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Belvederi Murri M, Triolo F, Coni A, Nerozzi E, Maietta Latessa P, Fantozzi S, Padula N, Escelsior A, Assirelli B, Ermini G, Bagnoli L, Zocchi D, Cabassi A, Tedeschi S, Toni G, Chattat R, Tripi F, Neviani F, Bertolotti M, Cremonini A, Bertakis KD, Amore M, Chiari L, Zanetidou S. The body of evidence of late-life depression: the complex relationship between depressive symptoms, movement, dyspnea and cognition. Exp Aging Res 2024; 50:296-311. [PMID: 37035934 DOI: 10.1080/0361073x.2023.2196504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/24/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Physical symptoms play an important role in late-life depression and may contribute to residual symptomatology after antidepressant treatment. In this exploratory study, we examined the role of specific bodily dimensions including movement, respiratory functions, fear of falling, cognition, and physical weakness in older people with depression. METHODS Clinically stable older patients with major depression within a Psychiatric Consultation-Liaison program for Primary Care underwent comprehensive assessment of depressive symptoms, instrumental movement analysis, dyspnea, weakness, activity limitations, cognitive function, and fear of falling. Network analysis was performed to explore the unique adjusted associations between clinical dimensions. RESULTS Sadness was associated with worse turning and walking ability and movement transitions from walking to sitting, as well as with worse general cognitive abilities. Sadness was also connected with dyspnea, while neurovegetative depressive burden was connected with activity limitations. DISCUSSION Limitations of motor and cognitive function, dyspnea, and weakness may contribute to the persistence of residual symptoms of late-life depression.
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Affiliation(s)
| | - Federico Triolo
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Alice Coni
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Bologna, Italy
| | - Erika Nerozzi
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | | | - Silvia Fantozzi
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Bologna, Italy
| | - Nicola Padula
- Association for Research on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
| | - Andrea Escelsior
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Barbara Assirelli
- Department of Primary Care, Azienda Unita' Locale Sanita', Bologna, Italy
| | - Giuliano Ermini
- Department of Primary Care, Azienda Unita' Locale Sanita', Bologna, Italy
| | - Luigi Bagnoli
- Department of Primary Care, Azienda Unita' Locale Sanita', Bologna, Italy
| | - Donato Zocchi
- Department of Primary Care, Azienda Unita' Locale Sanita', Bologna, Italy
| | - Aderville Cabassi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Stefano Tedeschi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Giulio Toni
- Association for Research on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
| | - Rabih Chattat
- Department of Psychology "Renzo Canestrari", University of Bologna, Bologna, Italy
| | - Ferdinando Tripi
- Association for Research on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
| | - Francesca Neviani
- Department of Geriatrics, Nuovo Ospedale Civile S. Agostino Estense, Modena and Reggio Emilia University, Modena, Italy
| | - Marco Bertolotti
- Department of Geriatrics, Nuovo Ospedale Civile S. Agostino Estense, Modena and Reggio Emilia University, Modena, Italy
| | - Alessandro Cremonini
- Association for Research on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
| | - Klea D Bertakis
- Department of Family and Community Medicine, University of California, Davis, California, United States
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Lorenzo Chiari
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Bologna, Italy
| | - Stamatula Zanetidou
- Association for Research on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
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Dafsari FS, Bewernick B, Böhringer S, Domschke K, Elsaesser M, Löbner M, Luppa M, Schmitt S, Wingenfeld K, Wolf E, Zehender N, Hellmich M, Müller W, Wagner M, Peters O, Frölich L, Riedel-Heller S, Schramm E, Hautzinger M, Jessen F. Perceived Physical Health and Cognitive Behavioral Therapy vs Supportive Psychotherapy Outcomes in Adults With Late-Life Depression: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e245841. [PMID: 38619842 PMCID: PMC11019392 DOI: 10.1001/jamanetworkopen.2024.5841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/06/2024] [Indexed: 04/16/2024] Open
Abstract
Importance Physical diseases co-occur with late-life depression (LLD). The influence of physical diseases and the subjective perception of physical health (PPH) on treatment outcome in LLD, however, is not well understood. Objective To assess the association of physical diseases and PPH with the outcomes of 2 different types of psychotherapy in LLD. Design, Setting, and Participants This post hoc secondary analysis of a multicenter, observer-blinded, controlled, parallel-group randomized clinical trial assessed participants 60 years or older with moderate to severe depression recruited at 7 psychiatric-psychotherapeutic outpatient trial sites in Germany from October 1, 2018, to November 11, 2020. Data analysis was performed from April 1 to October 31, 2023. Interventions Patients received LLD-specific cognitive behavioral therapy (LLD-CBT) or supportive unspecific intervention (SUI). Main Outcomes and Measures Depression severity, response, and remission were measured during treatment and at 6-month follow-up by the change in the 30-item Geriatric Depression Scale (GDS) score. Physical health and PPH were assessed by the number of physical diseases, Charlson Comorbidity Index (CCI), and the World Health Organization Quality of Life Brief Version physical health subscale. Results A total of 251 patients were randomized to LLD-CBT (n = 126) or SUI (n = 125), of whom 229 (mean [SD] age, 70.2 [7.1] years; 151 [66%] female) were included in the intention-to-treat analysis. Patients with low and moderate PPH at baseline had significantly less reduction in the GDS score across both treatment groups than patients with high PPH (estimated marginal mean difference [EMMD], 2.67; 95% CI, 0.37-4.97; P = .02 for low PPH and EMMD, 1.82; 95% CI, 0.22-3.42; P = .03 for moderate vs high PPH). Higher PPH at baseline was associated with higher likelihood of response (odds ratio [OR], 1.04; 95% CI, 1.00-1.06; P = .009) and remission at the end of treatment (OR, 1.04; 95% CI, 1.02-1.08; P = .002) and response (OR, 1.05; 95% CI, 1.02-1.08; P < .001) and remission at follow-up (OR, 1.06; 95% CI, 1.03-1.10; P < .001) across both treatment groups. However, a significant interaction of PPH with treatment group was observed with low PPH at baseline being associated with significantly larger reduction in GDS scores in SUI compared with LLD-CBT at the end of treatment (EMMD, -6.48; 95% CI, -11.31 to -1.64; P = .009) and follow-up (EMMD, -6.49; 95% CI, -11.51 to -1.47; P = .01). In contrast, patients with high PPH at baseline had a significantly greater reduction in GDS scores in LLD-CBT compared with SUI at all time points (week 5: EMMD, -4.08; 95% CI, -6.49 to -1.67; P = .001; end-of-treatment: EMMD, -3.67; 95% CI, -6.72 to -0.61; P = .02; and follow-up: EMMD, -3.57; 95% CI, -6.63 to -0.51; P = .02). The number of physical diseases or CCI at baseline did not have an effect on the change in GDS score, response, or remission, neither across both groups nor within either group. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, subjective PPH was associated with treatment outcome, response, and remission in psychotherapy of LLD. Patients with LLD responded differently to LLD-CBT and SUI, depending on their baseline PPH score. Treatment approaches for patients with LLD should address PPH in personalized interventions. Trial Registration ClinicalTrials.gov Identifier: NCT03735576; Deutsches Register Klinischer Studien Identifier: DRKS00013769.
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Affiliation(s)
- Forugh S. Dafsari
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Bettina Bewernick
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
| | - Sabine Böhringer
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Moritz Elsaesser
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Margrit Löbner
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Sandra Schmitt
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Katja Wingenfeld
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Elena Wolf
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
| | - Nadine Zehender
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Wiebke Müller
- Institute of Medical Statistics and Computational Biology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Wagner
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University of Bonn, Bonn, Germany
- German Center for Neurodegenerative Disease, Bonn, Germany
| | - Oliver Peters
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Lutz Frölich
- Department of Geriatric Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Steffi Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology and Psychotherapy, Eberhard Karls University, Tübingen, Germany
| | - Frank Jessen
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine, and University Hospital Cologne, Cologne, Germany
- German Center for Neurodegenerative Disease, Bonn, Germany
- Cellular Stress Response in Aging-Associated Diseases Cluster of Excellence, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Depression Is Associated with an Increased Risk of Subsequent Cancer Diagnosis: A Retrospective Cohort Study with 235,404 Patients. Brain Sci 2023; 13:brainsci13020302. [PMID: 36831845 PMCID: PMC9954234 DOI: 10.3390/brainsci13020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Background: Depression and cancer share common risk factors and mechanisms of disease. The current literature has not explored the effect of depression on cancer risk. We assessed the difference in cancer risk in patients with and without depression in a large cohort in Germany. Methods: We compared cancer risk and incidence in patients with and without depression aged 18 or above diagnosed between 2015 and 2018 documented in the Disease Analyzer Database. Patients from a comparator group were matched 1:1 to patients with depression based on propensity scores. Patients with previous bipolar disorder (F31), mania (F30) or schizophrenia (F20-29) and cancer diagnosis 3 years prior to index date were excluded. Analyses were stratified by cancer type, age group, and gender. Results: A total of 117,702 patients with depression were included and matched 1:1, resulting in a cohort overall of 235,404. 4.9% of patients with depression compared to 4.1% without depression received at least one cancer diagnosis over 3.9 years median follow-up. The depression group showed an 18% increase in risk for a cancer diagnosis overall, with largest increased risk in lung cancer (HR: 1.39 [1.21-1.60], p < 0.0001), cancers of the gastro-intestinal-tract (HR: 1.30 [1.15-1.46], p < 0.0001), breast (HR: 1.23 [1.12-1.35], p < 0.0001) and urinary (HR: 1.23 [1.06-1.43], p < 0.01). Similarly, the incidence of cancer diagnosis overall increased by 22% for depressed patients. IRs showed no difference across cancer types. Conclusions: Depression increased the risk for cancer diagnosis consistently independent of the comparison method used. The potential mediating factors or shared mechanisms of the disease require further investigation.
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Vaitheswaran S, Balasubramanian S, Natarajan N, Venkatesan S, Srinivasan N, Nagarajan G, Ramanujam V, Sargunan S. Ethical Issues in Delivering Psychological Therapies in Geriatric Psychiatry in India. Indian J Psychol Med 2021; 43:S66-S70. [PMID: 34732957 PMCID: PMC8543620 DOI: 10.1177/02537176211026970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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[Family physician's role in the primary and secondary prevention and in the treatment of depression in the elderly]. Semergen 2020; 47:114-121. [PMID: 33279386 DOI: 10.1016/j.semerg.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/12/2020] [Accepted: 09/29/2020] [Indexed: 11/21/2022]
Abstract
In recent years, the demographic transition has resulted in an aging population, which has increased the number of illnesses such as depression. Often, the family physician is the first contact with these patients, therefore, comprehensive patient management is essential, emphasizing the primary and secondary prevention of depression in the elderly population. From primary health care, all risk and protective factors related to depression should be comprehensively evaluated. Among the former, widowhood, disability, and chronic diseases stand out. Likewise, the diagnostic criteria must be known to provide timely treatment. And, on the other hand, knowing the appropriate treatment will reduce the symptoms of depression, suicidal behavior, relapse, or recurrence of symptoms. Treatment usually consists of psychotherapy, psychosocial interventions, antidepressants, and electroconvulsive therapy. Therefore, the objective of this review is to offer family physicians a guide on the primary prevention, secondary prevention, and treatment of depression in the elderly.
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Belvederi Murri M, Caruso R, Ounalli H, Zerbinati L, Berretti E, Costa S, Recla E, Folesani F, Kissane D, Nanni MG, Grassi L. The relationship between demoralization and depressive symptoms among patients from the general hospital: network and exploratory graph analysis. J Affect Disord 2020; 276:137-146. [PMID: 32697691 DOI: 10.1016/j.jad.2020.06.074] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/19/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Depression and demoralization are highly prevalent among individuals with physical illnesses but their relationship is still unclear. OBJECTIVE To examine the relationship between clinical features of depression and demoralization with the network approach to psychopathology. METHODS Participants were recruited from the medical wards of a University Hospital in Italy. The Demoralization Scale (DS) was used to assess demoralization, while the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. The structure of the depression-demoralization symptom network was examined and complemented by the analysis of topological overlap and Exploratory Graph Analysis (EGA) to identify the most relevant groupings (communities) of symptoms and their connections. The stability of network models was estimated with bootstrap procedures and results were compared with factor analysis. RESULTS Life feeling pointless, low mood/discouragement, hopelessness and feeling trapped were among the most central features of the network. EGA identified four communities: (1) Neurovegetative Depression, (2) Loss of purpose, (3) Frustrated Isolation and (4) Low mood and morale. Loss of purpose and low mood/morale were largely connected with other communities through anhedonia, hopelessness and items related to isolation and lack of emotional control. Results from EGA displayed good stability and were comparable to those from factor analysis. LIMITATIONS Cross-sectional design; sample heterogeneity CONCLUSIONS: Among general hospital inpatients, features of depression and demoralization are independent, with the exception of low mood and self-reproach. The identification of symptom groupings around entrapment and helplessness may provide a basis for a dimensional characterization of depressed/demoralized patients, with possible implications for treatment.
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Affiliation(s)
- Martino Belvederi Murri
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy.
| | - Rosangela Caruso
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Heifa Ounalli
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Luigi Zerbinati
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Eleonora Berretti
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Silvia Costa
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Elisabetta Recla
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Federica Folesani
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - David Kissane
- Cunningham Centre for Palliative Care Research, University of Notre Dame Australia and St Vincent's Hospital Sydney; and Cabrini Health and Monash Health, Monash University, Victoria, Australia
| | - Maria Giulia Nanni
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
| | - Luigi Grassi
- Institute of Psychiatry, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Integrated Department of Mental Health and Addictive Behavior, S. Anna University Hospital and Health Authorities, Ferrara. Italy
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Kao KL, Sung FC, Tzang RF, Huang HC, Lin CL, Fang CK, Wu SI, Stewart R. Associations of diabetes severity and risk of depression: a population-based cohort study. J Affect Disord 2020; 273:476-481. [PMID: 32560943 DOI: 10.1016/j.jad.2020.04.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Previous literature investigating effects of diabetes complications on subsequent depression have been inconsistent. We aim to investigate associations of diabetes, complication severity, and depression. DESIGN This study used a nationwide database to establish an 11-year cohort comprised of people with new onset Type II diabetes mellitus (DM) aged 20 and above. METHOD Severity of DM was measured using the adapted Diabetes Complication Severity Index (aDCSI). Status of depression was determined by having one recorded depression diagnosis from the inpatient setting or three recorded depression diagnoses from the outpatient setting. The risk of depression was analyzed by multivariate Cox proportional models. RESULTS In 50,590 cases with new onset DM from years 2000 to 2011, the incidence of depression increased with severity and rates of progressions in diabetes complications regardless of demographic status, comorbidities, or medication compliance. Adjusted hazard ratios (aHR) of depression were 1.21, 1.25, 1.48 (p<0.001 for trend) in patients with a total aDCSI score of 1, 2, and > 3, respectively. Risks of depression were the highest in subgroup with the most serious progression (change of aDCSI score >2 per year) (aHR ranged between 11.6~26.0). Elevated risks of depression (aHR: 1.59~4.36) were also observed in the slower progression subgroups throughout the disease course. CONCLUSIONS Risks of depression were associated with multiple DM-related complications and rates of progression in severity.
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Affiliation(s)
- Kai-Liang Kao
- Far Eastern Memorial Hospital, Department of Pediatrics, Taipei, Taiwan
| | - Fung-Chang Sung
- Department of Health Services Administration, China Medical University, College of Public Health, Taichung, Taiwan; Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Ruu-Feng Tzang
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Section of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
| | - Hui-Chun Huang
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Chun-Kai Fang
- Section of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-I Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Section of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.
| | - Robert Stewart
- King's College London (Institute of Psychiatry, Psychology & Neuroscience), Department of Psychological Medicine, London, UK
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The symptom network structure of depressive symptoms in late-life: Results from a European population study. Mol Psychiatry 2020; 25:1447-1456. [PMID: 30171210 DOI: 10.1038/s41380-018-0232-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/09/2018] [Accepted: 06/08/2018] [Indexed: 11/08/2022]
Abstract
The network theory conceptualizes mental disorders as complex networks of symptoms influencing each other by creating feedback loops, leading to a self-sustained syndromic constellation. Symptoms central to the network have the greatest impact in sustaining the rest of symptoms. This analysis focused on the network structure of depressive symptoms in late-life because of their distinct etiologic factors, clinical presentation, and outcomes. We analyzed cross-sectional data from wave 2 of the 19 country Survey of Health, Ageing, and Retirement in Europe (SHARE) and included non-institutionalized adults aged 65 years or older (mean age 74 years, 59% females) endorsing at least one depressive symptom on the EURO-D scale for depression (N =8,557). We characterized the network structure of depressive symptoms in late-life and used indices of "strength", "betweenness", and "closeness" to identify symptoms central to the network. We used a case-dropping bootstrap procedure to assess network stability. Death wishes, depressed mood, loss of interest, and pessimism had the highest values of centrality. Insomnia, fatigue and appetite changes had lower centrality values. The identified network remained stable after dropping 74.5% of the sample. Sex or age did not significantly influence the network structure. In conclusion, death wishes, depressed mood, loss of interest, and pessimism constitute the "backbone" that sustains depressive symptoms in late-life. Symptoms central to the network of depressive symptoms may be used as targets for novel, focused interventions and in studies investigating neurobiological processes central to late-life depression.
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Ionson E, Limbachia J, Rej S, Puka K, Newman RI, Wetmore S, Burhan AM, Vasudev A. Effects of Sahaj Samadhi meditation on heart rate variability and depressive symptoms in patients with late-life depression. Br J Psychiatry 2019; 214:218-224. [PMID: 30482255 DOI: 10.1192/bjp.2018.265] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Late-life depression (LLD) is a disabling disorder and antidepressants are ineffective in as many as 60% of cases. Converging evidence shows a strong correlation between LLD and subsequent risk of cardiovascular disease. There is a need for new, well-tolerated, non-pharmacological augmentation interventions that can treat depressive symptoms as well as improve heart rate variability (HRV), an important prognostic marker for development of subsequent cardiovascular disease. Meditation-based techniques are of interest based on positive findings in other samples.AimsWe aimed to assess the efficacy of Sahaj Samadhi meditation (SSM), an underevaluated, standardised and manualised meditation intervention, on HRV and depressive symptoms. METHOD Eighty-three men and women aged 60-85 years, with mild to moderate depression and receiving treatment as usual (TAU) were randomised to either the SSM or TAU arm. Those allocated to SSM attended 4 consecutive days of group meditation training, using personalised mantras followed by 11 weekly reinforcement sessions. HRV and Hamilton Rating Scale for Depression (HRSD; 17-item) score were measured at baseline and 12 weeks. RESULTS All time and frequency domain measures of HRV did not significantly change in either arm. However, there was significant improvement in the SSM arm, compared with TAU, on the HRSD (difference in mean, 2.66; 95% CI 0.26-5.05; P = 0.03). CONCLUSIONS Compared with TAU, SSM is associated with improvements in depressive symptoms but does not significantly improve HRV in patients with LLD. These results need to be replicated in subsequent studies incorporating a group-based, active control arm.Declaration of interestR.I.N. is the Director of Research and Health Promotion for the Art of Living Foundation, Canada and supervised the staff providing Sahaj Samadhi meditation. S.R. has received research funding from Satellite Healthcare for a mindfulness meditation trial in patients on haemodialysis. The remaining authors report no financial or other relationship relevant to the subject of this article.
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Affiliation(s)
- Emily Ionson
- Research Assistant,Department of Psychiatry,London Health Sciences Centre,Canada
| | - Jayneel Limbachia
- Research Assistant,Schulich School of Medicine and Dentistry, Western University,Canada
| | - Soham Rej
- Geriatric Psychiatrist,Department of Psychiatry,Lady Davis Institute/Jewish General Hospital, McGill University,Canada
| | - Klajdi Puka
- Master's student,Department of Epidemiology & Biostatistics,Western University,Canada
| | - Ronnie I Newman
- Director,Department of Research and Health Promotion,International Association of Human Values, Washington DC, USA and Faculty, Lifelong Learning Institute,Health Professions Division,Nova Southeastern University,Florida,US
| | - Stephen Wetmore
- Chair/Chief,Department of Family Medicine,Schulich School of Medicine and Dentistry, Western University,Canada
| | - Amer M Burhan
- (Psychiatry and Geriatric Psychiatry),Associate Professor,Department of Psychiatry,Schulich School of Medicine and Dentistry,Western University and Associate Scientist, Lawson Health Research Institute,Canada
| | - Akshya Vasudev
- Associate Professor of Psychiatry,Department of Psychiatry,Schulich School of Medicine and Dentistry,Western University and Associate Scientist, Lawson Health Research Institute,Canada
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10
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The effect of chronic physical illnesses on psychiatric hospital admission in patients with recurrent major depression. Psychiatry Res 2019; 272:602-608. [PMID: 30616130 DOI: 10.1016/j.psychres.2018.12.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 11/26/2018] [Accepted: 12/31/2018] [Indexed: 12/19/2022]
Abstract
People with major depressive disorder (MDD) have an increased burden of chronic physical illnesses (CPI). However, information about the effect of CPIs on recurrent MDD treatment outcome is limited. The objective of this study was to explore whether the number of CPIs in patients with recurrent MDD was associated with higher rate of psychiatric admissions. Data were collected for a consecutive sample of 190 patients diagnosed with recurrent MDD. The key outcome was the number of psychiatric admissions following psychiatric diagnosis. The independent variable was the number of CPIs. The effects of different clinical, sociodemographic, and lifestyle confounding factors were controlled using robust regression. The patients with CPI had significantly more psychiatric admissions than the patients without CPI, and the number of CPIs was significantly associated with the number of psychiatric admissions. The results of our study largely confirmed that more than two CPIs in patients diagnosed with recurrent MDD are associated with higher rates of psychiatric admission, independent of psychiatric comorbidities and other clinical and sociodemographic factors. These findings indicate that to improve treatment outcome and to reduce recurrence, it is crucial to enhance early recognition and treatment of physical comorbidity.
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11
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Lauriola M, Mangiacotti A, D'Onofrio G, Cascavilla L, Paris F, Ciccone F, Greco M, Paroni G, Seripa D, Greco A. Late-Life Depression versus Amnestic Mild Cognitive Impairment: Alzheimer's Disease Incidence in 4 Years of Follow-Up. Dement Geriatr Cogn Disord 2019; 46:140-153. [PMID: 30199883 DOI: 10.1159/000492489] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 07/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM The aim of the study was to evaluate the prognostic power of late-life depression (LLD) compared with amnestic mild cognitive impairment (aMCI) for the onset of Alzheimer's disease (AD) within 4 years of follow-up. METHODS We estimated the incidence of AD in 60 patients presenting with aMCI, 115 patients suffering of LLD treated with antidepressants with good compliance, and 66 healthy control (HC) patients, followed for 4 years. RESULTS The risk to develop AD, within 4 years, was 68.33% for aMCI and 49.57% for LLD. In AD patients 5.60% deteriorated without depression, and 72.20% deteriorated with depression after 4 years of follow-up (p < 0.0001). No HC patients deteriorated to AD or any other dementia type. CONCLUSION In our results, aMCI was the first predictive condition that increased the risk to develop AD. Depression is a potentially preventable medical condition across the lifespan and may be a modifiable risk factor.
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Affiliation(s)
- Michele Lauriola
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonio Mangiacotti
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Grazia D'Onofrio
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo,
| | - Leandro Cascavilla
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Francesco Paris
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Filomena Ciccone
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Monica Greco
- Clinical Unit of Internal Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino, Genova, Italy
| | - Giulia Paroni
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Davide Seripa
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Antonio Greco
- Complex Unit of Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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12
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Belvederi Murri M, Ekkekakis P, Magagnoli M, Zampogna D, Cattedra S, Capobianco L, Serafini G, Calcagno P, Zanetidou S, Amore M. Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes. Front Psychiatry 2018; 9:762. [PMID: 30687141 PMCID: PMC6335323 DOI: 10.3389/fpsyt.2018.00762] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
Major depression shortens life while the effectiveness of frontline treatments remains modest. Exercise has been shown to be effective both in reducing mortality and in treating symptoms of major depression, but it is still underutilized in clinical practice, possibly due to prevalent misperceptions. For instance, a common misperception is that exercise is beneficial for depression mostly because of its positive effects on the body ("from the neck down"), whereas its effectiveness in treating core features of depression ("from the neck up") is underappreciated. Other long-held misperceptions are that patients suffering from depression will not engage in exercise even if physicians prescribe it, and that only vigorous exercise is effective. Lastly, a false assumption is that exercise may be more harmful than beneficial in old age, and therefore should only be recommended to younger patients. This narrative review summarizes relevant literature to address the aforementioned misperceptions and to provide practical recommendations for prescribing exercise to individuals with major depression.
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Affiliation(s)
- Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Psychological Medicine, King's College London, London, United Kingdom
| | | | - Marco Magagnoli
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Domenico Zampogna
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Simone Cattedra
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Laura Capobianco
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pietro Calcagno
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Stamatula Zanetidou
- Department of Mental Health, Consultation Liaison Psychiatry Service, Bologna, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
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13
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Zanetidou S, Belvederi Murri M, Menchetti M, Toni G, Asioli F, Bagnoli L, Zocchi D, Siena M, Assirelli B, Luciano C, Masotti M, Spezia C, Magagnoli M, Neri M, Amore M, Bertakis KD. Physical Exercise for Late-Life Depression: Customizing an Intervention for Primary Care. J Am Geriatr Soc 2016; 65:348-355. [PMID: 27869986 DOI: 10.1111/jgs.14525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify which individual- and context-related factors influence the translation into clinical practice of interventions based on physical exercise (PE) as an adjunct to antidepressants (AD) for the treatment of late-life major depression (LLMD). DESIGN Secondary analysis of a randomized controlled trial. SETTING Primary care with psychiatric consultation-liaison programs (PCLPs)-organizational protocols that regulate the clinical management of individuals with psychiatric disorders. PARTICIPANTS Individuals aged 65 and older with major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (N = 121). INTERVENTION Participants with LLMD were randomized to AD (sertraline) or AD plus PE (AD + PE). MEASUREMENTS Participant characteristics that were associated with greater effectiveness of AD + PE (moderators) were identified, and effect sizes were calculated from success rate differences. Whether the characteristics of the study setting influenced participant flow and attendance at exercise sessions was then explored, and primary care physicians (PCPs) were surveyed regarding their opinions on PE as a treatment for LLMD. RESULTS The following participant characteristics were associated with greater likelihood of achieving remission from depression with AD + PE than with AD alone: aged 75 and older (effect size 0.32), polypharmacy (0.35), greater aerobic capacity (0.48), displaying psychomotor slowing (0.49), and less-severe anxiety (0.30). The longer the PCLP had been established at a particular center, the more individuals were recruited at that center. After participating in the study, PCPs expressed positive views on AD + PE as a treatment for LLMD and were more likely to use this as a therapeutic strategy. CONCLUSIONS The combination of PE and sertraline could improve the management of LLMD, especially when customized for individuals with specific clinical features. Liaison programs might influence the implementation of similar interventions in primary care, and PCPs viewed them positively.
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Affiliation(s)
- Stamatula Zanetidou
- Department of Mental Health, Consultation Liaison Psychiatry Service, Bologna, Italy
| | - Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy.,Department of Psychological Medicine, King's College London, London, United Kingdom
| | - Marco Menchetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giulio Toni
- Cardiology Unit, S. Sebastiano Hospital, Correggio, Italy
| | | | | | | | | | | | - Claudia Luciano
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mattia Masotti
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | | | | | - Mirco Neri
- Department of Geriatrics, Nuovo Ospedale Civile, Modena and Reggio Emilia University, Modena, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy
| | - Klea D Bertakis
- Department of Family and Community Medicine, School of Medicine, University of California, Davis, Sacramento, California.,Center for Healthcare Policy and Research, School of Medicine, University of California, Davis, Sacramento, California
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14
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Klotho Gene and Selective Serotonin Reuptake Inhibitors: Response to Treatment in Late-Life Major Depressive Disorder. Mol Neurobiol 2016; 54:1340-1351. [PMID: 26843110 DOI: 10.1007/s12035-016-9711-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 01/11/2016] [Indexed: 02/07/2023]
Abstract
Klotho protein, encoded by the Klotho gene (KL) at locus 13q12, is an antiaging hormone-like protein playing a pivotal role in cell metabolism homeostasis and associated to longevity and age-related diseases. In particular, altered cell metabolism in central nervous system may influence the behavior of serotoninergic neurons. The role of KL in the response to treatment with selective serotonin reuptake inhibitors (SSRIs) in late-life depressive syndromes and late-life major depressive disorder (MDD) is unclear. We genotyped three single-nucleotide polymorphisms (SNPs) of KL in 329 older patients with diagnosis of late-life MDD, treated with SSRIs and evaluated with the Hamilton Rating Scale for Depression 21-items (HRSD-21) at baseline and after 6 months. A reduction ≥50 and <10 % in HDRS-21 score was considered as response or nonresponse to therapy, respectively, and the values of reduction between 10 and 49 % as poor responders. After 6 months of SSRI treatment, 176 patients responded, 54 patients did not respond and 99 patients showed a poor response. Ordinal logistic models showed a significant association between mutation of SNP rs1207568 and responders and, similarly, for each unitary risk allele increase overlapping results were found. Conversely, a significantly higher frequency of the minor genotype of SNP rs9536314 was found in nonresponders. Considering the pre-post differences of HRSD-21 scores as a continue variable, we confirmed a significant improvement of depressive symptoms after treatment in patients carrying at least one minor allele at rs1207568 and a worse response in patients homozygous for the minor allele at rs9536314. Our results were the first that suggested a possible role of KL in the complex pathway of SSRI response in late-life MDD.
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15
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Rogers S, Audisio R, Lowe D. Do the elderly raise different issues when using the Patient Concerns Inventory in routine head and neck cancer follow-up clinics? Eur J Cancer Care (Engl) 2015; 24:189-97. [DOI: 10.1111/ecc.12289] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2014] [Indexed: 11/27/2022]
Affiliation(s)
- S.N. Rogers
- Evidence-Based Practice Research Centre (EPRC); Faculty of Health and Social Care; Edge Hill University; Ormskirk UK
- Regional Maxillofacial Unit; University Hospital Aintree; Liverpool UK
| | - R.A. Audisio
- St Helens Teaching Hospital; University of Liverpool; St Helens UK
| | - D. Lowe
- Evidence-Based Practice Research Centre (EPRC); Faculty of Health and Social Care; Edge Hill University; Ormskirk UK
- Regional Maxillofacial Unit; University Hospital Aintree; Liverpool UK
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16
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McCarty DE, Punjabi NM, Kim PY, Frilot C, Marino AA. Recurrence analysis of the EEG during sleep accurately identifies subjects with mental health symptoms. Psychiatry Res 2014; 224:335-40. [PMID: 25456523 DOI: 10.1016/j.pscychresns.2014.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 09/05/2014] [Accepted: 10/03/2014] [Indexed: 11/16/2022]
Abstract
Analysis of brain recurrence (ABR) is a novel computational method that uses two variables for sleep depth and two for sleep fragmentation to quantify temporal changes in non-random brain electrical activity. We postulated that ABR of the sleep-staged EEG could identify an EEG signature specific for the presence of mental health symptoms. Using the Mental Health Inventory Questionnaire (MHI-5) as ground truth, psychological distress was assessed in a study cohort obtained from the Sleep Heart Health Study. Subjects with MHI-5 <50 (N=34) were matched for sex, BMI, age, and race with 34 subjects who had MHI-5 scores >50. Sixteen ABR markers derived from the EEG were analyzed using linear discriminant analysis to identify marker combinations that reliably classified individual subjects. A biomarker function computed from 12 of the markers accurately classified the subjects based on their MHI-5 scores (AUROC=82%). Use of additional markers did not improve classification accuracy. Subgroup analysis (20 highest and 20 lowest MHI-5 scores) improved classification accuracy (AUROC=89%). Biomarker values for individual subjects were significantly correlated with MHI-5 score (r=0.36, 0.54 for N=68, 40, respectively). ABR of EEGs obtained during sleep successfully classified subjects with regard to the severity of mental health symptoms, indicating that mood systems were reflected in brain electrical activity.
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Affiliation(s)
- David E McCarty
- Division of Sleep Medicine, Department of Neurology, LSU Health Sciences Center, Shreveport, LA, USA
| | - Naresh M Punjabi
- Department of Pulmonary & Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Paul Y Kim
- Division of Sleep Medicine, Department of Neurology, LSU Health Sciences Center, Shreveport, LA, USA
| | - Clifton Frilot
- School of Allied Health Professions, LSU Health Sciences Center, Shreveport, LA, USA
| | - Andrew A Marino
- Division of Sleep Medicine, Department of Neurology, LSU Health Sciences Center, Shreveport, LA, USA.
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17
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Abstract
Major depression is a common, disabling condition seen frequently in primary care practices. Non-psychiatrist ambulatory providers are increasingly responsible for diagnosing, and primarily managing patients suffering from major depressive disorder (MDD). The goal of this review is to help primary care providers to understand the natural history of MDD, identify practical tools for screening, and a thoughtful approach to management. Clinically challenging topics like co-morbid conditions, treatment resistant depression and pharmacotherapy selection with consideration to side effects and medication interactions, are also covered.
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Affiliation(s)
- Susan M Bentley
- Department of Psychiatry & Behavioral Sciences, Harborview Medical Center, Box 359896, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Genevieve L Pagalilauan
- Department of Medicine, Division of General Internal Medicine, Roosevelt General Internal Medicine Clinic, University of Washington Medical Center, 4245 Roosevelt Way North East, Seattle, WA 98105
| | - Scott A Simpson
- Department of Psychiatry & Behavioral Sciences, Harborview Medical Center, Box 359896, 325 9th Avenue, Seattle, WA 98104, USA
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