Vascular factors and depression

Comparison of the 10-, 14- and 20-Item CES-D Scores as Predictors of Cognitive Decline

The association between depressive symptomatology and cognitive decline has been examined using the Centre for Epidemiologic Studies-Depression Scale (CES-D); however, concerns have been raised about this self-report measure. Here, we examined how the CES-D total score from the 14- and 10-item versions compared to the 20-item version in predicting progression to cognitive decline from a cognitively unimpaired baseline. Data from 1054 participants were analysed using ordinal logistic regression, alongside moderator and receiver-operating characteristics curve analyses. All baseline total scores significantly predicted progression to cognitive decline. The 14-item version was better than the 20-item version in predicting consensus diagnosis, as shown by their AICs, while also showing the highest accuracy when discriminating between participants by diagnosis at last visit. We did not find sex to moderate the relationship between CES-D score and cognitive decline. Current findings suggest the 10- and 14-item versions of the CES-D are comparable to the 20-item version, and that the 14-item version may be better at predicting longitudinal consensus diagnosis compared to the 20-item version.

Pathomechanisms of Vascular Depression in Older Adults

Depression in older individuals is a common complex mood disorder with high comorbidity of both psychiatric and physical diseases, associated with high disability, cognitive decline, and increased mortality The factors predicting the risk of late-life depression (LLD) are incompletely understood. The reciprocal relationship of depressive disorder and age- and disease-related processes has generated pathogenic hypotheses and provided various treatment options. The heterogeneity of depression complicates research into the underlying pathogenic cascade, and factors involved in LLD considerably differ from those involved in early life depression. Evidence suggests that a variety of vascular mechanisms, in particular cerebral small vessel disease, generalized microvascular, and endothelial dysfunction, as well as metabolic risk factors, including diabetes, and inflammation that may induce subcortical white and gray matter lesions by compromising fronto-limbic and other important neuronal networks, may contribute to the development of LLD. The "vascular depression" hypothesis postulates that cerebrovascular disease or vascular risk factors can predispose, precipitate, and perpetuate geriatric depression syndromes, based on their comorbidity with cerebrovascular lesions and the frequent development of depression after stroke. Vascular burden is associated with cognitive deficits and a specific form of LLD, vascular depression, which is marked by decreased white matter integrity, executive dysfunction, functional disability, and poorer response to antidepressive therapy than major depressive disorder without vascular risk factors. Other pathogenic factors of LLD, such as neurodegeneration or neuroimmune regulatory dysmechanisms, are briefly discussed. Treatment planning should consider a modest response of LLD to antidepressants, while vascular and metabolic factors may provide promising targets for its successful prevention and treatment. However, their effectiveness needs further investigation, and intervention studies are needed to assess which interventions are appropriate and effective in clinical practice.

Aberrant Amplitude of Low-Frequency Fluctuation and Degree Centrality within the Default Mode Network in Patients with Vascular Mild Cognitive Impairment

This study aimed to investigate whole-brain spontaneous activities changes in patients with vascular mild cognitive impairment (VaMCI), and to evaluate the relationships between these brain alterations and their neuropsychological assessments. Thirty-one patients with VaMCI and thirty-one healthy controls (HCs) underwent structural MRI and resting-state functional MRI (rs-fMRI) and neuropsychological assessments. The functional alterations were determined by the amplitude of low-frequency fluctuation (ALFF) and degree centrality (DC). The gray matter volume (GMV) changes were analyzed using voxel-based morphometry (VBM). Linear regression analysis was used to evaluate the relationships between the structural and functional changes of brain regions and neuropsychological assessments. The VaMCI group had significantly lower scores in the Montreal Cognitive Assessment (MoCA), and higher scores on the Hamilton Anxiety Rating Scale (HAMA) and Hamilton Depression Rating Scale (HAMD). Compared to the HCs, the VaMCI group exhibited GM atrophy in the right precentral gyrus (PreCG) and right inferior temporal gyrus (ITG). VaMCI patients further exhibited significantly decreased brain activity within the default mode network (DMN), including the bilateral precuneus (PCu), angular gyrus (AG), and medial frontal gyrus (medFG). Linear regression analysis revealed that the decreased ALFF was independently associated with lower MoCA scores, and the GM atrophy was independently associated with higher HAMD scores. The current finding suggested that aberrant spontaneous brain activity in the DMN might subserve as a potential biomarker of VaMCI, which may highlight the underlying mechanism of cognitive decline in cerebral small vessel disease.

Using Staged Care to Provide "Right Care First Time" to People With Common Affective Disorders

An ongoing need exists for innovation in service delivery to ensure that mental health services deliver high-quality treatment and prevention in the population. This Special Article proposes the adoption of "staged care" as a population health-oriented service delivery model for packages of specialized services delivered largely in ambulatory care settings for individuals with common affective disorders. Staged care integrates measures of clinical need alongside clinical stage and personal choice to select hierarchically arranged service packages for individuals. Packages then vary according to the intensity, duration, and mix of treatment options. This Special Article describes five levels of care in staged care: self- or family-directed monitoring and management, low-intensity services, moderate-intensity services, high-intensity services, and acute and specialist community mental health services. The care environment, treatment team, and length of treatment are also described, and provisional criteria are specified for assigning individuals to different care levels on the basis of current clinical need and clinical stage. Staged care is presented as a model that guides treatment selection and health service delivery to ensure that the high-quality care aims of "right care first time" and prevention are achieved and optimal use of available resources is considered.

Effects of treadmill exercise on activity, short-term memory, vascular dysfunction in maternal separation rats

Maternal separation during early life causes psychiatric and neurologi-cal disorders such as anxiety and depression. Depression or anxiety is closely associated with memory impairment. The purpose of this study was to investigate the effect of treadmill exercise on activity, short-term memory, vascular dysfunction using maternal separation-induced de-pression model. Maternal separation started on 15-day-old rats. The rats in the maternal separation and fluoxetine injection group received intraperitoneal injection of 5 mg/kg of fluoxetine one time daily for 15 days from 21 to 35 days. The rats performed treadmill exercise once a day during 15 days from 21 to 35 days. There was low activity and short-term memory was decreased in the maternal separation rats. Treadmill exercise and fluoxetine injection increased activity and ameliorated memory impairment. The number of rat endothelial cells antigen-1 (RECA-1) of microvessels was decreased in the maternal separation rats. The number of RECA-1was increased by treadmill exercise and fluoxetine injection. Expression of matrix metalloproteinase-9 (MMP-9) was increased and expressions of zonula occludens-2 (ZO-2) and oc-cludin were decreased in the maternal separation rats. Treadmill exer-cise and fluoxetine injection suppressed MMP-9 expression and en-hanced ZO-2 and occludin expressions in the maternal separation rats. The present study shows treadmill exercise and antidepressant treat-ment ameliorates depressive symptom and short-term memory impair-ment by protecting from blood-brain barrier damage.

Oxidative Stress-Related Endothelial Damage in Vascular Depression and Vascular Cognitive Impairment: Beneficial Effects of Aerobic Physical Exercise

Oxidative stress- (OS-) related endothelial damage is involved in the occurrence and progression of several disorders, such as vascular depression and dementia. It has been reported that moderate, aerobic, physical exercise could reduce OS and inflammation, thus limiting the cardiovascular risk factors while improving endothelial homeostasis, mood, and cognition. In this review, we will discuss about the role of OS and OS-related endothelial damage in vascular depression and vascular cognitive impairment. Then, we will comment on the effects of physical exercise on both disorders.

Oxygenation differs among white matter hyperintensities, intersected fiber tracts and unaffected white matter

White matter hyperintensities of presumed vascular origin are frequently observed on magnetic resonance imaging in normal aging. They are typically found in cerebral small vessel disease and suspected culprits in the etiology of complex age- and small vessel disease-related conditions, such as late-onset depression. White matter hyperintensities may interfere with surrounding white matter metabolic demands by disrupting fiber tract integrity. Meanwhile, risk factors for small vessel disease are thought to reduce tissue oxygenation, not only by reducing regional blood supply, but also by impairing capillary function. To address white matter oxygen supply–demand balance, we estimated voxel-wise capillary density as an index of resting white matter metabolism, and combined estimates of blood supply and capillary function to calculate white matter oxygen availability. We conducted a cross-sectional study with structural, perfusion- and diffusion-weighted magnetic resonance imaging in 21 patients with late-onset depression and 21 controls. We outlined white matter hyperintensities and used tractography to identify the tracts they intersect. Perfusion data comprised cerebral blood flow, blood volume, mean transit time and relative transit time heterogeneity—the latter a marker of capillary dysfunction. Based on these, white matter oxygenation was calculated as the steady state cerebral metabolic rate of oxygen under the assumption of normal tissue oxygen tension and vice versa. The number, volume and perfusion characteristics of white matter hyperintensities did not differ significantly between groups. Hemodynamic data showed white matter hyperintensities to have lower blood flow and blood volume, but higher relative transit time heterogeneity, than normal-appearing white matter, resulting in either reduced capillary metabolic rate of oxygen or oxygen tension. Intersected tracts showed significantly lower blood flow, blood volume and capillary metabolic rate of oxygen than normal-appearing white matter. Across groups, lower lesion oxygen tension was associated with higher lesion number and volume. Compared with normal-appearing white matter, tissue oxygenation is significantly reduced in white matter hyperintensities as well as the fiber tracts they intersect, independent of parallel late-onset depression. In white matter hyperintensities, reduced microvascular blood volume and concomitant capillary dysfunction indicate a severe oxygen supply–demand imbalance with hypoxic tissue injury. In intersected fiber tracts, parallel reductions in oxygenation and microvascular blood volume are consistent with adaptations to reduced metabolic demands. We speculate, that aging and vascular risk factors impair white matter hyperintensity perfusion and capillary function to create hypoxic tissue injury, which in turn affect the function and metabolic demands of the white matter tracts they disrupt.

Baseline characteristic of patients presenting with lacunar stroke and cerebral small vessel disease may predict future development of depression

OBJECTIVE

Cerebral small vessel disease (SVD) is associated with late-onset depression and increases the risk for depression after stroke. We aimed to investigate baseline predictors of depression after long-term follow-up in patients with SVD, initially presenting with first-ever lacunar stroke, free of depression and cognitive impairment.

METHODS

A total of 294 patients with SVD were evaluated 3-5 years after the qualifying event. We analyzed baseline demographic data, vascular risk factors, functional status expressed as a score on modified Rankin Scale (mRS), cognitive status, presence of depression, total number of lacunar infarcts and severity of white matter hyperintensities (WMH) on MRI with Age-Related White Matter Changes scale total score (tARWMC) and Fazekas scale periventricular and deep subcortical scores.

RESULTS

On follow-up, depression was registered in 117 (39.8%) SVD patients. At the baseline, patients with depression compared with non-depressed were older (64.4 vs 60.9 years; p = 0.007), had higher mRS score (2.8 ± 0.7 vs 1.5 ± 0.7; p < 0.0001) and had more severe lesions on MRI scales (p < 0.0001 for all parameters). On follow-up, depressed patients more frequently exhibited cognitive decline (75.2% depressed vs 56.5% non-depressed; p = 0.003). No difference was detected in risk factor frequency between groups. Multivariate Cox regression analysis adjusted by age and gender revealed independent predictors of depression: baseline mRS >2 (HR 2.17, 95%CI 1.74-2.72; p < 0.0001) and tARWMC (HR 1.05, 95%CI 1.02-1.09; p = 0.005), and cognitive decline on follow-up (HR 1.80, 95%CI 1.12-2.89; p = 0.015).

CONCLUSIONS

Baseline functional status and severity of WMH and development of cognitive decline predict the occurence of late-onset depression in patients with SVD.

White Matter Hyperintensity Accumulation During Treatment of Late-Life Depression

White matter hyperintensities (WMHs) have been shown to be associated with the development of late-life depression (LLD) and eventual treatment outcomes. This study sought to investigate longitudinal WMH changes in patients with LLD during a 12-week antidepressant treatment course. Forty-seven depressed elderly patients were included in this analysis. All depressed subjects started pharmacological treatment for depression shortly after a baseline magnetic resonance imaging (MRI) scan. At 12 weeks, patients underwent a follow-up MRI scan, and were categorized as either treatment remitters (n=23) or non-remitters (n=24). Among all patients, there was as a significant increase in WMHs over 12 weeks (t(46)=2.36, P=0.02). When patients were stratified by remission status, non-remitters demonstrated a significant increase in WMHs (t(23)=2.17, P=0.04), but this was not observed in remitters (t(22)=1.09, P=0.29). Other markers of brain integrity were also investigated including whole brain gray matter volume, hippocampal volume, and fractional anisotropy. No significant differences were observed in any of these markers during treatment, including when patients were stratified based on remission status. These results add to existing literature showing the association between WMH accumulation and LLD treatment outcomes. Moreover, this is the first study to demonstrate similar findings over a short interval (ie 12 weeks), which corresponds to the typical length of an antidepressant trial. These findings serve to highlight the acute interplay of cerebrovascular ischemic disease and LLD.

Pathogenesis of depression: Insights from human and rodent studies

Major depressive disorder (MDD) will affect one out of every five people in their lifetime and is the leading cause of disability worldwide. Nevertheless, mechanisms associated with the pathogenesis of MDD have yet to be completely understood and current treatments remain ineffective in a large subset of patients. In this review, we summarize the most recent discoveries and insights for which parallel findings have been obtained in human depressed subjects and rodent models of mood disorders in order to examine the potential etiology of depression. These mechanisms range from synaptic plasticity mechanisms to epigenetics and the immune system where there is strong evidence to support a functional role in the development of specific depression symptomology. Ultimately we conclude by discussing how novel therapeutic strategies targeting central and peripheral processes might ultimately aid in the development of effective new treatments for MDD and related stress disorders.

Increased depression risk among patients with chronic osteomyelitis

OBJECTIVE

Inflammatory processes, which provoke alternations of neurotransmitter metabolism, neuroendocrine function, and neuroplasticity in the brain, might promote depression. In depression patients who do not exhibit risk factors, including hypertension, diabetes, coronary heart disease, stroke, Parkinson's disease and dementia, particularly in young people, inflammation is a likely risk factor for depression. We explored whether chronic osteomyelitis (COM), a chronic inflammatory disease, increases depression risk.

METHODS

A Taiwanese national insurance claims data set of more than 22 million enrollees was used to select 15,529 COM patients without depression history and 62,116 randomly selected age- and gender-matched controls without depression and COM history to trace depression development for an 12-year follow-up period from January 1, 1999 to December 31, 2010. The depression risk was analyzed using the Cox proportional hazards regression model.

RESULTS

The above-mentioned risk factors for depression were more frequent in the COM cohort, who exhibited significantly higher depression risk than the control group did. Comparing only those without comorbidities, the COM group exhibited higher depression risk than the control group did (hazard ratio [HR]=3.04, 95% confidence interval [CI]: 2.55-3.62). The younger population carried even greater risk (age<45: HR=6.08, 95% CI: 1.71-7.85; age>65: HR=1.75, 95% CI: 1.39-2.19).

CONCLUSIONS

This is the first study connecting COM to increased risk of developing depression. The outcomes suggest that COM is a substantial depression predictor and call for a closer focus on these patients for more rigorous depression prevention, particularly in young people.

Is there any association of personality traits with vascular endothelial function or systemic inflammation?

Background:

Evidences showed association of some personality traits with increased risk of cardiovascular diseases, but mediated mechanisms are not entirely described. In this study, we investigated the association of different personality traits with systemic inflammation and endothelial function as probable mediators.

Methods:

This cross-sectional study was conducted in 2011 on 40-60 years old employees of an industrial company located in Isfahan city (central Iran). Participants were selected through simple random sampling. Personality types were evaluated using the neuroticism-extroversion-openness personality inventory and systemic inflammatory status was determined with high sensitive C-reactive protein (hs-CRP) level. To evaluate endothelial function flow mediated dilation (FMD) were measured. The obtained data were analyzed with univariate correlation and multiple linear regression tests.

Results:

A total of 254 cases with mean age of 51.4 ± 6.1 years were evaluated. There was no significant relationship between hs-CRP level and FMD with the personality traits in univariate analysis. In multivariate analysis, no association was found between the scores of personality traits and FMD with controlling the factors such as age, body mass index dyslipidemia, hypertension and diabetes. Only there was an inverse association between conscientiousness score and hs-CRP (β = −0.241, P = 0.013).

Conclusions:

In our population who were the employees of an industrial company, no relationship was found between specific personality trait and endothelial dysfunction. However, we found that the personality trait of responsibility (conscientiousness) is negatively associated with inflammation. Further multi-center studies and also cohort studies are recommended in this regard.

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

OBJECTIVES

Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

METHOD

The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

RESULTS

One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was -1.32 (95% confidence interval: -2.61, -0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

CONCLUSION

A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.

Quality of life in patients with non-CAD chest pain: associations to fear of pain and psychiatric disorder severity

Chest pain in the absence of identified cardiac cause, or non-cardiac chest pain (NCCP), is a common condition that may result in impaired quality of life. Theories of NCCP put forward that patients who react to cardiopulmonary sensations with fear may avoid activities that elicit cardiac sensations. Co-morbid psychiatric disorders, which are prevalent in this population, may predispose individuals to be more vigilant to physiological sensations, including cardiac-related symptoms. The daily impact of avoiding cardiopulmonary cues may limit quality of life. This study examined psychiatric disorders, fear of pain, and quality of life in 30 non-coronary artery disease (CAD) chest pain patients. Psychiatric disorder severity was independently associated with mental health related quality of life and fear of pain was independently associated with physical health related quality of life. This research adds understanding to contributory factors to impaired quality of life among patients with non-CAD chest pain.

Late-life depression, mild cognitive impairment, and dementia

OBJECTIVE

To evaluate the association of late-life depression with mild cognitive impairment (MCI) and dementia in a multiethnic community cohort.

DESIGN AND SETTING

A cohort study was conducted in Northern Manhattan, New York, New York.

PARTICIPANTS

A total of 2160 community-dwelling Medicare recipients aged 65 years or older were included in the study.

METHODS

Depression was assessed using the 10-item version of the Center for Epidemiological Studies Depression scale (CES-D) and defined by a CES-D score of 4 or more. We used logistic regression for cross-sectional association analyses and proportional hazards regression for longitudinal analyses.

MAIN OUTCOME MEASURES

Mild cognitive impairment dementia, and progression from MCI to dementia were the main outcome measures. We also used subcategories of MCI (amnestic and nonamnestic), and dementia (probable Alzheimer disease and vascular dementia, including possible Alzheimer disease with stroke).

RESULTS

Baseline depression was associated with prevalent MCI (odds ratio, 1.4; 95% CI, 1.1-1.9) and dementia (2.2; 1.6-3.1). Baseline depression was associated with an increased risk of incident dementia (hazard ratio [HR], 1.7; 95% CI, 1.2-2.3) but not with incident MCI (0.9; 0.7-1.2). Persons with MCI and coexisting depression at baseline had a higher risk of progression to dementia (HR, 2.0; 95% CI, 1.2-3.4), especially vascular dementia (4.3; 1.1-17.0), but not Alzheimer disease (1.9; 1.0-3.6).

CONCLUSION

The association of depression with prevalent MCI and with progression from MCI to dementia, but not with incident MCI, suggests that depression accompanies cognitive impairment but does not precede it.

Vascular growth factors in neuropsychiatry

Recent advances in understanding the cellular and molecular basis of psychiatric illnesses have shed light on the important role played by trophic factors in modulating functional parameters associated with disease causality and drug action. Disease mechanisms are now thought to involve multiple cell types, including neurons and endothelial cells. These functionally distinct but interactively coupled cell types engage in cellular cross talk via shared and common signaling molecules. Dysregulation in their cellular signaling pathways influences brain function and alters behavioral performance. Multifunctional trophic factors such as VEGF and EPO that possess both neurotrophic and angiogenic actions are of particular interest due to their ability to rescue structural and plasticity deficits in neurons and vasculature. Obtaining insight into the behavioral, cellular and molecular actions of multi-functional trophic factors has the potential to open new and transformative therapeutic approaches.

Therapeutic interventions for vascular depression: a systematic review

OBJECTIVE

Vascular depression (VaD) hypothesis supports a bidirectional relationship between cerebrovascular risk factors (CRFs) and depression. We examined whether such concept is appropriate for clinical interventions; i.e., whether treating depressive symptoms has an impact on cerebrovascular risk and vice-versa.

METHOD

Systematic review on interventional studies published from October-1997 to April-2010 on MEDLINE and other databases. Search terms were "depressive disorder" (MeSH), "cerebrovascular disorders" (MeSH), and a batch of highly accurate terms to search for experimental and quasi-experimental trials. We used a structured questionnaire to assess the adequacy of the VaD criteria used for vascular, depression, neuroimaging, and neuropsychological features, as well as the main results of each study.

RESULTS

Of the 357 retrieved studies, 12 met our eligibility criteria. These studies adequately reported depression criterion, moderately reported neuroimaging and neuropsychological criteria, and showed severe flaws in vascular assessment. Efficacy trials suggested that nimodipine, transcranial magnetic stimulation, carotid stent placement, and citalopram were effective for VaD. Exploratory studies suggested that white-matter hyperintensities and global vascular risk are predictors of poor response. Although the low quality of the studies hinders the findings' generalization, studies of higher validity support the VaD concept for interventions.

CONCLUSION

VaD seems to be a useful concept for clinical interventions; however, further trials should refine CRFs criteria to assess its impact on antidepressant efficacy.

Microvascular pathology in late-life depression

Since the era of Gaupp who introduced the concept of atheroscletic depressive disorder, the concept of late-life depression has been correlated with cerebrovascular comorbidities, microvascular lesions, frontal cortical and subcortical gray and white matter hyperintensities. The predominant neuropsychological deficits concern the domains of planning, organization and abstraction, with executive dysfunction being the predominant finding. MRI studies reveal a higher prevalence of white matter lesions in elderly patients with depression. Molecular mechanisms underlying the disease still remain unclear. Hyperhomocysteinemia has been associated with depression through its toxicity to neurons and blood vessels. Endothelial dysfunction is another possible mechanism referring to the loss of vasodilatation capacity. Inflammatory phenomena, such as increased peripheral leucocytes, elevated CRP and cytokine levels, could play a role in endothelial dysfunction. In this review we will briefly combine findings from neurobiological, epidemiological, structural and post-mortem data. A more complex model in late-life depression combining different modalities could be an elucidating approach to the disease's etiopathogeny in the future.

Factors associated with a depressive disorder in Alzheimer's disease are different from those found for other dementia disorders

Background

This study explores factors associated with depression in Alzheimer's disease (AD) compared with mild cognitive impairment (MCI) and other dementia disorders.

Method

In a prospective study we included 195 patients: 31 with MCI, 112 with AD and 52 with other dementias.

Results

According to the ICD-10 and the DSM-IV criteria, 88 (44.1%) and 59 (30.3%), respectively, had a depressive disorder. An adjusted multiple regression analysis showed that previous depression (p < 0.05) was significantly associated with depression in AD patients. Severity of dementia (p < 0.05) was significantly associated with a depressive disorder in a group of patients with frontotemporal dementia, vascular dementia, or dementia due to Lewy Body disease or Parkinson's disease.

Conclusion

We found different factors associated with a depressive disorder in AD compared to those found for other dementia disorders.

Depression in Alzheimer's disease: specificity of depressive symptoms using three different clinical criteria

BACKGROUND

Previous studies report contradictory results on whether the symptoms of depression in Alzheimer's disease patients are the same as in cognitively normal persons. Thus, provisional criteria for depression in Alzheimer's disease (PDC-dAD) have been developed.

AIM

To examine which symptoms in AD patients are significant in diagnosing depression according to PDC-dAD compared to those for the DSM-IV-TR and ICD-10 criteria.

METHODS

We included 112 patients with Alzheimer's disease. They were interviewed by a psychiatrist who diagnosed depression according to PDC-dAD, DSM-IV-TR and ICD-10. Without knowledge of that diagnosis, trained nurses interviewed the caregivers of the patients using the Cornell scale for depression in dementia (CSDD).

RESULTS

Mean age of the patients was 83.0 (s.d. 7.9), 77 (69.6%) were female. The proportion with depression according to each set of criteria was: PDC-dAD 53.5%, ICD-10, 47.3% and DSM-IV-TR, 34.8%. Sadness, loss of interest and agitation/retardation were the most prevalent symptoms in depressed subjects as evaluated by the psychiatrists. According to CSDD sadness, anxiety, suicidal thoughts, poor self-esteem, multiple physical complaints and pessimism best distinguished the depressed patients from the non-depressed. In multiple logistic regression analyses poor self-esteem, delusion and multiple physical complaints best predicted depression using PDC-dAD criteria, whereas sadness, suicidal thoughts and poor self-esteem best predicted depression using ICD-10 and DSM-IV-TR.

CONCLUSION

The most significant symptoms for a depressive disorder in AD are pretty much the same as for patients without dementia using the DSM-IV-TR and ICD-10 criteria, whereas they differ using the PDC-dAD criteria.

Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association

BACKGROUND AND PURPOSE

This scientific statement provides an overview of the evidence on vascular contributions to cognitive impairment and dementia. Vascular contributions to cognitive impairment and dementia of later life are common. Definitions of vascular cognitive impairment (VCI), neuropathology, basic science and pathophysiological aspects, role of neuroimaging and vascular and other associated risk factors, and potential opportunities for prevention and treatment are reviewed. This statement serves as an overall guide for practitioners to gain a better understanding of VCI and dementia, prevention, and treatment.

METHODS

Writing group members were nominated by the writing group co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council Scientific Statement Oversight Committee, the Council on Epidemiology and Prevention, and the Manuscript Oversight Committee. The writing group used systematic literature reviews (primarily covering publications from 1990 to May 1, 2010), previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. After peer review by the American Heart Association, as well as review by the Stroke Council leadership, Council on Epidemiology and Prevention Council, and Scientific Statements Oversight Committee, the statement was approved by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The construct of VCI has been introduced to capture the entire spectrum of cognitive disorders associated with all forms of cerebral vascular brain injury-not solely stroke-ranging from mild cognitive impairment through fully developed dementia. Dysfunction of the neurovascular unit and mechanisms regulating cerebral blood flow are likely to be important components of the pathophysiological processes underlying VCI. Cerebral amyloid angiopathy is emerging as an important marker of risk for Alzheimer disease, microinfarction, microhemorrhage and macrohemorrhage of the brain, and VCI. The neuropathology of cognitive impairment in later life is often a mixture of Alzheimer disease and microvascular brain damage, which may overlap and synergize to heighten the risk of cognitive impairment. In this regard, magnetic resonance imaging and other neuroimaging techniques play an important role in the definition and detection of VCI and provide evidence that subcortical forms of VCI with white matter hyperintensities and small deep infarcts are common. In many cases, risk markers for VCI are the same as traditional risk factors for stroke. These risks may include but are not limited to atrial fibrillation, hypertension, diabetes mellitus, and hypercholesterolemia. Furthermore, these same vascular risk factors may be risk markers for Alzheimer disease. Carotid intimal-medial thickness and arterial stiffness are emerging as markers of arterial aging and may serve as risk markers for VCI. Currently, no specific treatments for VCI have been approved by the US Food and Drug Administration. However, detection and control of the traditional risk factors for stroke and cardiovascular disease may be effective in the prevention of VCI, even in older people.

CONCLUSIONS

Vascular contributions to cognitive impairment and dementia are important. Understanding of VCI has evolved substantially in recent years, based on preclinical, neuropathologic, neuroimaging, physiological, and epidemiological studies. Transdisciplinary, translational, and transactional approaches are recommended to further our understanding of this entity and to better characterize its neuropsychological profile. There is a need for prospective, quantitative, clinical-pathological-neuroimaging studies to improve knowledge of the pathological basis of neuroimaging change and the complex interplay between vascular and Alzheimer disease pathologies in the evolution of clinical VCI and Alzheimer disease. Long-term vascular risk marker interventional studies beginning as early as midlife may be required to prevent or postpone the onset of VCI and Alzheimer disease. Studies of intensive reduction of vascular risk factors in high-risk groups are another important avenue of research.

Suicidal behavior in the older patient with schizophrenia

Little is known about treating elderly suicidal patients with schizophrenia. The purpose of this article is to review the literature dealing with this population and to discuss what is required to advance this field. Most available studies from middle-aged and older individuals suggest that risk factors include hopelessness, lower quality of life, past traumatic events, depressive symptoms, lifetime suicidal ideation and past attempts; it is not clear whether these findings are generalizable to geriatric populations. Although little treatment research has been performed in older suicidal patients with schizophrenia, an integrated psychosocial and pharmacologic approach is recommended. In addition, one recent study augmented antipsychotic treatment with an SSRI (i.e., citalopram) in a sample of middle-aged and older individuals with schizophrenia with subsyndromal depression; in that study, serotonin selective reuptake inhibitor augmentation reduced depressive symptoms and suicidal ideation. More research is required to better understand suicidal behavior in older patients with schizophrenia.

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles

OBJECTIVE

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

DESIGN

A critical review of the literature (1994-2009).

FINDINGS

The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations.

CONCLUSIONS

The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.

Depression-executive dysfunction syndrome relates to poor poststroke survival

BACKGROUND

The aim of this study was to investigate the influence of poststroke depression and executive dysfunction on long-term survival after acute stroke.

METHODS

A total of 257 consecutive acute ischemic stroke patients were included in the study and followed up to 12 years. Depression was diagnosed 3 months after stroke in 99 patients (38.5%).

FINDINGS

In Kaplan-Meier analysis, there was no difference in survival of patients with and without poststroke depression (8.7 versus 8.3 years). Instead, patients with both depression and executive dysfunction had shorter median survival than patients with neither depression nor executive dysfunction (6.6 versus 10.3 years). Comparison between all patients with executive dysfunction and patients without it, not regarding depressive status, showed that executive dysfunction in itself was strongly associated with poor poststroke survival (6.4 versus 10.6 years). In stepwise Cox regression proportional hazards analysis adjusted with covariates, poststroke depression with executive dysfunction (hazard ratio [HR] 1.63) and advanced age (HR 1.11) remained as independent predictors of poor long-term survival.

INTERPRETATION

The authors' well-defined poststroke cohort with long-term follow-up indicates that in poststroke depression, the depression-executive dysfunction syndrome is the predictor of poor long-term survival rather than depression in itself.

Vascular diseases and old age mental disorders: an update of neuroimaging findings

PURPOSE OF REVIEW

To review neuroimaging findings that have been reported in samples of patients with cardiovascular disorders and their association with the onset of Alzheimer's disease, vascular dementia, depression and bipolar disorder in the elderly and to highlight the implications of these findings to the knowledge about the pathophysiology of psychiatric disorders in old age, as well as their potential clinical implications.

RECENT FINDINGS

Vascular risk factors, such as hypertension, diabetes, dyslipidemia, smoking habits and heart failure, have all been associated with signs of cerebrovascular dysfunction, including structural MRI findings of signal hyperintensities, lacunes and stroke and functional imaging findings of brain regional hypoperfusion and hypometabolism. Such brain abnormalities have been found to increase the risk of onset of psychiatric disorder (depression, bipolar and dementia) in old age.

SUMMARY

As vascular risk factors are potentially modifiable when detected in midlife, the early characterization of brain changes associated with the presence of cardiovascular diseases holds promise to afford clinical applications in psychiatry, providing new perspectives for the prevention of old age psychiatric disorders.

Late life depression: a comparison of risk factors and symptoms according to age of onset in community dwelling older adults

BACKGROUND

It has been reported that late onset depression is more frequently associated with acquired organic pathology and that patients are less likely to report a family history of depression. Differences in phenomenology according to age of onset have been described although these have not been consistently replicated. The majority of these studies have been in hospital populations. The aim of this study is to address this question in a sample of community dwelling older adults.

METHODS

89 subjects with GMS-AGECAT depression were identified from a sample of 1231 community dwelling adults aged 65 years and over. Subjects were analysed across a range of aetiological and phenomenological variables according to age of onset of first depressive episode.

RESULTS

Subjects with late onset depression (≥ 60) were significantly less likely to report a family history of depression, were less likely to report previous hospitalisation for depression and had greater cognitive impairment. Late onset subjects were also less likely to report feelings of guilt or thoughts that life was not worth living in the previous month.

CONCLUSION

While we found that patients with late onset depression differed from early onset patients according to certain aetiological risk factors, we did not find a distinctive profile of depressive symptomatology which might be considered clinically useful at an individual level. These findings are consistent with studies based in hospital populations.

Hopelessness, depression, and early markers of endothelial dysfunction in U.S. adults

OBJECTIVE

To examine whether the psychological traits of hopelessness and depressive symptoms are related to endothelial dysfunction.

METHODS

Data are derived from a subsample of 434 respondents in the 2001 to 2003 Chicago Community Adult Health Study, a population-based survey designed to study the impact of psychological attributes, neighborhood environment, and socioeconomic circumstances on adults aged ≥18 years. Circulating biomarkers of endothelial dysfunction, including e-selectin, p-selectin, and soluble intercellular adhesion molecule-1 (s-ICAM1) were obtained from serum samples. Hopelessness was measured by responses to two questions, and depressive symptoms were measured by an 11-item version of the Center for Epidemiological Studies Depression scale. Multivariate regression models tested whether continuous levels of the biomarkers (natural log transformed) were associated with levels of hopelessness and depressive symptoms separately and concurrently.

RESULTS

In age- and sex-adjusted models, hopelessness showed significant positive linear associations with s-ICAM1. In contrast, there was no significant linear association between hopelessness and e-selectin and p-selectin. Adjustment for clinical risk factors, including systolic pressure, chronic health conditions, smoking, and body mass index, did not substantively alter these associations. Results from similar models for depressive symptoms did not reveal any association with the three biomarkers of endothelial dysfunction. The associations between hopelessness and e-selectin and s-ICAM1 were robust to the inclusion of adjustments for depressive symptoms.

CONCLUSIONS

Negative psychosocial traits may influence cardiovascular outcomes partially through their impact on the early stages of atherosclerosis, and specific psychosocial traits, such as hopelessness, may play a more direct role in this process than overall depressive symptoms.

Cardiovascular risk factors, cerebrovascular disease burden, and healthy brain aging

Cardiovascular risk factors have been associated with 2 common manifestation of unhealthy brain in older people, cognitive impairment and depression. The evidence for these effects is almost entirely observational, but links hypertension, smoking, hypercholesterolemia, diabetes mellitus, and hyperhomocysteinemia with cognitive impairment and depression. Unfortunately randomized trials evaluating interventions for these risk factors on the outcomes of cognition or mood have either been inconclusive or negative. However, as there are considerable other health benefits from targeting cardiovascular risk factors, these interventions should be more widely adopted, which would also probably result in positive outcomes for the brain.

[Diagnostic work-up and treatment of acute psycho-organic syndrome]

Psychiatric disorders due to a medical or neurological condition are the main differential diagnoses in newly admitted psychiatric patients, consultations and outpatient settings. Especially with the growing elderly population delirium occurs more frequently, often due to multiple causes. Although its prognosis is known to be unfavourable, delirium too often remains undiagnosed or untreated. Medications, neurological diseases, infections as well as metabolic and other medical conditions have to be ruled out in the differential diagnosis using the patient's history, physical examination, laboratory results and imaging procedures. First-time psychiatric symptoms of an unknown medical disease as well as co-occurring psychiatric symptoms in chronic diseases provoke a challenging diagnostic decision, as reactive psychiatric symptoms have to be distinguished which is not always possible. In psychiatric disorders confirmed to be due to a medical condition, therapeutic implications are primarily geared to the causes of the disease. Only in a second step psychiatric medication is warranted with antipsychotic, antidepressant or sedation-inducing properties depending on the patient's symptoms.

ROBERTE. Research advances in geriatric depression

Technical advances have facilitated the exploration of factors related to geriatric depression and have helped generate novel biological and psychosocial treatment approaches. This review summarizes the main advancements in epidemiology, clinical presentation and course, genetics, and other areas of biological research. Treatment interventions outlined in this paper include electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, deep brain stimulatn, depression prophylaxis, multidisciplinary approaches to depression treatment, and psychotherapy. Forms of psychotherapy for geriatric depression summarized include interpersonal psychotherapy, supportive psychotherapy, cognitive-behavioral therapy, problem-solving therapy, and ecosystem-focused therapy. Neuroimaging techniques based on magnetic resonance imaging are discussed briefly, including volumetric brain studies, diffusion tensor imaging, fractional anisotropy, fiber tractography, magnetization transfer imaging, and blood-oxygenation-level-dependent functional magnetic resonance imaging. Finally, treatment effectiveness is addressed in a discussion of new models to improve access to and quality of care offered in the community.

Considerations regarding neuropsychiatric nutritional requirements for intakes of omega-3 highly unsaturated fatty acids

BACKGROUND

Adverse neurodevelopmental and neuropsychiatric outcomes have been established as signs of nutrient deficiencies and may be applicable to insufficient dietary intakes of omega-3 highly unsaturated fatty acids (n-3 HUFAs).

OBJECTIVE

Consider if statistical definitions for Daily Reference Intakes can be applied to n-3 HUFAs intakes during pregnancy for maternal and neurodevelopmental deficiencies.

DESIGN

Data were prospectively collected from women during pregnancy and children up to age 8 years participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Statistical analyses took social and lifestyle factors into account.

RESULTS

During pregnancy, n-3 HUFA intakes from seafood that putatively meet statistical definitions of an estimated average requirement ranged from 0.05 to 0.06 en% (111-139 mg/d/2000 Cal) for suboptimal fine motor control at 42 m and 0.065-0.08 en% (114-181 mg/d/2000 Cal) for suboptimal verbal IQ at age 8 years and 0.18-0.22 en% (389-486 mg/d/2000 Cal) for maternal depression at 32 weeks. Intakes of n-3 ranging from 0.2 to 0.41 en% (445-917 mg/d/2000 Cal) prevented both increased risk of maternal depression and adverse neurodevelopmental outcomes for children among 97.5% of the population. No upper limit for safety was found.

CONCLUSION

During pregnancy, a n-3 HUFA intake of 0.40 en% (900 mg/d/2000 Cal) from seafood is likely to meet the nutritional requirements for 97.5% of the mothers and children of this population. These considerations do not constitute DRI's for docosahexaenoic acid and n-3 HUFAs, but may contribute to their formulation.