Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation

Primary Objective: The primary aim of this study was to determine the frequency of severe impaired self-awareness (ISA) in patients with severe traumatic brain injury (TBI) and the correlates of selected clinical, neuropsychiatric and cognitive variables. The secondary aim of the study was to assess depression and apathy on the basis of their level of self-awareness. Methods: Thirty patients with severe TBI and 30 demographically matched healthy control subjects (HCs) were compared on measures of ISA, depression, anxiety, alexithymia, neuropsychiatric symptoms and cognitive flexibility. Results: Twenty percent of the patients demonstrated severe ISA. Severe post-acute ISA was associated with more severe cognitive inflexibility, despite the absence of differences in TBI severity, as evidenced by a Glasgow Coma Scale (GCS) score lower than 9 in all cases in the acute phase. Patients with severe ISA showed lower levels of depression and anxiety but tended to show more apathy and to have greater difficulty describing their emotional state than patients with severe TBI who showed minimal or no disturbance in self-awareness. Conclusion: These findings support the general hypothesis that severe ISA following severe TBI is typically not associated with depression and anxiety, but rather with apathy and cognitive inflexibility.

Two-Year Follow-Up of Bibliotherapy and Individual Cognitive Therapy for Depressed Older Adults

This study examined the stability of treatment gains after receiving either cognitive bibliotherapy or individual cognitive psychotherapy for depression in older adults. A 2-year follow-up of 23 participants from Floyd, Scogin, McKendree-Smith, Floyd, and Rokke (2004) was conducted by comparing pre-and posttreatment scores with follow-up scores on the Hamilton Rating Scale for Depression (HRSD) and the Geriatric Depression Scale (GDS). Results indicated that treatment gains from baseline to the 2-year follow-up period were maintained on the HRSD and GDS, and there was not a significant decline from posttreatment to follow-up. There were no significant differences between the treatments on the GDS or HRSD at the 2-year follow-up; however, bibliotherapy participants had significantly more recurrences of depression during the follow-up period.

Prediction of antidepressant response in both 2.25xthreshold RUL and fixed high dose RUL ECT

Some forms of electroconvulsive therapy (ECT) can result in generalized seizures that lack efficacy, therefore physiological markers of treatment adequacy would be helpful. EEG measures of seizure quality, such as EEG regularity and post-ictal suppression, have largely supplanted seizure duration as a marker for seizure adequacy, yet no predictive algorithm has gained wide clinical acceptance. Electrographic seizure durations of less than 25 s still prompt re-stimulation in many settings. We re-examined the utility of EEG seizure duration and other measures of EEG seizure as predictors of antidepressant response to right unilateral (RUL) ECT.

METHODS

Seventy-two adult patients with major depression were randomized to either titrated RUL ECT at 2.25 times initial seizure threshold or RUL ECT at a fixed dose of 403 mC. Intent-to-treat responder status (defined by 60% reduction in HRSD scores and final score of 12 or less after the last RUL ECT session) was identified as the dependent variable in a nominal logistic regression model including EEG seizure quality candidate variables, controlled for age and gender.

RESULTS

A model including EEG seizure duration, EEG regularity, post-ictal suppression, age and gender and randomization status was significantly predictive of intent-to-treat responder status at treatment 2 (R2=.21 p<.003; N=66) and treatment 4 (R2=.27 p<.0004; N=67). The model remained significant at these time points even when randomization status (titrated moderately suprathreshold vs. high fixed dosage) was removed (Treatment 2: R2=.18 p<.007; Treatment 4: R2=.23 p<.0007).

CONCLUSION

EEG markers of seizure adequacy, including EEG seizure duration, are modestly predictive of antidepressant response for both titrated moderately suprathreshold and high fixed dosage RUL ECT.

No association between subjective memory complaints and apolipoprotein E genotype in cognitively intact elderly

OBJECTIVE

This cross-sectional study examined the relationship between subjective memory complaints and the apolipoprotein epsilon 4 allele (epsilon4), a genetic risk factor for Alzheimer's disease (AD), among cognitively normal subjects identified from a community memory screening.

DESIGN

The sample comprised 232 consecutive white non-Hispanic older adults who presented to a free community-based memory-screening program at a University affiliated memory disorders center. Participants were classified as cognitively normal based on scores on the age and educated adjusted Folstein Mini-Mental Status Exam (MMSAdj) and a brief Delayed Verbal Recall Test (DRT). Subjects were assessed for APOE genotype, subjective memory complaints (Memory Questionnaire, MQ), depressive symptoms (Hamilton Depression Rating Scale, HDRS), and history of four major medical conditions that have been associated with memory loss (stroke/transient ischemic attack [TIA], atherosclerotic heart disease, hypertension, and diabetes). A hierarchical regression analysis was performed to examine the association between APOE genotype and memory complaints after controlling for a host of potential confounding factors.

RESULTS

The APOE epsilon4 allele frequency for cognitively normal subjects was 0.13. Subjective memory complaints were predicted by depressive symptoms and a history of stroke/TIA. They were not associated with APOE genotype, MMSAdj score, DRT score, age, education, gender, and reported history of atherosclerotic heart disease, hypertension, or diabetes.

CONCLUSION

The results did not suggest an association between subjective memory complaints and the APOE epsilon4 allele in this sample of cognitively intact subjects. This indicates that memory complaints may confer risk for future dementia through pathways independent of APOE genotype. The results also show that older adults with memory complaints are at increased risk for underlying depression.

Standardizing the Hamilton Depression Rating Scale: past, present, and future

The Hamilton Depression Rating Scale (HAM-D) has become the most widely used depression severity rating scale in the world. It was originally published by Max Hamilton in 1960 to measure severity of depression in previously diagnosed depressed inpatients. Since that time, multiple versions of the scale have been created, although authors are rarely clear about which version they used. In addition, structured interview guides, self-report forms, and computerized versions have been developed in an effort to standardize administration of the scale and improve the psychometric characteristics of the individual items. The history of the development of these features is discussed, and the various versions of the scale are summarized in tables. This article is a fitting tribute to Per Bech, who has contributed so much to the assessment of depression severity.

Family history of dementia and current depression in nondemented community-dwelling older adults

Since it has been postulated that mood disturbance in nondemented older adults may represent a prodromal feature of dementia for a subgroup of patients, it would be expected that patients with these symptoms would evidence a greater prevalence of family history of dementia. In a sample of 3225 community-dwelling cognitively intact elderly recruited from a free memory-screening program, we found that current depression was more common in participants with a positive versus a negative family history of dementia in first-degree relatives (17% versus 11%; Fisher's Exact Test, P < .0001). This relationship remained significant after controlling for age, education, gender, ethnicity, and Folstein Mini-Mental State Examination score (OR = 1.5; 95% CI = 1.2-1.9, Wald X2 = 15.5, P < .001). The results suggest that symptoms of depression may herald the onset of an incipient dementia syndrome in a subset of geriatric patients. Alternatively, the results may be indicative of familial aggregation of dementia and depression.

Methodologic issues regarding outcome measures for clinical drug trials of psychiatric complications in dementia

Selecting outcome measures that are both psychometrically sound and sensitive to change is a very important aspect of clinical outcome research. A variety of measures have been introduced in recent years to assess behavioral complications in dementia, but few have been adequately tested in clinical trials. This article provides a discussion of factors to consider in selecting measures, including psychometrics, item content, assessment source, and sensitivity to change. A review of behavioral and psychiatric measures for dementia patients is provided, including measures of general behavioral disturbance, and measures specifically developed for agitation and depression. Each measure's psychometric characteristics, prior use with demented patients, and strengths and weaknesses with regard to treatment outcome research is summarized. The importance of linking measures to the investigators' hypotheses is discussed, along with recommendations for evaluating and selecting outcome measures depending on the needs of the specific investigation.

Depression in Alzheimer's disease patients: caregivers as surrogate reporters

OBJECTIVE

To evaluate the use of caregivers as surrogate reporters of depressive symptoms in Alzheimer's disease (AD) patients on five depression measures.

DESIGN

Scale characteristics, including means, ranges, internal consistency, sensitivity, and item content of modified self-report questionnaire and interview depression measures were compared.

PARTICIPANTS

Seventy-six patients, diagnosed with both depression and AD, and their family caregivers participated in this investigation. All subjects were community-residing participants in a treatment outcome investigation of behavioral treatment for depression.

MEASUREMENTS

A Schedule for Affective Disorders and Schizophrenia (SADS) interview was completed on all subjects to establish a diagnosis of depression. Caregivers then completed three additional questionnaire measures about their patient: the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the Center for Epidemiological Studies-Depression Scale (CESD), all modified to provide a surrogate report of their patient's depressive symptoms. In addition, two interview measures were completed based on interviews with the caregiver and patient: the Hamilton Depression Rating Scale (HDRS) and the Cornell Scale for Depression in Dementia (CSDD).

RESULTS

Mean scores for this sample were above the recommended cutoff score for mild levels of depression on all measures. Coefficient alpha levels were comparable to levels reported for the traditional self-report formats. Sensitivity varied among the measures, with the CSDD most sensitive and the HDRS least sensitive. Item content varied across measures, particularly between questionnaire and interview measures.

CONCLUSIONS

Based on these results, it appears that caregivers are able to act as surrogate reporters of depression in AD patients. The modification of self-report questionnaires did not decrease their internal consistency, and they remained highly correlated with each other, supporting their validity when used in this manner. A two-step process of evaluating AD patients for depression is recommended: first, a surrogate report questionnaire completed by caregivers to screen patients, eliminating those who are unlikely to be depressed, and then a more extensive interview with those patients-and their caregivers- who appear likely to be depressed.

Clinical determinants of dementia related to stroke

Among 251 patients examined 3 months after the onset of acute ischemic stroke, we diagnosed dementia in 66 (26.3%) by using modified DSM-III-R criteria based on neuropsychological, neurological, functional, and psychiatric examinations. We used a logistic regression model to derive odds ratios (ORs) for clinical factors independently related to dementia in this cross-sectional sample. Dementia was significantly associated with age, education, and race. A history of prior stroke (OR = 2.7) and diabetes mellitus (OR = 2.6) was also independently related to dementia, but hypertension and cardiac disease were not. Stroke features associated with dementia included lacunar infarction compared with all other subtypes combined (OR = 2.7) and hemispheric laterality in relation to brainstem or cerebellar location. There was a predominance of dementia in patients with left-sided lesions (OR = 4.7), an effect not explained by aphasia. Dementia was especially common with infarctions in the left posterior cerebral and anterior cerebral artery territories. A major dominant hemispheral syndrome (reflecting size and laterality) was also independently associated with dementia (OR = 3.9). We suggest that dementia after ischemic stroke is a result of multiple independent factors, including both small subcortical and large cortical infarcts especially involving the left medial frontal and temporal regions, with additional contributions by demographic and vascular risk factors.