Depressive symptoms and depressive diagnoses in a community population. Use of a new procedure for analysis of psychiatric classification

Some distance measures for pythagorean cubic fuzzy sets: Application selection in optimal treatment for depression and anxiety

Pythagorean cubic fuzzy sets represent an advancement beyond conventional interval-valued Pythagorean sets, integrating the principles of Pythagorean fuzzy sets and interval-valued Pythagorean fuzzy sets. Given the critical significance of distance measures in real-world decision-making and pattern recognition tasks, it is noteworthy that there exists a notable gap in the literature regarding distance measures specifically tailored for Pythagorean cubic fuzzy sets. The objectives of this paper are:•To define novel generalized distance measures between Pythagorean cubic fuzzy sets (PCFSs) to tackle intricate decision-making challenges.•These novel distance measures are undergoing testing on a real-world scenario concerning the management of anxiety and depression to evaluate their effectiveness and practical application.•We have illustrated the boundedness and nonlinear characteristics inherent in these distance measures. In addition, we conduct comparative analyses with existing approaches to validate the proposed methodology, thereby providing insights into its advantages and potential applications.

Increased ventromedial prefrontal cortex activity and connectivity predict poor sertraline treatment outcome in late-life depression

OBJECTIVE

Previous studies of imaging predictors on acute treatment response in late-life depression (LLD) demonstrated that poor response to selective serotonin reuptake inhibitors (SSRIs) is associated with pre-treatment low functional connectivity (FC) within executive control network and high FC within default-mode network including the ventromedial prefrontal cortex (vmPFC). However, there is less research in regional resting-state functional activity that explains FC changes related to SSRI response.

METHODS

Thirty-six older major depressive disorder (MDD) patients not currently on antidepressant treatment had a baseline, pre-treatment resting-state functional magnetic resonance imaging scan, followed by sertraline treatment for 12 weeks. Depression severity was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS). Subjects whose MADRS score decreased less than 50% from baseline or who discontinued sertraline for any reason were classified as nonresponders (n = 21). Subjects whose 12-week MADRS score dropped greater than or equal to 50% from baseline were defined as responders (n = 15). We conducted the amplitude of low-frequency fluctuation (ALFF) and region of interest (ROI)-to-ROI FC analyses independently. Significance threshold was set at P < 0.05 with false discovery rate (FDR) correction for multiple comparisons.

RESULTS

Relative to the responder group, the nonresponder group showed significantly less ALFF in the dorsomedial prefrontal cortex (dmPFC) and greater ALFF in the vmPFC/subgenual cingulate area. For ROI-to-ROI connectivity, there was significantly greater connectivity between the vmPFC and the cerebellar vermis in the nonresponder group.

CONCLUSION

Our study highlighted the association of vmPFC resting-state activity and connectivity with SSRI response. Future studies are warranted for understanding the role of vmPFC-vermis connectivity in LLD.

Affective, neurocognitive and psychosocial disorders associated with traumatic brain injury and post-traumatic epilepsy

Survivors of traumatic brain injury (TBI) often develop chronic neurological, neurocognitive, psychological, and psychosocial deficits that can have a profound impact on an individual's wellbeing and quality of life. TBI is also a common cause of acquired epilepsy, which is itself associated with significant behavioral morbidity. This review considers the clinical and preclinical evidence that post-traumatic epilepsy (PTE) acts as a 'second-hit' insult to worsen chronic behavioral outcomes for brain-injured patients, across the domains of emotional, cognitive, and psychosocial functioning. Surprisingly, few well-designed studies have specifically examined the relationship between seizures and behavioral outcomes after TBI. The complex mechanisms underlying these comorbidities remain incompletely understood, although many of the biological processes that precipitate seizure occurrence and epileptogenesis may also contribute to the development of chronic behavioral deficits. Further, the relationship between PTE and behavioral dysfunction is increasingly recognized to be a bidirectional one, whereby premorbid conditions are a risk factor for PTE. Clinical studies in this arena are often challenged by the confounding effects of anti-seizure medications, while preclinical studies have rarely examined an adequately extended time course to fully capture the time course of epilepsy development after a TBI. To drive the field forward towards improved treatment strategies, it is imperative that both seizures and neurobehavioral outcomes are assessed in parallel after TBI, both in patient populations and preclinical models.

The Contribution of Cognitive Networks to Depression in Epilepsy

This review poses the question: Does disruption to cognitive brain networks in epilepsy contribute to the problem of comorbid depression? Initial evidence suggests that the network disease that gives rise to seizures has a predilection for the same cognition-related networks that regulate mood, with comorbidity reflective of more extensive disease. Framing both epilepsy and its psychiatric comorbidities in terms of dysfunction in overlapping (cognitive) networks raises the possibility that depression can be a primary feature of the disease in some cases and facilitates an epilepsy classification system where behavioral features of the disorder are embedded in a neurobiological mechanism.

Depression and the Heart: A Systematic Overview of Definition, Measurement, Consequences and Treatment of Depression in Cardiovascular Disease

Depression is an independent risk factor in the pathogenesis of cardiovascular disease and it is a prevalent disorder after cardiovascular disease associated with negative outcome in terms of mortality and morbidity. It is a dangerous condition requiring adequate screening and treatment, however, it often remains undiagnosed and thus untreated. Non-psychiatric healthcare workers, like nurses, general practitioners, physiotherapists and cardiologists are the health providers most closely involved in the management of patients with cardiovascular disease. They can play an important role in screening cardiovascular patients for depressive symptoms and in referring them for treatment. The purpose of this article therefore is to provide an evidence-based framework, aiming to educate non-psychiatric healthcare providers on depressive disorder in the context of chronic cardiovascular disease. In this paper, an overview of the definition, prevalence and consequences of depression will be discussed. Moreover, an overview of measurement methods and treatment modalities for depression will be provided. In addition, a step-by-step guide is provided in order to help non-psychiatric healthcare providers in dealing with depressed patients.

Two distinct symptom-based phenotypes of depression in epilepsy yield specific clinical and etiological insights

Depression is common but underdiagnosed in epilepsy. A quarter of patients meet criteria for a depressive disorder, yet few receive active treatment. We hypothesize that the presentation of depression is less recognizable in epilepsy because the symptoms are heterogeneous and often incorrectly attributed to the secondary effects of seizures or medication. Extending the ILAE's new phenomenological approach to classification of the epilepsies to include psychiatric comorbidity, we use data-driven profiling of the symptoms of depression to perform a preliminary investigation of whether there is a distinctive symptom-based phenotype of depression in epilepsy that could facilitate its recognition in the neurology clinic. The psychiatric and neuropsychological functioning of 91 patients with focal epilepsy was compared with that of 77 healthy controls (N=168). Cluster analysis of current depressive symptoms identified three clusters: one comprising nondepressed patients and two symptom-based phenotypes of depression. The 'Cognitive' phenotype (base rate=17%) was characterized by symptoms taking the form of self-critical cognitions and dysphoria and was accompanied by pervasive memory deficits. The 'Somatic' phenotype (7%) was characterized by vegetative depressive symptoms and anhedonia and was accompanied by greater anxiety. It is hoped that identification of the features of these two phenotypes will ultimately facilitate improved detection and diagnosis of depression in patients with epilepsy and thereby lead to appropriate and timely treatment, to the benefit of patient wellbeing and the potential efficacy of treatment of the seizure disorder. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".

Effects of Manipulating Valence and Arousal Components of Mood on Specificity of Autobiographical Memory

An important cognitive deficit in clinical depression is the inability to be specific in recalling personal memories, a phenomenon coined “overgeneral memory” by Williams and Broadbent. Although there is general consensus that overgeneral memory is not state-dependent, most of the evidence originates from studies of this effect in clinical populations. The two components of mood, valence and arousal, were manipulated to examine their influence on memory specificity in a nonclinical sample of university undergraduate students. In Exp. 1, a Velten procedure was used to induce elated, depressed, or neutral mood states. No difference was found in autobiographical memory specificity among the three groups. In Exp. 2, high and low arousal states were induced through physical exercise. A low arousal state resulted in an increased proportion of overgeneral memories, suggesting that this memory phenomenon may be influenced by the arousal component of mood.

Changes in Prevalence of Depressive Symptoms in Alameda County

Trends in depression are examined using data from the Alameda County Study, a three-wave, prospective community survey covering an 18-year period (1965-1974-1983). Age-period-cohort effects in rates of depressive symptoms were analyzed using logistic regression procedures to adjust for attrition due to loss-to-follow-up and nonresponse. The results indicate the presence of all three effects. There was a marked period effect, with rates in 1974 significantly higher than in either 1965 or 1983. There also was a definite cohort effect, with older cohorts exhibiting higher rates of depressive symptoms than younger cohorts. These findings do not provide support for an "age of melancholia" nor for an increasing cohort effect in succeeding generations. These prospective data on depressive symptoms are contrasted with those from studies that use cross-sectional data to estimate temporal trends in clinical depression, employing retrospective reports of lifetime prevalence and discussing possible reasons for the disparate findings.

Prevention of anxiety and depression in Chinese: a randomized clinical trial testing the effectiveness of a stepped care program in primary care

BACKGROUND

Despite empirical evidence demonstrating the effectiveness of collaborative stepped care program (SCP) in Western countries, such programs have not been evaluated in the east, which has a different services system structure and cultural nuances in seeking help for mental illness. Furthermore, only a few studies have used SCP for depression and anxiety prevention. We conducted a trial to test its effectiveness in preventing major depressive disorder and generalized anxiety disorder among primary care patients with subthreshold depression and/or anxiety in Hong Kong.

METHODS

Subthreshold depression and/or anxiety patients were randomized into the SCP group (n=121) or care as usual (CAU) group (n=119). The SCP included watchful waiting, telephone counseling, problem solving therapy, and family doctor treatment within one year. The primary outcome was the onset of major depressive disorder or generalized anxiety disorder in 15 months. The secondary outcomes were depressive and anxiety symptoms, quality of life and time absent from work due to any illness.

RESULTS

Survival analysis showed no differences between the SCP and CAU groups (the cumulative probability of onset at 15 month was 23.1% in the SCP group and 20.5% in the CAU group; Hazard Ratio=1.62; 95% Confidence Interval: 0.82-3.18; p=0.16). No significant differences were found in secondary outcomes.

LIMITATIONS

Sample size might not have been large enough.

CONCLUSIONS

SCP did not show beneficial effect on depression/anxiety prevention compared with CAU in Hong Kong primary care. As a large majority of patients improved overtime without any intervention, we are not able to exclude the possibility that the intervention might be effective. Future studies would need to have a larger sample size and conduct on patients with more severe symptoms or perform a second screening.

Anxious forms of depression

Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of "mixed anxiety depression disorder" (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD-11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.

Latent subtypes of depression in a community sample of older adults: can depression clusters predict future depression trajectories?

Identifying sources of heterogeneity in late life depression remains an important focus of psychiatric investigation. Community samples are particularly informative since many older adults have clinically significant depressive symptoms but fail to meet criteria for major depression and older adults generally do not seek treatment for their depressive symptoms. The primary data used for these analyses were those collected in a community-based survey of over 3000 adults age 65 or older followed for up to ten years. Depressive symptoms were measured by the Center for Epidemiologic Studies-Depression scale (CES-D). Latent class analysis was used to identify clusters of participants based on their symptom profiles at baseline. Mixed models were used to examine trajectories of CES-D scores based on cluster assignment. A model with three unique clusters best fit the data. Cluster 1 (59%) had a low probability of any symptom endorsement. Cluster 2 (31%) endorsed as a group some negative affect and somatic symptoms but their endorsement of low positive affect did not differ from Cluster 1. Participants in Cluster 3 (10%) had a higher probability of endorsement of all symptoms compared to Clusters 1 and 2. The results did not appreciably differ when symptom severity was included. Cluster assignment was a significant predictor of change in CES-D score over the ten-year follow-up period, and the effects over time differed by sex. Depressive symptom profiles predict the longitudinal course of depression in a community sample of older adults, findings that are important especially in primary care settings.

The relationship between depressive symptoms and health service utilization for elderly people in Taiwan

OBJECTIVE

This study analyzes the relationship between depressive symptoms and the utilization of medical services for elderly people in Taiwan.

METHODS

Because depressive symptoms and physical health may have a reciprocal relationship, a simultaneous equations model was used by performing a 3-stage least squares (3SLS) regression. The data in this study were obtained from the 2003 Survey of Health and Living Status of the Elderly in Taiwan (SHLSE).

RESULTS

The findings show that depressive symptoms have a significantly negative effect on the utilization of outpatient, inpatient, and emergency services. Furthermore, the magnitude of the 3SLS estimates of physical health status in relation to health service utilization is substantially greater than that in the OLS estimates. The results may reveal that people with depressive symptoms may seek healthcare services because of physical discomfort.

CONCLUSIONS

Those with depressive symptoms may not seek specialty mental treatments, suggesting that policy interventions to monitor the need to care for elderly people with depressive symptoms through primary care services are important in screening and maintaining the mental health of elderly people.

Psychiatric disorders in the elderly

Recent research has shown that depression, anxiety disorders, and psychosis are more common than previously supposed in elderly populations without dementia. It is unclear whether the frequency of these disorders increases or decreases with age. Clinical expression of psychiatric disorders in old age may be different from that seen in younger age groups, with less and often milder symptoms. Concurrently, comorbidity between different psychiatric disorders is immense, as well as comorbidity with somatic disorders. Cognitive function is often decreased in people with depression, anxiety disorders, and psychosis, but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders in the elderly are often related to cerebral neurodegeneration and cerebrovascular disease, although psychosocial risk factors are also important. Psychiatric disorders, common among the elderly, have consequences that include social deprivation, poor quality of life, cognitive decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal mortality.

Somatic and non-affective symptoms of old age depression: ethnic differences among Chinese, Indians and Malays

BACKGROUND

Somatic and other non-affective symptomatology characterizes late life depression and contributes to its under-diagnosis, especially in some ethnic groups.

OBJECTIVES

We examined variations in non-affective presentation and its health and functional significance across different ethnic groups of Chinese, Malays and Indians.

METHOD

We analyzed data from the National Mental Health Survey for Elderly, a population-based cross-sectional study of older adults aged 60 and above (N = 1092).

RESULTS

Compared to the depressed Chinese as the reference group, depressed Malays were more likely to endorse symptoms of appetite decrease (OR = 5.19), sleep disturbances (OR = 2.93), disabling pain (OR = 3.12), psychomotor slowing (OR = 2.73) and anergia (OR = 3.70), while concurrently reporting poorer general health status and greater role limitations resulting from their mental and emotional problems (OR from 2.13 to 3.31). These differences were not influenced by anxiety, dementia or physical comorbidity.

CONCLUSION

We revealed striking differences in the somatic and non-affective symptomatology of geriatric depression among different Asian ethnic groups. Non-affective symptoms in depression have large health and functional significance and important implications for the diagnosis and management of depression among elderly in primary care.

Applicability of 15-item Geriatric Depression Scale to detect depression in elderly medical outpatients

Elder depressives approach physicians for their medical problems, but the detection of their depression is poor. This study aimed to explore the screening for depressive symptoms using a 15-item Geriatric Depression Scale (GDS) in medical clinics. The study was carried out in outpatient setting of geriatric clinic of tertiary care hospital using the Hindi version of GDS-15. Out of 100 eligible older medical clinic patients, 22% of participants scored high on the GDS (≥5) and 18% were definitely having a depressive disorder as per ICD10. The sensitivity of the GDS instrument was 100% and specificity 94%. This study confirmed that a brief screening instrument like the GDS helps physicians to identify and diagnose depression in the medical settings. The need of the hour is to train health personnel involved in geriatric care regarding identifying, diagnosing and managing depression in medical clinics.

Profiles of depressive symptoms in older adults diagnosed with major depression: latent cluster analysis

OBJECTIVE

To explore the underlying structure of symptom presentation in older adults with major depression by identifying homogeneous clusters of individuals based on symptom profiles.

DESIGN

Secondary data analysis using latent class cluster analysis.

SETTING

Clinical Research Center for the Study of Depression in Later Life conducted at Duke University.

PARTICIPANTS

Three hundred sixty-six patients age 60+ who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression and were enrolled in a longitudinal naturalistic treatment study.

MEASUREMENTS

Responses to the 10 items of the Montgomery-Asberg Depression Rating Scale at the time of study enrollment.

RESULTS

The authors identified four latent clusters of older adults with major depression. Patients in Cluster 1 (47.2%) had mean scores of average severity for reported and apparent sadness and lassitude and low mean scores for reduced appetite. Patients in Cluster 2 (27.1%) had higher mean scores compared with Cluster 1 for all items, and particularly for apparent sadness. Patients in Cluster 3 (18.9%) had the lowest mean scores for both apparent and reported sadness, but a similar profile compared with Cluster 1 for inner tension, reduced sleep, reduced appetite, and concentration difficulties. Cluster 4 (6.8%) had the highest mean scores for each item. Both apparent and reported sadness accounted for a large amount of variance among the four clusters. Patients in Cluster 4 were more likely to have 12 or less years of education and/or one or more functional limitations.

CONCLUSION

The heterogeneity in symptom presentation among older adults diagnosed with major depression can potentially inform the development of DSM-V.

Depression, cognition, apolipoprotein e genotype: latent class approach to identifying subtype

OBJECTIVES

Possessing the epsilon4 allele of apolipoprotein E (APOE-epsilon4) genotype is associated with cognitive impairment in nondemented older adults. The authors hypothesized that they might find a subtype of depression related to impaired cognitive performance associated with the APOE-epsilon4 allele.

DESIGN

A survey conducted between 2001 and 2003 with APOE genotyping.

SETTING

Primary care offices in the Baltimore area.

PARTICIPANTS

The study sample consisted of 305 adults aged 65 or older with complete information on APOE genotyping and covariates.

MEASUREMENTS

The authors used the latent class model to classify respondents according to symptom criteria of American Psychiatric Association's Diagnostic and Statistical Manual as assessed in the Composite International Diagnostic Interview and the following four measures of cognitive function: the Mini-Mental State Exam, Hopkins Verbal Learning Test, Controlled Oral Word Association Test, and the Brief Test of Attention. The authors examined the relationship between class membership and APOE genotype.

RESULTS

The latent class model yielded three classes: a nondepressed class, a class with depressive symptoms and average cognitive functioning, and a class with depressive symptoms (particularly thoughts of death and suicide) and impaired cognitive functioning. Possessing at least one APOE-epsilon4 allele was not predictive of class membership.

CONCLUSION

A subgroup of elderly patients with depressive symptoms, cognitive impairment, and a high likelihood of experiencing thoughts of death or suicide may exist that may not be related to APOE-epsilon4. Subgroups of older patients with depressive symptoms may be important to identify because of the association with thoughts of death or suicide and cognitive impairment.

Subtypes of depression in a nationally representative sample

BACKGROUND

Continued research efforts aim to elucidate the heterogeneity in depression. The identification of meaningful and valid subtypes has implications for research and clinical practice. Based on patterns of depressive symptomatology, this study identified a typology of depressive syndromes using data from a large, nationally representative survey.

METHODS

Analyses were based on a subsample of 12,180 respondents from the 2001-2002 Wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Latent class analysis was applied to the DSM-IV 'A' criteria for major depression to identify homogenous subtypes or classes of depressive syndromes. Associations between the emergent latent classes and demographic and clinical characteristics were assessed.

RESULTS

Three clinically relevant subtypes were identified, in addition to a class who reported few depressive symptoms: severely depressed (40.9%), psychosomatic (30.6%), cognitive-emotional (10.2%) and non-depressed (18.3%). The odds of experiencing negative life events, psychiatric disorders, and having a family background of major depression were significantly higher for the severely depressed, psychosomatic and cognitive-emotional classes, compared to the non-depressed class. Several unique differences between the latent classes also emerged.

LIMITATIONS

Methodological shortcomings included: reliance on lay interviewer-administered structured interviews to determine diagnoses; basing sample selection on the endorsement of screener items; and, using measures of 'any anxiety disorder', 'any mood disorder', and 'any personality disorder' to determine psychiatric disorder prevalence rates.

CONCLUSIONS

Significant heterogeneity in depressive symptomatology exists in this U.S. sample. Profiling symptom patterns is potentially useful as a first step in developing tailored intervention and treatment programmes.

Higher burden of depression among older women: the effect of onset, persistence, and mortality over time

CONTEXT

The prevalence of depression is disproportionately higher in older women than men, yet the reasons for this sex difference are not clear.

OBJECTIVE

To determine whether the higher burden of depression among older women than men might be attributable to sex differences in the onset (ie, first or recurrent episodes) or persistence of depression and/or to differential mortality among those who are depressed.

DESIGN

Prospective cohort study.

SETTING

General community in greater New Haven, Connecticut, from March 23, 1998, to August 31, 2005.

PARTICIPANTS

A total of 754 persons, 70 years or older, who were evaluated at 18-month intervals for 72 months.

MAIN OUTCOME MEASURES

The 3 outcome states were depressed, nondepressed, and death, with scores of 20 or more and less than 20 on the Center for Epidemiological Studies Depression Scale denoting depressed and nondepressed, respectively. The association between sex and the likelihood of 6 possible transitions (namely, from nondepressed or depressed to nondepressed, depressed, or death) was evaluated over time.

RESULTS

The prevalence of depression was substantially higher among women than men at each of the 5 time points (P < .001). In most cases, transitions between the nondepressed and depressed states were characterized by moderate to large absolute changes in depression scores (ie, > or = 10 points). Adjusting for other demographic characteristics, women had a higher likelihood of transitioning from nondepressed to depressed (odds ratio, 2.02; 95% confidence interval, 1.39-2.94) and a lower likelihood of transitioning from depressed to nondepressed (odds ratio, 0.27; 95% confidence interval, 0.13-0.56) or death (odds ratio, 0.24; 95% confidence interval, 0.09-0.60).

CONCLUSION

Among older persons, the higher burden of depression in women than men seems to be attributable to a greater susceptibility to depression and, once depressed, to more persistent depression and a lower probability of death.

Subsyndromal depression in old age: clinical significance and impact in a multi-ethnic community sample of elderly Singaporeans

OBJECTIVE

This cross-sectional study examined the clinical significance and impact of subsyndromal depression in a sample of elderly people living in the community in Singapore.

METHOD

Data were analyzed from a population survey (the Singapore National Mental Health Survey of the Elderly). A total of 1092 respondents from a nationally representative multi-ethnic (Chinese, Malay and Indian) stratified random sample of older adults aged 60 and above were examined for depression using the Geriatric Mental State Examination (GMS). Diagnostic confidence levels of 3-5 indicated a DSM-IV diagnosis of syndromal depression, and 1-2 indicated subsyndromal depression. Other variables included sociodemographic characteristics, psychiatric and medical comorbidities, MMSE, health awareness, health and functional status.

RESULTS

Subjects with subsyndromal depression were more likely to have poor socioeconomic status, cognitive impairment, anxiety, and measures of poor mental, physical and functional status compared with non-depressed subjects, and were similar to or worse than syndromal cases. In multivariate analyses that controlled for age, gender, ethnicity, education and several other sociodemographic factors, both subsyndromal and syndromal depression were significantly associated with higher numbers of medical comorbidities, diagnoses of comorbid dementia and anxiety, lower MMSE scores, self-reported mental health problem, functional disability and poor health status.

CONCLUSION

In this Asian population, subsydromal depression had the same clinical significance and health impact as syndromal depression, similar to findings in the West.

Restoring melancholia in the classification of mood disorders

The present DSM criteria for major depression poorly identify samples for treatment selection, prognosis, and assessments of pathophysiology. Melancholia, in contrast, is a disorder with definable clinical signs that can be verified by laboratory tests and treatment response. It identifies more specific populations than the present system and deserves individual identification in psychiatric classification. Its re-introduction will refine diagnosis, prognosis, treatment selection, and studies of pathophysiology of a large segment of the psychiatrically ill.

Comorbid anxiety and depression: illumination of a controversy

Depression and anxiety frequently coexist in the same individual, either concurrently or at different times, and numerous studies show that the presence of an anxiety disorder is the single strongest risk factor for development of depression. When the two coexist simultaneously, either as diagnosed disorders or subsyndromal states, they may be viewed as mixed anxiety-depression or as comorbid syndromes, i.e. separate disorders occurring concurrently. Controversy continues over the nature of the relationship between depression and anxiety, some believing they are distinct, separate entities while others - now the majority - view them as overlapping syndromes that present at different points on a phenomenological and/or chronological continuum, and share a common neurobiology, the degree of overlap depending on whether each is described at the level of symptoms, syndrome or diagnosis. Community data likely underestimate true prevalence, since affected individuals frequently present in primary care with somatic, rather than psychological, complaints. Irrespective of the nature of the relationship, patients with both disorders experience significant vocational and interpersonal impairment, and more frequent recurrence, with greater likelihood of suicide, than individuals with single disorders. Various classes of antidepressant drugs offer symptom relief for these patients, the most selective of th SSRIs holding the greatest promise for sustained clinical improvement. Yet, the crucial parameter of successful pharmacotherapy seems to be the length of treatment, ensuring enhancement of the compromised neuroprotective and neuroplastic mechanisms. Further clarification of the relationship is a prerequisite for offering effective treatment to the many patients who experience lifetime depression and anxiety.

Issues in selecting outcome measures to assess functional recovery after stroke

Most patients who survive a stroke experience some degree of physical recovery. Selecting the appropriate outcome measure to assess physical recovery is a difficult task, given the heterogeneity of stroke etiology, symptoms, severity, and even recovery itself. Despite these complexities, a number of strategies can facilitate the selection of functional outcome measures in stroke clinical trial research and practice. Clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability, such as the International Classification of Functioning, Disability, and Health (ICF). The ICF provides the conceptual basis for measurement and policy formulations for disability and health assessment. All outcome measures selected should also have sound psychometric properties. The essential psychometric properties are reliability, validity, responsiveness, sensibility, and established minimal clinically important difference. It is also important to establish the purpose of the measurement (discriminative, predictive, or evaluative) and to determine whether the purpose of the study is to evaluate the efficacy or effectiveness of an intervention. In addition, when selecting outcome measures and time of assessment, the natural history of stroke and stroke severity must be regarded. Finally, methods for acquiring data must also be considered. We present a comprehensive overview of the issues in selecting stroke outcome measures and characterize existing measures relative to these issues.

Distress and functioning in mixed anxiety and depressive disorder

The aim of the present study was to evaluate the validity of mixed anxiety and depressive disorder (MADD) with reference to functional characteristics and symptomatic characteristics in comparison with anxiety disorders, depressive disorders, and groups showing subthreshold symptoms (exclusively depressive or anxiety related). The present study was carried out in the following three medical settings: two psychiatric and one primary care. Patients seeking care in psychiatric institutions due to anxiety and depressive symptoms and attending primary medical settings for any reason were taken into account. A total of 104 patients (65 women and 39 men, mean age 41.1 years) were given a General Health Questionnaire (GHQ-30), Global Assessment of Functioning (GAF) and Present State Examination questionnaire, a part of Schedules for Clinical Assessment in Neuropsychiatry, Version 2.0. There were no statistically relevant differences between MADD and anxiety disorders in median GHQ score (19 vs 16) and median GAF score (median 68.5 vs 65). When considering depressive disorders the median GHQ score (28) was higher, and median GAF score (59) was lower than that in MADD. In groups with separated subthreshold anxiety or depressive symptoms, median GHQ scores (12) were lower and median GAF scores (75) were higher than that in MADD. The most frequent symptoms of MADD are symptoms of generalized anxiety disorder (GAD) and depression. Mixed anxiety and depressive disorder differs significantly from GAD only in higher rates of depressed mood and lower rates of somatic anxiety symptoms. Distinction from depression was clearer; six of 10 depressive symptoms are more minor in severity in MADD than in the case of depression. Distress and interference with personal functions in MADD are similar to that of other anxiety disorders. A pattern of MADD symptoms locates this disorder between depression and GAD.

Longitudinal research to promote effective refugee resettlement

Canada's relative generosity in admitting refugees and fairness in considering refugee claims has earned this country an enviable reputation. However, having opened its doors to those selected, Canada's resettlement policies and programs fail to provide for their needs, and to promote their optimal adaptation. Based on a decade-long investigation of the resettlement of more than 1300 Southeast Asian refugee--'Boat People'--the current report examines how research concerning (a) the impact of pre-migration trauma; (b) the mental health impact of social resources such as the like-ethnic community, refugee sponsorship programs, and language training; and (c) individual coping strategies such as suppressing the past, can contribute both to theory and to improving policy and practice. The presentation acknowledges the contributions of Dr. Alexander H. Leighton by demonstrating the importance of his insistence on the need for a longitudinal perspective both for conducting research and for planning programs and services.

Aging-related diagnostic variations: need for diagnostic criteria appropriate for elderly psychiatric patients

It is commonly thought and taught that most psychiatric disorders other than dementia are much less prevalent among the elderly than among younger adults. This perception is based on a relatively small number of published epidemiologic investigations of the incidence and prevalence of mental illnesses in elderly populations. Most of these studies have had a number of methodologic problems, including improper definitions and diagnostic criteria for older persons. A likely consequence of these misconceptions is that clinically significant and potentially treatable mental illnesses might be overlooked, misdiagnosed, and mistreated in elderly patients. Studies in community samples suggest that many older adults who experience clinically significant psychopathology do not fit easily into our existing nomenclature, and yet are disabled. There is a need to develop aging-appropriate diagnostic criteria for major psychiatric disorders. In this article, we discuss the potential causes of this diagnostic confusion. Four specific classes of disorders-mood (specifically depressive) disorders, schizophrenia (and related psychotic disorders), anxiety disorders, and substance use disorders-are discussed as examples. Finally, we suggest some future steps for clarifying this diagnostic confusion.

Stability of DSM-IV criterion symptoms for major depressive disorder

Given the chronic and recurrent nature of major depressive disorder (MDD), it is important to understand whether specific symptoms are stable over time or vary over the course of the disorder. This is the first longitudinal investigation examining the stability of the nine criterion symptoms of depression, as specified in the DSM-IV, among diagnosed depressed adults who were not recovered at follow-up. In this study, participants were assessed twice, ten months apart, with the structured clinical interview for DSM-IV, and stability of the nine criterion symptoms of MDD was examined. Findings indicate strong stability in individuals' symptom profiles. Among individuals who were clinically depressed at both assessments, there were no statistically significant fluctuations in specific symptoms endorsed. Changes in symptom endorsement among individuals who no longer met diagnostic criteria for MDD at Time 2 were attributable to reduced severity (i.e., number of symptoms) rather than to inconsistency of symptom endorsement. These results indicate that depressed individuals experience essentially the same pattern of specific symptoms over the course of a year. Variation in clinical course is likely to be attributable more to fluctuations in overall severity than to changes in specific symptoms of depression.

Using a Bayesian latent growth curve model to identify trajectories of positive affect and negative events following myocardial infarction

Positive and negative affect data are often collected over time in psychiatric care settings, yet no generally accepted means are available to relate these data to useful diagnoses or treatments. Latent class analysis attempts data reduction by classifying subjects into one of K unobserved classes based on observed data. Latent class models have recently been extended to accommodate longitudinally observed data. We extend these approaches in a Bayesian framework to accommodate trajectories of both continuous and discrete data. We consider whether latent class models might be used to distinguish patients on the basis of trajectories of observed affect scores, reported events, and presence or absence of clinical depression.

Prevalence and correlates of depression symptoms at 10 years after heart transplantation: continuous attention required

This study investigates the presence and correlates of symptoms of depression at 5 and 10 years after heart transplantation, with particular attention given to patients showing symptoms at both time points. Prevalence of depression symptoms were studied in 41 patients, prospectively, at 5 and 10 years after heart transplantation. We examined potential correlates of depression symptoms (i.e. worse functional capacity, inadequate coping mechanisms and lack of social contacts) 10 years after transplantation. The prevalence of depression symptoms was 30% at 5 years and 22% at 10 years. Of the 41 patients, 20% were depressed at both time points. Those patients had significantly higher scores on passive coping and had significantly lower club membership. They also tended to have more negative emotions (i.e. anger, hostility and irritability) and less engagement in sports activities. Functional capacity was not different. Depression symptoms were prevalent and persistent in the long-term after heart transplantation. This study opens perspectives for beyond-standard pharmacological and psychotherapeutic treatment for depression, i.e. training patients who are using passive coping to use problem-solving capacities instead and motivating them to engage in social life and sports activities.

Emotional withdrawal, CT abnormalities and drug response in late life depression

In this study, the authors investigated if CNS degenerative abnormalities could correlate with depressive symptoms in elderly patients, if the presence of mild/moderate cognitive impairment could be related to the response to treatment and the role of peculiar clinical features in influencing the response to treatment. Fifty-three patients (60-75 years) diagnosed as affected by late onset (after 60 years) Major Depressive Episodes according to DSM-IV criteria were studied. Brain vascular and degenerative markers were assessed by computed tomography (CT) through measurements of a lateralized version of the bifrontal index and a rating scale addressing subcortical disease. The presence of mild/moderate cognitive impairment [(24-28 total score at the Mini-Mental State Examination (MMSE)], and of specific symptoms were assessed at baseline and evaluated with respect to the antidepressant response. Patients with CT abnormalities showed higher baseline scores on Hamilton Rating Scale for Depression (HAM-D) items "late insomnia" (t=-2.674, P=.002), "somatic symptoms" (t=-3.355 P=.002), and Brief Psychiatric Rating Scale (BPRS) item "emotional withdrawal" (t=-3.355, P=.002). No significant correlation was found between the vascular index and baseline clinical symptoms, while the HAM-D "depressed mood" item was negatively correlated to the right frontal index (R=-0.692, P=.006). Patients with CT abnormalities showed a lower reduction of HAM-D total scores than patients with normal CT (time effect: F=29.277, P<.0001; group effect: F=5.154, P<.03), while a significant reduction of symptoms in time (time effect: F=33.33, P<.0001) but no differences between groups were found on Hamilton Rating Scale for Anxiety (HAM-A). Both patients with and without mild cognitive impairment improved on the HAM-D (time effect: F=19.668, P<.0001), BPRS (time effect: F=18.345, P<.0001), and HAM-A (time effect: F=17.959, P<.0001) total scores. Patients with emotional withdrawal showed lower improvement on BPRS total scores (time effect: F=26.946, P<.0001; group effect: F=5.121, P<.03). The results from this study showed that patients with baseline emotional withdrawal and CT abnormalities have poorer outcome. Further investigations on larger samples are needed to confirm these findings.

Lifetime patterns of depressive symptoms in the community and among primary care attenders: an application of grade of membership analysis

The objective of this study was to describe empirical and natural lifetime patterns of depressive and anxiety symptoms reported by community respondents and primary care attenders. The Grade of Membership model was used to analyze data collected from 716 subjects between 18 and 64 years of age with a lifetime diagnosis of DIS/DSM-III-R Major Depressive Episode. Symptoms of depression, mania, and anxiety (GAD, panic attack, and phobias) were processed. Six prototype categories (pure types) provided the best description of the structure of symptoms included in the analysis. Type I: bipolar depression with marked suicidal behaviour, comorbidity and early onset. Type II: non-melancholic-somatisation depression with late onset. Type III: non-melancholic, non-severe bipolar depression with male preponderance. Type IV: depression secondary to anxiety with marked female preponderance. Type V: melancholic depression with suicide ideation. Type VI: melancholic depression with panic attacks and female preponderance. The results support the heterogeneity of the longitudinal symptom pattern of depression and the existence of two time-trend types of comorbid anxiety disorders.

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.

The impact of ADL disability on depression symptoms in a community of Beijing elderly, China

OBJECTIVE

The purpose of this study was to test the hypothesis that ADL disability affects the risk of onset of depressive symptoms and the role of possible confounding variables in this relation.

METHODS

The data was obtained from the Beijing Longitudinal Study of Aging, a community-based cohort study of 3,257 elderly, aged 55 through 99 years, who were assessed four time at an 8-year interval. ADL disability and depressive symptoms were assessed by self-reported measures.

RESULTS

Compared with non-disabled persons, the disabled persons were associated with an increased risk of onset depression (RR=7.28 for urban, R=2.22 for non-urban). Although an adjustment for possible confounders reduced the risk for depression association with the disability, the detrimental effect of disability remained significantly present. This excess risk is partly explained by the lower satisfation with economy and poor perceived health status of the disabled elderly.

CONCLUSIONS

Disability among elderly may significantly increase the risk for depressive symptoms.

The differential influence of distinct clusters of psychiatric symptoms, as assessed by the general health questionnaire, on cause of death in older persons living in a rural community of Japan

OBJECTIVES

To examine the influence of distinct clusters of psychiatric symptoms on subsequent cause-specific mortality in older persons living in the community.

DESIGN

A prospective cohort study over 7.5 years.

SETTING

Otsuki-town, Kochi prefecture, Japan.

PARTICIPANTS

Nine hundred eighty community-dwelling persons, aged 65 to 84 in 1991.

MEASUREMENTS

Psychiatric symptoms at baseline were measured using the 30-item version of the General Health Questionnaire (GHQ-30). A factor analysis was performed on the responses of all 980 subjects. The relationships between subscale scores on the identified factors and causes of deaths occurring over 7.5 years in 817 respondents with no physical disability at baseline were assessed using a proportional hazards model adjusted for age, gender, chronic conditions under treatment, regular physical activity, and availability of close or casual neighbors.

RESULTS

The factor analysis identified three clusters of psychiatric symptoms: depression, apathy/anergia, and anxiety. In the proportional hazards model, which included three GHQ subscales depicting these factors simultaneously, the depression subscale was associated with increased mortality from cerebrovascular disease (multivariate adjusted hazard ratio per unit increase in the standard score on the depression subscale=2.04, 95% confidence interval (CI)=1.17-3.55), and the apathy/anergia subscale was associated with increased mortality from noncancer and noncardiovascular causes (multivariate adjusted hazard ratio per unit increase in the standard score on the apathy/anergia subscale=1.71, 95% CI=1.25-2.34). The anxiety subscale was not associated with any cause of death.

CONCLUSION

Depressive symptoms and symptoms indicating apathy/anergia have differential influences on subsequent causes of death in older persons living in the community. Identification of specific psychiatric symptom clusters may contribute to the prevention of deaths from specific causes in older populations.

Language acquisition, unemployment and depressive disorder among Southeast Asian refugees: a 10-year study

The current study examines the risk-inducing effects of unemployment and the protective effects of language facility on the mental health of Southeast Asian refugees resettling in Canada. Rates of depression and of unemployment declined dramatically during the first decade after arrival. Although language fluency also improved during this period, approximately 8% of the sample spoke no English even after 10 years in the country. Initial depression was a strong predictor of subsequent depression. For males, job experience in Canada was the strongest predictor of subsequent employment whereas, for women, depression proved an important predictor of employability. For men in particular, unemployment was a potent risk factor for depression. During the initial period of resettlement, English-speaking ability had no effect on depression or on employment. However, by the end of the first decade in Canada. English language fluency was a significant predictor of depression and employment, particularly among refugee women and among people who did not become engaged in the labor market during the earliest years of resettlement. Study results demonstrate that the mental health salience of risk and protective factors changes according to the phase of resettlement.

Depressive disorders in elderly Chinese patients in Macau: a comparison of general practitioners' consultations with a depression screening scale

OBJECTIVE

The objectives of this study were to identify the prevalence of depressive symptomatology in an elderly population using a screening scale; to assess general practitioner (GP) recognition of depression; to determine patient reasons for consultation; and to relate depression to social and demographic factors.

METHOD

An analytical cross-sectional study was carried out on a systematic sample of elderly Chinese patients currently resident in Macau, who presented to general practices in December 1997. Data collected included patient demographics, economic and social supports, patient depressive status assessed using the Hospital Anxiety and Depression scale (HAD), reason for attendance, and the reason for the consultation. Clinical records were analysed in order to collect GP-registered morbidity and recent relevant management.

RESULTS

Data were collected from 386 elderly Chinese patients of 31 GPs (97% patient response rate). Patients presented with somatic symptoms rather than psychological issues. Using HAD cut-off score of >8, 47% of the population studied were depressed; with a HAD subscale score >11, 26.2% were depressed. Depression was detected more often in women (59%) and being female was associated with depressive status (p = 0.010). Age (greater than 75 years) was also associated with being depressed, as was not having someone to talk to (p = 0.037), and being from low social class (p = 0.050). Not having someone willing to listen to their problems, difficulties and worries, was significantly related to depression (p = 0.041). There were no referrals or antidepressive medications detected in the clinical charts.

CONCLUSION

Participants' characteristics such as being over 75 years of age, being female and socially isolated were related to depression. General practitioners can play an important role in the early detection and management of psychological disorders. Although studies on a sample of Chinese patients in Macau cannot be generalized to Chinese populations elsewhere, awareness of somatic presentation of psychological illness is crucial in detecting depression in this and possibly other Chinese populations.

Comorbidity and mixed anxiety-depressive disorder: clinical curiosity or pathophysiological need?

The paper reviews available epidemiological evidence for the existence of and the implications of comorbidity of anxiety and depressive disorders and mixed anxiety-depressive (MAD) disorders. Using epidemiolological evidence of prevalence and incidence and data relating to time-course of illness, risk factor and outcome, it is concluded: (1) that anxiety-depression comorbidity is quite frequent in epidemiological and clinical settings throughout the world; (2) this comorbidity is diagnosis-specific and is associated with increased vulnerabilities and risks as well as poorer outcome and marked disabilities; and (3) no such evidence was found for MAD disorders. Contrary to what was predicted, the prevalence of MAD disorders was quite low even when using the more recent criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. (4) Furthermore, there was quite a heterogeneous pattern in terms of risk, severity and outcome making it questionable whether this disorder, as currently defined, is a clinical entity. These findings are discussed in terms of two perspectives, the 'lumpers' with their dimensional view and the 'splitters' with their categorical view. It is concluded that although comorbidity of threshold anxiety and depressive disorders seems to be an important phenomenon, no such evidence is provided for MAD disorders. Copyright 2001 John Wiley & Sons, Ltd.

Depressive comorbidity in children and adolescents with generalized anxiety disorder

Aim of this study is to examine the effect of depressive comorbidity in 108 children and adolescents with Generalized Anxiety Disorder (GAD). Fifty-five patients with GAD and depression were compared with 53 patients with GAD without depression. Age, gender and socioeconomic status did not differentiate the groups. Patients with comorbid depression had significantly more anxiety symptoms than patients without depression. Clinical presentation of GAD and pattern of comorbidity was similar in the two groups. Subjects with comorbid depression showed a more severe functional impairment, assessed with C-GAS. Data are discussed in the light of conceptualizations about the relationship between anxiety and depression.

Understanding the heterogeneity of depression through the triad of symptoms, course and risk factors: a longitudinal, population-based study

BACKGROUND

There is an ongoing research effort to test if depression is a homogeneous clinical syndrome and to identify valid and useful subtypes based on the number and nature of depressive symptoms. This study summarizes the patterns of depressive symptoms evident in a prospective study of the general population and examines the validity of potential subtypes by studying their course and etiologic heterogeneity.

METHODS

A general population sample of 1920 adults (aged 18-96) from the Baltimore Epidemiologic Catchment Area (ECA) follow-up study (1981 to 1993/6) were examined. Data on diagnoses, symptoms, course and risk factors were collected using the Diagnostic Interview Schedule (DIS). Latent class analysis was applied to summarize symptom patterns. Course characteristics and risk factor profiles were compared among potential subtypes based on the number of symptom groups or symptom patterns. Logistic regression models were used to examine the etiologic heterogeneity among potential subtypes based on symptoms.

RESULTS

The number of symptom groups gave the most efficient insight into differential etiologic processes. Severe depression (7-9 symptom groups) was associated with female gender, family history of depression but not with stressful life events before the onset of the first episode. Moderate (5-6 symptom groups) and mild depression (3-4 symptom groups) were associated with family history of depression, stressful life events before the onset, but not with female gender. The latent class model generated patterns of depressive psychopathology as follows: anhedonia, suicidal, psychomotor, and severely depressed subtypes. The Anhedonia subtype showed a course and risk factor profile distinct from the others.

LIMITATIONS

The measurement of psychopathology was based on self-reported DIS interviews instead of psychiatric assessments. Recall or report bias cannot be excluded in the ascertainment of family history and stressful life events.

CONCLUSIONS

Depression is heterogeneous, even below the threshold of syndromal diagnosis. The severity of an episode appears to be more informative than the pattern of symptoms, with the possible exception of a putative anhedonic subtype.

Depressive symptoms, stress, and coping among women recovering from addiction

This article focuses on the variability in well-being of 102 women in continuous recovery from addiction for 1 to 5 years. Univariate and bivariate analyses of cross-sectional data on recent depressive symptomatology, and psychosocial stress and coping strategies before and during recovery yielded the following findings: (a) Nearly a third of the sample reported scores above the 16-point cut-off on the Center for Epidemiologic Studies Depression Scale, indicating risk for depression; (b) over half had a history of diagnosed depression; (c) perceived stress in 16 life domains significantly decreased from prerecovery to recovery; (d) by recovery, participants significantly increase their use of positive strategies, but they continued use some negative ones; and (e) risk for high depressive symptomatology was greatest among those who were married or cohabiting, had a history of clinical of depression, high perceived stress in areas of money and emotional and physical health. Findings are discussed in terms of their implications for treatment and aftercare.

Depressive spectrum diagnoses

There has been widespread debate about the validity of the contemporary diagnostic classification system of depression. The major goal of this study is to examine the prognostic significance of each of the major subtypes of depression using data from 5 interviews of a 15-year prospective community-based cohort study. The stability of the following diagnostic subtypes across the duration of the study was examined: major depressive disorder (MDD), dysthymia, recurrent brief depression (RBD), and minor depression. The results show that there was little stability for the specific subtypes of depression among those who continued to manifest depression during the follow-up period; 51% of those with MDD and 44% of those with RBD met criteria for another subtype of depression. When stability was observed, the same subtype often occurred in combination with the development of another subtype. Among individuals with a single subtype, severity was greatest among those with dysthymia, whereas individuals with combined subtypes had greater severity than those with a single subtype. The lack of longitudinal stability of the diagnostic subtypes of depression suggests that depression is better expressed as a spectrum rather than a set of discrete subtypes.

Recognition and treatment of dysthymia in elderly patients

This review focuses on recent literature concerning dysthymia in the elderly population. Epidemiological data and clinical picture, diagnostic and therapeutic issues are evaluated and discussed. Although depressive syndromes are common in older patients, prevalence rates of dysthymia in the elderly are lower than in younger adults. This finding may be the consequence of the diagnostic criteria provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM) which are not specific for older adults. Other factors that complicate making diagnoses of dysthymia in older individuals are comorbid general conditions, cognitive deterioration and disorders, and frequent adverse life events (e.g. bereavement). The effects of these factors should be better defined to clarify whether elderly dysthymia is underestimated and if modified diagnostic criteria should be provided. A few researchers have identified a series of clinical features that are clearly different in the elderly and in young adult patients with dysthymia. These features are particularly related to the late onset and to the peculiar comorbidity of this disorder and suggest that dysthymia is a different disorder in the elderly. Drug treatment of depressive conditions in the elderly is currently based on new antidepressants [selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, norepinephrine (noradrenaline) reuptake inhibitors, benzamides]. These agents have an improved adverse effect profile compared with some of the older agents. Moreover, very few systematic studies have been performed using these drugs in samples of older patients with dysthymia and available data do not allow conclusions on drug choice and dosage. Besides, no specific data are available concerning the psychotherapy of dysthymia in this age group. All these topics need to be further investigated in studies comparing the elderly with control groups of younger patients with dysthymia.