Childhood abuse, family history and stressors in older patients with bipolar disorder in relation to age at onset

OBJECTIVES

The aim of this study is to explore the family history of psychiatric disorders, childhood abuse, and stressors in older patients with Bipolar Disorder (BD) and the association of these variables with the age at onset of BD.

METHODS

The Questionnaire for Bipolar Disorder (QBP) and the Mini International Neuropsychiatric Interview (MINI-Plus) were obtained from 78 patients aged 60 and over to determine diagnosis, age at onset of the first affective episode, childhood abuse, family history of psychiatric disorders and past and recent stressful life events.

RESULTS

Increased family history of psychiatric disorders was the only factor associated with an earlier age at onset of BD. Less family history of psychiatric disorders and more negative stressors were significantly associated with a later age at onset of the first (hypo)manic episode.

LIMITATIONS

Age at onset, history of childhood abuse, and past stressful life events were assessed retrospectively. Family members of BD patients were not interviewed.

CONCLUSIONS

Our findings suggest that age at onset can define distinct BD phenotypes. More specifically there was a stronger heredity of BD and other psychiatric disorders in patients with an early age of onset of BD. Negative stressors may play a specific role in patients with a late age at onset of a first (hypo)manic episode.

Limited effect of screening for depression with written feedback in outpatients with diabetes mellitus: a randomised controlled trial

AIMS/HYPOTHESIS

The aim of this study was to test the effectiveness of a screening procedure for depression (SCR) vs care as usual (CAU) in outpatients with diabetes. The primary outcome measured was depression score and the secondary outcomes were mental healthcare consumption, diabetes-distress and HbA(1c).

MATERIALS AND METHODS

In a multicentre parallel randomised controlled trial, 223 outpatients with diabetes, who had an elevated depression score, were randomly assigned to SCR (n = 116) or CAU (n = 107), using computer generated numbers. SCR-patients were invited for a Composite International Diagnostic Interview (CIDI) to diagnose depression and/or anxiety (interviewers were not blinded for group assignment). As part of the intervention, patients and their physicians were informed of the outcome of the CIDI in a letter and provided with treatment advice. At baseline and 6 month follow-up, depression and diabetes-distress were measured using the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Problem Areas in Diabetes survey (PAID). HbA(1c) levels were obtained from medical charts.

RESULTS

Mean CES-D depression scores decreased from baseline to 6 months in both groups (24 ± 8 to 21 ± 8 [CAU] and 26 ± 7 to 22 ± 10 [SCR] respectively [p < 0.001]), with no significant differences between groups. Neither diabetes-distress nor HbA(1c) changed significantly within and between groups. The percentage of patients receiving mental healthcare increased in the SCR group from 20% to 28%, compared with 15% to 18% in the CAU group.

CONCLUSIONS/INTERPRETATION

Depression screening with written feedback to patient and physician does not improve depression scores and has a limited impact on mental healthcare utilisation, compared with CAU. It appears that more intensive depression management is required to improve depression outcomes in patients with diabetes.

Diabetes-specific emotional distress mediates the association between depressive symptoms and glycaemic control in Type 1 and Type 2 diabetes

OBJECTIVES

To investigate whether diabetes-specific emotional distress mediates the relationship between depression and glycaemic control in patients with Type 1 and Type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were derived from the baseline assessment of a depression in diabetes screening study carried out in three tertiary diabetes clinics in the Netherlands. Most recent glycated haemoglobin (HbA(1c)) measurement was obtained from medical records. The Centre for Epidemiologic Studies Depression Scale (CES-D) and Problem Areas in Diabetes scale (PAID) were used to measure depression and diabetes-specific emotional distress respectively. Linear regression was performed to examine the mediating effect of diabetes-distress.

RESULTS

Complete data were available for 627 outpatients with Type 1 (n = 280) and Type 2 (n = 347) diabetes. Analyses showed that diabetes-distress mediated the relation between depression and glycaemic control and not differently for both disease types. Post-hoc analyses revealed that patients depressed and distressed by their diabetes were in significantly poorer glycaemic control relative to those not depressed nor distressed (HbA(1c) 8.7 +/- 1.7 vs. 7.6 +/- 1.2% in those without depressive symptoms, 7.6 +/- 1.1% in depressed only and 7.7 +/- 1.1% in the distressed only, P < 0.001). Depressed patients without elevated diabetes-distress did not show a significantly increased risk of elevated HbA(1c).

CONCLUSIONS

In explaining the association between depression and glycaemic control, diabetes-specific emotional distress appears to be an important mediator. Addressing diabetes-specific emotional problems as part of depression treatment in diabetes patients may help improve glycaemic outcomes.

The current status of urban-rural differences in psychiatric disorders

OBJECTIVE

Reviews of urban-rural differences in psychiatric disorders conclude that urban rates may be marginally higher and, specifically, somewhat higher for depression. However, pooled results are not available.

METHOD

A meta-analysis of urban-rural differences in prevalence was conducted on data taken from 20 population survey studies published since 1985. Pooled urban-rural odds ratios (OR) were calculated for the total prevalence of psychiatric disorders, and specifically for mood, anxiety and substance use disorders.

RESULTS

Significant pooled urban-rural OR were found for the total prevalence of psychiatric disorders, and for mood disorders and anxiety disorders. No significant association with urbanization was found for substance use disorders. Adjustment for various confounders had a limited impact on the urban-rural OR.

CONCLUSION

Urbanization may be taken into account in the allocation of mental health services.

Fat food for a bad mood. Could we treat and prevent depression in Type 2 diabetes by means of omega-3 polyunsaturated fatty acids? A review of the evidence

AIMS

Evidence strongly suggests that depression is a common complication of Type 2 diabetes mellitus. However, there is considerable room to improve the effectiveness of pharmacological antidepressant agents, as in only 50-60% of the depressed subjects with diabetes does pharmacotherapy lead to remission of depression. The aim of the present paper was to review whether polyunsaturated fatty acids (PUFA) of the omega-3 family could be used for the prevention and treatment of depression in Type 2 diabetes.

METHODS

MEDLINE database and published reference lists were used to identify studies that examined the associations between omega-3 PUFA and depression. To examine potential side-effects, such as on glycaemic control, studies regarding the use of omega-3 supplements in Type 2 diabetes were also reviewed.

RESULTS

Epidemiological and clinical studies suggest that a high intake of omega-3 PUFA protects against the development of depression. There is also some evidence that a low intake of omega-3 is associated with an increased risk of Type 2 diabetes, but the results are less conclusive. Results from randomized controlled trials in non-diabetic subjects with major depression show that eicosapentaenoic acid is an effective adjunct treatment of depression in diabetes, while docosahexanoic acid is not. Moreover, consumption of omega-3 PUFA reduces the risk of cardiovascular disease and may therefore indirectly decrease depression in Type 2 diabetes, via the reduction of cardiovascular complications.

CONCLUSIONS

Supplementation with omega-3 PUFA, in particular eicosapentaenoic acid, may be a safe and helpful tool to reduce the incidence of depression and to treat depression in Type 2 diabetes. Further studies are now justified to test these hypotheses in patients with Type 2 diabetes.

[Explanations for the relation between depression and increased mortality]

Depression is a highly prevalent disorder at all levels of health-care delivery. Depression has an unfavourable effect on the prognosis of somatic illnesses, and is associated with excess mortality. Several mechanisms may contribute to these relationships. First of all, depression affects behaviour. Depressed patients show more unhealthy living habits, less compliance with medical treatment, and a higher number of accidents and suicides. Secondly, biological aspects of depression are important. Dysregulation of the neuro-immune system, hyperactivity of the hypothalamic pituitary adrenal axis, and autonomic dysregulation may all have a negative effect on both the prognosis of somatic illnesses and the lifespan. Although studies have suggested beneficial effects of the treatment of depression in (somatic) patients, it remains unclear whether treatment may also affect survival. Further research is needed to investigate the occurrence of and to unravel the mutual influences of depression and somatic illnesses, to search for possible pathogenetic mechanisms that may underlie both depression and medical disorders, and to assess the effects of depression treatment on biological parameters and survival.

[Anxiety disorders in nursing homes: a literature review of prevalence, course and risk indicators]

Psychiatric disorders such as dementia and depression are highly prevalent in nursing homes. The prevalence of anxiety disorders is less clear. Prevalence, course and risk-indicators of anxiety disorders among nursing home residents were examined, based on a review of the literature. Medline and PsychINFO searches were conducted for 1966-2002. Twelve studies were considered relevant. These differed substantially with respect to study-population, diagnostic instruments and diagnostic criteria that were used and the specific anxiety disorders investigated. The prevalence of anxiety disorders ranged from 0-20%. Only in one study the course of anxiety disorders was investigated. About 60% of the nursing home residents recovered in one year. The most important risk-indicators for anxiety disorders identified were: female sex, depression, lack of social support, poor physical health and functional and cognitive impairments. Generalization of these results to the Dutch nursing home population is restricted by the substantial heterogeneity of the studies. Further studies are required to provide reliable estimates of prevalence, course and risk-indicators of anxiety disorders among nursing home residents using appropriate diagnostic instruments and adjusted diagnostic criteria. This will enhance detection and improve treatment of anxiety disorders among nursing home residents.

[Apathy syndrome: a clinical entity?]

Apathy is defined as a disorder of motivation that expresses itself at an emotional, cognitive and behavioural level. Apathy can occur as a symptom and a syndrome. In the recent years diagnostic criteria and a number of scales for measuring apathy in elderly with psychiatric or neurological disorders have been introduced. Two scales are specifically developed to measure apathy, the Apathy Evaluation Scale (AES) from Marin and the Apathy Scale (AS) from Starkstein. Both scales have been translated into Dutch. The AS is more convenient. The AS in addition can be used when applying the criteria for the apathy syndrome which has been introduced in 2001 by Starkstein. In addition, the Neuropsychiatric Inventory (NPI) and the 'Gedragsobservatieschaal voor de Intramurale Psychogeniatrie' (GIP) (a scale in Dutch) have an apathy domain. Conceptual problems surrounding apathy have only partly been resolved. The criteria for the apathy syndrome can only be used for assessing the extent of the problem. Apathy and depression are strongly correlated. Studies show that apathy as a syndrome can occur without concomitant depression in the elderly, but regularly occurs besides a depressive disorder, in percentages varying between 9% and 53% of the population under study. Especially the varying validity of an apathy syndrome in relation to late life depression needs further clarification.

[Neuroticism in the elderly. The utility of the shortened DPQ-scales]

This article reports on the relation between aging and personal adjustment. Current personality scales are not developed for older persons. Scales contain items which are not valid for an aging population and contain too many items for administration in older populations. As part of the Longitudinal Aging Study Amsterdam (LASA) Neuroticism in older persons was measured with a shortened version of the Inadequacy (IN) and Social Inadequacy (SI) scales of the Dutch Personality Questionnaire (DPQ). The utility of these shortened scales was assessed based on internal consistency, inter-item correlations, test-retest reliability and factor analysis. The consistency of the personality dimension Neuroticism was assessed based on cohort-differences and a 6-year longitudinal comparison. The research-population contained 2118 respondents at baseline, aged between 55 and 85 years, 49% were male and they were not living in an institution. The shortened scales appeared to be reliable and valid instruments to measure Neuroticism in the elderly. The gaining of time due to the administration of the shortened scales enlarges the feasibility of the scales for measuring Neuroticism in older persons. Results showed no significant age-difference on the IN-scale, but revealed a significant difference on the SI-scale (p < .01). The 65+ elderly (65-74 and 75-85) have higher scores on Social Inadequacy than the youngest elderly (55-64). Longitudinal analyses showed an interaction between age at baseline and the stability and change of the level of Neuroticism. On both scales the youngest age-group showed a significant decline in mean level of Neuroticism (p < .01). The mean level of Social Inadequacy in the oldest age-group showed an increase during the 6-year follow-up period (p < .05). However, the differences were very small. Future research is needed to assess the effect of related variables on Neuroticism in older persons.

Electroconvulsive therapy for the depressed elderly

BACKGROUND

Depressive disorder is a common mental disorder in old age, with serious health consequences such as increased morbidity, disability, and mortality. The frailty of elderly may seriously hamper the efficacy and safety of pharmacotherapy in depressed elderly. Electroconvulsive therapy (ECT) in depressed elderly therefore may be an alternative to treatment with antidepressants.

OBJECTIVES

To assess the efficacy and safety of ECT (compared to simulated ECT or antidepressants) in depressed elderly.

SEARCH STRATEGY

We searched the CCDANCTR database, Medline 1966-2000, EMBase 1980-2000, Biological abstracts 1985-2000, Cinahl 1982-2000, Lilacs from 1982 onwards, Psyclit 1887-2000, Sigle 1980-2000. The reference lists of relevant papers were scanned for published reports. Hand searching of the Journal of ECT and the Journal of Geriatric Psychiatry was done. Based on the title of the publication and its abstract, non-eligible citations were excluded.

SELECTION CRITERIA

Data were independently extracted by at least two reviewers. Randomised, controlled trials on depressed elderly (> 60 years) with or without concomitant with conditions like cerebrovascular disease, dementia of the Alzheimer's type, vascular dementia or Parkinson's disease were included.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by at least two reviewers. For continuous data weighted mean differences (WMD) between groups were calculated.

MAIN RESULTS

Randomised evidence is sparse. Only three trials could be included, one on the efficacy of real ECT versus simulated ECT (O'Leary et al 1994), one on the efficacy of unilateral versus bilateral ECT (Fraser 1980) and the other comparing the efficacy of ECT once a week with ECT three times weekly (Kellner 1992). All had major methodological shortcomings; data were mostly lacking essential information to perform a quantitative analysis. Although the O'Leary study concluded that real ECT was superior over simulated ECT, these conclusions need to be interpreted cautiously. Only results from the second trial (unilateral versus bilateral ECT) could be analysed, not convincingly showing efficacy of unilateral ECT over bilateral ECT, WMD 6.06 (CI -5.20,17.32). Randomised evidence on the efficacy and safety of ECT in depressed elderly with concomitant dementia, cerebrovascular disorders or Parkinson's disease is completely lacking. Possible side-effects could not be adequately examined because the lack of randomised evidence and the methodological shortcomings.

REVIEWER'S CONCLUSIONS

None of the objectives of this review could be adequately tested because of the lack of firm, randomised evidence. Given the specific problems in the treatment of depressed elderly, it is of importance to conduct a well designed randomised controlled trial in which the efficacy of ECT is compared to one or more antidepressants.

The longitudinal effect of depression on functional limitations and disability in older adults: an eight-wave prospective community-based study

BACKGROUND

The temporal relationship between depression and adverse functional outcomes in older adults is ambiguous. In the present eight-wave prospective community-based study, the longitudinal effect of depression on functional limitations and disability (in terms of disability days and bed days) was studied, thereby taking into account the role of chronic physical diseases.

METHODS

The study is based on a sample which at the outset consisted of 325 non-depressed and 327 depressed persons (55-85 years) drawn from a larger random community based sample in the Netherlands. Generalized estimating equations time-lag models were used to examine the longitudinal relation between depression and both functional limitations and disability.

RESULTS

Functional limitations were very persistent over time, whereas disability days and bed days were more fluctuating functional outcomes. Only in the presence of chronic physical diseases, there was a significant longitudinal association between depression at the previous measurement and functional limitations, disability days and bed days at the next measurement. The effect on functional limitations was small, which was probably partly due to their persistent nature.

CONCLUSIONS

The finding of a longitudinal relationship between depression and functional outcomes in older adults with a compromised health status provides a rationale for treatment of chronic physical diseases as well as depression in depressed chronically ill elderly, in order to prevent a spiralling decline in psychological and physical health.

Emergence and persistence of late life depression: a 3-year follow-up of the Longitudinal Aging Study Amsterdam

BACKGROUND

The present study was designed to assess onset and persistence of late-life depression, systematically comparing the factors associated with prevalence, onset and prognosis.

METHODS

The data were derived from a large (n=2200), random, age and sex stratified sample of the elderly (55-85 years) in The Netherlands. Using a 3-year, prospective longitudinal design, both the onset and the persistence of depression were assessed. Depression was measured using the Center for Epidemiologic Studies Depression Scale. Risk factors associated with prevalence, onset and persistence were compared using both bivariate and multivariate analyses.

RESULTS

In those not depressed at index assessment, the onset of depression was 9.7%. Among those depressed at baseline, persistence occurred in 50.4%. Risk factors predicting onset were almost identical to those associated with prevalence. Persistence was predicted by very few factors (external locus of control and chronic physical illness).

CONCLUSIONS

The data suggest that cross-sectional studies are biased due to their overrepresenting chronic depressive episodes. However, the risk factors derived from cross-sectional studies do seem to adequately reflect factors associated with onset. The prognosis is not adequately predicted by variables usually included in epidemiological studies of late life depression. It is speculated that including more biological correlates of depression and data concerning positive life-changes may improve our understanding of the prognosis of late life depression.

Religion as a cross-cultural determinant of depression in elderly Europeans: results from the EURODEP collaboration

BACKGROUND

The protective effects of religion against late life depression may depend on the broader sociocultural environment. This paper examines whether the prevailing religious climate is related to cross-cultural differences of depression in elderly Europeans.

METHODS

Two approaches were employed, using data from the EURODEP collaboration. First, associations were studied between church-attendance, religious denomination and depression at the syndrome level for six EURODEP study centres (five countries, N = 8398). Secondly, ecological associations were computed by multi-level analysis between national estimates of religious climate, derived from the European Value Survey and depressive symptoms, for the pooled dataset of 13 EURODEP study centres (11 countries, N = 17,739).

RESULTS

In the first study, depression rates were lower among regular church-attenders, most prominently among Roman Catholics. In the second study, fewer depressive symptoms were found among the female elderly in countries, generally Roman Catholic, with high rates of regular church-attendance. Higher levels of depressive symptoms were found among the male elderly in Protestant countries.

CONCLUSIONS

Religious practice is associated with less depression in elderly Europeans, both on the individual and the national level. Religious practice, especially when it is embedded within a traditional value-orientation, may facilitate coping with adversity in later life.

Depression in later life: three etiologically different subgroups

BACKGROUND

Various studies support the notion that early onset depression and late onset depression have different etiological pathways. Late onset depression has been found to be a heterogeneous group. This study attempts to divide the late onset group in two subgroups with different aetiology and find evidence for the vascular depression hypothesis.

METHODS

Subjects were 132 depressed elderly persons from the general population, general practitioners and mental health care outpatient clinics. Sixty-four had early-onset depression (< 60), 69 had late-onset depression (> or = 60). The latter group was divided into subjects with (n = 15) and without (n = 15) severe life stress. The groups were compared with respect to a variety of variables including vascular risk factors

RESULTS

Early-onset depression was associated with neuroticism and parental history. Subjects with late-onset depression and no severe life stress had higher vascular risk factors than whose depression was preceded by a severe stressor did.

CONCLUSIONS

Our findings suggest that late life depression can be divided into subgroups with different etiological pathways: (1) early-onset with longstanding psychobiological vulnerability; (2) late-onset as reaction to severe life stress; and (3) late-onset with vascular risk factors.

The association between depressive symptoms and cognitive decline in community-dwelling elderly persons

OBJECTIVE

To investigate whether depressive symptoms predict specific types of cognitive decline in order to elucidate the association between late life depression and cognitive decline.

BACKGROUND

Mechanisms underlying the association between late life depression and cognitive decline are still unclear.

METHOD

Six hundred and forty-one elderly persons of the Longitudinal Aging Study Amsterdam (LASA) aged 70-85 were examined by means of two measurement occasions over a period of 3 years. Depressive symptoms were assessed by means of the CES-D. Various cognitive functions were examined using neuropsychological tests.

RESULTS

Depressive symptoms were associated with decline in speed of information processing over a 3-year period, whereas there was no association between depression and increasing memory impairment or global mental deterioration.

CONCLUSION

These findings suggest that depressive symptoms are associated with subcortical pathology, most probable white matter lesions.

Depression and cardiac mortality: results from a community-based longitudinal study

BACKGROUND

Depression may be a potential risk factor for subsequent cardiac death. The impact of depression on cardiac mortality has been suggested to depend on cardiac disease status, and to be stronger among cardiac patients. This study examined and compared the effect of depression on cardiac mortality in community-dwelling persons with and without cardiac disease.

METHODS

A cohort of 2847 men and women aged 55 to 85 years was evaluated for 4 years. Major depression was defined according to psychiatric DSM-III criteria. Minor depression was defined by Center for Epidemiologic Studies-Depression Scale scores of 16 or higher. Effects of minor and major depression on cardiac mortality were examined separately in 450 subjects with a diagnosis of cardiac disease and in 2397 subjects without cardiac disease after adjusting for demographics, smoking, alcohol use, blood pressure, body mass index, and comorbidity.

RESULTS

Compared with nondepressed cardiac patients, the relative risk of subsequent cardiac mortality was 1.6 (95% confidence interval [CI], 1.0-2.7) for cardiac patients with minor depression and 3.0 (95% CI, 1.1-7.8) for cardiac patients with major depression, after adjustment for confounding variables. Among subjects without cardiac disease at baseline, similar increased cardiac mortality risks were found for minor depression (1.5 [95% CI, 0.9-2.6]) and major depression (3.9 [95% CI, 1.4-10.9]).

CONCLUSION

Depression increases the risk for cardiac mortality in subjects with and without cardiac disease at baseline. The excess cardiac mortality risk was more than twice as high for major depression as for minor depression.

Changes in depression and physical decline in older adults: a longitudinal perspective

BACKGROUND

The impact of chronicity and changes in depression on physical decline over time in older persons has not been elucidated.

METHODS

This prospective cohort study of 2121 community-dwelling persons aged 55-85 years uses two measurement occasions of depression (CES-D scale) over 3 years to distinguish persons with chronic, remitted, or emerging depression and persons who were never depressed. Physical function is assessed by self-reported physical ability as well as by observed performance on a short battery of tests.

RESULTS

After adjustment for baseline physical function, health status and sociodemographic factors, chronic depression was associated with significantly greater decline in self-reported physical ability over 3 years when compared to never depressed persons (odds ratio (OR)=2.83, 95% confidence interval (CI)=1.86-4. 30). In the oldest old, but not in the youngest old, chronic depression was also significantly predictive of greater decline in observed physical performance over 3 years (OR=2.22, 95% CI=1.43-3. 79). Comparable effects were found for older persons with emerging depression. Persons with remitted depression did not have greater decline in reported physical ability or observed performance than persons who were never depressed.

CONCLUSIONS

Our findings among community-dwelling older persons show that chronicity of depression has a large impact on physical decline over time. Since persons with remitted depression did not have greater physical decline than never depressed persons, these findings suggest that early recognition and treatment of depression in older persons could be protective for subsequent physical decline.

[Effects of depression on physical health and mortality in the elderly. Longitudinal results of the LASA research]

This longitudinal study examines the physical health consequences of depression among 3107 older persons (55-85 years). Major depression was defined according to DSM-III criteria in a psychiatric interview. Minor depression was defined by a Center for Epidemiologic Studies Depression score > or = 16. Health consequences were assessed by 3-year change in self-reported functional status, 3-year change in performance on objective tests, and risk of death over 4.5 years. At baseline, 12.8% of the older persons had minor depression and 2.0% major depression. Minor depression was associated with a significantly greater decline in functional status and performance and, only in men but not in women, with an increased risk of death. Major depression also increases decline in functional status and the risk of death (irrespective of sex), but was not associated with decline in physical performance. These results show that late-life depression has strong unfavorable physical health consequences. The consequences of minor depression are comparable with those of major depression.

Association of depression and gender with mortality in old age. Results from the Amsterdam Study of the Elderly (AMSTEL)

BACKGROUND

The association between depression and increased mortality risk in older persons may depend on the severity of the depressive disorder and gender.

AIMS

To investigate the association between major and mild depressive syndromes and excess mortality in community-living elderly men and women.

METHOD

Depression (Geriatric Mental State AGECAT) was assessed in 4051 older persons, with a 6-year follow-up of community death registers. The mortality risk of neurotic and psychotic depression was calculated after adjustment for demographic variables, physical illness, cognitive decline and functional disabilities.

RESULTS

A total of 75% of men and 41% of women with psychotic depression had diet at follow-up. Psychotic depression was associated with significant excess mortality in both men and women. Neurotic depression was associated with a 1.67-fold higher mortality risk in men only.

CONCLUSIONS

In the elderly, major depressive syndromes increase the risk of death in both men and women, but mild depression increases the risk of death only in men.

[Health status and anxiety in the elderly. A longitudinal perspective]

The prognostic value of physical health for changes in anxiety symptoms in older people was investigated in a prospective longitudinal study design with data from the Longitudinal Aging Study Amsterdam (LASA). In a sample of 2165 older (> 55 yrs.) respondents anxiety symptoms were measured twice over a three year interval with the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A). Utilizing a cut-off value of 4 on the HADS-A, subjects were considered as anxious or as non-anxious. Based on the first assessment two groups were formed: subjects with and subjects without anxiety symptoms. In the non-anxious cohort the effect of physical health on the development of anxiety symptoms was studied; in the anxious cohort the same factors were evaluated on their predictive value for chronicity of anxiety. Indices of physical health included the presence of chronic diseases, functional limitations, and self-perceived health at the first assessment and changes on these variables over time. Results revealed that poor self-perceived health was predictive of incidence (OR = 1.5; 95% CI = 1.3-1.8) and chronicity of anxiety (OR = 1.2; CI = 1.0-1.5). Regarding chronic diseases, the results showed that suffering from more than one chronic disease predicted becoming anxious and chronicity of anxiety (OR = 1.7; CI = 1.2-2.5 and OR = 2.2; CI = 1.3-3.6, respectively). Specific chronic diseases were not strongly related to a change in anxiety levels. Thus, somatic diseases not only lead to depression, a finding reported in numerous studies, but also increase the likelihood of anxiety symptoms at a later point in time.

Risk factors for depression in later life; results of a prospective community based study (AMSTEL)

BACKGROUND

Depression in the elderly was found to be associated with a variety of risk-factors in cross sectional designs. Based on the vulnerability-stress model, etiologic pathways for depression have been suggested, with vulnerability modifying the effect of stress factors. The current prospective study tests an etiologic model for depression incidence, by assessing modifying effects of three types of vulnerability: genetic/familial vulnerability, organic vulnerability, and environmental vulnerability.

METHODS

1940 non-depressed community-living elderly were interviewed at baseline, and at follow-up three years later. Bivariate and multivariate relationships between risk factors and incident depression (GMS-AGECAT) were studied.

RESULTS

Higher age, personal history of depression, death of spouse, health related factors and comorbid organic or anxiety syndrome showed significant bivariate associations with depression incidence. In multivariate analysis, the effect of stress factors on incident depression was not modified by a genetic/familial vulnerability, nor by an organic vulnerability. Effect modification by environmental factors was however evident; having a marital partner, and if unmarried having social support, significantly reduced the impact of functional disabilities on the incidence of depression.

LIMITATIONS

The study consisted of two measurements with a three years interval, depressive episodes with a short duration may be under-represented.

CONCLUSIONS

In the elderly, the effect of stress on incident depression is modified by environmental vulnerability. No evidence was found of effect modification by either genetic/familial or organic vulnerability. The results have implications for both recognition and treatment of late-life depression.

The implication of selection bias in clinical studies of late life depression: an empirical approach

OBJECTIVES

It is supposed that selection bias precludes the extrapolation of results of studies carried out in a clinical setting to the general population. There is little empirical evidence demonstrating the degree to which those depressed in the community are different from those treated in clinical settings. This study compared elderly patients with major depression admitted to a psychiatric hospital with those living in the community.

METHODS

All elderly (55 years and older) patients admitted between 1990 and 1992 to a psychiatric hospital with DSM major depression as the primary diagnosis (n=104), were compared with all elderly patients with the same diagnosis (n=59) who were participating in a large community study (Longitudinal Aging Study, Amsterdam). Data were gathered from the clinical sample using chart-reviews while the community-based sample was interviewed. The two groups were compared with respect to differences in demographic variables, presenting symptoms, risk factors and treatment.

RESULTS

The following characteristics were significantly more prevalent in the clinical sample: late onset of the depression, threat of suicide, conflicts with significant others and use of antidepressant medication. Chronic physical illness was the only characteristic that was more prevalent in the community sample.

CONCLUSION

The results confirm that elderly patients treated in clinical psychiatry represent a group with more threatening and more disruptive depressive illness. Major depression in the community was more often associated with chronic physical illness, which may hamper the recognition and treatment of depression. As the two samples were similar in all other respects, selection bias, hampering comparison of results of studies carried out across treatment settings, appears to have a very limited effect.

Depression and risk of cognitive decline and Alzheimer's disease. Results of two prospective community-based studies in The Netherlands

BACKGROUND

Depression may be associated with cognitive decline in elderly people with impaired cognition.

AIMS

To investigate whether depressed elderly people with normal cognition are at increased risk of cognitive decline and Alzheimer's disease.

METHODS

Two independent samples of older people with normal cognition were selected from the community-based Amsterdam Study of the Elderly (AMSTEL) and the Longitudinal Aging Study Amsterdam (LASA). In AMSTEL, depression was assessed by means of the Geriatric Mental State Schedule. Clinical diagnoses of incident Alzheimer's disease were made using a two-step procedure. In LASA, depression was assessed with the Center for Epidemiologic Studies Depression Scale. Cognitive decline was defined as a drop of > or = 3 on the Mini-Mental State Examination at follow-up.

RESULTS

Both in the AMSTEL and the LASA sample, depression was associated with an increased risk of Alzheimer's disease and cognitive decline, respectively, but only in subjects with higher levels of education.

CONCLUSIONS

In a subgroup of more highly educated elderly people, depression may be an early manifestation of Alzheimer's disease before cognitive symptoms become apparent.

Religious denomination as a symptom-formation factor of depression in older Dutch citizens

OBJECTIVES

The type of symptoms in depression is likely to be influenced by cultural environment. As religion represents an important cultural resource for older adults, it is hypothesised that religious denomination represents a symptom-formation factor of depression in the older generation. Focusing on older Dutch citizens, it is expected that depressed Calvinists report: (1) less depressed affect, (2) more vegetative symptoms, and (3) more guilt feelings, than Roman Catholics and non-church members.

METHODS AND PROCEDURES

The Center for Epidemiologic Studies Depression Scale (CES-D) was used to distinguish depressed (N=395) and non-depressed (N=2333) older adults, and to assess depressive symptom-profiles. The Diagnostic Interview Schedule (DIS) was used to assess major depressive episodes and criterion-symptoms of depression.

RESULTS

Depressed Calvinists, especially males, had higher scores on the vegetative CES-D subscale. The same was found for non-church members with Calvinist parents. Among those who have had a major depressive episode in later life (N=84), support was found for all hypotheses. Feelings of guilt were also more prevalent among Roman Catholics.

CONCLUSIONS

Religious denomination modified the type of symptoms in late-life depression. As a Calvinist background was associated with less depressive affect and more inhibition, there is a risk of underdiagnosis of major depression in older Calvinists in The Netherlands.

Predictors of change in anxiety symptoms of older persons: results from the Longitudinal Aging Study Amsterdam

BACKGROUND

Data on the course of anxiety in late life are scarce. The present study sets out to investigate the course of anxiety, as measured by the HADS-A (Zigmond & Snaith, 1983) in community dwelling older persons, and to evaluate predictive factors for change over 3 years in anxiety symptoms following the vulnerability/stress model.

METHOD

Based on the first anxiety assessment, two cohorts were formed: subjects with and subjects without anxiety symptoms. In the non-anxious cohort (N = 1602) we studied risk factors for the development of anxiety symptoms; in the anxious cohort (N = 563) the same factors were evaluated on their predictive value for restitution of symptoms. Risk factors included vulnerability factors (demographics, health status, personality characteristics and social resources) and stressors (life events occurring in between both anxiety assessments). Logistic regression models estimated the effects of vulnerability factors, stress and their interaction on the likelihood of becoming anxious and chronicity of anxiety symptoms.

RESULTS

It was indicated that the best predictors for becoming anxious were being female, high neuroticism, hearing/eyesight problems and life-events. Female sex and neuroticism also increased the likelihood of chronicity of anxiety symptoms in older adults, but life events were not related to chronicity. The main stressful event in late life associated with anxiety was death of one's partner. Vulnerability factors and stress added on to each other rather than their interaction being associated with development or chronicity of anxiety.

CONCLUSION

The vulnerability/stress model offers a useful framework for organizing risk factors for development and chronicity of anxiety symptoms in older persons, but no support was attained for the hypothesis that vulnerability and stress amplify each others effects. Finally, the results indicate to whom preventive efforts should be directed: persons high in neuroticism, women, and those who experience distressing life events.

Sex differences in late-life depression

OBJECTIVE

The primary aim of this study was to assess sex differences in depression in later life.

METHOD

In a random, age and sex-stratified community sample of 3056 older Dutch people (55 85 years) the prevalence, symptom-reporting and risk factors associated with depression in later life were studied. Depression was measured with the Center for Epidemiologic Studies Depression scale (CES-D). Bivariate, multivariate and factor analyses were used.

RESULTS

Prevalence of depression in women was almost twice as high as in men. Controlling for age and competing risk factors reduced the relative risk for females with more than half. Symptom-patterns in men and women were very much alike. Sex differences in associations with risk factors were small, but exposure to these risk factors was considerably higher in females.

CONCLUSION

Very little evidence for a typical 'female depression' was found. Female preponderance in depression was related to a greater exposure to risk factors.

Physical health and the onset and persistence of depression in older adults: an eight-wave prospective community-based study

BACKGROUND

Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults. Since many aspects of physical health can be targeted for improvement in primary care, it is important to know whether physical health problems predict the onset and/or the persistence of depression.

METHODS

The study is based on a sample which at the outset consisted of 327 depressed and 325 non-depressed older adults (55-85) drawn from a larger random community-based sample in the Netherlands. Depression was measured using the Center for Epidemiologic Studies Depression scale (CES-D) at eight successive waves.

RESULTS

From all incident episodes, the majority (57%) was short-lived. These short episodes could generally not be predicted by physical health problems. The remaining incident episodes (43%) were not short-lived and could be predicted by poor physical health. Chronicity (34%) was also predicted by physical health problems.

CONCLUSIONS

The study design with its frequent measurements recognized more incident cases than previous studies; these cases however did have a better prognosis than is often assumed. The prognosis of prevalent cases was rather poor. Physical health problems were demonstrated to be a predictor of both the onset and the persistence of depression. This may well have implications for prevention and intervention.

Comorbidity of the anxiety disorders in a community-based older population in The Netherlands

OBJECTIVE

The aim of the study was to investigate patterns of comorbidity among the anxiety disorders in a community-based older population, and the relationship of these disorders with major depression, use of alcohol and benzodiazepines, cognitive impairment and chronic somatic illnesses.

METHOD

The data were derived from the Longitudinal Aging Study Amsterdam (LASA) study. A two-stage screening design was adopted to identify respondents with anxiety disorders.

RESULTS

In total, 10% of the elderly with an anxiety diagnosis suffered from two or more anxiety disorders. Major depression (13% vs. 3%), benzodiazepine use (24% vs. 11%) and chronic somatic diseases (12% vs. 7%) were significantly more prevalent in respondents with an anxiety disorder than in respondents without anxiety disorders. Heavy or excessive alcohol intake (5% vs. 4%) and cognitive impairment (11% vs. 13%) were not significantly associated with any anxiety disorder.

CONCLUSION

When anxiety disorders are diagnosed, in older people there is a relatively high probability of comorbid conditions being present.

Anxiety and depression in later life: Co-occurrence and communality of risk factors

OBJECTIVE

The purpose of this study was to examine the comorbidity of and communality of risk factors associated with major depressive disorder and anxiety disorders in later life.

METHOD

A random age- and sex-stratified community-based sample (N=3,056) of the elderly (age 55-85 years) in the Netherlands was studied. A two-stage screening design was used, with the Center for Epidemiologic Studies Depression Scale as a screening instrument and the National Institute of Mental Health Diagnostic Interview Schedule as a criterion instrument. Risk factors were measured with well-validated instruments and represented a broad range of vulnerability and stress-related factors associated with anxiety and depression. Multivariate analyses examined risk factors associated with pure major depressive disorder, pure anxiety disorders, and comorbid conditions.

RESULTS

Comorbidity was highly prevalent: 47.5% of those with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorder. While the only variables associated with pure major depressive disorder were younger age and external locus of control, risk factors representing a wide range of both vulnerability and stress were associated with pure anxiety disorders. External locus of control was the only common factor. The group with anxiety disorders plus major depressive disorder had a distinct risk factor profile and may represent those with a more severe disorder.

CONCLUSIONS

Although high levels of comorbidity between major depressive disorder and anxiety disorders were found, comparing risk factors associated with pure major depressive disorder and pure anxiety disorders revealed more differences than similarities. Anxiety disorders in later life merit separate study.

Minor and major depression and the risk of death in older persons

BACKGROUND

The association between depression and mortality in older community-dwelling populations is still unresolved. This study determined the effect of both minor and major depression on mortality and examined the role of confounding and explanatory variables on this relationship.

METHODS

A cohort of 3056 men and women from the Netherlands aged 55 to 85 years were followed up for 4 years. Major depression was defined according to DSM-III criteria by means of the Diagnostic Interview Schedule. Minor depression was defined as clinically relevant depression (defined by a Center for Epidemiologic Studies Depression score > or = 16) not fulfilling diagnostic criteria for major depression.

RESULTS

After adjustment for confounding variables (sociodemographics, health status), men with minor depression had a 1.80-fold higher risk of death (95% confidence interval, 1.35-2.39) during follow-up than nondepressed men. In women, minor depression did not significantly increase the mortality risk. Irrespective of sex, major depression was associated with a 1.83-fold higher mortality risk (95% confidence interval, 1.09-3.10) after adjustment for sociodemographics and health status. Health behaviors such as smoking and physical inactivity explained only a small part of the excess mortality risk associated with depression.

CONCLUSION

Even after adjustment for sociodemographics, health status, and health behaviors, minor depression in older men and major depression in both older men and women increase the risk of dying.

Religious climate and geographical distribution of depressive symptoms in older Dutch citizens

This study examines whether the degree of conservatism of the religious climate affects the geographical distribution of late life depressive symptoms. A U-shaped relationship is hypothesized: high levels of depressive symptoms at the extremes (both a-religious and hyperconservative), and a low level in the middle (moderate-conservative). Subjects are 3051 older Dutch citizens (55-85 years), living in 11 municipalities. Depressive symptoms are assessed using the CES-D. Religious climate is estimated on the municipality level, using percentages votes on political parties with a Christian background (moderate-conservative versus hyperconservative). Using multi-level analysis, the results support the U-curve hypothesis.

Sex differences in depression after widowhood. Do men suffer more?

BACKGROUND

This study focuses on sex differences in depression of the widowed. Previous research showed different results in sex differences and in depression after bereavement. We assessed the effects of widowhood on depressive symptoms for men and women and examined whether environmental strain like social support, finances and housekeeping concerns explain these effects.

METHODS

Data were used from a large community-based study of older people in three regions of the Netherlands. Our study sample consists of 2626 widowed and married subjects in the age group of 55-85 years. Depression was measured using the CES-D scale; the various strains were obtained by structured interviews. Multiple linear regression, performed for men and women separately, were used.

RESULTS

The results show that widowhood is associated with higher levels of depressive symptoms and that this association is stronger for men than for women. The effect of widowhood is mediated by different types of environmental strain for men and women. However, a strong direct main effect of widowhood on depression remains. The difference in depression rates between men and women is most evident among those widowed for a longer period of time.

CONCLUSIONS

It appears that, over time, women adapt to widowhood more successfully than men. From a clinical point of view this is important, as it suggests that men who remain alone after losing their partner are at a higher risk of developing symptoms of chronic depression.

Consequences of anxiety in older persons: its effect on disability, well-being and use of health services

BACKGROUND

Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources.

METHODS

Data of a large community-based random probability sample (N = 659) of older subjects (55-85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables.

RESULTS

Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low.

CONCLUSIONS

Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Development of the EURO-D scale--a European, Union initiative to compare symptoms of depression in 14 European centres

BACKGROUND

In an 11-country European collaboration, 14 population-based surveys included 21,724 subjects aged > or = 65 years. Most participating centres used the Geriatric Mental State (GMS), but other measures were also used.

AIMS

To derive from these instruments a common depression symptoms scale, the EURO-D, to allow comparison of risk factor profiles between centres.

METHOD

Common items were identified from the instruments. Algorithms for fitting items to GMS were derived by observation of item correspondence or expert opinion. The resulting 12-item scale was checked for internal consistency, criterion validity and uniformity of factor-analytic profile.

RESULTS

The EURO-D is internally consistent, capturing the essence of its parent instrument. A two-factor solution seemed appropriate: depression, tearfulness and wishing to die loaded on the first factor (affective suffering), and loss of interest, poor concentration and lack of enjoyment on the second (motivation).

CONCLUSIONS

The EURO-D scale should permit valid comparison of risk-factor associations between centres, even if between-centre variation remains difficult to attribute.

Depression in Europe. Geographical distribution among older people

BACKGROUND

This is the first report of results from the EURODEP Programme.

AIMS

To assess the prevalence of depression judged suitable for intervention in randomised samples of those aged > or = 65 in nine European centres.

METHOD

The GMS-AGECAT package.

RESULTS

Differences in prevalence are apparent, 8.8% (Iceland) to 236% (Munich). When sub-cases and cases are added together, five high- and four low-scoring centres emerge. Women predominated over men. Proportions of sub-cases to cases revealed striking differences but did not explain prevalence. There was no constant association between prevalence and age. A meta-analysis (n = 13,808) gave an overall prevalence of 12.3%, 14.1% for women and 8.6% for men.

CONCLUSIONS

Considerable variation occurs in the levels of depression across Europe, the cause for which is not immediately obvious. Case and sub-case levels taken together show greater variability, suggesting that it is not a matter of case/sub-case selection criteria, which were standardised by computer. Substantial levels of depression are shown but 62-82% of persons had no depressive level. Opportunities for treatment exist.

Review of community prevalence of depression in later life

BACKGROUND

Despite considerable interest, there is no consensus regarding the prevalence of depression in later life.

AIMS

To assess the prevalence of late-life depression in the community.

METHOD

A systematic review of community-based studies of the prevalence of depression in later life (55+). Literature was analysed by level of caseness at which depression was defined and measured.

RESULTS

Thirty-four studies eligible for inclusion were found. The reported prevalence rates vary enormously (0.4-35%). Arranged according to level of caseness, major depression is relatively rare among the elderly (weighted average prevalence 1.8%), minor depression is more common (weighted average prevalence 9.8%), while all depressive syndromes deemed clinically relevant yield an average prevalence of 13.5%. There is consistent evidence for higher prevalence rates for women and among older people living under adverse socio-economic circumstances.

CONCLUSIONS

Depression is common in later life. Methodological differences between studies preclude firm conclusions about cross-cultural and geographical variation. Improving the comparability of epidemiological research constitutes an important step forward.

Depression symptoms in late life assessed using the EURO-D scale. Effect of age, gender and marital status in 14 European centres

BACKGROUND

Data from surveys involving 21,724 subjects aged > or = 65 years were analysed using a harmonised depression symptom scale, the EURO-D.

AIMS

To describe and compare the effects of age, gender and mental status on depressive symptoms across Europe.

METHOD

We tested for the effects of centre, age, gender and marital status on EURO-D score. Between-centre variance was partitioned according to centre characteristics: region, religion and survey instrument used.

RESULTS

EURO-D scores tended to increase with age, women scored higher than men, and widowed and separated subjects scored higher than others. The EURO-D scale could be reduced into two factors: affective suffering, responsible for the gender difference, and motivation, accounting for the positive association with age.

CONCLUSIONS

Large between-centre differences in depression symptoms were not explained by demography or by the depression measure used in the survey. Consistent, small effects of age, gender and marital status were observed across Europe. Depression may be overdiagnosed in older persons because of an increase in lack of motivation that may be affectively neutral, and is possibly related to cognitive decline.

Religious denomination and depression in older Dutch citizens: patterns and models

This study describes the distribution of depressive symptoms in older Dutch citizens (N = 3,020) across religious denominations. Reformed Calvinists had the lowest depressive scores (CES-D); Protestants from liberal denominations the highest; Roman Catholics, Dutch Reformed, and nonchurch members were in between. Two types of explanatory mechanisms are examined: (a) social integration and (b) positive self-perceptions, which both help to prevent depression. Alternatively, strict Calvinist doctrines are hypothesized to enforce negative self-perceptions, facilitating depression. For 2,509 respondents, complete data were available on social integration and self-perceptions, as well as on the parental religious denomination. Explanatory effects were tested using hierarchic regression models. The negative association between Calvinist background and depressive symptoms was partly explained by size of social network, and between Roman Catholic background and depressive symptoms by self-esteem. Leaving church had a positive association with depressive symptoms. This depressogenic effect remained after controlling for explanatory variables.

Depression in survivor of stroke: a community-based study of prevalence, risk factors and consequences

Depression in survivors of stroke is both common and clinically relevant. It is associated with excess suffering, handicap, suicidal ideation and mortality and it hampers rehabilitation. Most of the data currently available are derived from clinical studies. The objective of the present study was to study the prevalence, risk factors and consequences of depression in survivors of stroke, in a large (n = 3050) community-based study of older (55-85 years) people in three regions of the Netherlands. Depression was measured using the CES-D scale; histories of stroke were obtained using self-reports and data from general practitioners. The study was designed as a case-control study, using both bivariate and multivariate analyses. The prevalence of depression in stroke survivors was 27%, which was significantly higher than the base rate (OR 2.28, 95% CI 1.61-3.24). Both stroke-related disease characteristics and psychosocial characteristics of the respondents were predictors of depression. The consequences of depression were most evident in the realm of disability and impairment of well-being. The patterns of service utilization showed that depressed survivors of stroke are relatively high users of a wide range of health services.

Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam

OBJECTIVE

To study the prevalence and risk factors of anxiety disorders in the older (55-85) population of The Netherlands.

METHOD

The Longitudinal Aging Study Amsterdam (LASA) is based on a random sample of 3107 older adults, stratified for age and sex, which was drawn from the community registries of 11 municipalities in three regions in The Netherlands. Anxiety disorders were diagnosed using the Diagnostic Interview Schedule in a two-stage screening design. The risk factors under study comprise vulnerability, stress and network-related variables. Both bivariate and multivariate statistical methods were used to evaluate the risk factors.

RESULTS

The overall prevalence of anxiety disorders was estimated at 10.2%. Generalized anxiety disorder was the most common disorder (7.3%), followed by phobic disorders (3.1%). Both panic disorder (1.0%) and obsessive compulsive disorder (0.6%) were rare. These figures are roughly similar to previous findings. Ageing itself did not have any impact on the prevalence in both bivariate and multivariate analyses. The impact of other factors did not change much with age. Vulnerability factors (female sex, lower levels of education, having suffered extreme experiences during World War II and external locus of control) appeared to dominate, while stresses commonly experienced by older people (recent losses in the family and chronic physical illness) also played a part. Of the network-related variables, only a smaller size of the network was associated with anxiety disorders.

CONCLUSIONS

Anxiety disorders are common in later life. The risk factors support using a vulnerability-stress model to conceptualize anxiety disorders. Although the prevalence of risk factors changes dramatically with age, their impact is not age-dependent. The risk factors indicate which groups of older people are at a high risk for anxiety disorders and in whom active screening and treatment may be warranted.

[Gerotranscendence as a life cycle perspective: an initial empirical approach among the elderly in The Netherlands]

Gerotranscendence has been defined as a shift in meta-perspective, from a materialistic and rationalistic perspective to a more cosmic and transcendent one that accompanies the process of aging. The present study describes scale characteristics of the Dutch translation of Tornstam's gerotranscendence scale, using data from a sample among adults aged 56-76 years (N = 556). Two subscales evolve from scale analysis, similar to those found by Tornstam: cosmic transcendence and egotranscendence. Scores on both subscales are higher for the older old, as well as for the unmarried; divorced or widowed respondents who suffer from physical impairments. Scale scores are also higher for respondents with depressive complaints. On the subscale cosmic transcendence Roman Catholics have higher scores than Protestants and non-church members. On the subscale ego-transcendence well educated respondents and those with few social contacts have higher scores than persons with less education and those with many contacts. The strength of the associations is modest and the variance explained is small. The findings warrant further research into the question whether gerotranscendence adds to competence in later life.

Depression and physical health in later life: results from the Longitudinal Aging Study Amsterdam (LASA)

BACKGROUND

In later life, declining physical health is often thought to be one of the most important risk factors for depression. Major depressive disorders are relatively rare, while depressive syndromes which do not fulfill diagnostic criteria (minor depression) are common.

METHODS

Community-based sample of older adults (55-85) in the Netherlands: baseline sample n = 3056; study sample in two stage screening procedure n = 646. Both relative (odds ratios) and absolute (population attributable risks) measures of associations reported.

RESULTS

In multivariate analyses minor depression was related to physical health, while major depression was not. General aspects of physical health had stronger associations with depression than specific disease categories. Significant interactions between ill health and social support were found only for minor depression. Major depression was associated with variables reflecting long-standing vulnerability.

CONCLUSION

Major and minor depression differ in their association with physical health.

LIMITATION

Cross-sectional study relying largely on self-reported data.

CLINICAL RELEVANCE

In major depression, with or without somatic co-morbidity, primary treatment of the affective disorder should not be delayed. In minor depression associated with declining physical health, intervention may be aimed at either or both conditions.

Consequences of major and minor depression in later life: a study of disability, well-being and service utilization

BACKGROUND

The consequences of major depression for disability, impaired well-being and service utilization have been studied primarily in younger adults. In all age groups the consequences of minor depression are virtually unknown. In later life, the increased co-morbidity with physical illness may modify the consequences of depression, warranting special study of the elderly. With rising numbers of elderly people, excess service utilization by depressed elderly represents an increasingly important issue.

METHODS

Based on a large, random community-based sample of older inhabitants of the Netherlands (55-85 years), the associations of major and minor depression with various indicators of disability, well-being and service utilization were assessed, controlling for potential confounding factors. Depression was diagnosed using a two-stage screening design. Diagnosis took place in all subjects with high depressive symptom levels and a random sample of those with low depressive symptom levels. The study sample consists of all participants to diagnostic interviews (N = 646).

RESULTS

As in younger adults, associations of both major and minor depression with disability and well-being remained significant after controlling for chronic disease and functional limitations. Adequate treatment is often not administered, even in subjects with major depression. As the vast majority of those depressed were recently seen by their general practitioners, treatment could have been provided in most cases. Bivariate analyses show that major and minor depression are associated with an excess use of non-mental health services, underscoring the importance of recognition. In multivariate analyses the evidence of excess service utilization was less compelling.

CONCLUSIONS

Both major and minor depression are consequential for well-being and disability, supporting efforts to improve the recognition and treatment in primary care. However, controlled trials are necessary to assess the impact this may have on service utilization.

Religiosity as a protective or prognostic factor of depression in later life; results from a community survey in The Netherlands

This study examines the impact of religiosity on the incidence and course of depressive syndromes in a community-based sample of elderly people in The Netherlands (n = 177). The course of depression was assessed in five waves of measurements, covering a period of 1 year. Religiosity was defined as salience of religion compared to the salience of other aspects of life. Religious salience was not associated with incidence of depression, but showed a relatively strong association with improvement of depression among the respondents who were depressed at the first measurement. This association was most prominent among subjects with poor physical health.

Chronic medical conditions and mental health in older people: disability and psychosocial resources mediate specific mental health effects

BACKGROUND

This study describes the differences in psychological distress, disability and psychosocial resources between types of major medical conditions and sensory impairments (collectively denoted as CMCs); and tests whether disability and psychosocial resources mediate CMC-specific mental health effects.

METHODS

Data were obtained from a population-based, cross-sectional survey of 5078 non-institutionalized, late middle-aged and older Dutch persons. The predictors were 16 types of CMCs, including all major chronic medical diseases as well as impairment of hearing, vision, and cognition. The outcomes were assessed in terms of psychological distress as measured by the Hospital Anxiety and Depression Scale. Two aspects of disability were measured (namely, physical and role functioning) and also three psychosocial resources (namely, mastery, self-efficacy and social support).

RESULTS

Level of psychological distress varied across type of CMC. Hearing impairment, neurological disease, vision impairment, and lung and heart disease had particularly strong associations with distress. The level of distress in patients with hearing impairment was 0.45 standard deviation higher than in those without hearing impairment (adjusted for demographics and all other CMCs). Roughly similar patterns of association were found between type of CMC and disability, and also, but to a lesser extent, mastery and self-efficacy. Stepwise multiple regression revealed that type of CMC accounted for 9% of the variance in distress initially, but this fell to 1% after the variance due to disability, mastery and self-efficacy was taken out. Social support was not a mediator. Disability and psychosocial resources accounted for 13% and 14% of the variance in distress, respectively.

CONCLUSION

These results support the conventional wisdom that it is not the nature of the condition that determines psychological distress, but instead the severity of the disability and loss of psychological resources associated with the condition on the one hand and the psychological characteristics of the patient on the other.