Recent understandings in geriatric affective disorder

[Family physician's role in the primary and secondary prevention and in the treatment of depression in the elderly]

In recent years, the demographic transition has resulted in an aging population, which has increased the number of illnesses such as depression. Often, the family physician is the first contact with these patients, therefore, comprehensive patient management is essential, emphasizing the primary and secondary prevention of depression in the elderly population. From primary health care, all risk and protective factors related to depression should be comprehensively evaluated. Among the former, widowhood, disability, and chronic diseases stand out. Likewise, the diagnostic criteria must be known to provide timely treatment. And, on the other hand, knowing the appropriate treatment will reduce the symptoms of depression, suicidal behavior, relapse, or recurrence of symptoms. Treatment usually consists of psychotherapy, psychosocial interventions, antidepressants, and electroconvulsive therapy. Therefore, the objective of this review is to offer family physicians a guide on the primary prevention, secondary prevention, and treatment of depression in the elderly.

Better antidepressant efficacy of mecamylamine in combination with L-NAME than with L-arginine

Aff ;ective disorders, including anxiety and mood disorders, are a constellation of psychiatric diseases that aff ;ect over 10 % of the world's population. It has been proposed that drugs that change nicotinic acetylcholine receptor (nAChR) activity can affect mood- and anxiety-related behaviors. Also, neuronal nitric oxide synthase (nNOS) is closely associated with the pathophysiology of these disorders. To limit the potential adverse effects of alteration in cholinergic and nitric oxide (NO) systems, we investigated the combined efficacy of subthreshold doses of nAChR antagonist mecamylamine and NO ligands (L-arginine as agonist and l-NAME as an antagonist) on depression- and anxiety-related behaviors in male NMRI mice. Depression-related behaviors using the forced swim test (FST) and anxiety-like activity using the hole-board test were assessed. In our results, mecamylamine (3 mg/kg) showed antidepressant-like properties, and it also tended to have anxiolytic-like effects, though not significant. Concomitant treatment of subthreshold doses of mecamylamine (1 mg/kg) and l-arginine (25 mg/kg), l-NAME (1 mg/kg), or l-arginine/L-NAME were antidepressive. In contrast, l-arginine/L-NAME alone or in associated with mecamylamine showed anxiogenic-like efficacy. Isobolographic analysis exhibited an additive antidepressant effect of the combined subthreshold doses of mecamylamine and l-arginine, and a synergistic antidepressant effect of the combined subthreshold doses of mecamylamine and l-NAME. It should be noted that mecamylamine (3 mg/kg) elicited hypolocomotion. Our results suggest that mecamylamine produces a better antidepressant efficacy in combination with l-NAME than with l-arginine.

Neuronal nitric oxide synthase and affective disorders

Affective disorders including major depressive disorder (MDD), bipolar disorder (BPD), and general anxiety affect more than 10% of population in the world. Notably, neuronal nitric oxide synthase (nNOS), a downstream signal molecule of N-methyl-D-aspartate receptors (NMDARs) activation, is abundant in many regions of the brain such as the prefrontal cortex (PFC), hippocampus, amygdala, dorsal raphe nucleus (DRN), locus coeruleus (LC), and hypothalamus, which are closely associated with the pathophysiology of affective disorders. Decreased levels of the neurotransmitters including 5-hydroxytryptamine or serotonin (5-HT), noradrenalin (NA), and dopamine (DA) as well as hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis are common pathological changes of MDD, BPD, and anxiety. Increasing data suggests that nNOS in the hippocampus play a crucial role in the etiology of MDD whereas nNOS-related dysregulation of the nitrergic system in the LC is closely associated with the pathogenesis of BPD. Moreover, hippocampal nNOS is implicated in the role of serotonin receptor 1 A (5-HTR1 A) in modulating anxiety behaviors. Augment of nNOS and its carboxy-terminal PDZ ligand (CAPON) complex mediate stress-induced anxiety and disrupting the nNOS-CAPON interaction by small molecular drug generates anxiolytic effect. To date, however, the function of nNOS in affective disorders is not well reviewed. Here, we summarize works about nNOS and its signal mechanisms implicated in the pathophysiology of affective disorders. On the basis of this review, it is suggested that future research should more fully focus on the role of nNOS in the pathomechanism and treatment of affective disorders.

Mania and stroke: a systematic review

BACKGROUND

Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.

METHODS

We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.

RESULTS

From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).

CONCLUSIONS

Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

Descriptive epidemiology of undetected depression in institutionalized older people

OBJECTIVE

To measure the prevalence and associated factors of undetected depression in institutionalized older people.

DESIGN AND SETTING

Epidemiologic cross-sectional study in nursing homes and residential facilities.

PARTICIPANTS

A stratified cluster sample of residents 65 years of age and older living in institutions of Madrid (Spain).

MEASUREMENTS

Residents were considered to be depressed if they met at least 1 of the following 3 criteria: 10-item Geriatric Depression Scale score of 4 or higher, physician's diagnosis, or antidepressant use. Prevalence of undetected depression was defined as the proportion of depressed residents without documented diagnosis or treatment.

RESULTS

A total of 255 of 579 residents had depression (weighted prevalence 46.1%, 95% confidence interval [CI] 41.0%-51.3%) and 108 depressed residents were undetected (undetection prevalence 41.5%, 95% CI 33.2%-50.2%). Undetection was lower in younger residents, private versus public facilities (sex-, age-, and size-adjusted prevalence ratio [PR] 0.59, 95% CI 0.37-0.94), and larger facilities (sex-, age-, and ownership-adjusted PR 0.94 per 50-bed increase, 95% CI 0.88-1.00). Undetected depression was higher in residents with poor self-rated health (sex- and age-adjusted PR 1.83, 95% CI 1.24-2.73), whereas the opposite came about for physician-rated health (PR 0.65, 95% CI 0.44-0.95). Undetection decreased 11% (95% CI 4%-17%) per 1-medication increase, and it was lower in patients with Alzheimer disease, anxiety, and arrhythmia.

CONCLUSIONS

Number of medications and self-rated health were the main determinants of undetected depression. Physician-rated health, facility characteristics (size and ownership), and some diseases could also be considered.