A transdiagnostic view on MDD and ADHD: shared cognitive characteristics?

BACKGROUND

Major Depressive disorder (MDD) and Attention Deficit Hyperactivity Disorder (ADHD) are prevalent mental disorders that often co-occur. There is overlap in symptomatology between MDD and ADHD that complicates diagnostics and treatment selection. Hence, to aid diagnostics of single and comorbid disorders, we aimed to examine the discriminative power of common symptom measures and cognitive dysfunction to differentiate between participants diagnosed with MDD, ADHD, ADHD and comorbid MDD and without a mental disorder.

METHODS

Four diagnosed groups were compared: MDD (n = 103), ADHD (n = 78), comorbid MDD + ADHD (n = 29), healthy controls (HC; n = 123). We examined between-group differences and discriminative functions of clinically validated self-report symptom questionnaires, as well as task-based and self-report measures of cognitive dysfunction.

RESULTS

Based on the between group comparisons, all patient groups were characterized by clinically relevant levels of ADHD-symptomatology, executive dysfunction, and diminished cognitive performances in the domain of attention; even the MDD-only group. In addition, based on self-reported symptoms of MDD, ADHD, and executive dysfunction, discriminant function analysis classified all HC correctly (100%) and patients diagnosed with ADHD or MDD relatively well (resp. 85% and 82%). Comorbid MDD + ADHD was poorly differentiated from single MDD or ADHD by the commonly used self-report symptom questionnaires for MDD and ADHD (0% correct predictions), which substantially improved by incorporating the questionnaire on executive functioning (42% correct predictions).

CONCLUSIONS

In both MDD and ADHD, clinical levels of attentional and executive dysfunction were found, while these clinical groups differed in cognitive flexibility, initiating, inhibition and meta-cognition. Comorbid MDD + ADHD was poorly distinguishable from non-comorbid MDD and ADHD based on self-reported symptoms of depression and ADHD. Addition of subjective executive function in the discrimination models resulted in increased discriminative power. Our findings indicate that executive functioning measure can improve the diagnostic process of ADHD and MDD.

Association Between Personality Traits and Functional Limitations in Older Adults with Affective Disorders: A Cross Sectional Study

OBJECTIVES

Personality traits and affective disorders are both related to functional limitations. It is unknown whether personality traits have an additional effect on functioning in older adults with affective disorders. We studied the association between personality traits and functioning within this group.

METHODS

We performed a cross-sectional study of 180 older patients referred to outpatient specialized geriatric mental health care centers with a depressive, anxiety and/or somatic symptom disorder according to DSM-criteria. We studied the association between the Big Five personality traits and functional limitations assessed with the WHO-DAS II, adjusting for potential confounders, including the severity of various affective disorders.

RESULTS

The 180 patients (57.1% female, mean age 69.2 years) had an average WHO-DAS II score of 31.3 (SD 15.1). Lower scores on Conscientiousness were associated with more overall functional limitations (p = .001), particularly limitations in self-care (p = .001) and household activities (p = .001). Lower Extraversion scores were associated with more limitations in getting along with others (p = .001).

CONCLUSIONS

Personality traits are related to functional limitations independent of the severity of affective disorders in older adults.

CLINICAL IMPLICATIONS

Personality traits may be used as predictive factors for functioning in older adults with affective disorders.

Brain structure and function link to variation in biobehavioral dimensions across the psychopathological continuum

In line with the Research Domain Criteria (RDoC) , we set out to investigate the brain basis of psychopathology within a transdiagnostic, dimensional framework. We performed an integrative structural-functional linked independent component analysis to study the relationship between brain measures and a broad set of biobehavioral measures in a sample (n = 295) with both mentally healthy participants and patients with diverse non-psychotic psychiatric disorders (i.e. mood, anxiety, addiction, and neurodevelopmental disorders). To get a more complete understanding of the underlying brain mechanisms, we used gray and white matter measures for brain structure and both resting-state and stress scans for brain function. The results emphasize the importance of the executive control network (ECN) during the functional scans for the understanding of transdiagnostic symptom dimensions. The connectivity between the ECN and the frontoparietal network in the aftermath of stress was correlated with symptom dimensions across both the cognitive and negative valence domains, and also with various other health-related biological and behavioral measures. Finally, we identified a multimodal component that was specifically associated with the diagnosis of autism spectrum disorder (ASD). The involvement of the default mode network, precentral gyrus, and thalamus across the different modalities of this component may reflect the broad functional domains that may be affected in ASD, like theory of mind, motor problems, and sensitivity to sensory stimuli, respectively. Taken together, the findings from our extensive, exploratory analyses emphasize the importance of a dimensional and more integrative approach for getting a better understanding of the brain basis of psychopathology.

Transdiagnostic psychiatry: Symptom profiles and their direct and indirect relationship with well-being

BACKGROUND

Heterogeneity and comorbidity in psychiatric disorders are common, however, little is known about the impact on well-being and the role of functional limitations. We aimed to identify transdiagnostic psychiatric symptom profiles and to study their association with well-being and the mediating role of functional limitations in a naturalistic psychiatric patient group.

METHODS

We used four disorder-specific questionnaires to assess symptom severity within a sample of 448 psychiatric patients with stress-related and/or neurodevelopmental disorders and 101 healthy controls. Using both exploratory and confirmatory factor analyses we identified transdiagnostic symptom profiles, which we entered into a linear regression analysis to assess their association with well-being and the mediating role of functional limitations in this association.

RESULTS

We identified eight transdiagnostic symptom profiles, covering mood, self-image, anxiety, agitation, empathy, non-social interest, hyperactivity and cognitive focus. Mood and self-image showed the strongest association with well-being in both patients and controls, while self-image also showed the highest transdiagnostic value. Functional limitations were significantly associated with well-being and fully mediated the relationship between cognitive focus and well-being.

LIMITATIONS

The participant sample consisted of a naturalistic group of out-patients. While this strengthens the ecological validity and transdiagnostic perspective of this study, the patients with a single neurodevelopmental disorder were underrepresented.

CONCLUSION

Transdiagnostic symptom profiles are valuable in understanding what reduces well-being in psychiatric populations, thereby opening new avenues for functionally meaningful interventions.

Striatal connectopic maps link to functional domains across psychiatric disorders

Transdiagnostic approaches to psychiatry have significant potential in overcoming the limitations of conventional diagnostic paradigms. However, while frameworks such as the Research Domain Criteria have garnered significant enthusiasm among researchers and clinicians from a theoretical angle, examples of how such an approach might translate in practice to understand the biological mechanisms underlying complex patterns of behaviors in realistic and heterogeneous populations have been sparse. In a richly phenotyped clinical sample (n = 186) specifically designed to capture the complex nature of heterogeneity and comorbidity within- and between stress- and neurodevelopmental disorders, we use exploratory factor analysis on a wide range of clinical questionnaires to identify four stable functional domains that transcend diagnosis and relate to negative valence, cognition, social functioning and inhibition/arousal before replicating them in an independent dataset (n = 188). We then use connectopic mapping to map inter-individual variation in fine-grained topographical organization of functional connectivity in the striatum-a central hub in motor, cognitive, affective and reward-related brain circuits-and use multivariate machine learning (canonical correlation analysis) to show that these individualized topographic representations predict transdiagnostic functional domains out of sample (r = 0.20, p = 0.026). We propose that investigating psychiatric symptoms across disorders is a promising path to linking them to underlying biology, and can help bridge the gap between neuroscience and clinical psychiatry.

Depressive Symptoms Account for Loss of Positive Attention Bias in ADHD Patients: An Eye-Tracking Study

OBJECTIVES

Depression and ADHD often co-occur and are both characterized by altered attentional processing. Differences and overlap in the profile of attention to emotional information may help explain the co-occurence. We examined negative attention bias in ADHD as neurocognitive marker for comorbid depression.

METHODS

Patients with depression (n = 63), ADHD (n = 43), ADHD and depression (n = 25), and non-psychiatric controls (n = 68) were compared on attention allocation toward emotional faces. The following eye-tracking indices were used: gaze duration, number of revisits, and location and duration of first fixation.

RESULTS

Controls revisited the happy faces more than the other facial expressions. Both the depression and the comorbid group showed significantly less revisits of the happy faces compared to the ADHD and the control group. Interestingly, after controlling for depressive symptoms, the groups no longer differed on the number of revisits.

CONCLUSION

ADHD patients show a relative positive attention bias, while negative attention bias in ADHD likely indicates (sub)clinical comorbid depression.

Effectiveness of late-life depression interventions on functional limitations: A systematic review

Depression is one of the most prevalent mental disorders in older adults and leads to considerable decreases in health, well-being, and impaired functioning. Intervention studies have focused on the effects on symptomatic recovery, and most do not include functional recovery as an outcome. Reduction of functional limitations as a treatment goal in old-age psychiatry aligns with the values of older persons. The objective of this review was therefore to evaluate the effectiveness of late-life depression interventions on functional limitations. This systematic review identified 15 randomized controlled trials in which the effectiveness of different interventions on functional limitations was evaluated in patients with late-life depression. The interventions were categorized into four categories: psychological interventions, drug treatment, physical exercise, and collaborative care. Multicomponent and collaborative-care interventions appear to be the most promising for improvement of functional limitations, particularly in primary care and community-dwelling populations of older persons with symptoms of depression. There is, however, a lack of evidence regarding studies in specialized mental health care.

Amygdala sensitivity for negative information as a neural marker for negative memory bias across psychiatric diagnoses

Self-referent negative memory bias is a known risk factor for depression, but recent evidence suggests its function as a transdiagnostic cognitive depressotypic marker. The amygdala's sensitivity for negative information is considered a neurobiological depressotypic marker. However, their relationship remains unknown. We transdiagnostically investigated the association between the amygdala's sensitivity, self-referent negative memory bias and its two components: negative endorsement bias and negative recall bias. Patients (n= 125) with (multimorbid) stress-related and neurodevelopmental psychiatric disorders and healthy controls (n= 78) performed an fMRI task to assess the amygdala's sensitivity for negative information and a task outside the scanner for the biases. Linear regression models assessed their associations. The left amygdala's sensitivity for negative information was significantly positively associated with negative recall bias in patients, but not controls. There were no significant associations with self-referent negative memory bias or negative endorsement bias or between the two depressotypic markers. Thus, the left amygdala's sensitivity for negative information may be considered a neural marker of negative memory bias across psychiatric diagnoses. Further research on the interactons with known determinants such as genetic predisposition is required to fully understand the relationship between the amygdala's sensitivity for negative information and these biases.

Challenging the negative learning bias hypothesis of depression: reversal learning in a naturalistic psychiatric sample

BACKGROUND

Classic theories posit that depression is driven by a negative learning bias. Most studies supporting this proposition used small and selected samples, excluding patients with comorbidities. However, comorbidity between psychiatric disorders occurs in up to 70% of the population. Therefore, the generalizability of the negative bias hypothesis to a naturalistic psychiatric sample as well as the specificity of the bias to depression, remain unclear. In the present study, we tested the negative learning bias hypothesis in a large naturalistic sample of psychiatric patients, including depression, anxiety, addiction, attention-deficit/hyperactivity disorder, and/or autism. First, we assessed whether the negative bias hypothesis of depression generalized to a heterogeneous (and hence more naturalistic) depression sample compared with controls. Second, we assessed whether negative bias extends to other psychiatric disorders. Third, we adopted a dimensional approach, by using symptom severity as a way to assess associations across the sample.

METHODS

We administered a probabilistic reversal learning task to 217 patients and 81 healthy controls. According to the negative bias hypothesis, participants with depression should exhibit enhanced learning and flexibility based on punishment v. reward. We combined analyses of traditional measures with more sensitive computational modeling.

RESULTS

In contrast to previous findings, this sample of depressed patients with psychiatric comorbidities did not show a negative learning bias.

CONCLUSIONS

These results speak against the generalizability of the negative learning bias hypothesis to depressed patients with comorbidities. This study highlights the importance of investigating unselected samples of psychiatric patients, which represent the vast majority of the psychiatric population.

The Role of Perseverative Cognition for Both Mental and Somatic Disorders in a Naturalistic Psychiatric Patient Sample

OBJECTIVE

Perseverative cognition (PC) is the repeated or long-term activation of the cognitive representation of psychological stressors and is associated with prolonged stress including somatic and mental consequences. Hence, PC might represent a cognitive process linking mental and somatic pathology, but current research on this link is limited by investigating healthy samples, markers of somatic disease, and single disorders. The present study explored the importance of PC for different mental and somatic disorders in psychiatric patients.

METHODS

Data from 260 naturalistic psychiatric outpatients were used. Psychiatric diagnoses were based on structured clinical interviews. Somatic diseases were assessed using a well-validated questionnaire and were clustered into (cardio)vascular and immune/endocrine diseases. PC was operationalized using the Perseverative Thinking Questionnaire (PTQ).

RESULTS

Multiple regression complemented with relative importance analyses showed that the PTQ total and subscale scores were associated with the presence of mood disorders, addiction, and anxiety. Unexpectedly, no relatively important associations were found between the PTQ and autism spectrum disorder, attention-deficit/hyperactivity disorder, or somatic disease.

CONCLUSIONS

Our data complement previous work linking PC to stress-related mental disorders but question its immediate role in neurodevelopmental and somatic disorders. Targeting PC in the treatment of mood disorders and perhaps also in addiction seems promising.

Frailty as a Predictor of Mortality in Late-Life Depression: A Prospective Clinical Cohort Study

OBJECTIVE

Frailty is a clinical phenotype that predicts negative health outcomes, including mortality, and is increasingly used for risk stratification in geriatric medicine. Similar to frailty, late-life depression is also associated with increased mortality rates. Therefore, we examined whether frailty and frailty-related biomarkers predict mortality among depressed older patients.

METHODS

In our study of 378 older patients aged ≥ 60 years with a depressive disorder (DSM-IV criteria), we examined whether frailty predicts time-to-death during a 6-year follow-up using Cox proportional hazard regression analyses adjusted for confounders. Baseline data were collected from 2007 to September 2010. Frailty was defined according to the Fried Frailty Phenotype criteria (muscle weakness, slowness, exhaustion, low activity level, unintended weight loss). Similarly, we examined the predictive value of 3 inflammatory markers, vitamin D level, and leukocyte telomere length and whether these effects were independent of the frailty phenotype.

RESULTS

During follow-up, 27 (26.2%) of 103 frail depressed patients died compared with 35 (12.7%) of 275 non-frail depressed patients (P < .001). Adjusted for confounders, the number of frailty components was associated with an increased mortality rate (hazard ratio = 1.38 [95% CI, 1.06-1.78], P = .015). All biomarkers except for interleukin 6 were prospectively associated with mortality, but only higher levels of high-sensitivity C-reactive protein and lower levels of vitamin D were independent of frailty associated with mortality.

CONCLUSIONS

In late-life depression, frailty identifies older patients at increased risk of adverse negative health outcomes. Therefore, among frail depressed patients, treatment models that include frailty-specific interventions might reduce mortality rates.

Is a Negative Attentional Bias in Individuals with Autism Spectrum Disorder Explained by Comorbid Depression? An Eye-Tracking Study

Heightened attention towards negative information is characteristic of depression. Evidence is emerging for a negative attentional bias in Autism spectrum disorder (ASD), perhaps driven by the high comorbidity between ASD and depression. We investigated whether ASD is characterised by a negative attentional bias and whether this can be explained by comorbid (sub) clinical depression. Participants (n = 116) with current (CD) or remitted depression (RD) and/or ASD, and 64 controls viewed positively and negatively valenced (non-)social pictures. Groups were compared on three components of visual attention using linear mixed models. Both CD individuals with and without ASD, but not remitted depressed and never-depressed ASD individuals showed a negative bias, suggesting that negative attentional bias might be a depressive state-specific marker for depression in ASD.

Negative memory bias as a transdiagnostic cognitive marker for depression symptom severity

BACKGROUND

Negative memory bias is a strong risk factor for the development and maintenance of depression. Recent evidence also found negative memory bias in other mental disorders. Here, we aim to: 1) assess the presence and strength of negative memory bias in a range of (comorbid) mental disorders, 2) investigate which disorder-specific symptoms are associated with negative memory bias, and 3) test whether negative memory bias might be a transdiagnostic mechanism.

METHODS

Negative memory bias was measured in patients with at least one diagnosis of a stress-related disorder (n = 86), a neurodevelopmental disorder (n = 53), or both (n = 68), and 51 controls. Depression, anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorder symptom severity was assessed using questionnaires. Groups were compared on negative memory bias and the associations between negative memory bias and symptom severity were made using linear regression models.

RESULTS

All patient groups showed stronger negative memory bias than the controls. Negative memory bias was individually associated with all symptom severity indices, but when added into a single model, only the association with depressive symptom severity remained. This persisted after controlling for diagnostic group.

LIMITATIONS

Due to the cross-sectional sectional study design, we could only look at the associations between negative memory bias and disorder-specific symptoms and not at the direction of the effects.

CONCLUSIONS

Negative memory bias is characteristic of a depressotypic processing style and present in different mental disorders. It might play a mechanistic role in the development of (subclinical) co-occurrence between mental disorders.

Negative Learning Bias in Depression Revisited: Enhanced Neural Response to Surprising Reward Across Psychiatric Disorders

BACKGROUND

Prior work has proposed that major depressive disorder (MDD) is associated with a specific cognitive bias: patients with depression seem to learn more from punishment than from reward. This learning bias has been associated with blunting of reward-related neural responses in the striatum. A key question is whether negative learning bias is also present in patients with MDD and comorbid disorders and whether this bias is specific to depression or shared across disorders.

METHODS

We employed a transdiagnostic approach assessing a heterogeneous group of (nonpsychotic) psychiatric patients from the MIND-Set (Measuring Integrated Novel Dimensions in Neurodevelopmental and Stress-Related Mental Disorders) cohort with and without MDD but also with anxiety, attention-deficit/hyperactivity disorder, and/or autism (n = 66) and healthy control subjects (n = 24). To investigate reward and punishment learning, we employed a deterministic reversal learning task with functional magnetic resonance imaging.

RESULTS

In contrast to previous studies, patients with MDD did not exhibit impaired reward learning or reduced reward-related neural activity anywhere in the brain. Interestingly, we observed consistently increased neural responses in the bilateral lateral prefrontal cortex of patients when they received a surprising reward. This increase was not specific to MDD, but generalized to anxiety, attention-deficit/hyperactivity disorder, and autism. Critically, increased prefrontal activity to surprising reward scaled with transdiagnostic symptom severity, particularly that associated with concentration and attention, as well as the number of diagnoses; patients with more comorbidities showed a stronger prefrontal response to surprising reward.

CONCLUSIONS

Prefrontal enhancement may reflect compensatory working memory recruitment, possibly to counteract the inability to swiftly update reward expectations. This neural mechanism may provide a candidate transdiagnostic index of psychiatric severity.

Vitamin D deficiency and course of frailty in a depressed older population

Objective: To study the association between vitamin D levels and frailty, its components and course in a depressed sample.Methods: Baseline and two-year follow-up data from the depressed sample of the Netherlands Study of Depression in Older persons (NESDO), a prospective observational cohort study, were analyzed. The 378 participants (aged 60-93) had a diagnosis of depression according to DSM-IV criteria. Frailty was defined according to Fried's physical phenotype. 25-OH vitamin D measurement was performed by liquid chromatography - tandem mass spectrometry. Linear and logistic regression analyses were performed, adjusted for covariates.Results: Higher vitamin D levels were cross-sectionally associated with lower prevalence of frailty (OR 0.64 [95%-CI 0.45 - 0.90], p = .010), predicted a lower incidence of frailty among non-frail depressed patients (OR 0.51 [95%-CI 0.26 - 1.00], p=.050), and, surprisingly, the persistence of frailty among frail depressed patients (OR 2.82 [95%-CI 1.23 - 6.49], p=.015).Conclusions: In a depressed population, higher vitamin D levels were associated with lower prevalence and incidence of frailty. Future studies should examine whether the favorable effect of low vitamin D levels on the course of frailty can be explained by confounding or whether unknown pathophysiological mechanisms may exert protective effects.

Trajectories and determinants of functional limitations in late-life depression: A 2-year prospective cohort study

Background:

In mental health research, functional recovery is increasingly valued as an important outcome in addition to symptomatic remission.

Methods:

Course types of functional limitations among depressed older patients and its relation with symptomatic remission were explored in a naturalistic cohort study (Netherlands Study of Depression in Older persons). 378 depressed older patients (≥60 years) and 132 non-depressed persons were included. Depressive disorders were assessed with Composite International Diagnostic Interview at baseline and two-year follow-up. Functional limitations were assessed every 6 months with the World Health Organization Disability Assessment II.

Results:

Depressed patients had more functional limitations compared to their non-depressed counterparts. Growth Mixture Modeling among depressed patients identified two trajectories of functional limitations, both starting at a high disability level. The largest subgroup (81.2%) was characterized by a course of high disability levels over time. The smaller subgroup (18.8%) had an improving course (functional recovery). After two years, the main predictor of functional recovery was the remission of depression. Among symptomatic remitted patients, female sex, higher level of education, higher gait speed, and less severe depression were associated with no functional recovery. Non-remitted patients without functional recovery were characterized by the presence of more chronic somatic diseases, a lower sense of mastery, and a higher level of anxiety.

Conclusions:

1 in 5 depressed older patients have a course with functional recovery. Combining functional and symptomatic recovery points to a subgroup of older patients that might profit from more rigorous psychiatric treatment targeted at psychiatric comorbidity and a group of frail depressed older patients that might profit from integrated geriatric rehabilitation.

The Effect of Alexithymia on Attentional Bias Toward Emotional Stimuli in Depression: An Eye-Tracking Study

Alexithymia-reflecting deficits in cognitive emotion processing-is highly prevalent in individuals with depressive disorders. Subsequently, mixed evidence for attentional bias is found in these individuals. Alexithymia may be a potential influencing factor for attentional bias in depression. In the current study, 83 currently depressed (CD) and 76 never-depressed (ND) controls completed an eye-tracker task consisting of valenced (non)-social pictures. Alexithymia scores were also included as a moderator as both a continuous and categorical measure (so high vs. low alexithymia). No group difference or moderating effect of alexithymia was found on attentional bias. Thus, alexithymic symptoms, included both dimensionally and categorically, may not influence biased attentional processing in depression compared to ND individuals. Thus, it is important to explore other potential explaining factors for the equivocal results found on biased attentional processing of emotional information in depression.

Symptomatic and functional recovery in depression in later life

OBJECTIVES

Functional limitations give an indication of the total impact of diseases, such as depression, on individuals health and recovery. This study examines the change in several domains of functioning over 2 years in older persons depressed at baseline (non-remitted group and remitted group after 2 years) and in a non-depressed comparison group.

METHODS

Data were used from a cohort study (Netherlands Study of Depression in Older persons [NESDO]) consisting of depressed older persons ≥ 60 years (N = 378) and a non-depressed comparison group (N = 132) with 2 years of follow-up (attrition rate 24%). Functional limitations (outcome) were assessed with the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire every 6 months. Total scores and domain scores were used. Depression was classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria at baseline and at 2-year follow-up. Severity of depression (predictor) was assessed with the Inventory of Depressive Symptomatology (IDS) at 6-month intervals.

RESULTS

Linear mixed models showed that the level of functional limitations differed between the three groups during 2 years of follow-up. The non-remitted group had the highest level of functional limitations during 2 years, followed by the remitted group. Stable low levels of functional limitations were found for the non-depressed group. Remission from depression was accompanied by improvements in functioning, however, compared to the non-depressed comparison group significant functional limitations remained. Higher severity of depression appeared as risk factor for a declining course of functioning, especially the social aspects of functioning.

METHODOLOGICAL CONSIDERATIONS

Participants that were more severely depressed and more functionally impaired at baseline had higher attrition rates than the participants that were included in the analytical sample.

CONCLUSION

This study showed that depression in later life has long-term debilitating effects on functioning, enduring even after remission from depression. This implies that depression treatment in later life should aim broader than just symptomatic recovery, but also include functional recovery.

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.

Leucocyte telomere length is no molecular marker of physical frailty in late-life depression

BACKGROUND

Although average life-expectancy is still increasing worldwide, ageing processes markedly differ between individuals, which has stimulated the search for biomarkers of biological ageing.

OBJECTIVES

Firstly, to explore the cross-sectional and longitudinal association between leucocyte telomere length (LTL) as molecular marker of ageing and the physical frailty phenotype (PFP) as a clinical marker of ageing and secondly, to examine whether these associations are moderated by the presence of a depressive disorder, as depression can be considered a condition of accelerated ageing.

METHODS

Among 378 depressed older patients (according to DSM-IV criteria) and 132 non-depressed older persons participating in the Netherlands Study of Depression in Older persons, we have assessed the physical frailty phenotype and LTL. The PFP was defined according to Fried's criteria and its components were reassessed at two-year follow-up.

RESULTS

LTL was neither associated with the PFP at baseline by Spearman rank correlation tests, nor did it predict change in frailty parameters over a two-year follow-up using regression analyses adjusted for potential confounders.

CONCLUSION

LTL is not associated with frailty; neither in non-depressed nor in depressed older persons. As LTL and physical frailty appear to represent different aspects of ageing, they may complement each other in future studies.

The reciprocal relationship between physical activity and depression: Does age matter?

BACKGROUND

The level of physical activity (PA) and the prevalence of depression both change across the lifespan. We examined whether the association between PA and depression is moderated by age. As sense of mastery and functional limitations have been previously associated with low PA and depression in older adults, we also examined whether these are determinants of the differential effect of age on PA and depression.

METHODS

1079 patients with major depressive disorder (aged 18-88 years) were followed-up after two-years; depression diagnosis and severity as well as PA were re-assessed. Linear and logistic regression analyses were used to test reciprocal prospective associations between PA and depression outcomes. In all models the interaction with age was tested.

RESULTS

PA at baseline predicted remission of depressive disorder at follow-up (OR = 1.43 [95% CI: 1.07-1.93], p = .018). This effect was not moderated by age. PA predicted improvement of depression symptom severity in younger (B = -2.03; SE = .88; p = .022), but not in older adults (B = 2.24; SE = 1.48; p = .128) (p = .015 for the interaction PA by age in the whole sample). The level of PA was relatively stable over time. Depression, sense of mastery and functional limitation were for all ages not associated with PA at follow-up.

CONCLUSIONS

Age did not moderate the impact of PA on depressive disorder remission. Only in younger adults, sufficient PA independently predicts improvement of depressive symptom severity after two-year follow-up. Level of PA rarely changed over time, and none of the determinants tested predicted change in PA, independent of age.

The impact of frailty on depressive disorder in later life: Findings from the Netherlands Study of depression in older persons

BACKGROUND

Physical frailty and depressive symptoms are reciprocally related in community-based studies, but its prognostic impact on depressive disorder remains unknown.

METHODS

A cohort of 378 older persons (≥60 years) suffering from a depressive disorder (DSM-IV criteria) was reassessed at two-year follow-up. Depressive symptom severity was assessed every six months with the Inventory of Depressive Symptomatology, including a mood, motivational, and somatic subscale. Frailty was assessed according to the physical frailty phenotype at the baseline examination.

RESULTS

For each additional frailty component, the odds of non-remission was 1.24 [95% CI=1.01-1.52] (P=040). Linear mixed models showed that only improvement of the motivational (P<001) subscale and the somatic subscale (P=003) of the IDS over time were dependent on the frailty severity.

CONCLUSIONS

Physical frailty negatively impacts the course of late-life depression. Since only improvement of mood symptoms was independent of frailty severity, one may hypothesize that frailty and residual depression are easily mixed-up in psychiatric treatment.

Physical Frailty and Cognitive Functioning in Depressed Older Adults: Findings From the NESDO Study

OBJECTIVES

Cognitive frailty has recently been defined as the co-occurrence of physical frailty and cognitive impairment. Late-life depression is associated with both physical frailty and cognitive impairment, especially processing speed and executive functioning. The objective of this study was to investigate the association between physical frailty and cognitive functioning in depressed older persons.

DESIGN

Baseline data of a depressed cohort, participating in the Netherlands Study of Depression in Older persons (NESDO).

SETTING

Primary care and specialized mental health care.

PARTICIPANTS

A total of 378 patients (≥60 years) with depression according to DSM-IV criteria and a MMSE score of 24 points or higher.

MEASUREMENTS

The physical frailty phenotype as well as its individual criteria (weight loss, weakness, exhaustion, slowness, low activity). Cognitive functioning was examined in 4 domains: verbal memory, working memory, interference control, and processing speed.

RESULTS

Of the 378 depressed patients (range 60-90 years; 66.1% women), 61 were classified as robust (no frailty criteria present), 214 as prefrail (1 or 2 frailty criteria present), and 103 as frail (≥3 criteria). Linear regression analyses, adjusted for confounders, showed that the severity of physical frailty was associated with poorer verbal memory (ß = -0.13, P = .039), slower processing speed (ß = -0.20, P = .001), and decreased working memory (ß = -0.18, P = .004), but not with changes in interference control (ß = 0.04, P = .54).

CONCLUSION

In late-life depression, physical frailty is associated with poorer cognitive functioning, although not consistently for executive functioning. Future studies should examine whether cognitive impairment in the presence of physical frailty belongs to cognitive frailty and is indeed an important concept to identify a specific subgroup of depressed older patients, who need multimodal treatment strategies integrating physical, cognitive, and psychological functioning.

The association between depression and emotional and social loneliness in older persons and the influence of social support, cognitive functioning and personality: A cross-sectional study

BACKGROUND

We investigated the association between old age depression and emotional and social loneliness.

METHODS

A cross-sectional study was performed using data from the Netherlands Study of Depression in Older Persons (NESDO). A total of 341 participants diagnosed with a depressive disorder, and 125 non-depressed participants were included. Depression diagnosis was confirmed with the Composite International Diagnostic Interview. Emotional and social loneliness were assessed using the De Jong Gierveld Loneliness Scale. Socio-demographic variables, social support variables, depression characteristics (Inventory of Depressive Symptoms), cognitive functioning (Mini Mental State Examination) and personality factors (the NEO- Five Factor Inventory and the Pearlin Mastery Scale) were considered as possible explanatory factors or confounders. (Multiple) logistic regression analyses were performed.

RESULTS

Depression was strongly associated with emotional loneliness, but not with social loneliness. A higher sense of neuroticism and lower sense of mastery were the most important explanatory factors. Also, we found several other explanatory and confounding factors in the association of depression and emotional loneliness; a lower sense of extraversion and higher severity of depression.

LIMITATIONS

We performed a cross-sectional observational study. Therefore we cannot add evidence in regard to causation; whether depression leads to loneliness or vice versa.

CONCLUSIONS

Depression in older persons is strongly associated with emotional loneliness but not with social loneliness. Several personality traits and the severity of depression are important in regard to the association of depression and emotional loneliness. It is important to develop interventions in which both can be treated.

Physical frailty: vulnerability of patients suffering from late-life depression

OBJECTIVES

Frailty, a state of increased risk of negative health outcomes, is increasingly recognized as a relevant concept for identifying older persons in need of preventative geriatric interventions. Even though broader concepts of frailty include psychological characteristics, frailty is largely neglected in mental health care. The aim of the present study is to examine the prevalence of physical frailty in depressed older patients and its potential overlap with depression criteria.

METHOD

Cross-sectional observational study including 378 depressed and 132 non-depressed adults aged ≥60 years according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Physical frailty was defined as ≥3 out of 5 criteria (handgrip strength, weight loss, poor endurance, walking speed, low physical activity).

RESULTS

Prevalence rates of physical frailty were 27.2% and 9.1% among depressed and non-depressed participants, respectively, which remained significant after controlling for relevant covariates (odds ratio [OR] = 2.66 [95% confidence interval [C.I.] = 1.36, 5.24], p = .004). Physical frailty in depression was associated with more severe depressive symptoms; this association remained significant in subsequent analyses with purely physical proxies for frailty (hand grip strength, walking speed) and different severity measures of depressive symptoms.

CONCLUSION

A quarter of depressed older patients is physically frail, especially the most depressed group. This cannot be explained by overlap in criteria and should be examined in future studies, primarily on its presumed clinical relevance.

Physical (in)activity and depression in older people

BACKGROUND

Knowledge about characteristics explaining low level of physical activity in late-life depression is needed to develop specific interventions aimed at improving physical health in depressed people above the age of 60.

METHODS

This cross-sectional study used data from the Netherlands Study of Depression in Older Persons (NESDO), a longitudinal multi-site naturalistic cohort study. People aged 60 and over with current depression and a non-depressed comparison group were included, and total amount of PA per week was assessed with the short version of the International Physical Activity Questionnaire (IPAQ). Depression characteristics, socio-demographics, cognitive function, somatic condition, psycho-social, environment and other lifestyle factors were added in a multiple regression analysis.

RESULTS

Depressed persons >60y were less physically active in comparison with non-depressed subjects. The difference was determined by somatic condition (especially, functional limitations) and by psychosocial characteristics (especially sense of mastery). Within the depressed subgroup only, a lower degree of physical activity was associated with more functional limitations, being an inpatient, and the use of more medication, but not with the severity of the depression.

LIMITATION

This study is based on cross-sectional data, so no conclusions can be drawn regarding causality.

CONCLUSIONS

This study confirms that depression in people over 60 is associated with lower physical activity. Patient characteristics seem more important than the depression diagnosis itself or the severity of depression. Interventions aimed at improving physical activity in depressed persons aged 60 and over should take these characteristics into account.

[Frailty; a fragile concept]

BACKGROUND

Frailty can be regarded as a condition in which the reserve capacity of various physical systems has sunk to a critical low, at which point minor disturbances can develop into serious health problems.

AIM

To review the various operationalisations of the concept of frailty and describe the relationship between frailty and psychopathology.

METHOD

We searched the literature up to October 2010 using PubMed, PsycINFO and CINAHL.

RESULTS

We found 35 operationalisations of the concept of frailty; 4 single measurements as a proxy for frailty (e.g. muscle strength), 18 syndrome diagnoses which can be subdivided into single (n = 5) and multiple syndrome diagnoses (n = 13) and 13 dimensional operationalisations for which measurement instruments were used. Only 6 studies reported the relationship between frailty and psychopathology. The studies revealed an association between depression and psychopathology. An important finding was the association between depression and frailty, but the direction of the association is unknown.

CONCLUSION

No consensus has been reached regarding the operationalisation of the concept of frailty. For the purpose of gerontopsychiatric research we recommend the inclusion of a syndrome diagnosis based on physical criteria (physical frailty) because this should make it possible to unravel the relationship between psychopathology and underlying ageing mechanisms.