The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability

Gender differences in morbidity and mortality related to depression: a review of the literature

In this review of the existing evidence regarding a gender-specific association of depression with major health outcomes in older adults, we were unable to confirm that relative risk of morbidity and/or mortality due to depression varies with respect to gender. Future researchers may wish to concentrate their efforts in the identification of possible biophysiologic mechanisms underlying the association between depression and a variety of health outcomes.

The nosology of dementia

The nosology of dementia has evolved from the simple distinctions between senility, degenerative dementia, and vascular insults that existed a few decades ago. The differentiation of normal cognitive aging from very mild dementia has sharpened considerably; however, appreciation of the heterogeneity of Alzheimer's disease (AD) and its clinical and pathologic overlap with other dementing disorders has blurred previous classification systems. Rather than viewing AD and vascular dementia, for example, as dichotomous entities, it may be more relevant to consider their additive or synergistic interactions producing dementia. Further elucidation of the nature and contribution of genetic factors in AD and related disorders will accelerate the use of genotype-phenotype correlations in dementia classification.

Treatment preferences among depressed primary care patients

OBJECTIVE

To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

DESIGN

Patient questionnaires and interviews.

SETTING

Forty-six primary care clinics in 7 geographic regions of the United States.

PARTICIPANTS

One thousand one hundred eighty-seven English- and Spanish-speaking primary care patients with current depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P =.001) and had greater knowledge about antidepressant medication ( OR, 2.6; 95% CI, 1.6 to 4.4; P

CONCLUSIONS

Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

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Key Words

• depression
• primary care
• patient preferences
• treatment preferences

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MESH Headings

• Adolescent
• Adult
• Depression/classification
• Depression/diagnosis
• Depression/therapy
• Female
• Humans
• Interviews as Topic
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Satisfaction
• Primary Health Care
• Socioeconomic Factors
• Surveys and Questionnaires

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Grants

• R01 HS008349 AHRQ HHS
• K12 MH00990-01-01 NIMH NIH HHS
• HS08349-02 AHRQ HHS

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Affiliation(s)

M Dwight-Johnson Department of Psychiatry, University of Southern California, Los Angeles, Calif, USA.
C D Sherbourne
D Liao
K B Wells

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Depressed mood in a cohort of elderly medical inpatients: prevalence, clinical correlates and recognition rate

The objectives of this prospective cohort study were to 1) determine the prevalence of depressed mood, 2) identify the characteristics associated with it, and 3) evaluate the recognition rate of depressed mood by clinicians. The study population was a cohort of 401 elderly patients, aged 75 years and older, admitted to the internal medicine service of a tertiary care academic medical center in Western Switzerland over six months. We excluded patients with severe cognitive impairment, terminal disease or those living in a nursing home. Data on demographics, medical, physical, social and mental status were collected upon admission. Presence of depressed mood was defined as a score > or = 6 on the Geriatric Depression Scale (GDS), short form (15-item). An independent reviewer performed a discharge summary abstraction to assess recognition rate. Subjects' mean age was 82.4 years, 60.9% were women. Overall, 90 patients (22.40%) had an abnormal GDS score (> or =6). Compared to those without a depressed mood, these subjects were (all p<0.05) older (83.5 vs 82.0 years), more frequently living alone (66.7 vs 55.0%), dependent in both basic activities of daily living (BADL) and instrumental ADL (48.9 vs 36.0%, and 91.1 vs 84.9%, respectively), and cognitively impaired (47.8 vs 27.7% with MMSE score<24). In addition, they had more comorbidities (Charlson index 1.6 vs 1.2). In multivariate analysis, an independent association remains for subjects living alone (OR 1.8, 95%CI 1.1-3.0), with cognitive impairment (OR 1.9, 95%CI 1.1-3.2), and comorbidities (OR 1.3 per point, 95%CI 1.1-1.5). Detection rate during the index hospitalization was only 16.7% (15/90). In conclusion, depressed mood was frequent but rarely detected in this population. These findings emphasize the need to improve screening efforts, and to develop additional strategies such as using a pre-screening question to enhance clinical recognition.

Randomized trial of case-finding for depression in elderly primary care patients

OBJECTIVE

To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients.

DESIGN

Randomized controlled trial.

SETTING

Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics).

PARTICIPANTS

A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression.

INTERVENTIONS

Primary care physicians in the intervention clinics were notified of their patients' GDS scores. We suggested that participants with severe depressive symptoms (GDS score >/= 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6 -10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients' GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years.

MEASUREMENTS AND MAIN RESULTS

Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS >/= 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P =.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P =.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P =.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (-2.4 +/- SD 3.7 vs -2.1 SD +/- 3.6; P =.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 +/- SD 3.1 vs 1.6 +/- SD 2.8; P =.5) or mean number of hospitalizations (1.1 +/- SD 1.6 vs 1.0 +/- SD 1.4; P =.8) during the 2-year period. In participants with initial GDS scores > 11, there was a mean change in GDS score of -5.6 +/- SD 3.9 for intervention participants (n = 13) and -3.4 +/- SD 4.5 for control participants (n = 21). Adjusting for differences in baseline characteristics between groups did not affect results.

CONCLUSIONS

We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression.

[Depression in the elderly and the role of family dynamics]

OBJECTIVE

The objective was to find the relationship between the lived experience within the family and depression in the elderly.

DESIGN

The study had a crossover and descriptive design.

SETTING

Carranque and Campanillas Health Districts, Málaga.

PATIENTS

The target population was the over 65's. The sample consisted of 97 people attended at 2 health centres, one rural and one urban.

MEASUREMENTS AND MAIN RESULTS

The main study variable was the results on the Yesavage Geriatric Depression Scale (GDS), which were contrasted through multiple linear regression with the variables of age, sex, marital status, tobacco dependency, number of people living together, presence of the children in the home (concretely, daughters), family income, ownership of the home, social support network, and Apgar Family II. The results showed that the GDS correlated only with the results of the Apgar Family II (p = 0.00003).

CONCLUSIONS

When tackling the depression of elderly people in primary care, it is absolutely vital to look at the family context, as this is a factor strongly linked to the depression.