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Recent
Published and Unpublished Research Findings
Investigators
in related fields may find the results cited below to be useful.
However, some of the studies have not completed the peer review process.
For this reason, these findings may not be quoted.
A
- Mechanisms
B
- Medical Comorbidity
C - Disability
D - Suicidal Ideation
E - Depressive Disorders in Non-Psychiatric Patients
1.
Social Support
2. Adherence
3. Primary Care Physicians
4. Homecare Nurses
5. Clergy
H
- Methodology Studies
A
- Mechanisms
1.
Clinical Presentation
Non-demented
patients with the “depression-executive dysfunction syndrome” of
late life have more psychomotor retardation, loss of interest and
suspiciousness compared to cognitively unimpaired elderly depressives.
In
elderly patients with late onset depression, those with history
or presence of vascular disease had more difficulty in understanding
the nature of their illness and greater cognitive impairment. There
was a trend for greater psychomotor retardation and abnormal score
of initiation-perseveration in patients with vascular disease. These
findings suggest that “vascular depression” is characterized by
symptomatology indicative of striatofrontal dysfunction.
In elderly patients with major depression and cognitive impairment
ranging from mild dementia to unimpaired cognition, clinical symptoms
(psychomotor retardation) and neuropsychological findings (executive
dysfunction) associated with striatofrontal dysfunction were predictors
of disability. The relationships were also observed in non-demented
depressed patients.
In elderly non-demented patients with major depression, depression
was associated with IADL impairment mainly in-patients with impaired
initiation/perseveration. Depression did not contribute significantly
to disability in-patients with unimpaired executive functions.
2.
Course of Geriatric Mood Disorders
In depressed patients abnormal initiation/perseveration score on
the Mattis Dementia Rating scale, psychomotor retardation, and long
P300 latency predicted 58% of the variance in change of depression
scores from baseline to 6 weeks during acute antidepressant drug
treatment. Depressed patients who remained symptomatic had more
abnormal IP scores and longer P300 latency compared to depressed
patients who achieved remission and to control subjects.
Compared to responders and control subjects, non-responders to 6-week
treatment with citalopram, sertraline, or nortriptyline had longer
latency and larger amplitude for the error negative wave at the
left frontal sites than the right frontal sites. The association
of a left frontal error negative wave deficit with poor response
to treatment was not explained by differences in clinical characteristics,
neuropsychological Stroop performance, or treatment intensity between
responders and non-responders.
In manic elderly patients, lateral ventricle enlargement noted to
be greater scores larger in geriatric manic patients with less response
to inpatient treatment.
In recovered elderly patients initially diagnosed with major depression,
executive dysfunction, but not memory impairment, was a predictor
of relapse, recurrence and fluctuations of depressive symptomology
over time.
In depressed elderly patients, low caudate volume was associated
with less change in depression scores during nortriptyline (NT)
treatment.
In depressed patients with major depression, high frontal deep white
matter signal hyperintensity scores were associated with poor antidepressant
response to nortriptyline (NT).
In geriatric manic patients, low caudate volume was associated with
limited change in mania rating scale scores after treatment.
3.
Structural Neuroimaging
In depressed elderly patients, low caudate volume was associated
with less change in depression scores during nortriptyline (NT)
treatment.
In depressed elderly patients, low caudate volume was associated
with greater motor side-effects of nortriptyline (NT).
In depressed patients with major depression, high frontal deep white
matter signal hyperintensity scores were associated with poor antidepressant
response to nortriptyline (NT).
In depressed elderly patients, frontal deep white matter signal
hyperintensity scores were associated with motor side effect of
nortriptyline (NT).
In geriatric manic patients, low caudate volume was associated with
limited change in mania rating scale scores after treatment.
Geriatric manic patients show more bifrontal deep white matter hyperintensities
than elderly control subjects, and in controls age is associated
with right more than with left prefrontal white matter hyperintensities.
In manic elderly patients, lateral ventricle enlargement noted to
be greater scores larger in geriatric manic patients with less response
to inpatient treatment.
4.
Functional Neuroimaging
Resting H2 15O PET scans of depressed elderly
patients show decreased regional cerebral blood flow in the left
and increased flow in right prefrontal cortex compared to control
subjects who show increased blood flow in the left compared to the
right prefrontal cortex.
Compared to control subjects, depressed elderly patients showed
decreased bilateral anterior cingulate and hippocampal activation
on H2 15O PET scans performed during administration
of a paced word generation task.
5.
Electrophysiology
Impairment in executive functioning and long P300 latency were greater
in geriatric depressed patients than in control subjects. Measures
of speeded executive performance in depressed patients and control
subjects were found to correlate with P300 latency.
The latency of the error negative wave component of the evoked response
elicited by the Stroop Color Interference task was longer in symptomatic
depressed elderly patients than in control subjects.
In depressed patients abnormal initiation/perseveration score on
the Mattis Dementia Rating scale, psychomotor retardation, and long
P300 latency predicted 58% of the variance in change of depression
scores from baseline to 6 weeks during acute antidepressant drug
treatment. Depressed patients who remained symptomatic had more
abnormal IP scores and longer P300 latency compared to depressed
patients who achieved remission and to control subjects.
Compared to responders and control subjects, non-responders to 6-week
treatment with citalopram, sertraline, or nortriptyline had longer
latency and larger amplitude for the error negative wave at the
left frontal sites than the right frontal sites. The association
of a left frontal error negative wave deficit with poor response
to treatment was not explained by differences in clinical characteristics,
neuropsychological Stroop performance, or treatment intensity between
responders and non-responders.
B
- Medical Comorbidity
In a study of elderly patients receiving homecare, major depression
was significantly associated with greater medical morbidity as measured
by the Charlson Comorbidity Scale. The prevalence of depression
was significantly higher in patients having myocardial infarction,
peripheral vascular disease, and end-organ diabetes.
Depressed elderly patients receiving homecare reported greater disability
than non-depressed patients in the areas of self-care, mobility,
and complex activities.
Patients of general medical practices with depressive disorders
have a higher medical burden than medical patients without depressive
disorders.
General medical patients with depression have a higher average burden
of comorbid medical illness, but lower Hamilton Depression Rating
Scale scores, than elderly depressives treated in psychiatric settings.
Elderly primary care patients with depression are more likely to
have nonspecific medical diagnoses (e.g., back pain, constipation)
than patients without depression.
Data from minority (Asian-American, Latino and African-American)
inner-city primary care clinic patients demonstrate that high Center
for Epidemiologic Studies'—Depression Scale (CES-D) scores are significantly
associated with poor perceived health status. High acculturation
scores are also associated with decreased Provider recognition of
depression.
C
- Disability
In elderly patients with major depression and cognitive impairment
ranging from mild dementia to unimpaired cognition, clinical symptoms
(psychomotor retardation) and neuropsychological findings (executive
dysfunction) associated with striatofrontal dysfunction were predictors
of disability. The relationships were also observed in non-demented
depressed patients.
In elderly non-demented patients with major depression, depression
was associated with IADL impairment mainly in-patients with impaired
initiation/perseveration. Depression did not contribute significantly
to disability in-patients with unimpaired executive functions.
Among five specific cognitive impairments, executive dysfunction
is the strongest contributor to IADL impairment.
In depressed elderly patients, depressive ideation and anxiety contribute
to disability directly, while psychomotor retardation and loss of
interest have a pronounced effect in the context of executive dysfunction.
Depressed elderly patients receiving homecare reported greater disability
than non-depressed patients in the areas of self-care, mobility,
and complex activities.
D
- Suicidal Ideation
During the initial evaluation of elderly patients with major depression,
severity of depression and previous attempts with serious intent
predicted closely the course of suicidal ideation (concordance correlation,
0.78). During follow-up (mean 1.8 years), contemporaneous severity
of depression was the most important determinant of suicidal ideation
over time (concordance correlation, 0.88).
In a study of elderly patients requiring homecare, 14.7% of the
participants reported suicidal ideation (i.e., wanted to die or
had thoughts of suicide) at their baseline interview. 1% reported
a plan and/or the intent to commit suicide, indicating high suicide
risk. For these patients, as well as several patients identified
as high suicide risk at either the one month or one year follow-up
interview, the study initiated high-risk procedures by notifying
the home health agency, family, and patients’ physicians.
In a study of elderly patients receiving homecare, suicide ideation
was associated with major and minor depression, although approximately
25% of the patients with suicidal ideation had no depression. Other
factors significantly associated with suicide ideation included
feelings of worthlessness, hopelessness, impairment in Activities
of Daily Living (ADL), restricted mobility, medical morbidity,
and pain. Suicide ideation was associated with major depression,
minor depression and ADL disabilities. These data suggest that
depression mediates the impact of pain, medical illness, and impaired
functioning on suicide ideation.
E
- Depressive Disorders in Non-Psychiatric Patients
1.
Major Depression in Non-Psychiatric Patients
Among inpatients hospitalized in a pulmonary rehabilitation center
for COPD, 30% had major or minor depression.
Among patients referred to home care with the primary diagnosis
of COPD, the prevalence of major and minor depression was 30%, similar
to that of COPD patients of a pulmonary rehabilitation center.
In a representative sample of 539 newly admitted elderly home care
patients, the point prevalence of major depression (DSM-IV criteria)
was 13.6%. Rates of depression did not vary by age, gender, race,
marital status or living situation.
Patients referred to home care because of hip fractures or other
injuries had significantly lower rates of major depression than
patients referred for other medical conditions (6.7% vs. 15.2%;
p<.02).
In a pilot study assessing religious beliefs and practice of home
care patients depression was negatively associated with belief in
life after death: 13.6% of participants reporting this belief had
a DSM-IV diagnosis of depression compared to 37% of those who did
not. Belief in life after death did not vary by religious denomination
and remained negatively associated with depression when controlling
for health status and religious practice.
In elderly patients receiving home care, major depression was not
associated with either MMSE or the diagnosis of dementia, but depressed
patients did perform more poorly on the Initiation-Perseveration
subscale of the Mattis Dementia Rating Scale.
2.
Subsyndromal Depression in Non-Psychiatric Patients
Among inpatients hospitalized in a pulmonary rehabilitation center
for COPD, 8.7% met criteria for minor depression.
Primary care patients with major or minor depression have higher
severity of depression, lower scores in the positive affect scale,
more current suicidal ideation, and greater scores of neuroticism
compared to subjects with high CES-D scores and no depression diagnoses.
Primary care patients with CES-D scores higher than 20 but no diagnosis
of depression had similar scores in anxiety, history of suicidal
ideation, negative affect, disability, social interactions, optimism,
and subjective and instrumental social support with patients with
major or minor depression.
Patients with high CES-D and no depression diagnoses had more symptoms
of depression and anxiety, less positive affect, lower optimism,
greater perceived and actual disability than patients with CES-D
below 21. These findings suggest that distressed elderly primary
care patients require clinical attention even when they do not meet
criteria for depression.
F
- Health Care Utilization
Elderly medical patients with diagnosed depressive illness have
a higher utilization of outpatient medical resources (increased
visits, increased test use, and increased consults) than patients
without depression, after adjustment for medical comorbidity.
Depression after bypass surgery predicts a greater than three-fold
increase in health services use and mortality rate over a three-year
follow-up.
Depressed elderly primary care patients receive a greater number
of medications, have more outpatient visits and longer hospital
stay when admitted than non depressed patients.
In primary care patients, age predicts increased utilization of
services controlling for anxiety sensitivity and gender. In primary
care patients, anxiety sensitivity predicts increased utilization
of services after controlling for age and gender.
G
- Treatment Effectiveness
1.
Social Support
Depressed home care patients did not differ from non-depressed patients
in reported social network size or the amount of received instrumental
or emotional support. However, specific aspects of social support
among elderly homecare patients were associated with depression.
Subjective support was associated with a diagnosis of major depression
and with depression severity, and satisfaction with instrumental
support was associated with depression severity.
For elderly outpatients presenting with major depression, both subjective
and instrumental social support predicted symptom remission.
2.
Adherence
Among newly older outpatients who started pharmacotherapy for major
depression, 25% discontinued treatment within the first six weeks.
In a mixed age sample of outpatients, younger adults reported higher
perceived stigma at intake than older adults. However, in older
adults, higher stigma on admission predicted treatment discontinuation.
In a prospective study of newly admitted depressed outpatients,
patients with higher self-rated illness severity and lower stigma
were more adherent to the recommended antidepressant treatment for
depression.
3.
Primary Care Studies
Only 29% of primary care patients diagnosed as depressed by their
primary care physicians were on antidepressant medications, but
44% had been offered treatment and refused.
There is a high concordance (76% agreement rate) between a primary
care physicians' diagnoses of depression and Hamilton Depression
Rating Scale scores of 12 or greater
Medical
patients with major depression have lower levels of depressed mood,
guilt and psychic anxiety compared to age- and gender-matched psychiatric
patients with similar overall severity of depressive symptomatology.
These clinical characteristics of medical patients may, in part,
explain the low frequency of antidepressant treatment offered in
primary care settings.
4.
Homecare Studies
The nurses providing home care recognized depression in 50% of patients
with depression. Nurses also labeled as depressed 27% of non-depressed
patients.
Homecare
nurses identify depression with accuracy similar or better than
other health care providers.
Nurses accurately identified 49% of depressed patients and also
labeled as depressed 27.6% of the patients without SCID diagnosis.
A survey study revealed that 69% of homecare nurses do not believe,
based on their experience, that antidepressants alone are effective
in treating depression in the elderly. Forty-eight percent do not
believe that psychotherapy/counseling combined with antidepressant
medication is effective in treating depression in the elderly.
Pilot data suggest that an educational intervention can improve
management of depression in the homebound elderly by Homecare Nurses.
5.
Clergy Studies
In a national survey of rabbis and psychologists, rabbis reported
that 35% of members of their congregation are over 50 years old,
whereas psychologists reported that 7% of their clients were over
50 years of age.
In a national survey of rabbis and psychologists, rabbis reported
significantly greater experience than psychologists in counseling
people on issues of death and dying.
H
- Methodology Studies
A sensitive Expanded Initiation/Perseveration scale was developed.
The scale eliminated the ceiling effect noted for the Initiation/Perseveration
subscale of the Mattis Dementia Rating Scale.
In a representative sample patients 60 years or older from 6 primary
care practices located in New York City and Westchester County,
NY., the sensitivity and specificity of the Center for Epidemiologic
Studies'—Depression Scale (CES-D) for major or minor depression
was 100% and 58%, respectively.
In primary care patients, the specificity of the CES-D for major
or minor depression did not differ by gender, age, or education,
but was greater in high vs. low income (70% vs. 47%) and white vs.
black patients (65% vs. 45%). In multivariate models, both race
and income contributed to specificity.
The predictive value of the CES-D’s 4 subscales varied by socioeconomic
status. Only depressed mood uniformly predicted depression. The
positive affect and somatic subscales predicted diagnosis in high
income patients only. The interpersonal subscale was negatively
related to depression in white patients only.
The Charlson Comorbidity Score (CCS) and the Cumulative Illness
Rating Scale—Geriatric (CIRS-G) are responsive to significant changes
in comorbid medical conditions over time, while the Chronic Disease
Score is not. The CCS or the CIRS-G are thus preferred measures
if comorbidity is to be considered as both a baseline and dynamic
variable.
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