of MDD, those with MDD were more likely to have lifetime and 12-month comorbid psychiatric disorders. Except for lifetime dysthymia, we found no significant interaction between rates of current somatic comorbidity, lifetime and 12-month psychiatric comorbidity, and age groups. Compared with younger participants with a 12-month MDD, they had an older age at onset, reported a similar number of lifetime major depressive episodes and perceived health status, and had lower mental health service utilization rates. CONCLUSIONS: Current major depression in the elderly seems to be as disabling as in younger adults in terms of comorbid psychiatric disorders and impaired quality of life. Poorer prognosis of MDD in older adults might be explained by a lower perceived need of treatment, resulting in a lower rate of treatment-seeking behavior.

[Epidemiology of psychiatric disorders in elderly and their impact on somatic health]. / Troubles psychiatriques du sujet âgé : données épidémiologiques et morbi-mortalité associée.

Increasing life expectancy over the past half century results in higher demand for healthcare of the aging population, therefore adapting the health system to the needs. The prevalence of psychiatric disorders is high in the elderly, especially for depression. Several studies have shown that twenty percent of elderly residents of public facilities meet the criteria for major depressive episode. Depression is a major burden in the elderly, with increased risk of suicide, impaired quality of life and functional autonomy, consequences on somatic morbidity and elevated mortality rates. It is thus necessary to find out how to improve physicians' abilities to detect and treat depression in older adults. Moreover, use of psychotropic drugs is frequent and increases the risk of injury in this population more vulnerable to drug effects. It is also necessary to develop specific gerontopsychiatric wards in large general hospitals and nursing homes.

Personality disorders in older adults: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

OBJECTIVES: To examine the prevalence, sociodemographic correlates, psychiatric and medical comorbidities, and the disability of personality disorders among adults age 65 years and older. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, focusing on a subsample of 8,205 adults age 65 years and older. RESULTS: A total of 8.07% (SE: 0.37) of American adults age 65 years and older presented at least one personality disorder. The most prevalent personality disorder was the obsessive-compulsive personality disorder. The overall pattern of associations between each personality disorder and lifetime psychiatric comorbidity correlates was statistically significant. Participants with a personality disorder show a lower quality of life than their counterparts. CONCLUSIONS: Personality disorders in older adults are highly associated with disability, medical, and psychiatric disorders. These findings highlight the need to develop more effective prevention and intervention programs in this specific population.

Peritraumatic distress but not dissociation predicts posttraumatic stress disorder in the elderly.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a severe anxiety disorder whose symptoms include re-experiencing, avoidance, and hyperarousal after a particularly intense event. In view of the aging of the population, increased clinical knowledge is required for better understanding of PTSD in the elderly. Extending previous research in this field in adults and children, the aim of our study was to assess the utility of peri-traumatic dissociation and distress as a predictor of PTSD in the elderly. METHODS: A prospective longitudinal study was conducted in a consecutive cohort of subjects aged 65 years and over admitted to emergency departments after a physical assault or a road traffic accident. Peri-traumatic responses of distress and of dissociation were measured. One, 6, and 12 months after trauma exposure, PTSD symptoms and diagnosis were assessed using both a dimensional and a semistructured interview. RESULTS: Thirty-nine male and female participants with an average age of 72.4 years were recruited. Mixed model regression analyses did not detect a significant effect of age, sex, nor time. Significant associations were detected between peri-traumatic distress and the self-report PTSD Checklist (p = 0.008), as well as the Clinician-administered PTSD scale (p = 0.03). No association was detected between peri-traumatic dissociation and PTSD. CONCLUSIONS: Peri-traumatic distress predicts PTSD symptoms and diagnosis in the elderly, thereby suggesting its systematic evaluation at the emergency department would be a worthwhile thing to do.

Why does the lifetime prevalence of major depressive disorder in the elderly appear to be lower than in younger adults? Results from a national representative sample.

BACKGROUND: The explanation of the lower lifetime prevalence rate of major depressive disorder (MDD) in older adults compared to younger people in community surveys is debated. This study examines the hypothesis that the decrease of the lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression. METHODS: Data were derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a national representative sample of 43,093 adults of the United States population. We examined lifetime prevalence rates of pure MDD and MDD plus subthreshold hypomania (D(m)) by age, assuming that the lifetime prevalence of pure MDD in older adults would be similar to that in the youngest cohort, consequent to an inverse age-D(m) relationship. We further considered non-hierarchical MDD (i.e., general medical condition depressive disorders were not ruled out) with the same method. RESULTS: The lifetime prevalence of D(m) among depressed adults aged 65 years and over was substantially lower compared to the youngest group. When considering non-hierarchical MDD, the odds ratio of the lifetime prevalence estimates of non-hierarchical pure MDD in older adults compared to the youngest group appeared not significantly different from 1. CONCLUSIONS: Findings indicate that the decrease of lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression.