MRI and neuropsychological differences in early- and late-life-onset geriatric depression

Subcortical lesion severity and orbitofrontal cortex volume in geriatric depression

Previous studies have shown a reduction of orbital frontal cortex volume and an increase in magnetic resonance imaging signal hyperintensities in geriatric depression. We aimed to assess the relationship between subcortical gray- and deep white-matter lesions and orbital frontal cortex volume in elderly depressives and controls. The study included 41 elderly depressed patients and 41 age-matched control subjects. The orbital frontal cortex volume was measured in both hemispheres using a standardized MRI procedure. Signal hyperintensities were rated on (T2)-weighted MRI with qualitative lesion analyses performed according to an established hyperintensity classification system. After controlling for total cerebral hemisphere, age and sex, the geriatric depressed subjects had significant reduction in orbital frontal cortex volume and compared with the control group. Multiple linear regression modeling indicated that reduced orbital frontal cortex volumes were significantly associated with increased subcortical gray-matter lesions. Our study confirmed the reduction of OFC volume in geriatric depressed subjects. We also suggest that subcortical lesions may decrease OFC volume. Further studies are needed to understand how subcortical lesions may be related to OFC volume changes.

Apathy and cognitive performance in older adults with depression

OBJECTIVES

Recent studies have linked apathy to frontal lobe dysfunction in persons with dementia, but few studies have explored this relationship in older, depressed persons without dementia. We examined the association between apathy and cognitive function in a group of older persons with major depression using standardized neuropsychological tests. We hypothesized that presence of apathy in depression is associated with poorer frontal executive performance.

METHODS

We analyzed data from 89 older adults with major depression. We defined apathy using four items from the Hamilton Psychiatric Rating Scale for Depression which reflect the clinical state of apathy, including 'diminished work/interest,' 'psychomotor retardation,' 'anergy' and 'lack of insight.'

RESULTS

Apathy most strongly correlated with two verbal executive measures (Stroop C and FAS), a nonverbal executive measure (Wisconsin Card Sorting Test-Other Responses), and a measure of information processing speed (Stroop B). Apathy was not associated with age, sex, education, medical illness burden, Mini-Mental State Examination score and Full Scale IQ score. Stepwise regression analyses of significant cognitive tests showed that apathy alone or apathy plus depression severity, age, or education accounted for a significant amount of the variance.

CONCLUSIONS

The results of this study provide support for an apathy syndrome associated with poorer executive function in older adults with major depression.

Localization of age-associated white matter hyperintensities in late-life depression

OBJECTIVE

Deep white matter hyperintense lesions are associated with advanced age and late-life depression. The authors examined where age-related cerebral lesions occurred in elderly depressed and healthy control subjects.

METHODS

Eighty-seven depressed subjects and 47 control subjects underwent 1.5 T cranial magnetic resonance imaging (MRI). Utilizing a semiautomated method, a segmented image was created containing only white matter lesions. We created a statistical parametric map (SPM) separately for each subject group that displayed the association between lesions in any voxel and advanced age.

RESULTS

The SPM analysis in depressed subjects demonstrates a significant association between age and lesions found in bilateral, frontal, and left parietal regions. The analysis in control subjects found significant associations only in bilateral parieto-temporal regions, not frontal regions.

CONCLUSIONS

This study demonstrates a different pattern of age-related lesion location between depressed and control subjects. It further supports the theory that frontostriatal disconnection contributes to late-life depression.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

Deep white matter hyperintensities in patients with bipolar depression, unipolar depression and age-matched control subjects

OBJECTIVE

Hyperintensities in the white matter of the brain (DWH) and in the periventricular area (PVH) seen on magnetic resonance imaging (MRI) have been reported to be more frequent in patients with bipolar disorder (BP) than in normal subjects. To examine this further we compared MRI of patients with BP with age-matched patients with major depressive disorder (unipolar depression, UP) and healthy control subjects.

METHODS

T2 weighted axial and coronal brain MRI scans were obtained from 13 patients in the depressive phase of BP, 11 with current UP and 19 age-matched control subjects. The degree of DWH and PVH present in each scan was determined using a standardized scoring method.

RESULTS

The PVH ratings were similar in the three groups of subjects. However, proportionately more BP patients had higher DWH scores than either UP patients or controls. Although this difference did attain statistical significant, a main effect of age was noted. Further, subjects over the age of 50 were under-represented in the UP group.

CONCLUSIONS

Notwithstanding the small total sample size and relative lack of older subjects in the UP group, the fact that almost twice as many BP patients showed more severe DWH suggests that patients with BP may be more vulnerable to develop these changes than UP patients and healthy controls.

MRI subcortical hyperintensities in old and very old depressed outpatients: the important role of age in late-life depression

OBJECTIVE

There is increasing evidence that cerebrovascular factors play a key role in the etiology of late-life depression. This study examined the severity of subcortical hyperintensities (SH) and the relationship between SH and depression characteristics in two samples of elderly depressed outpatients differing in age.

METHODS

The samples consisted of 59 subjects age 60 and over, (69+/-5.6 years), who participated in a trial of sertraline, and 111 subjects age 75 and over, (79+/-4.1 years), who participated in a trial of citalopram.

RESULTS

The citalopram group was significantly older than the sertraline group and had more severe SH (72% vs. 42% high ratings). The High SH group was significantly older than the Low SH group in the sertraline study but there was no difference in age in the SH groups in the citalopram sample. There was no relationship between SH severity and baseline depression or age of onset. However, age strongly correlated with later age of onset. There was no relationship between SH severity and cardiovascular risk factors or treatment response in the sertraline sample.

CONCLUSION

Age is a major factor for the development of SH and late-life depression. There may not be an association between SH and depression severity, cardiovascular risk factors, or treatment response in geriatric depressed outpatients. The etiologic factors and clinical course of late-life depression requires further study.

Age-related white matter changes and cognitive impairment

Age-related white matter changes (WMC) are a frequent finding in CT/MRI of older subjects. The role of WMC in cognitive impairment has been studied in community-dwelling and healthy old people, subjects with vascular risk factors, stroke patients, depressed and demented subjects. Although there are several negative studies, the majority of the evidence points towards an association between WMC and cognitive impairment. Speed of mental processes, attention, concentration, executive functions and visual spatial skills are the cognitive domains more commonly affected. The methodological problems of the negative studies are discussed, a number of unsolved issues are raised stressing the need for longitudinal studies of WMC with a adequate inception cohort.

Cognitive associations of subcortical white matter lesions in older people

Hyperintense lesions (HL), as visualized on T2-weighted or FLAIR MRI, are a common finding in older people, but their clinical significance and influence on cognitive function remain to be clarified. We investigated the relationship between HL in deep white and gray matter structures and cognition in older subjects. We recruited 154 nondemented (Mini-Mental State Examination > 24) subjects (79 males) over the age of 70 from primary care (103 subjects with mild hypertension and 51 normotensive subjects). All subjects underwent FLAIR and proton density and T2-weighted axial 1.5-tesla MRI scans (slice thickness: 5 mm). The scans were rated for the presence and distribution of HL in the subcortical gray matter (caudate, putamen, globus pallidus, thalamus) and associated white matter tracts (internal/external capsule). Subjects (n = 149) underwent a comprehensive cognitive assessment involving tests of attention, processing speed, episodic memory, working memory, and executive function. Partial correlations (correcting for age, systolic blood pressure, and New Adult Reading Test [NART] score) were performed to investigate the relationship between cognition and white matter change. HL were found in 49% of subjects. HL in both the gray (thalamus and caudate) and white matter were significantly associated with impaired cognitive function in tasks involving processing speed and/or executive function, but showed no associations with episodic or working memory. HL in both subcortical gray matter structures and associated fiber tracts correlate with impairments in attention, executive function and processing, and memory retrieval speed in nondemented older community-dwelling subjects. Such lesions may be an important cause of age-related attentional and executive dysfunction in the elderly, as well as temporal lobe and hippocampal changes that have previously been reported to be associated with impairments to the ability to actually store and retrieve information from memory.

Is late onset depression a prodrome to dementia?

BACKGROUND

Recent research suggests there are clinical and biological differences between late onset depression (LOD) and early-onset depression (EOD).

OBJECTIVES

In this paper we review clinical, epidemiological, structural neuroimaging and genetic investigations of late life depression that have been performed over the past two decades and offer evidence that LOD is often a prodromal disorder for dementia.

RESULTS

LOD patients are more likely to have cognitive impairment and to have more deep white matter lesions (DWMLs). Evidence concerning cortical and temporal lobe atrophy is conflicting, while the ApoE 4 allele is not associated with LOD.

CONCLUSIONS

It is likely that LOD is not a prodrome for a particular type of dementia, but the majority of patients who do develop dementia will acquire Alzheimer's disease (AD) or a vascular dementia, as these are by far the most common causes of dementia. This issue requires further clarification with follow-up of patients over the long term.

Anatomic location and laterality of MRI signal hyperintensities in late-life depression

OBJECTIVES

Evidence is mounting linking cerebrovascular disease with the development of major depression in the elderly. Lesions in both white and gray matter have been associated with geriatric depression. In addition, the literature on poststroke depression suggests that left-sided lesions are associated with depression. We sought to examine the severity and location of white- and gray-matter lesions in a group of elderly depressives and nondepressed control subjects.

METHOD

115 depressed patients (69 with late onset, 46 with early onset) and 37 controls, all over age 45, received magnetic resonance imaging (MRI). Semiquantitative severity ratings and quantitative measurements of number and size of MRI hyperintensities were obtained, and groups were compared using Cochran-Mantel-Haenszel (CMH) analyses and repeated-measures analyses of covariance adjusting for age.

RESULTS

Late-onset depressed patients had more severe hyperintensity ratings in deep white matter than early-onset patients and controls. Late- and early-onset patients had more severe subcortical gray-matter hyperintensities (particularly in the putamen) compared with controls. Left-sided white-matter lesions were significantly associated with older age of depression onset, whereas right-anterior white matter and left-subcortical lesions (particularly in the putamen) were associated with melancholia in the depressed group.

CONCLUSION

These findings extend previous reports of an association between cerebrovascular disease and depression, as well as recent studies showing lateralized lesion involvement in geriatric depression. Such vascular pathology may disrupt neural pathways involved in affective processing and the maintenance of a normal mood and psychomotor state.

The relationship of MRI subcortical hyperintensities to treatment response in a trial of sertraline in geriatric depressed outpatients

The authors examined differences in antidepressant treatment response in geriatric outpatients with high vs. low levels of magnetic resonance imaging (MRI)-defined subcortical hyperintensities (SH). Participants included 59 outpatients with mild-to-moderate depression (mean age: 69+/-5.63 years; mean Hamilton Rating Scale for Depression score: 21+/-2.88) who participated in a placebo-controlled trial of sertraline and underwent a standardized brain MRI. Results revealed that the high-SH group was significantly older than the low-SH group but, contrary to the hypothesis, antidepressant treatment response did not differ between the high- and low-SH groups. The association between SH and antidepressant treatment response in depressed geriatric outpatients remains unclear and deserves further investigation.

Vascular basis of late-onset depressive disorder

BACKGROUND

Growing evidence suggests that there may be a subtype of depression arising in later life that is characterised by a distinct clinical presentation and an association with cerebrovascular disease. This has been termed 'vascular depression'.

AIMS

To review the evidence for associations between cardiovascular disease and depression and between cerebrovascular disease and depression, and to examine implications for clinical practice and research.

METHOD

The authors reviewed the medical literature covering the past 5 years.

RESULTS

There is strong evidence for an association between cardiovascular disease and depression, but this is not confined to older people. The causal pathway may be bi-directional. There is also a convergence of evidence suggesting a causal link between cerebrovascular disease and depression, especially that occurring later in life. The major focus has been on neuroradiological findings thought to be due to vascular disease, although the pathology may be heterogeneous.

CONCLUSIONS

Although there are gaps in the evidence there is strong support for the concept of vascular depression, characterised by reduced depression ideation, subcortical neurological dysfunction, apathy and psychomotor change. This has implications for both treatment and prevention.

Structural changes in the brain in depression and relationship to symptom recurrence

Depression is an important public health problem affecting about 15% of the general population; however, little is known about possible changes in the brain that might underlie the disorder. Neuroimaging has been a powerful tool to map actual changes in the brain structure of depressed patients that might be directly related to their symptoms of depression. Some imaging studies of brain structure have shown smaller hippocampal volume with the chronicity of depression correlating to a reduction in volume. Although the meaning of these findings is unclear, other studies have shown increased amygdala volume. Studies have found reductions in volume of the frontal cortex, with some studies showing specific reductions in subregions of the frontal cortex, including the orbitofrontal cortex. Findings of an increase in white matter lesions in elderly patients with depression have been replicated and correlated with late-onset depression, as well as impairments in social and cognitive function. These findings point to alterations in a circuit of brain regions hypothesized to include the frontal cortex, hippocampus, amygdala, striatum, and thalamus, that underlie symptoms of depression.

Early and late onset depression in old age: different aetiologies, same phenomenology

BACKGROUND

Phenomenological differences between older patients with early onset (EO; onset of first major depressive episode before 60 years) and late onset (LO) depression have been inconsistent but, if real, may reflect differences in aetiology. We aimed to compare aetiological factors, phenomenology and cognitive function in older patients with depression by age of onset.

METHODS

Subjects were all patients > or =60 years old (n=73) from 407 consecutive attenders to a Mood Disorders Unit, diagnosed with DSM-III-R Major Depressive Episode, at or close to the nadir of their episode. Putative risk factors were assessed by structured interview. Psychological morbidity and depressive symptoms were assessed by the 21-item Hamilton Rating Scale for Depression, CORE rating of psychomotor disturbance, Newcastle Endogeneity Scale, Zung Depression Scale and General Health Questionnaire. Cognition was assessed by tests of memory, attention, executive function and motor speed.

RESULTS

Personality abnormalities, a family history of psychiatric illness and dysfunctional past maternal relationships were significantly more common in EO depression. The two age of onset groups were essentially similar in terms of depressive sub-type and severity, phenomenology, history of previous episode, and in neuropsychological performance.

LIMITATIONS

Use of self-report data, moderate sample size, sample not age-matched, tertiary referral patients.

CONCLUSIONS

EO and LO depression are similar phenotypically, but differ aetiologically. The pursuit of mechanisms which predispose depressive episodes may be heuristically more valuable than further investigation of individual depressive features in distinguishing early from late onset depression.

Evidence of white matter tract disruption in MRI hyperintensities

BACKGROUND

Diffusion tensor imaging (DTI) of brain tissue measures the apparent diffusion coefficient (ADC), or isotropic diffusion, and anisotropy, or diffusion as influenced by tissue structure. We hypothesized that hyperintensities, when compared with normal tissue by DTI, would show evidence of damage through an increased ADC and decreased anisotropy. We also hypothesized that DTI changes in hyperintensities would be similar between depressed subjects and control subjects.

METHODS

Fourteen depressed geriatric patients and nineteen control subjects received DTI. The ADC and aniso-tropy of normal tissue from standard regions were compared with hyperintensities from these regions. The Students' t test compared individual regions and averaged white matter results.

RESULTS

Hyperintensities showed higher ADC and lower anisotropy than normal regions. Gray matter exhibited similar trends. There was no significant difference in diffusion characteristics of hyperintensities between subjects and control subjects.

CONCLUSIONS

Hyperintensities damage the structure of brain tissue, and do so comparably in depressed subjects and control subjects.

Single photon emission computed tomography, magnetic resonance imaging hyperintensity, and cognitive impairments in patients with vascular dementia

BACKGROUND

The relationship between subcortical hyperintensity (SH) on magnetic resonance imaging (MRI), cortical perfusion on single photon emission computed tomography (SPECT), and cognitive function is not well understood. The authors examined these relationships in individuals with vascular dementia (VaD), paying particular attention to frontal lobe function to determine whether the presence of SH on MRI was associated with frontal hypoperfusion on SPECT, which in turn would be associated with impairments of executive-attention function.

METHODS

Patients with vascular dementia (n = 26) were assessed on neurocognitive tests and brain MRI and SPECT. SH volume was quantified from the axial T2-weighted fluid attenuated inversion recovery MRI. Total counts of activation across voxels for 12 cortical regions of interest were determined from SPECT. Perfusion ratios of both total cortical and frontal activation relative to cerebellum activation were derived, and regression analyses were performed to determine the relationships between cognitive, MRI, and SPECT indices.

RESULTS

SH volume on MRI was significantly associated with frontal lobe perfusion, but not with global cortical perfusion as measured by SPECT. Frontal lobe perfusion did not consistently correlate with performance on measures of executive-attention function, although both total and frontal perfusion ratios were significantly associated with other cognitive functions.

CONCLUSIONS

These results suggest that a functional "disconnection" between the frontal lobes and subcortical structures does not fully account for the magnitude of global cognitive impairment in VaD. Cortical perfusion as measured by SPECT appears to be associated with cognitive performance, but not specifically executive-attention dysfunction. Additional studies are needed to further examine the relationship between subcortical and cortical function in VaD.

Structural neuroimaging studies in late-life depression: a review

Which patients presenting with depression in late life will progress to a dementia syndrome has been an important research question in recent times. In this paper we review selectively structural neuroimaging investigations of late-life depression (LLD) that have been performed over the past two decades. These studies indicate that there are neuroimaging changes commonly observed in LLD patients when compared to normal controls. Findings include ventricular enlargement and sulcal widening, and reduction in volume size of frontal lobes, hippocampus and caudate nucleus. White matter lesions are more common in depressed subjects and tend to be more severe. Some studies report these changes to be more pronounced in patients who present with late-onset depression (LOD) but this has been contradicted by other studies. Preliminary work suggests that these changes may be associated with a poor prognosis but there is a dearth of systematic, well-controlled longitudinal studies.

The association between depressive symptoms and cognitive decline in community-dwelling elderly persons

OBJECTIVE

To investigate whether depressive symptoms predict specific types of cognitive decline in order to elucidate the association between late life depression and cognitive decline.

BACKGROUND

Mechanisms underlying the association between late life depression and cognitive decline are still unclear.

METHOD

Six hundred and forty-one elderly persons of the Longitudinal Aging Study Amsterdam (LASA) aged 70-85 were examined by means of two measurement occasions over a period of 3 years. Depressive symptoms were assessed by means of the CES-D. Various cognitive functions were examined using neuropsychological tests.

RESULTS

Depressive symptoms were associated with decline in speed of information processing over a 3-year period, whereas there was no association between depression and increasing memory impairment or global mental deterioration.

CONCLUSION

These findings suggest that depressive symptoms are associated with subcortical pathology, most probable white matter lesions.

Depression in late life, cognitive decline and white matter pathology in two clinico-pathologically investigated cases

CASE REPORTS

We report two cases of late life depression who became progressively more resistant to treatment, developed cognitive impairment, and began to exhibit neurological abnormalities and evidence of vascular disease. A discussion of the clinical features of the cases is accompanied by reports of neuropathology and neuroimaging findings. Extensive white matter lesions were present on computed tomography in both patients, and basal ganglia infarcts were seen in one. Neuropathology revealed evidence of cerebral atrophy, demyelination and white matter lesions in addition to cerebrovascular and generalised vascular disease. Neither patient exhibited Alzheimer pathology outwith the norm for their age. We believe this to be the first report of neuropathological findings in depression with white matter changes.

LITERATURE REVIEW

The pathological basis of white matter lesions and their relationship to depression, its age of onset and clinical features is addressed in relation to the cases described. Pathological investigation of white matter lesions has not previously been carried out in depression and hypotheses regarding their nature in this illness are based on extrapolation from research in a variety of other disorders. The association of depression with vascular risk factors is considered, as is the relationship between depression and cognitive deficits. There is a need for further investigation in this area.

Cognitive impairment in depression is not associated with neuropathologic evidence of increased vascular or Alzheimer-type pathology

BACKGROUND

Cognitive impairment is common in depression, but underlying mechanisms remain unknown. We examined whether increases in Alzheimer-type or vascular pathology are associated with cognitive impairments in elderly depressed subjects.

METHODS

Eleven subjects who had died during a well-documented episode of DSM-IV major depression were included. Neuropathologic assessments, blind to group membership, included standardized assessment of neuritic plaques, neurofibrillary tangles, and Lewy Bodies in frontal, temporal, parietal, and occipital cortices. Braak staging of Alzheimer pathology was also performed. Cerebral microvascular disease was scored according to a previously validated scale, and a score for cerebral and systemic atheroma of large and medium sized arteries was obtained.

RESULTS

No subject had Lewy bodies. Plaque and tangle counts for all subjects were well within published norms for age-matched control subjects. There were no significant differences in plaque or tangle counts between subjects who were cognitively impaired (n = 5) and those who were nonimpaired (n = 6) during their depressive illness. Similarly, neither total microvascular pathology nor deep frontal microvascular pathology differed between the two groups.

CONCLUSIONS

Our results indicate that the liability for some patients to develop cognitive impairment during a depressive episode is not related to an increase in Alzheimer-type or vascular neuropathologic change. This indicates that other mechanisms must underlie both the cognitive impairment associated with depression and the observation that depression is a risk factor for dementia.

Distinction of early- and late-onset depression in the elderly by their lifetime symptomatology

OBJECTIVE

It has been proposed that early-onset depression (EOD) and late-onset depression (LOD) differ etiologically and phenomenologically. To validate the phenomenological distinction, the affective symptoms of elderly subjects with EOD and LOD were compared.

METHODS

Seventy-one patients with age-at-onset of depression below 60 years (EOD) and 67 age-matched patients with age-at-onset above 60 years (LOD) were consecutively recruited from the Departments of Psychiatry of the University of Mainz and the University of Bonn. To reduce the effect of interepisode variance of symptoms, we focused on the lifetime prevalence of different affective symptoms which were evaluated using the Composite International Diagnostic Interview (CIDI). Logistic regression analysis was performed to identify particular depressive symptoms which might discriminate EOD and LOD, and to account for possible sociodemographic differences between the two groups.

RESULTS AND CONCLUSION

Low spirits and feelings of worthlessness were more frequently found in EOD, they were sufficient discriminators to distinguish elderly subjects with EOD and LOD. This study provides further evidence for a phenomenological distinction between early- and late-onset depression in the elderly.

Cerebrovascular disease and late life depression: an age old association revisited

OBJECTIVES

To examine the relationship between depression and cerebrovascular disease in three distinct settings: depression in established cerebrovascular disease, cerebrovascular disease in established depression and depression in vascular dementia.

METHODS

Medline, EMBASE, PsychLit and PsychInfo databases were scanned to locate relevant articles. Data were also extracted from other articles, cited by those articles generated from the above databases.

RESULTS

Using operational criteria, the prevalence of depression is higher than controls only within the first year after stroke, but most studies have not employed control groups. The prevalence of depression in vascular dementia compared with Alzheimer's disease is higher in the majority of studies, but matching for sociodemographic factors and severity of cognitive impairment has been inconsistent. An association between frontal/subcortical cerebrovascular lesions and depression in later life has been observed, but there may be methodological flaws underlying this observation in some computerized tomography studies.

CONCLUSION

There is some evidence that cerebrovascular disease has an aetiopathological role in late life depression. The increased likelihood of damage to frontal/subcortical brain circuitry following stroke, transient ischaemia and hypertension may explain the high prevalence of depression in older people with vascular risk factors. More valid definitions of lesion location and the use of appropriately matched control groups would seek to clarify this issue. The extrapolation to care settings from the high prevalence of depression accompanying cerebrovascular disease and the prolongation of disability in depressed people with stroke, suggests closer liaison between old age psychiatrists, neurologists and physicians caring for the elderly.

Neuroanatomic substrates of late-life mental disorders

Advances in magnetic resonance imaging (MRI) techniques have made it possible to quantify anatomic brain abnormalities in neuropsychiatric disorders. This review focuses on controlled, quantitative MRI studies in depression, degenerative disorders, and psychosis in the elderly. Although many of the anatomic abnormalities detected are observed across disorders, the patterns of regional involvement may be more selective and disorder specific. We integrate MRI findings with relevant clinical and neurobiologic observations in an attempt to develop a cohesive model of late-life psychiatric illness. Although the model primarily alludes to the pathophysiology of late-life depression, it may have broader biologic implications for other mental disorders in the elderly.

Late-life chronic depression: a 399-case study in private practice

OBJECTIVE

Aims of the study were to find the prevalence of chronic depression in elderly patients compared with younger patients, and to compare chronic depression between elderly and younger patients, to find if there were clinical differences. A major feature of the study was the inclusion of a large number of bipolar II patients, usually not included in previous studies.

METHODS

Three hundred and ninety-nine consecutive unipolar (N=200) and bipolar II (N=199) depression outpatients were interviewed with the Structured Clinical Interview for DSM-IV and depression rating scales in a private practice.

RESULTS

Chronic depression was more common in elderly patients than in younger patients (53.6% vs 40.1%, p=0.0299). Late-life chronic depression patients had later age at onset, longer duration of illness, fewer bipolar II cases, more unipolar cases and more relapses than younger chronic depression patients.

CONCLUSIONS

Results suggest that late-life depression is more likely to be chronic than depression in younger patients. The subtyping of chronic depression according to age seems supported by a different age at onset and some clinical differences.

The neuropsychiatry of subcortical ischemic brain disease

The subcortical regions of the brain, by virtue of their extensive connections to neocortical and limbic structures, play an important role in the regulation of neurobehavioral functions such as mood, memory, and affect. Compromise of the blood supply to the subcortex and its connections result in behavioral syndromes that often include disturbances in cognition and mood. The extent of the underlying vascular pathology and the precise circuits compromised, in general, determine the nature of the behavioral problems. The neurobiologic mechanisms responsible for these behaviors are complex and clinical management is symptomatic and largely aimed at treating the primary clinical features with appropriate pharmacologic and behavioral approaches.

Age of onset of depression and quantitative neuroanatomic measures: absence of specific correlates

The purpose of our study was to examine the relationship between volumetric neuroanatomic measures and age of onset of illness in subjects with late-life major depression. Our sample was composed of 51 elderly subjects with Major Depressive Disorder who were scanned using a 1.5-tesla GE magnetic resonance imaging scanner with head coil. Absolute total and focal brain volumes were obtained together with quantified estimates of high intensity lesions. The relationship of these measures to onset age was examined using a regression while adjusting for subjects' current age and total intracranial volume. There was no significant linear relationship between age of onset of the first episode and any of the neuroanatomic measures examined. These data do not support the notion that neuroanatomical contributions to depression increase with a later age of onset of illness.

White matter lesions on magnetic resonance imaging in dementia with Lewy bodies, Alzheimer's disease, vascular dementia, and normal aging

OBJECTIVES

Alzheimer's disease and vascular dementia are associated with an increase in changes in white matter on MRI. The aims were to investigate whether white matter changes also occur in dementia with Lewy bodies and to examine the relation between white matter lesions and the cognitive and non-cognitive features of dementia with Lewy bodies, Alzheimer's disease, and vascular dementia.

METHODS

Proton density and T2 weighted images were obtained on a 1.0 Tesla MRI scanner in patients with dementia with Lewy bodies (consensus criteria; n=27, mean age=75.9 years), Alzheimer's disease (NINCDS/ADRDA; n=28, mean age=77.4 years), vascular dementia (NINDS/AIREN; n=25, mean age=76.8 years), and normal controls (n=26, mean age=76.2 years). Cognitive function, depressive symptoms, and psychotic features were assessed using a standardised protocol. Periventricular hyperintensities (PVHs), white matter hyperintensities (WMHs) and basal ganglia hyperintensities (BGHs) were visually rated blind to diagnosis using a semiquantitative scale.

RESULTS

Periventricular hyperintensities were positively correlated with age and were more severe in all dementia groups than controls. Total deep hyperintensities scores (WMHs plus BGHs) were significantly higher in all dementia groups than controls and higher in patients with vascular dementia than those with dementia with Lewy bodies or Alzheimer's disease. In all patients with dementia, frontal WMHs were associated with higher depression scores and occipital WMHs were associated with an absence of visual hallucinations and delusions.

CONCLUSION

In common with Alzheimer's disease and vascular dementia, PVHs and WMHs were significantly more extensive in dementia with Lewy bodies than in controls. This overlap between different dementias may reflect shared pathological mechanisms. The link between frontal WMHs and depression and the absence of occipital WMHs and psychotic symptoms has important implications for understanding the neurobiological basis of these symptoms.

Frequently missed diagnosis in geriatric psychiatry

Older adults are an important segment of the population that has specific health care needs. Their unique biopsychosocial characteristics impact the presentation, evaluation, and management of psychiatric illnesses. This article describes how common psychiatric disorders present in an aging population. Research in this area is relatively new and much more information is still needed. Close attention should be paid to new knowledge as it emerges about this growing population.

Selective serotonin reuptake inhibitor efficacy in severe and melancholic depression

Depression with melancholic features appears to be a discrete affective syndrome characterised by profound psychomotor, cognitive and mood disturbances that are qualitatively different from other forms of depression. Some investigators have hypothesised that melancholia may have a neurological basis with psychomotor disturbances associated with selective alterations in dopamine neurotransmission and disturbances in basal ganglia function. A number of studies have examined the role of selective serotonin reuptake inhibitors (SSRIs) in the treatment of melancholia. Although relatively few prospective trials have focused on melancholic depression, several retrospective meta-analyses and trials in populations that are likely to include a high proportion of melancholic patients have provided a wealth of data. While some early studies suggested that SSRIs might be less effective in the treatment of melancholia, the results of these may have been biased and confounded by several side-effects of tricyclic antidepressants (TCAs), which might contribute to their apparent efficacy. It appears, however, that the SSRIs may vary among themselves in their apparent efficacy in melancholia. In this regard, sertraline may be more efficacious than other SSRIs and similar to TCAs in the treatment of patients with melancholia. Several studies have suggested that the presence of melancholic features may predict a good response to sertraline, and it has been hypothesised that this may be the result of the relatively potent dopaminergic activity of sertraline, compared with other SSRIs.

Frontostriatal deficits in unipolar major depression

Recent accounts of major depression have tended to focus on dysfunction of frontothalamic-striatal reentrant circuits as a possible source of the disorder. Evidence of frontostriatal involvement in unipolar major depression from lesion and neuropsychological studies, and functional and structural imaging studies is examined. The high incidence of depressive symptomatology following left frontal and basal ganglia lesions implicate these as possible sites of dysfunction. Neuropsychological evidence indicates similar deficits in patients with major depression, perhaps with dorsolateral prefrontal deficits most prominent. Structural imaging studies report frontal and basal ganglia (BG) abnormalities particularly in cases of late-age onset depression. Resting state functional imaging studies show deficits in dorsolateral, anterior cingulate (medial frontal), and BG structures. Activation imaging studies show less consistent evidence of dorsolateral deficit, while anterior cingulate deficit is more consistently demonstrated. Variability in findings across studies may reflect differences between subtypes of depression and differences in methodology. Possible involvement of the BG in the psychomotor retardation of depression is examined. It is concluded that, while there is evidence of frontostriatal deficit in major depression, the exact nature of such deficits is uncertain. Issues such as component vs. system dysfunction need to be addressed.

The use of multivariate statistical methods in psychiatry

Multivariate methods such as factor analysis and cluster analysis have been used for many years by psychiatric researchers primarily for investigating the problems of psychiatric diagnosis. In more recent times, the range of multivariate techniques used has been extended as has the number of areas in which they are being applied.

SSRI-induced extrapyramidal side-effects and akathisia: implications for treatment

The selective serotonin reuptake inhibitors (SSRIs) may occasionally induce extrapyramidal side-effects (EPS) and/or akathisia. This may be a consequence of serotonergically-mediated inhibition of the dopaminergic system. Manifestations of these effects in patients may depend on predisposing factors such as the presence of psychomotor disturbance, a previous history of drug-induced akathisia and/or EPS, concurrent antidopaminergic and/or serotonergic therapy, recent monoamine oxidase inhibitor discontinuation, comorbid Parkinson's disease and possibly deficient cytochrome P450 (CYP) isoenzyme status. There is increasing awareness that there may be a distinct form of melancholic or endogenous depression with neurobiological underpinnings similar to those of disorders of the basal ganglia such as Parkinson's disease. Thus, it is not surprising that some individuals with depressive disorders appear to be susceptible to developing drug-induced EPS and/or akathisia. In addition, the propensity for the SSRIs to induce these effects in individual patients may vary within the drug class depending, for example, on their selectivity for serotonin relative to other monoamines, affinity for the 5-HT2C receptor, pharmacokinetic drug interaction potential with concomitantly administered neuroleptics and potential for accumulation due to a long half-life. The relative risk of EPS and akathisia associated with SSRIs have yet to be clearly established. The potential risks may be reduced by avoiding rapid and unnecessary dose titration. Furthermore, early recognition and appropriate management of EPS and/or akathisia is required to prevent the impact of these effects on patient compliance and subjective well-being. It is important that the rare occurrence of EPS in patients receiving SSRIs does not preclude their use in Parkinson's disease where their potentially significant role requires more systematic evaluation.

Structural neuroimaging and mood disorders: recent findings, implications for classification, and future directions

Neuroimaging is playing an increasing role in research of affective disorders, with investigators examining both volumetric changes of specific brain structures and vascular changes within white and gray matter. Recent studies have attempted to make clinical correlations between neuroimaging changes in unipolar and bipolar mood disorders. In this review, we focus particularly on those changes that are clinically meaningful. We conclude that there is enough evidence to begin to evaluate inclusion of neuroimaging findings in our mood disorder classification system. To this end, we propose two new mood disorder subtypes, vascular depression and vascular mania. Directions for future research in neuroimaging are then discussed.

Memory processes in depressed geriatric patients with and without subcortical hyperintensities on MRI

In this study, 12 patients over age 60 with depression with moderate to severe subcortical hyperintensities (SH) localized to the periventricular white matter were identified by quantitative MRI. Using the California Verbal Learning Test, they were compared with 12 age-, education-, and severity-matched patients with depression with minimal white matter changes on specific aspects of memory performance. Patients with cortical lesions, neurologic or systemic illness affecting cognition, and history of substance abuse were excluded. Patients in the group with high SH showed reduced use of semantic encoding strategies (p < 0.05), reduced learning efficiency (p < 0.05), and a greater discrepancy between free recall and recognition discriminability (p < 0.05) than their low SH counterparts. This pattern of performance on memory tasks is similar to that found in previous studies to be associated with subcortical degenerative disorders such as Huntington's and Parkinson's diseases. Geriatric patients with depression with SH may represent a subgroup with greater subcortical involvement, with associated cognitive and functional decline.

Cerebral magnetic resonance T2 high intensities in end-stage renal disease

BACKGROUND AND PURPOSE

The pathophysiological mechanisms that cause cerebral MR T2 high intensities in end-stage renal disease (ESRD) are unclear. We evaluated the incidence and the risk factors of T2-weighted MR brain high intensities in patients with ESRD.

METHODS

We examined the degree of T2-weighted MR brain high intensities (high intensity score) and determined the variables that had an independent association with the occurrence of high intensities in 38 patients with ESRD before chronic dialysis treatment, 173 patients with essential hypertension, and 72 normotensive control subjects.

RESULTS

The whole brain high intensity score was significantly higher in patients with ESRD than in the control subjects, but there was no significant difference in high intensity score between the ESRD and the hypertensive groups. Age, hypertension, and smoking were significant independent predictors of high intensities in a multiple logistic regression model. The distribution pattern of high intensities in ESRD patients was very similar to that obtained from hypertensive patients; the high intensity score was highest in the corona radiata and was lowest in the cerebellum.

CONCLUSIONS

T2 high intensities on MR images of ESRD may reflect subcortical small-vessel alterations induced by hypertension.

Differences in geriatric psychiatry outpatients with early- vs late-onset depression

This study assessed clinical and demographic differences between 74 geriatric psychiatry outpatients with early-onset vs late-onset depression. The following data were considered: age, gender, marital status, years of education, number of prescription medications and active medical diagnoses (including presence of various categories of medical disorder), presence of any comorbid dementia or other psychiatric disorder, age of depression onset, number of depressive episodes and MMSE score. Fifteen patients (20.3%) had an early onset of depression (before age 60 years) and 59 (79.7%) had a late onset of depression. Early-onset patients had significantly more episodes of depression than late-onset patients (4.2 vs 1.9, t = 4.74, p < 0.001). Patients with early-onset depression also had a higher mean number of prescribed medications (5.3 vs 3.5, t = 2.29, p = 0.025) and active medical disorders (4.6 vs 3.1, t = 2.89, p = 0.005). Specifically, early onset of depression was associated with an elevated prevalence of cardiac disease (53.3% vs 23.7%, chi 2 = 5.0, df = 1, p = 0.025), diabetes (46.7% vs 16.9%, chi 2 = 6.0, df = 1, p = 0.015), gastrointestinal disorder (40.0% vs 12.0%, chi 2 = 6.5, df = 1, p = 0.011) and arthritis (26.7% vs 6.8%, chi 2 = 4.9, df = 1, p = 0.027). These findings support previous reports that people with a history of depression experience greater medical morbidity than those without a history of depression. The study groups did not differ with respect to MMSE score or presence of a concurrent dementia disorder. These results were unexpected given previous studies that indicate greater cognitive impairment in late- vs early-onset depression. The potential contribution of increased vascular risk factors among the early-onset depression group may have partly contributed to the finding of no difference in cognition between groups in the present study.

1997 IPA/Bayer Research Awards in Psychogeriatrics. Subcortical hyperintensities in late-life depression: acute response to treatment and neuropsychological impairment

Subcortical hyperintensities are easily visualized areas of signal abnormality that are seen on T2-weighted magnetic resonance imaging (MRI). Characteristically they occur in the white matter of the brain and are more common in elderly people. In depression, little is known of the clinical significance of subcortical hyperintensities or their contribution to the prognosis. Fifty-eight consecutive patients with DSM-III-R depression and an age range of 65 to 85 years were prospectively collected from an old-age psychiatry service. Response to treatment was assessed with a clinical global outcome measure. A neuropsychology battery was completed on all patients after treatment. Forty-four patients completed MRI scanning. The scans were scored using a regional rating system for hyperintensities. Forty-eight percent of patients had a favorable response to treatment on the clinical global outcome scale. Poor outcome was associated with female sex (p = .07), poor physical health (p = .040), diabetes (p = .018), psychosis (p = .026), and an early age at onset of first episode of depression (p = .036). Even after adjustment for confounding effects, there were significant neuropsychological associations with the regional hyperintensities. Distribution in the periventricular area correlated with delayed recall after distraction (p = .025), and punctate lesions in the basal ganglia correlated with impaired category production (p = .020). Pontine reticular formation hyperintensities were related to impaired psychomotor speed (p = .04). Location in the frontal deep-white matter (p = .024), basal ganglia (p = .03), and pontine reticular formation (p = .02) was associated with a poor acute response to treatment. However, the response to treatment was not related to total cerebral white-matter hyperintensity load. A logistic regression equation included all the significant prognostic features and found four independent predictors of poor outcome: More than five punctate lesions of the basal ganglia, diabetes, lower mean arterial pressure, and hyperintensity of the pontine reticular formation significantly predicted outcome. These four factors correctly predicted 95.6% of patients with a poor outcome and 85.7% with a favorable outcome. In late-life depression, subcortical hyperintensities are common. Lesions in the cerebral white matter are predominantly associated with memory disturbance, and those in deeper infratentorial areas, with psychomotor slowing and executive deficits. Total white-matter load has no prognostic value, and although some subcortical regions are associated with poor response, individually they have little specificity. However, a combination of involvement in three areas (basal ganglia, pons, and frontal lobe) is clinically relevant and predicts outcome with great accuracy (91%). Patients with lesions in the basal ganglia and deep white matter had an especially poor response to pharmacotherapy.

Quantitative magnetic resonance imaging in geriatric depression and primary degenerative dementia

Quantitative magnetic resonance imaging (MRI) was used to investigate volumes of different brain structures in 19 patients with late-onset major depression (DSM-III-R), 27 patients with Alzheimer's disease (NINCDS-ADRDA criteria) and 13 age matched controls. 3-D MRI sequences were acquired using a Siemens 1.5 T scanner. Whole brain volume, CSF volume, volume of the frontal and temporal lobes and the volume of the amygdala-hippocampus complex were assessed using the software NMR Win. Compared to the controls, depressed patients showed a significantly lower whole brain volume and a significantly higher CSF volume, whereas volumes of the frontal and temporal lobes as well as the amygdala-hippocampus complex volumes were not significantly decreased. In addition, depressed patients exhibited a higher ventricle-brain ratio suggesting a higher degree of central atrophy compared to healthy individuals. In contrast, Alzheimer patients showed significantly lower volumes than depressed patients and controls with respect to all volumetric parameters. Although the findings indicate the presence of brain atrophy in patients with late-onset depression, the pattern of volumetric changes in these patients differs markedly from that observed in patients with primary degenerative dementia.