Biological Aging and the Future of Geriatric Psychiatry

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Geroscience-Centric Perspective for Geriatric Psychiatry: Integrating Aging Biology With Geriatric Mental Health Research

The geroscience hypothesis asserts that physiological aging is caused by a small number of biological pathways. Despite the explosion of geroscience research over the past couple of decades, the research on how serious mental illnesses (SMI) affects the biological aging processes is still in its infancy. In this review, we aim to provide a critical appraisal of the emerging literature focusing on how we measure biological aging systematically, and in the brain and how SMIs affect biological aging measures in older adults. We will also review recent developments in the field of cellular senescence and potential targets for interventions for SMIs in older adults, based on the geroscience hypothesis.

Effects of accelerated biological age on depressive symptoms in a causal reasoning framework

BACKGROUND

Depression in middle-aged and elderly individuals is multifaceted and heterogeneous, linked to biological age (BA) based on aging-related biomarkers. However, due to confounding with chronological age and the absence of subgroup analysis and causal reasoning, the association between BA and depressive symptoms (DS) might be unstable and requires further investigation.

METHODS

We utilized data from the China Health and Retirement Longitudinal Study (N = 9478) to perform association analysis, causal inference, and subgroup analysis. BA acceleration (BAA) was derived using machine learning and adjusted for chronological age. A generalized linear mixed-effects model (GLMM) tree algorithm was employed to identify subgroups. The causal reasoning frame included propensity score matching and fast large-scale almost matching exactly.

RESULTS

In the longitudinal analysis, BAA exhibited a consistent and significant positive association with DS, even after controlling for demographic characteristics, lifestyle factors, health status, and physical functions. This association remained unchanged within the causal framework. GLMM tree analysis identified three partitioning variables (sex, satisfaction, and BMI) and five subgroups. Further subgroup analysis revealed that BAA exerted the strongest effect on DS among women with less satisfying lives.

LIMITATIONS

Depressive symptoms were evaluated through scale measurements rather than clinical diagnosis. The sample was derived from the general population, not the clinically depressed population.

CONCLUSIONS

This study provided the first longitudinal evidence that biological age acceleration increases depressive symptoms under causal reasoning and subgroup analysis, particularly among less satisfied women. And the association between BAA and DS was independent of known risk factors.

Associations between Physical Activity and Kyphosis and Lumbar Lordosis Abnormalities, Pain, and Quality of Life in Healthy Older Adults: A Cross-Sectional Study

Significant evidence suggests that regular physical activity (PA) leads to numerous physical and psychological outcomes in the elderly. This cross-sectional study was designed to further explore this issue by investigating the associations between PA (measured by accelerometer) and kyphosis and lumbar lordosis abnormalities, pain, and quality of life (QoL) in the elderly. In this cross-sectional study, 163 older adults (73 women) over 65 years of age (mean age: 68.70 ± 3.09) from Russia acted as participants. The following instruments were used to measure research variables: ActiGraph wGT3X-BT for measuring PA, spinal-mouse for measuring kyphosis and lumbar lordosis abnormalities, and the World Health Organization Quality of Life Scale (WHOQOL-BREF) questionnaire for measuring QoL. Pain was measured using two questions. The Independent t-test and a regression analysis were used to analyze data. The results showed that our sample participated on average in 15.8 min of moderate PA (MPA) per day, which is lower than the recommended guidelines. Men were significantly more physically active than women. In addition, MPA was significantly associated with lower kyphosis and lumbar lordosis abnormalities and pain in older adults. Finally, MPA was significantly associated with higher QoL. These findings indicate that PA is a critical concern for the elderly. Accordingly, physical educators and fitness instructors should adopt appropriate strategies to promote an active lifestyle among older adults.

Late life depression and concepts of aging: an emerging paradigm

Late life depression (LLD) is an emerging challenge, and recognized as a significant barrier to long-term healthy aging. Viewed within the context of the medical/biological model, advances in brain sciences over the last several decades have led to a deeper understanding of the biology of LLD. These advances in current knowledge include the description of aging brain pathophysiology; the biology and biochemistry of neurotransmitters; the correspondence between changes in neurological structure, function, and neural network; the description of neural, hormonal and inflammatory biomarkers; and identification of typical phenotypic subtypes of LLD. Despite these advances, current treatment of LLD, which remains largely pharmacological with accompanying cognitive and behavioral interventions, has poor success rate for long-term remission among older people. A wider perspective, in keeping with several emerging aging concepts, is suggested as an alternative framework within which to view LLD. A growing body of research supports the important role in LLD of frailty, resilience, intrinsic capacity, and functional integrity. Similarly, important social determinants need to be addressed in the etiology of LLD, rooted largely in negative stereotypes of aging, with consequent repercussions of reduced participation and inclusion, growing social isolation, with loss of identity, meaning and hope. This perspective suggests the importance of a wider integrative conceptualization of depression, set against a background of emerging aging concepts.

[Fertility preservation in female cancer patients.]

The incidence of cancer increases with age and as family planning is being delayed, there is a growing number of cancer patients whose fertility may be affected by oncological treatments. International guidelines recommend that all reproductive age cancer patients, including adolescent patients, should be referred for fertility preservation consultation, and if necessary, fertility preservation procedures should be performed. Fertility preservation enables cancer survivors to offer a chance for biological parenthood after recovery. In this review, the gonadotoxic effects of oncological therapies and the fertility preservation possibilities for female cancer patients based on international recommendations and literature are discussed. Our next review will provide detailed information on the special fertility preservation possibilities for different cancer types. The two reviews may help to elaborate a national guidance. Orv Hetil. 2023; 164(28): 1094-1101.

Biological factors influencing depression in later life: role of aging processes and treatment implications

Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.

Accelerated biological aging and risk of depression and anxiety: evidence from 424,299 UK Biobank participants

Theory predicts that biological processes of aging may contribute to poor mental health in late life. To test this hypothesis, we evaluated prospective associations between biological age and incident depression and anxiety in 424,299 UK Biobank participants. We measured biological age from clinical traits using the KDM-BA and PhenoAge algorithms. At baseline, participants who were biologically older more often experienced depression/anxiety. During a median of 8.7 years of follow-up, participants with older biological age were at increased risk of incident depression/anxiety (5.9% increase per standard deviation [SD] of KDM-BA acceleration, 95% confidence intervals [CI]: 3.3%-8.5%; 11.3% increase per SD of PhenoAge acceleration, 95% CI: 9.%-13.0%). Biological-aging-associated risk of depression/anxiety was independent of and additive to genetic risk measured by genome-wide-association-study-based polygenic scores. Advanced biological aging may represent a potential risk factor for incident depression/anxiety in midlife and older adults and a potential target for risk assessment and intervention.

Association between adiposity and emergent depressive symptoms in a 10-years prospective cohort of older adults: The EpiFloripa Aging study

BACKGROUND

The association between obesity and depressive symptoms has been described in the literature, but there is a scarcity of longitudinal data. This study aimed to verify the association between body mass index (BMI) and waist circumference and the incidence of depressive symptoms over a 10-year follow-up in a cohort of older adults.

METHODS

Data from the first (2009-2010), second (2013-2014), and third (2017-2019) waves of the EpiFloripa Aging Cohort Study were used. Depressive symptoms were assessed by the 15-item Geriatric Depression Scale (GDS-15) and classified in significant depressive symptoms for those with ≥6 points. The Generalized Estimating Equations model was used to estimate the longitudinal association between BMI and waist circumference and depressive symptoms across a 10-year follow-up.

RESULTS

The incidence of depressive symptoms (N = 580) was 9.9 %. The relationship between BMI and the incidence of depressive symptoms in older adults followed a U-shaped curve. Older adults with obesity had an incidence relative ratio of 76 % (IRR = 1.24, p = 0.035) for increasing the score of depressive symptoms after 10 years, compared to those with overweight. The higher category of waist circumference (Male: ≥102; Female: ≥88 cm) was associated with depressive symptoms (IRR = 1.09, p = 0.033), only in a non-adjusted analysis.

LIMITATIONS

Relatively high follow-up dropout rate; Few individuals in the underweight BMI category; BMI must be considered with caution because it does not measure only fat mass.

CONCLUSIONS

Obesity was associated with the incidence of depressive symptoms when compared with overweight in older adults.

Lower cognitive function attenuates the convergence between self-ratings and observer ratings of depressive symptoms in late-life cognitive impairment

OBJECTIVES

Assessment of depressive symptoms in older adults is challenging especially in the presence of risks in cognitive impairment. We aimed to examine whether the convergence between two measures of depressive symptoms (self-report and observer ratings) is affected by varying levels of cognitive function in older adults.

METHODS

Self-reported scale of depression, informant-based rating of affective symptoms, and global cognitive function were assessed in 2533 older adults with no impairment, mild cognitive impairment, and Alzheimer's disease. The strength of rank-order correlation between the Geriatric Depression Scale (GDS) and behavioral ratings of the Neuropsychiatric Inventory (NPI) was examined as the metric of convergent validity.

RESULTS

The results showed that the strength of convergence between the two measurements gradually decreased as a function of lowered cognitive function. Overall tendency showed that diagnoses of cognitive impairment and lower levels of cognitive function were associated with lower correspondence between the two depression measurements. The loss of convergent validity is especially evident in the behavioral symptom of apathy.

CONCLUSIONS

Utilizing self-report scales of depression in older adults requires a cautious approach even with minimal or mild levels of cognitive impairment.

Profile changes in admissions to a psychiatric hospitalisation unit over 15 years (2006-2021), considering the impact of the pandemic caused by SARS-CoV-2

The objective of this current work was to explore whether modification of the diagnostic criteria upon the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the impact of the COVID-19 pandemic had influenced the diagnostic and sociodemographic profiles of mental health admissions. For that purpose, we designed an observational, longitudinal, and retrospective study of the data recorded in the discharge reports of the Brief Hospitalization Unit at Castellon (Spain), between January 2006 and December 2021. The sample consisted of 7,037 participants, with a mean age of 42.1 years. The mean age of admissions, number of women, and presentation of affective disorders, addictions, and dementias all increased significantly during the DSM-5 period. Beyond diagnoses, the reduction in readmissions before the pandemic could be attributed to the use of long-acting injectable antipsychotics. In contrast, the pandemic did not change the percentage of readmissions or the volume of admissions. Also, during the pandemic period, the significant results obtained indicate that the average stay was reduced, affective disorders decreased, and addictions increased. Therefore, clinicians should consider these diagnostic and sociodemographic fluctuations when adapting clinical care, taking into account gender perspective, ageing of patients and increasing of dual and affective disorders.

The effectiveness of off-label dopamine stimulating agents in depressive disorder: A systematic review and meta-analysis

The chronicity of depressive disorders is a major problem. Dopamine stimulating agents (DSA) are suggested to hold a promising potential in depression management, particularly in older adults, in whom dopamine deficiency due to aging may be an underlying cause. More evidence is needed to support these drugs in the management of depression. Therefore, we conducted a systematic literature review and meta-analysis. Data was extracted from eighteen randomized-controlled-trials and eight open-label-studies. Additional meta-regression-analyses were performed to examine superiority of monotherapy versus augmentation, and to rule out a putative age effect. DSA were found to reduce depressive symptoms (SMD=-0.26, 95%CI[-0.43;-0.10]). Heterogeneity was high and a significant Egger's test indicated publication bias. Adjustment for missing studies, using trim-and-fill-methodology, reduced the effect size (SMD=-0.17, 95%CI[-0.39;0.05]), which lost statistical significance. Removing the outlier study from the analysis, the effect size remained marginally small, but was statistically-significant (SMD=-0.17, 95%CI[-0.31;-0.02]). Neither augmentation nor monotherapy was superior. No age effect was found. It can be concluded that off-label DSA are overall effective in reducing depressive symptoms. However, the evidence is weak, regarding the publication bias, and modest-to-weak treatment effects. Well-designed high-quality trials are highly needed, before dopamine stimulating agents can be adequately positioned in future depression treatment protocols.

Clinical and biological subtypes of late-life depression

BACKGROUND

Late-life depression (LDD) results from multiple psychosocial and neurobiological changes occurring in later life. The current study investigated how patterns of clinical symptoms and brain structural features are classified into LDD subtypes.

METHOD

Self-report scale of depression, behavioral rating of affective symptoms, and brain structural imaging of white matter change and cortical thickness were assessed in 541 older adults with no cognitive impairment or mild cognitive impairment. Latent profile analysis was used to identify distinct subtypes of depression.

RESULTS

The latent profile analysis identified four classes with mild to severe depressive symptoms and two classes with minimal symptoms. While the classes primarily differed in the overall severity, the combinatory patterns of clinical symptoms and neuropathological signature distinguished the classes with similar severity. The classes were distinguished in terms of whether or not neurodegenerative risk accompanied the corresponding depressive symptoms. The presence of the negative self-scheme and cortical thinning pattern notably characterized the subtypes of LDD.

LIMITATIONS

The underlying etiologies of the biological subtypes are still speculative, and the current study lacks clinical history that differentiates late- and early-onset depression.

CONCLUSIONS

Our finding provides insight in identifying heterogeneities of depressive disorder in later life and suggests that self-report and behavioral symptom profile in combination with white matter lesion and cortical thickness effectively characterizes distinct subtypes of LDD.

Structural MRI-Based Measures of Accelerated Brain Aging do not Moderate the Acute Antidepressant Response in Late-Life Depression

OBJECTIVE

Late-life depression (LLD) is characterized by accelerated biological aging. Accelerated brain aging, estimated from structural magnetic resonance imaging (sMRI) data by a machine learning algorithm, is associated with LLD diagnosis, poorer cognitive performance, and disability. We hypothesized that accelerated brain aging moderates the antidepressant response.

DESIGN AND INTERVENTIONS

Following MRI, participants entered an 8-week randomized, controlled trial of escitalopram. Nonremitting participants then entered an open-label 8-week trial of bupropion.

PARTICIPANTS

Ninety-five individuals with LLD.

MEASUREMENTS

A machine learning algorithm estimated each participant's brain age from sMRI data. This was used to calculate the brain-age gap (BAG), or how estimated age differed from chronological age. Secondary sMRI measures of aging pathology included white matter hyperintensity (WMH) volumes and hippocampal volumes. Mixed models examined the relationship between sMRI measures and change in depression severity. Initial analyses tested for a moderating effect of MRI measures on change in depression severity with escitalopram. Subsequent analyses tested for the effect of MRI measures on change in depression severity over time across trials.

RESULTS

In the blinded initial phase, BAG was not significantly associated with a differential response to escitalopram over time. BAG was also not associated with a change in depression severity over time across both arms in the blinded phase or in the subsequent open-label bupropion phase. We similarly did not observe effects of WMH volume or hippocampal volume on change in depression severity over time.

CONCLUSION

sMRI markers of accelerated brain aging were not associated with treatment response in this sequential antidepressant trial.

Association of Molecular Senescence Markers in Late-Life Depression With Clinical Characteristics and Treatment Outcome

IMPORTANCE

Many older adults with depression do not experience remission with antidepressant treatment, and markers of cellular senescence in late-life depression (LLD) are associated with greater severity of depression, greater executive dysfunction, and higher medical illness burden. Since these clinical characteristics are associated with remission in LLD, molecular and cellular senescence abnormalities could be a possible biological mechanism underlying poor treatment response in this population.

OBJECTIVE

To examine whether the senescence-associated secretory phenotype (SASP) index was associated with the likelihood of remission from a depressive episode in older adults.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized, open-label clinical trial was conducted between August 2009 and August 2014 in Pittsburgh, Pennsylvania; St Louis, Missouri; and Toronto, Ontario, Canada, with older adults in a current major depressive episode according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnostic criteria. Data from biomarker analyses were reported according to the clinical trial archived plasma samples run in March 2021. Data were analyzed from June to November 2021.

EXPOSURE

Venlafaxine extended release (dose ranging from 37.5 mg to 300 mg daily) for up to 12 weeks.

MAIN OUTCOMES AND MEASURES

The association between a composite biomarker-based index (SASP index) and treatment remission in older adults with major depression was measured using clinical data and blood samples.

RESULTS

There were 416 participants with a mean (SD) age of 60.02 (7.13) years; 64% (265 participants) were self-reported female, and the mean (SD) Montgomery-Asberg Depression Rating Scale score was 26.6 (5.7). Higher SASP index scores were independently associated with higher rates of nonremission, with an increase of 1 unit in the SASP index score increasing the odds of nonremission by 19% (adjusted odds ratio, 1.19; 95% CI, 1.05-1.35; P = .006). In contrast, no individual SASP factors were associated with remission in LLD.

CONCLUSIONS AND RELEVANCE

Using clinical data and blood samples from a nonrandomized clinical trial, the results of this study suggest that molecular and cellular senescence, as measured with the SASP index, is associated with worse treatment outcomes in LLD. Combining this index score reflecting interrelated biological processes with other molecular, clinical, and neuroimaging markers may be useful in evaluating antidepressant treatment outcomes. These findings inform a path forward for geroscience-guided interventions targeting senescence to improve remission rates in LLD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00892047.

Frailty and Depression in Late Life: A High-Risk Comorbidity With Distinctive Clinical Presentation and Poor Antidepressant Response

BACKGROUND

To investigate the longitudinal relationship between physical frailty, the clinical representation of accelerated biological aging, and antidepressant medication response in older adults with depressive illness.

METHODS

An 8-week randomized placebo-controlled trial (escitalopram or duloxetine) followed by 10 months of open antidepressant medication treatment (augmentation, switch strategies) was conducted in an outpatient research clinic. 121 adults aged 60 years or older with major depressive disorder (MDD) or persistent depressive disorder and a 24-item Hamilton Rating Scale for Depression (HRSD) ≥16 were enrolled. Primary measures assessed serially over 12 months include response (50% reduction from baseline HRSD score), remission (HRSD score <10), and frailty (non/intermediate frail [0-2 deficits] vs frail [≥3 deficits]); latent class analysis was used to classify longitudinal frailty trajectories.

RESULTS

A 2-class model best fit the data, identifying a consistently low frailty risk (63% of the sample) and consistently high frailty risk (37% of the sample) trajectory. Response and remission rates (ps ≤ .002) for adults in the high-risk frailty class were at least 21 percentage points worse than those in the low-risk class over 12 months. Furthermore, subsequent frailty was associated with previous frailty (ps ≤ .01) but not previous response or remission (ps ≥ .10).

CONCLUSIONS

Antidepressant medication is poorly effective for MDD occurring in the context of frailty in older adults. Furthermore, even when an antidepressant response is achieved, this response does little to improve their frailty. These data suggest that standard psychiatric assessment of depressed older adults should include frailty measures and that novel therapeutic strategies to address comorbid frailty and depression are needed.

Clozapine Long-Term Treatment Might Reduce Epigenetic Age Through Hypomethylation of Longevity Regulatory Pathways Genes

Long-term studies have shown significantly lower mortality rates in patients with continuous clozapine (CLZ) treatment than other antipsychotics. We aimed to evaluate epigenetic age and DNA methylome differences between CLZ-treated patients and those without psychopharmacological treatment. The DNA methylome was analyzed using the Infinium MethylationEPIC BeadChip in 31 CLZ-treated patients with psychotic disorders and 56 patients with psychiatric disorders naive to psychopharmacological treatment. Delta age (Δage) was calculated as the difference between predicted epigenetic age and chronological age. CLZ-treated patients were stratified by sex, age, and years of treatment. Differential methylation sites between both groups were determined using linear regression models. The Δage in CLZ-treated patients was on average lower compared with drug-naive patients for the three clocks analyzed; however, after data-stratification, this difference remained only in male patients. Additional differences were observed in Hannum and Horvath clocks when comparing chronological age and years of CLZ treatment. We identified 44,716 differentially methylated sites, of which 87.7% were hypomethylated in CLZ-treated patients, and enriched in the longevity pathway genes. Moreover, by protein-protein interaction, AMPK and insulin signaling pathways were found enriched. CLZ could promote a lower Δage in individuals with long-term treatment and modify the DNA methylome of the longevity-regulating pathways genes.

Influences of dopaminergic system dysfunction on late-life depression

Deficits in cognition, reward processing, and motor function are clinical features relevant to both aging and depression. Individuals with late-life depression often show impairment across these domains, all of which are moderated by the functioning of dopaminergic circuits. As dopaminergic function declines with normal aging and increased inflammatory burden, the role of dopamine may be particularly salient for late-life depression. We review the literature examining the role of dopamine in the pathogenesis of depression, as well as how dopamine function changes with aging and is influenced by inflammation. Applying a Research Domain Criteria (RDoC) Initiative perspective, we then review work examining how dopaminergic signaling affects these domains, specifically focusing on Cognitive, Positive Valence, and Sensorimotor Systems. We propose a unified model incorporating the effects of aging and low-grade inflammation on dopaminergic functioning, with a resulting negative effect on cognition, reward processing, and motor function. Interplay between these systems may influence development of a depressive phenotype, with an initial deficit in one domain reinforcing decline in others. This model extends RDoC concepts into late-life depression while also providing opportunities for novel and personalized interventions.

Inflammaging and Cannabinoids

Aging is a complex phenomenon associated with a wide spectrum of physical and physiological changes affecting every part of all metazoans, if they escape death prior to reaching maturity. Critical to survival, the immune system evolved as the principal component of response to injury and defense against pathogen invasions. Because how significantly immune system affects and is affected by aging, several neologisms now appear to encapsulate these reciprocal relationships, such as Immunosenescence. The central part of Immunosenescence is Inflammaging -a sustained, low-grade, sterile inflammation occurring after reaching reproductive prime. Once initiated, the impact of Inflammaging and its adverse effects determine the direction and magnitudes of further Inflammaging. In this article, we review the nature of this vicious cycle, we will propose that phytocannabinoids as immune regulators may possess the potential as effective adjunctive therapies to slow and, in certain cases, reverse the pathologic senescence to permit a more healthy aging.

Who benefits most from expectancy effects? A combined neuroimaging and antidepressant trial in depressed older adults

Depressed patients' expectations of improvement drive placebo effects in antidepressant clinical trials, yet there is considerable heterogeneity in the magnitude of expectancy effects. The present study seeks to identify those individuals who benefit most from expectancy effects using baseline neuroimaging and cognitive measures. Older adult outpatients diagnosed with major depressive disorder (MDD) participated in a prospective, 8-week clinical trial in which expectancy was experimentally manipulated and its effects on depression outcome measured. Based on the literature, we selected a priori 12 cognitive and brain-based variables linked to depression and expectancy, together with demographic variables, and incorporated them into a combined moderator. The combined moderator was developed as a weighted combination of the individual moderators, and was used to identify individuals who benefited most from expectancy effects. The combined moderator was found to predict differential change in depression severity scores between the high- vs. low-expectancy groups with a medium-size effect (Spearman effect size: 0.28). While at the sample level no expectancy effect was found, the combined moderator divided older adults with MDD into those who did and those who did not improve as the result of expectancy manipulation, with those benefiting from the manipulation showing greater processing speed, executive function, and frontostriatal white matter tract integrity. The findings suggest that it is possible to identify a subgroup of older adult individuals with MDD for whom expectancy manipulation results in greater antidepressant treatment response, supporting a precision medicine approach. This subgroup is characterized by distinct cognitive dysfunction and neuroimaging impairments profiles.

Frailty Worsens Antidepressant Treatment Outcomes in Late Life Depression

OBJECTIVE

To investigate the relationship between frailty and treatment response to antidepressant medications in adults with late life depression (LLD).

METHODS

Data were evaluated from 100 individuals over age 60 years (34 men, 66 women) with a depressive diagnosis, who were assessed for frailty at baseline (characteristics include gait speed, grip strength, activity levels, fatigue, and weight loss) and enrolled in an 8-week trial of antidepressant medication followed by 10 months of open-treatment.

RESULTS

Frail individuals (n = 49 with ≥3 deficits in frailty characteristics) did not differ at baseline from the non/intermediate frail (n = 51 with 0-2 deficits) on demographic, medical comorbidity, cognitive, or depression variables. On average, frail individuals experienced 2.82 fewer Hamilton Rating Scale for Depression (HRSD) points of improvement (t = 2.12, df 89, p = 0.037) than the non/intermediate frail over acute treatment, with this difference persisting over 10 months of open-treatment. Weak grip strength and low physical activity levels were each associated with decreased HRSD improvement, and lower response and remission rates over the course of the study. Despite their poorer outcomes, frail individuals received more antidepressant medication trials than the non/intermediate frail.

CONCLUSION

Adults with LLD and frailty have an attenuated response to antidepressant medication and a greater degree of disability compared to non/intermediate frail individuals. This disability and attenuated response remain even after receiving a greater number of antidepressant medication trials. Future research must focus on understanding the specific pathophysiology associated with the frail-depressed phenotype to permit the design and implementation of precision medicine interventions for this high-risk population.

Be Fit, Be Sharp, Be Well: The Case for Exercise as a Treatment for Cognitive Impairment in Late-life Depression

OBJECTIVE

To lay out the argument that exercise impacts neurobiological targets common to both mood and cognitive functioning, and thus more research should be conducted on its use as an alternative or adjunctive treatment for cognitive impairment in late-life depression (LLD).

METHOD

This narrative review summarizes the literature on cognitive impairment in LLD, describes the structural and functional brain changes and neurochemical changes that are linked to both cognitive impairment and mood disruption, and explains how exercise targets these same neurobiological changes and can thus provide an alternative or adjunctive treatment for cognitive impairment in LLD.

RESULTS

Cognitive impairment is common in LLD and predicts recurrence of depression, poor response to antidepressant treatment, and overall disability. Traditional depression treatment with medication, psychotherapy, or both, is not effective in fully reversing cognitive impairment for most depressed older adults. Physical exercise is an ideal treatment candidate based on evidence that it 1) is an effective treatment for depression, 2) enhances cognitive functioning in normal aging and in other patient populations, and 3) targets many of the neurobiological mechanisms that underlie mood and cognitive functioning. Results of the limited existing clinical trials of exercise for cognitive impairment in depression are mixed but overall support this contention.

CONCLUSIONS

Although limited, existing evidence suggests exercise may be a viable alternative or adjunctive treatment to address cognitive impairment in LLD, and thus more research in this area is warranted. Moving forward, additional research is needed in large, diverse samples to translate the growing research findings into clinical practice.

Structural and functional neuroimaging of late-life depression: a coordinate-based meta-analysis

Several neuroimaging studies have investigated localized aberrations in brain structure, function or connectivity in late-life depression, but the ensuing results are equivocal and often conflicting. Here, we provide a quantitative consolidation of neuroimaging in late-life depression using coordinate-based meta-analysis by searching multiple databases up to March 2020. Our search revealed 3252 unique records, among which we identified 32 eligible whole-brain neuroimaging publications comparing 674 patients with 568 controls. The peak coordinates of group comparisons between the patients and the controls were extracted and then analyzed using activation likelihood estimation method. Our sufficiently powered analysis on all the experiments, and more homogenous subsections of the data (patients > controls, controls > patients, and functional imaging experiments) revealed no significant convergent regional abnormality in late-life depression. This inconsistency might be due to clinical and biological heterogeneity of LLD, as well as experimental (e.g., choice of tasks, image modalities) and analytic flexibility (e.g., preprocessing and analytic parameters), and distributed patterns of neural abnormalities. Our findings highlight the importance of clinical/biological heterogeneity of late-life depression, in addition to the need for more reproducible research by using pre-registered and standardized protocols on more homogenous populations to identify potential consistent brain abnormalities in late-life depression.

Physical Activity in Early- and Mid-Adulthood Are Independently Associated With Longitudinal Memory Trajectories in Later Life

BACKGROUND

Physical activity (PA) in later life may reduce dementia risk, but little is known regarding long-term cognitive effects of PA that occurred earlier in adulthood or mechanisms underlying associations. PA patterns at different ages may independently contribute to dementia risk, which would implicate multiple critical periods for intervention. The current study tested whether retrospective reports of PA in early and mid-adulthood were independently associated with later-life longitudinal memory outcomes and whether associations were mediated by late-life cardiometabolic diseases.

METHOD

Participants comprised 5200 Health and Retirement Study Life History Mail Survey respondents. Latent growth curves estimated independent associations between retrospectively reported PA in early adulthood (age 18-29) and mid-adulthood (age 40-49) and 16-year episodic memory trajectories. Indirect pathways involving the maintenance of PA from early- to mid-adulthood and the influence of PA on later-life cardiometabolic diseases (hypertension, diabetes, and heart disease) were also estimated.

RESULTS

PA in early- and mid-adulthood independently predicted higher initial memory level and slower memory decline in later life, respectively. Early-adulthood PA was indirectly associated with later-life memory level through higher mid-adulthood PA and lower rates of later-life hypertension, as well as with subsequent memory decline through higher mid-adulthood PA.

CONCLUSIONS

The current findings highlight the importance of PA throughout adulthood, such that initiating and/or maintaining exercise in early- or mid-adulthood may be protective for later-life cognitive health, and hypertension appears to represent a key mediator of these effects.

Investigating patient-specific mechanisms of change in SET vs. EFT for depression: study protocol for a mechanistic randomized controlled trial

BACKGROUND

Major depressive disorder (MDD) is the leading cause of disability worldwide and one of the most heterogeneous mental health disorders. Although there are effective treatments for MDD, about 50% of patients do not respond to treatment. One of the greatest challenges in improving current treatments is identifying the mechanisms responsible for therapeutic change in MDD. The proposed study aims to identify patient-specific mechanisms of change in two treatments for MDD by investigating whether subpopulations of patients differ in the mechanisms of change that operate when receiving a given treatment. Based on theories of targeting weakness and building on strength, we will examine whether the mechanism of change operating when a treatment is provided depends on whether the treatment targets the patient's strength or weakness.

METHOD

To test our hypothesis that two treatments, supportive-expressive treatment (SET) and emotion-focused treatment (EFT), differ in their mechanisms of change and to explore whether focusing on the patient's strength or weakness will result in better treatment outcome, we conduct a mechanistic randomized controlled trial. One hundred and twenty-four individuals diagnosed with MDD are randomized to 16 sessions of either SET or EFT. The two treatments are theorized to differ in their main mechanism of change: SET places emphasis on insight as its main mechanism of change, and EFT places emphasis on emotional processing. Both can serve as strength- or weakness-focused treatments, based on the patient's baseline levels of insight and emotional processing. The primary outcome is the Hamilton Rating Scale for Depression. Additional measures include self-report measures and clinical interviews, hormonal, motion, acoustic, physiological, and neuroimaging assessments, performance on cognitive tasks, and narrative material (collected from the sessions and interviews).

DISCUSSION

The RCT will expand our understanding of mechanisms of change in psychotherapy, from one-size-fits-all to patient-specific mechanisms of change. By informing therapists about which of the two approaches is most effective with patients based on their baseline characteristics, the RCT will contribute to progress toward personalized treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT04576182 submitted on October 1st 2020.

FUNDING

The Israel Science Foundation. Trial status: Recruitment is ongoing.

Association between neuromelanin-sensitive MRI signal and psychomotor slowing in late-life depression

Late-life depression (LLD) is a prevalent and disabling condition in older adults that is often accompanied by slowed processing and gait speed. These symptoms are related to impaired dopamine function and sometimes remedied by levodopa (L-DOPA). In this study, we recruited 33 older adults with LLD to determine the association between a proxy measure of dopamine function-neuromelanin-sensitive magnetic resonance imaging (NM-MRI)-and baseline slowing measured by the Digit Symbol test and a gait speed paradigm. In secondary analyses, we also assessed the ability of NM-MRI to predict L-DOPA treatment response in a subset of these patients (N = 15) who received 3 weeks of L-DOPA. We scanned a further subset of these patients (N = 6) with NM-MRI at baseline and after treatment to preliminarily evaluate the effects of L-DOPA treatment on the NM-MRI signal. We found that lower baseline NM-MRI correlated with slower baseline gait speed (346 of 1807 substantia nigra-ventral tegmental area (SN-VTA) voxels, Pcorrected = 0.038), particularly in the more medial, anterior, and dorsal SN-VTA. Secondary analyses failed to show an association between baseline NM-MRI and treatment-related changes in gait speed, processing speed, or depression severity (all Pcorrected > 0.361); we however found preliminary evidence of increases in the NM-MRI signal 3 weeks post-treatment with L-DOPA compared to baseline (200 of 1807 SN-VTA voxels; Pcorrected = 0.046), although the small sample size of these preliminary analyses warrants caution in their interpretation and future replications. Overall, our findings indicate that NM-MRI is sensitive to variability in gait speed in patients with LLD, suggesting this non-invasive MRI measure may provide a promising marker for dopamine-related psychomotor slowing in geriatric neuropsychiatry.

Cortical inhibition, facilitation and plasticity in late-life depression: effects of venlafaxine pharmacotherapy

BACKGROUND

Late-life depression is often associated with non-response or relapse following conventional antidepressant treatment. The pathophysiology of late-life depression likely involves a complex interplay between aging and depression, and may include abnormalities in cortical inhibition and plasticity. However, the extent to which these cortical processes are modifiable by antidepressant pharmacotherapy is unknown.

METHODS

Sixty-eight patients with late-life depression received 12 weeks of treatment with open-label venlafaxine, a serotonin-norepinephrine reuptake inhibitor (≤ 300 mg/d). We combined transcranial magnetic stimulation of the left motor cortex with electromyography recordings from the right hand to measure cortical inhibition using contralateral cortical silent period and paired-pulse short-interval intracortical inhibition paradigms; cortical facilitation using a paired-pulse intracortical facilitation paradigm; and short-term cortical plasticity using a paired associative stimulation paradigm. All measures were collected at baseline, 1 week into treatment (n = 23) and after approximately 12 weeks of treatment.

RESULTS

Venlafaxine did not significantly alter cortical inhibition, facilitation or plasticity after 1 or 12 weeks of treatment. Improvements in depressive symptoms during treatment were not associated with changes in cortical physiology.

LIMITATIONS

The results presented here are specific to the motor cortex. Future work should investigate whether these findings extend to cortical areas more closely associated with depression, such as the dorsolateral prefrontal cortex.

CONCLUSION

These findings suggest that antidepressant treatment with venlafaxine does not exert meaningful changes in motor cortical inhibition or plasticity in late-life depression. The absence of changes in motor cortical physiology, alongside improvements in depressive symptoms, suggests that age-related changes may play a role in previously identified abnormalities in motor cortical processes in latelife depression, and that venlafaxine treatment does not target these abnormalities.

Social Activities and Health-Related Quality of Life in Rural Older Adults in South Korea: A 4-Year Longitudinal Analysis

During later life, inadequate social interactions may be associated with worse quality of life in older adults. Rural older adults are prone to developing unhealthy lifestyles related to social activities, which can lead to a poorer quality of life than that enjoyed by older adults living in urban areas. This study aimed to describe longitudinal changes in social activity participation and health-related quality of life among rural older adults, exploring potential associations with changes to in-person social activity over four years. We used prospective community-based cohort data from the Korean Social Life, Health, and Aging Project (KSHAP) collected between December 2011 and January 2016. The sample included 525 older adults who completed the measure of health-related quality of life. Our results showed a significant change in health-related quality of life according to changes in participation in meeting with friends. Even though an individual's participation in other social activities did not show significant differences in health-related quality of life, our findings imply that in-person social activities may be an important resource to encourage participation in physical activities and to develop other positive outcomes, such as a sense of belonging or satisfaction with later life, among rural older adults.

The symptom network structure of depressive symptoms in late-life: Results from a European population study

The network theory conceptualizes mental disorders as complex networks of symptoms influencing each other by creating feedback loops, leading to a self-sustained syndromic constellation. Symptoms central to the network have the greatest impact in sustaining the rest of symptoms. This analysis focused on the network structure of depressive symptoms in late-life because of their distinct etiologic factors, clinical presentation, and outcomes. We analyzed cross-sectional data from wave 2 of the 19 country Survey of Health, Ageing, and Retirement in Europe (SHARE) and included non-institutionalized adults aged 65 years or older (mean age 74 years, 59% females) endorsing at least one depressive symptom on the EURO-D scale for depression (N =8,557). We characterized the network structure of depressive symptoms in late-life and used indices of "strength", "betweenness", and "closeness" to identify symptoms central to the network. We used a case-dropping bootstrap procedure to assess network stability. Death wishes, depressed mood, loss of interest, and pessimism had the highest values of centrality. Insomnia, fatigue and appetite changes had lower centrality values. The identified network remained stable after dropping 74.5% of the sample. Sex or age did not significantly influence the network structure. In conclusion, death wishes, depressed mood, loss of interest, and pessimism constitute the "backbone" that sustains depressive symptoms in late-life. Symptoms central to the network of depressive symptoms may be used as targets for novel, focused interventions and in studies investigating neurobiological processes central to late-life depression.

Mobility but Not Balance Limitations Are Associated With Cognitive Decline among Older Hispanics

Aging is associated with changes in lower-body functioning. The extent to which lower-body function is associated with cognitive changes over time is unclear, especially among older Hispanics, a high-risk population for declines in physical and cognitive functioning. We sought to determine if the association between lower-body functioning and cognitive decline over 9-years differentially varied with respect to balance, gait speed, lower-body strength (chair stands), or a summary score of the three measures. This retrospective cohort study used clinical performance data from the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE). Cognitive function was measured using the Mini-Mental Status Exam. Linear mixed modeling was used to investigate the association between lower-body function and cognitive decline, controlling for patients' demographic and health characteristics. We found that gait speed and timed chair stands but not balance were associated with accelerated cognitive decline in Mexican-Americans age 75 years and older. These parameters of lower-body function can be feasibly measured in any clinic. As limitations in lower-body functioning may be an early marker of cognitive decline, this suggests an opportunity for the development of interventions to slow cognitive and physical disablement and promote successful aging among persons older than 75 years.

Declining Skeletal Muscle Mitochondrial Function Associated With Increased Risk of Depression in Later Life

OBJECTIVE

Late-life depression (LLD) is a chronic and heterogeneous disorder. Recent studies have implicated non-normative age-related processes in its pathogenesis. This investigation examined both cross-sectional and longitudinal associations between skeletal muscle mitochondrial function and LLD.

METHODS

Data from 603 men and women from the Baltimore Longitudinal Study on Aging were analyzed, of whom 167 provided data from a follow-up visit. Muscle bioenergetics was measured by postexercise recovery rate of phosphocreatine (PCr) using phosphorus magnetic resonance spectroscopy. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

There was no cross-sectional association between baseline depression status and either the PCr recovery rate constant (kPCr; t = -0.553, df = 542; p = 0.580) or mitochondrial capacity largely independent of exercise intensity (adenosine triphosphate maximum [ATP_max]; t = 0.804, df = 553; p = 0.422). Covariate-adjusted Firth logistic regression models however showed that greater decreases in skeletal muscle mitochondrial function from baseline to follow-up were associated with higher odds of clinically significant depressive symptoms (CES-D ≥16) at follow-up (ΔATP_max: odds ratio = 2.63, χ² = 5.62, df =1; p = 0.018; ΔkPCr: odds ratio = 2.32, χ² = 5.79, df =1; p = 0.016).

CONCLUSION

Findings suggest that declining skeletal muscle mitochondrial function in older adults is associated with clinically significant depressive symptoms at follow-up, thereby providing preliminary support for the hypothesis that mitochondrial dysfunction may be a potential key pathophysiological mechanism in adults with LLD.

Basal Ganglia Calcification: A Case Report of Fahr Disease With Pure Psychiatric Symptoms

Fahr disease, also known as familial idiopathic basal ganglia calcification, is a rare neurodegenerative disorder, the etiology of which remains unknown. Given its various presentations, Fahr disease is presumed to be underdiagnosed and its prevalence underestimated. We present a case of Fahr disease that presented mainly with pure psychiatric symptoms. Isolated psychiatric symptoms without neurological manifestations are rarely seen in patients diagnosed with Fahr disease. Psychiatrists should consider Fahr disease as a differential diagnosis in the evaluation of psychiatric illness.

Commentary on "Basal Ganglia Calcification: A Case Report of Fahr Disease With Pure Psychiatric Symptoms"

Fahr disease, also known as familial idiopathic basal ganglia calcification, is a rare neurodegenerative disorder, the etiology of which remains unknown. Given its various presentations, Fahr disease is presumed to be underdiagnosed and its prevalence underestimated. We present a case of Fahr disease that presented mainly with pure psychiatric symptoms. Isolated psychiatric symptoms without neurological manifestations are rarely seen in patients diagnosed with Fahr disease. Psychiatrists should consider Fahr disease as a differential diagnosis in the evaluation of psychiatric illness.

Not Just Nonspecific Factors: The Roles of Alliance and Expectancy in Treatment, and Their Neurobiological Underpinnings

Therapeutic factors such as alliance and expectancy have been found to greatly affect treatment outcome in both psychotherapy and psychopharmacotherapy. Often, these factors are referred to as nonspecific because of their common roles across treatment modalities. Here we argue that conceptualizing such factors as nonspecific is not accurate at best, misleading at worst and may undermine treatment outcome across various modalities. We argue that alliance and expectancy contain both a trait-like common factor component and a state-like specific effect, and that it is clinically, conceptually and methodologically critical to disentangle the two. In other words, both alliance and expectancy may also function as active ingredients of treatment, leading to better outcome. We review the literature regarding the neurobiological underpinnings of alliance and of the expectancy effect, and suggest how future studies on the neurobiological basis of these effects can shed further light on the potentially distinct mechanisms of the trait-like and state-like components of each therapeutic factor.

Identifying the most suitable treatment for depression based on patients' attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments

BACKGROUND

In the absence of one intervention that can cure all patients with major depressive disorder (MDD), the leading cause of disability worldwide, increased attention has been focused on selecting the best treatment based on patient characteristics. Theory-driven hypotheses for selecting the best treatments have not yet been adequately investigated. The present study tested the a priory hypothesis that attachment orientations may determine whether patients benefit more from a treatment where alliance provides a facilitative environment for the treatment to work, as in the case of supportive-expressive psychotherapy, vs. where alliance is conceptualized as an active ingredient in itself, as in the case of supportive psychotherapy.

METHOD/DESIGN

To test the hypothesis that attachment orientation moderates the effect of treatment condition on outcome, we conduct a randomized controlled trial (RCT). One hundred patients are randomized to 16 sessions of either supportive-expressive or supportive psychotherapy for MDD, conducted by experienced psychologists. The primary outcome is change in the Hamilton Rating Scale for Depression. Secondary outcome measures include self-reported depressive and other symptoms, psychological and interpersonal functioning, quality of life, and the presence of the diagnosis of depression. Additional measures include hormonal levels, motion synchrony, and acoustic attributes, performance on cognitive tasks, and narrative material (collected from the sessions and from interviews).

DISCUSSION

The RCT will expand our understanding of how the outcome of treatment can be optimized by identifying the most promising role of alliance in treatment, based on patients' pre-treatment attachment orientation. Results will contribute to the ongoing theoretical debate concerning the differential efficacy of various psychotherapeutic approaches for patients with different attachment orientations. The RCT will also contribute to progress toward personalized treatment by informing therapists about which of two approaches are most effective with patients based on their attachment styles.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02728557 submitted on the 15.3.16.

FUNDING

The Israel Science Foundation. Trial status: Recruitment is ongoing.

Biological Age, Not Chronological Age, Is Associated with Late-Life Depression

Background

The pathophysiology of late-life depression (LLD) is complex and heterogeneous, with age-related processes implicated in its pathogenesis. This study examined the cross-sectional and longitudinal association between depressive symptoms and a baseline multibiomarker algorithm of biological age (BA) that aggregates indicators of inflammatory, metabolic, cardiovascular, lung, liver, and kidney functioning.

Method

Data were analyzed from 2,776 men and women from the prospective observational Health Aging and Body Composition Study, who had both evaluable chronological age (CA) and BA. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale.

Results

A covariate-adjusted regression model showed that BA (B = 0.03, p = .0471) but not CA (B = -0.01, p = .7185) is associated with baseline CES-D scores. The mean baseline BA for individuals with a CES-D ≥ 10 was 1.28 years greater than in those with a CES-D < 10. Comparatively, there is only a 0.05-year difference in mean CA between the two depression groups. A covariate-adjusted longitudinal model found that baseline BA predicts CES-D score at follow-up (B = 0.04, p = .0058), whereas CA does not (B = 0.03, p = .4125). Additionally, an older BA significantly predicted a CES-D ≥ 10 (B = 0.02, p = .032) over a 10-year period.

Conclusions

A multibiomarker index of an older adult's BA outperformed their CA in predicting subsequent increased and clinically significant depressive symptoms. This result supports the evolving view of LLD as a brain disorder resulting from deleterious age-associated changes across numerous physiological systems.

A Six-Year Prospective Study of the Prognosis and Predictors in Patients With Late-Life Depression

OBJECTIVES

To examine the six-year prognosis of patients with late-life depression and to identify prognostic factors of an unfavorable course.

DESIGN AND SETTING

The Netherlands Study of Depression in Older Persons (NESDO) is a multisite naturalistic prospective cohort study with six-year follow-up.

PARTICIPANTS

Three hundred seventy-eight clinically depressed patients (according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria) and 132 nondepressed comparisons were included at baseline between 2007 and 2010.

MEASUREMENTS

Depression was measured by the Inventory of Depressive Symptomatology at 6-month intervals and a diagnostic interview at 2- and 6-year follow-up. Multinomial regression and mixed model analyses were both used to identify depression-related clinical, health, and psychosocial prognostic factors of an unfavorable course.

RESULTS

Among depressed patients at baseline, 46.8% were lost to follow-up; 15.9% had an unfavorable course, i.e., chronic or recurrent; 24.6% had partial remission; and 12.7% had full remission at six-year follow-up. The relative risk of mortality in depressed patients was 2.5 (95% confidence interval 1.26-4.81) versus nondepressed comparisons. An unfavorable course of depression was associated with a younger age at depression onset; higher symptom severity of depression, pain, and neuroticism; and loneliness at baseline. Additionally, partial remission was associated with chronic diseases and loneliness at baseline when compared with full remission.

CONCLUSIONS

The long-term prognosis of late-life depression is poor with regard to mortality and course of depression. Chronic diseases, loneliness, and pain may be used as putative targets for optimizing prevention and treatment strategies for relapse and chronicity.

A Machine Learning Approach to Identifying Placebo Responders in Late-Life Depression Trials

OBJECTIVE

Despite efforts to identify characteristics associated with medication-placebo differences in antidepressant trials, few consistent findings have emerged to guide participant selection in drug development settings and differential therapeutics in clinical practice. Limitations in the methodologies used, particularly searching for a single moderator while treating all other variables as noise, may partially explain the failure to generate consistent results. The present study tested whether interactions between pretreatment patient characteristics, rather than a single-variable solution, may better predict who is most likely to benefit from placebo versus medication.

METHODS

Data were analyzed from 174 patients aged 75 years and older with unipolar depression who were randomly assigned to citalopram or placebo. Model-based recursive partitioning analysis was conducted to identify the most robust significant moderators of placebo versus citalopram response.

RESULTS

The greatest signal detection between medication and placebo in favor of medication was among patients with fewer years of education (≤12) who suffered from a longer duration of depression since their first episode (>3.47 years) (B = 2.53, t(32) = 3.01, p = 0.004). Compared with medication, placebo had the greatest response for those who were more educated (>12 years), to the point where placebo almost outperformed medication (B = -0.57, t(96) = -1.90, p = 0.06).

CONCLUSION

Machine learning approaches capable of evaluating the contributions of multiple predictor variables may be a promising methodology for identifying placebo versus medication responders. Duration of depression and education should be considered in the efforts to modulate placebo magnitude in drug development settings and in clinical practice.

Depression Among Older Adults: A 20-Year Update on Five Common Myths and Misconceptions

Is depression among older adults symptomatically different than younger adults? Is it more common or chronic or difficult to treat? Is depression in late life more likely to be attributed to psychological problems? Twenty-years ago, Dan Blazer, a pioneer known for his groundbreaking work on depression in older adulthood, conducted an important review of the existing literature to refute five commonly held beliefs about depression in late life. Now, two decades later, we call upon selected articles that are representative of our current knowledge to provide an update and identify research priorities. The research consensus spanning the past 20 years suggests that when compared with their younger counterparts, depression in older adults is not more common and is not more often caused by psychological factors. Although some studies have suggested that depression in late life may be symptomatically different and characterized by a more somatic presentation, there is insufficient empirical evidence to conclude that depression presents differently across adulthood. Overall, older adults respond to psychological interventions as well as younger adults, although evidence suggests that antidepressants are less efficacious in late life. Finally, compared with middle-aged adults, depression in older adults is associated with a more chronic course (i.e., higher rate of relapse), which is likely moderated by medical comorbidity. This special article summarizes our current understanding of the nature and treatment of late-life depression and highlights areas of inquiry in need of further study.

Effect of Metabolic Syndrome on Late-Life Depression: Associations with Disease Severity and Treatment Resistance

BACKGROUND/OBJECTIVES

Metabolic syndrome (MetS) is the co-occurrence of obesity and metabolic derangements. Prior research implicates MetS in prolongation of the course of depression in older adults, but its effect on antidepressant response is unknown in this population. The objective was to determine whether MetS and related metabolic dyscrasias are associated with decreased rate of remission from depression in older adults treated pharmacologically for depression.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Three academic medical centers in North America.

PARTICIPANTS

Adults aged 60 and older (mean age 69.1) with major depressive disorder (MDD) (N = 435).

INTERVENTION

Open-label, protocolized treatment with extended-release venlafaxine for 12 or more weeks.

MEASUREMENTS

Time to remission from depression, with remission defined as a Montgomery-Åsberg Depression Rating Scale (MADRS) score of 10 or less at last two visits.

RESULTS

Two hundred twenty-two participants (51%) met criteria for MetS at baseline; MetS was associated with greater severity (MADRS score) and chronicity of depression at baseline. Remission was achieved in 182 participants (42%). In the unadjusted analysis, MetS was associated with prolonged time to remission (hazard ratio for remission = 0.71, 95% confidence interval = 0.52-0.95), but this relationship was not significant in the adjusted model; greater number of MetS components and lower high-density lipoprotein cholesterol had similar effects. Only diastolic blood pressure (DBP) was a significant predictor of time to remission before and after adjustment, with higher DBP predicting longer time to remission. Insulin sensitivity did not predict time to remission.

CONCLUSION

The presence of MetS in older adults with depression was associated with greater symptom severity and chronicity of depression, which appears to have accounted for the poorer antidepressant response observed in those with MetS. Additionally, our preliminary finding of an association between higher DBP and poorer antidepressant response bears further examination and replication.

Early Symptom Trajectories as Predictors of Treatment Outcome for Citalopram Versus Placebo

OBJECTIVES

The high percentage of failed clinical trials for anti-depressant medications, especially in elderly populations, obscures the fact that some patients may benefit greatly from treatment. Early detection of patients who may benefit most from antidepressant medication may improve treatment decisions. We examined whether depressed patients in a large clinical trial exhibit distinct trajectories of early symptom change that predict differential response to medication or placebo.

METHODS

We reanalyzed data of 174 patients aged 75 years and older with unipolar depression who were randomly assigned to citalopram or placebo. We used growth mixture modeling to identify trajectories of early change (weeks 1-4) on the Hamilton Rating Scale for Depression in the citalopram and placebo conditions.

RESULTS

In the citalopram condition, two distinct trajectories of early change were detected that were associated with significantly different symptom reduction, but only one trajectory was detected for the placebo condition. One of the early trajectories of patients receiving citalopram (N = 33) showed significantly better symptomatic change than placebo; the other trajectory (N = 51) did not differ significantly from placebo. Poor baseline functional scores predicted trajectory membership, so that individuals with a score below 4.5 on baseline instrumental activities of daily living showed a higher tendency to be in the trajectory that outperformed placebo.

CONCLUSIONS

The subgroup of citalopram-treated patients exhibiting better symptom trajectory early in a trial are likely to have beneficial outcomes relative to placebo. Future research should focus on developing reliable pre-treatment clinical and biological measures to identify this subgroup.