Semi-structured depression scale sensitive to change with treatment for use in the elderly

Beliefs about medications predict adherence to antidepressants in older adults

BACKGROUND

Adherence to treatment is a complex and poorly understood phenomenon. This study investigates the relationship between older depressed patients' adherence to antidepressants and their beliefs about and knowledge of the medication.

METHODS

Assessment was undertaken of 108 outpatients over the age of 55 years diagnosed with depressive disorder and treated for at least four weeks with antidepressants. Adherence was assessed using two self-report measures: the Medication Adherence Rating Scale (MARS) and a Global Adherence Measure (GAM). Potential predictors of adherence investigated included sociodemographic, medication and illness variables. In addition, 33 carers were interviewed regarding general medication beliefs.

RESULTS

56% of patients reported 80% or higher adherence on the GAM. Sociodemographic variables were not associated with adherence on the MARS. Specific beliefs about medicines, such as "my health depends on antidepressants" (necessity) and being less worried about becoming dependant on antidepressants (concern) were highly correlated with adherence. General beliefs about medicines causing harm or being overprescribed, experiencing medication side-effects and severity of depression also correlated with poor adherence. Linear regression with the MARS as the dependent variable explained 44.3% of the variance and showed adherence to be higher in subjects with healthy specific beliefs who received more information about antidepressants and worse with depression severity and autonomic side-effects.

CONCLUSIONS

Our findings strongly support a role for specific beliefs about medicines in adherence. Challenging patients' beliefs, providing information about treatment and discussing side-effects could improve adherence. Poor response to treatment and medication side-effects can indicate poor adherence and should be considered before switching medications.

The care home activity project: does introducing an occupational therapy programme reduce depression in care homes?

The primary aim of the study was to test the hypothesis that depression severity in care homes for older people would be reduced by an occupational therapy programme. This was a feasibility study for a cluster randomised controlled trial and involved four intervention and four control homes in northern England. In each intervention home a registered occupational therapist worked full-time for one year delivering an individualised programme to participants. Pre- and post-intervention data for the Geriatric Mental State-Depression Scale (primary outcome measure) were obtained for 143 participants. Secondary outcomes included dependency and quality of life. No significant intervention effects were found in any of the quantitative outcome measures, though qualitative interviews showed the intervention was valued by many participants, staff and relatives. Therapist ratings and qualitative interviews suggested that the intervention was beneficial to some participants but no distinctive characteristics were found that might enable prediction of likely benefit on initial assessment. This exploratory study provides no evidence that this intervention produced benefits in terms of depression, dependency or quality of life. Lack of prior power calculations means these are not definitive findings; but numbers were sufficient to perform the required analyses and data did not suggest effects that would have reached statistical significance with a larger sample. This study highlights issues for consideration in providing such services in care homes.

Analysis of a care planning intervention for reducing depression in older people in residential care

Approximately 40% of older people in residential care have significant symptoms of depression. A training and care-planning approach to reducing depression was implemented for 114 depressed residents living in 14 residential care homes in North Yorkshire, UK. Care staff were offered brief mental health training by community mental health teams for older people. They were then assigned to work individually with residents in implementing the care-planning intervention, which was aimed at alleviating depression and any health, social or emotional factors that might contribute to the resident's depression. Clinically significant improvements in depression scores were associated with implementation of the care-planning intervention as evidenced by changes in scores on the Geriatric Mental State Schedule-Depression Scale. There was evidence of an interaction between the power of the intervention and degree of dementia. These improvements were not accounted for by any changes in psychotropic medication. The training was highly valued by care staff and heads of homes, and they considered that the care-planning intervention represented an improvement in quality of care for all residents, irrespective of levels of dementia. Staff also reported improvements in morale and increased confidence in the caring role as a result of their participation. The limitations of this study are discussed. On the basis of a growing body of evidence, it is argued that there is an urgent need for a suitably powered randomised controlled trial and economic evaluation, to test the cost-effectiveness of personalised care planning interventions aimed at reducing depression in older people in residential care.

Development and application of the mania rating guide (MRG)

In this article we present the development and application of the Mania Rating Guide (MRG), a semi-structured interview. This guide was created in order to assist the filling of three mania Scales: Mania Rating Scale, Bech-Rafaelsen Mania Scale and Clinician-Administered Rating Scale for Mania. The MRG consists of twenty-one Psychopathological Dimensions, that correspond to the Items of the original Scales, and are structured in Questions. The guide was applied to fifteen manic patients admitted in the Psychiatric Unit of the Clinical Hospital of Porto Alegre. A psychiatrist interviewed them using the MRG, and the interviews were videotaped. Afterwards, three independent raters scored the Mania scales based on the films. The impression of the raters was that the MRG allows not only to easily score all the Items of the Scales but also to cover the wide spectrum of the symptomatological presentation of a manic syndrome.

Just keep taking the tablets: adherence to antidepressant treatment in older people in primary care

BACKGROUND

poor adherence to antidepressant medication may account for a significant proportion of treatment failures. Adherence levels and factors associated with adherence have not previously been studied in older people.

OBJECTIVES

to report the prevalence and correlates of adherence to antidepressants in people > or = 65 years of age in a primary care setting.

METHOD

sixty-seven patients currently being prescribed antidepressants from a single rural general practice were assessed using a range of questionnaires measuring adherence to antidepressants, severity of depression, specific health education about antidepressants, level of side-effects, insight, positive and negatives beliefs about medication in general and antidepressants in particular, level of intellectual functioning (past and present), a past history of recovery from depression, type of antidepressant, complexity of prescriptions, age and living arrangements.

RESULTS

forty-five participants (67.2%) were fully adherent; seven (10.4%) mostly adherent, three (4.5%) adhered sometimes, three rarely and nine (13.4%) never. Backwards linear regression found that adherence increased with information given and cognitive impairment and decreased with concerns about taking antidepressants and severity of side-effects.

CONCLUSIONS

non-adherence to antidepressant medication is a significant problem in older patients. Our study probably overestimated adherence as it was self-report, which usually overestimates adherence and the refusals are more likely to have been people not taking tablets but still found nearly one third of the patients were non-adherent. An intervention comprising education, eliciting and addressing specific concerns about antidepressant medication and using medication, which minimises side effects, may be helpful.

The natural history of depression and the anxiety disorders in older people: the Islington community study

BACKGROUND

This study reports the outcome of depression and anxiety disorders in older people.

METHODS

Follow-up of 165 subjects age 65 or over, initially identified in a community study in inner London as depressed or having an anxiety disorder.

RESULTS

117 subjects still living in the area; 25 had died. Death was predicted only by activity limitation at first interview and not by other demographic or morbidity variables. Eighty-six subjects reinterviewed; 21 males, 65 females. Of the depressed, 34% had recovered, 39% were depressed and 27% were dead. Predictors from initial interview of continuing depression were female gender and more severe depression. Of those with phobic anxiety, 16% had recovered, 18% died and 66% were still phobic. Predictors of continuing phobic anxiety from initial interview were female gender and "stand-alone" phobic anxiety, i.e., not being depressed at initial interview. Sixty percent of those with early onset phobias had specific phobias; 82% of those with late-onset phobias had agoraphobia. Twenty-two subjects were prescribed psychotropics. The only significant predictor of psychotropic prescription was having sleep disturbance at initial interview. A low score on life satisfaction was significantly correlated with depression but not with phobic disorder. A high score was correlated with not having a current psychiatric disorder.

LIMITATIONS

Some subjects were lost to follow-up. Those on psychotropics were particularly likely to refuse an interview.

CONCLUSION AND CLINICAL RELEVANCE

In older people, neither depression nor the anxiety disorders generally remit spontaneously. Those with a particularly poor prognosis are women and those with a more severe depression. Agoraphobia may be precipitated in older people by stressful events and interferes with life satisfaction. There is potential for increased pharmacological treatment of older people with affective disorders.

Experience with a Swedish version of the Geriatric Depression Scale in primary care centres

OBJECTIVE

The purpose of this study was to use a Swedish version of the Geriatric Depression Scale (GDS-20) for diagnosis of depression in the elderly in primary care.

DESIGN

Elderly consecutive patients visiting two primary care centres (> or = 65 years of age; N = 1189) were rated by educated nurses using the GDS-20.

SETTING

All elderly patients attending two primary care centres in an urban-based community in the south of Sweden.

PATIENTS

Of the 1189 patients interviewed, 1002 were rated using the GDS-20.

MEASURES

The GDS-20, and in 26 patients also the Geriatric Mental State Schedule--Depression Scale (GMSS-DS).

RESULTS

Of 1002 rated patients, 93 had scores of 5 or above on the GDS-20. Further analysis showed that 158 (13.3%) suffered from affective disorders.

CONCLUSION

Depression in the elderly is underdiagnosed in primary care centres. A screening instrument such as the GDS-20 is of value in identifying the patients.