Changes in severity of depressive symptoms and mortality: the Italian Longitudinal Study on Aging

Risk and sex-specific trends of dementia and stroke in Italy Compared to European and high-income countries and the world: global implications

BACKGROUND

Understanding the increasing trends in Italy may inform new prevention strategies and better treatments. We investigated trends and risk factors of dementia, stroke, and ischemic heart disease (IHD) in Italy with the second-oldest population globally, compared to European and high-income countries and the world.

METHODS

We analyzed the Global Burden of Disease Study (GBD) 2019 estimates on incidence and burden (i.e., disability and death combined) of the three conditions in both sexes. We also analyzed the burden attributable to 12 modifiable risk factors and their changes during 1990-2019.

RESULTS

In 2019, Italy had 186,108 new dementias (123,885 women) and 94,074 new strokes (53,572 women). Women had 98% higher crude dementia and 24% higher crude stroke burdens than men. The average age-standardized new dementia rate was 114.7 per 100,000 women and 88.4 per 100,000 men, both higher than Western Europe, the European Union, high-income countries, and the world. During 1990-2019, this rate increased in both sexes (4%), despite a decline in stroke (- 45%) and IHD (- 17%) in Italy. Dementia burden attributable to tobacco decreased in both sexes (- 12.7%) during 1990-2019, while high blood glucose and high body mass index combined burden increased (25.4%). Stroke and IHD had similar trends.

CONCLUSIONS

While decreases in new strokes and IHDs are encouraging, new approaches to their joint prevention are required to reverse the rising dementia trends, especially among women. Life course approaches to promoting holistic brain health should be implemented at the community, national, and international levels before the growing trends become overwhelming.

The Influence of Depressive Mood on Mortality in Elderly with Different Health Status: Evidence from the Taiwan Longitudinal Study on Aging (TLSA)

Depression and related syndromes are well identified in older adults. Depression has been reported to increase the incidence of a multitude of somatic disorders. In older adults, the severity of depression is associated with higher mortality rates. The aim of the study is to examine whether the effect of depression screening on mortality is different between individuals with different physical health status. In order to meet this aim, we will first reprove the relationship between depression and mortality rate, and then we will set a subgroup analysis by using self-reported health (SRH) status. Our data source, Taiwan Longitudinal Study on Aging (TLSA), is a population-based prospective cohort study that was initiated by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan. The depression risk was evaluated by 10-items Center for Epidemiologic Studies Depression (CES-D-10), we set 3 CES-D-10 cutting points (5, 10, and 12) and cut our subjects into four groups. Taking mortality as an end point, we use the Taiwan National Death Registry (TNDR) record from 1999 to 2012. Self-rated health (SRH) was taken as an effect modifier between depression and mortality in the elderly group, and stratification took place into three groups (good, fair, poor). The case numbers of 4 CES-D-10 groups were 2253, 939, 285 and 522, respectively. After dividing into 4 CES-D-10 groups, the mortality prevalence rose as the CES-D-10 level grew (40.7%, 47.82%, 54.39% and 67.62%, respectively). In the subgroup analysis, although the p-value of log-rank test showed <0.05 in three groups, as the SRH got worse the Hazard Ratio became more significant (p = 0.122, 0.033, <0.001, respectively). Kaplan−Meier (K-M) survival estimates for different CES-D groups in SRH were poor, and we can see the curves representing second and third CES-D group going almost together, which may suggest the cutting point of CES-D-10 in predicting depression risk should be adjusted in the relatively unhealthy elderly. The importance of the relationship between depression and mortality is re-emphasized in our study. Moreover, through joining SRH in our analysis, we can conclude that in self-rated poor health any sign of depression may lead to a rise in mortality. Therefore, we should pay attention to the old age group’s psychological status, and remember that depressive mood should be scrutinized more carefully in the elderly who feel themselves to be unhealthy.

Time-dependent cognitive and somatic symptoms of depression as predictors of new cardiac-related events in at-risk patients: the UPBEAT-UK cohort

BACKGROUND

Evidence suggests that somatic rather than cognitive depressive symptoms are risk factors for recurrent cardiac events in at-risk patients. However, this has never been explored using a time-dependent approach in a narrow time-frame, allowing a cardiac event-free time-window.

METHODS

The analysis was performed on 595 participants [70.6% male, median age 72 (27-98)] drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Depressive symptomatology was measured using the Patient Health Questionnaire-9 (PHQ-9) (four somatic, five cognitive items). New cardiac events (NCEs) including cardiac-related mortality were identified by expert examination of patient records. Analyses were performed using Cox proportional hazard models with delayed entry, with time-dependent depressive dimensions and covariates measured 12-18 months (median: 14.1, IQR: 3.5) prior to the event, with a 12-month cardiac event-free gap.

RESULTS

There were 95 NCEs during the follow-up [median time-to-event from baseline: 22.3 months (IQR: 13.4)]. Both the somatic (HR 1.12, 95% CI 1.05-1.20, p = 0.001) and cognitive dimensions (HR 1.11, 95% CI 1.03-1.18, p = 0.004) were time-dependent risk factors for an NCE in the multi-adjusted models. Specific symptoms (poor appetite/overeating for the somatic dimension, hopelessness and feeling like a failure for the cognitive dimension) were also significantly associated.

CONCLUSION

This is the first study of the association between depressive symptom dimensions and NCEs in at-risk patients using a time-to-event standardised approach. Both dimensions considered apart were independent predictors of an NCE, along with specific items, suggesting regular assessments and tailored interventions targeting specific depressive symptoms may help to prevent NCEs in at-risk populations.

Clinical characteristics of late-life depression predicting mortality

OBJECTIVE

Depression has been associated with increased mortality rates, and modifying mechanisms have not yet been elucidated. We examined whether specific subtypes or characteristics of late-life depression predict mortality.

METHODS

A cohort study including 378 depressed older patients according to DSM-IV criteria and 132 never depressed comparisons. The predictive value of depression subtypes and characteristics on the six-year mortality rate, as well as their interaction with somatic disease burden and antidepressant drug use, were studied by Cox proportional hazard analysis adjusted for demographic and lifestyle characteristics.

RESULTS

Depressed persons had a higher mortality risk than non-depressed comparisons (HR = 2.95 [95% CI: 1.41-6.16], p = .004), which lost significance after adjustment for age, sex, education, smoking, alcohol, physical activity, number of prescribed medications and somatic comorbidity. Regarding depression subtypes and characteristics, only minor depression was associated with a higher mortality risk when adjusted for confounders (HR = 6.59 [95% CI: 1.79-24.2], p = .005).

CONCLUSIONS

Increased mortality rates of depressed older persons seem best explained by unhealthy lifestyle characteristics and multiple drug prescriptions. The high mortality rate in minor depression, independent of these factors, might point to another, yet unknown, pathway towards mortality for this depression subtype. An explanation might be that minor depression in later life reflects depressive symptoms due to underlying aging-related processes, such as inflammation-based sickness behavior, frailty, and mild cognitive impairment, which have all been associated with increased mortality.

Combined influence of depression severity and low-grade inflammation on incident hospitalization and mortality risk in Italian adults

BACKGROUND

Depression and low-grade systemic inflammation are associated risk factors for hospitalizations and mortality, although the nature of this relationship is under-investigated.

METHODS

We performed multivariable Cox regressions of first hospitalization/mortality for all and specific causes vs depression severity, in an Italian population cohort (N=13,176; age≥35 years; 49.4% men), incrementally adjusting for sociodemographic, health and lifestyle factors. We tested potential mediation, additive and interactive effects of INFLA-score, a composite circulating inflammation index, and potential concurrent mediations of main lifestyles and chronic conditions.

RESULTS

Over 4,856 hospitalizations (median follow-up 7.28 years), we observed an increased incident risk of events by 24% (CI=17-32%) and 59% (30-90%) for moderate and severe depression, which also showed a 125% (33-281%) increased risk of all-cause mortality (over 471 deaths, 8.24 years). These remained stable after adjustment for lifestyles, health conditions and INFLA-score, which explained 2.1%, 7.6%, 16.3% and 8%, 14.9% and 12% of depression influence on hospitalizations and mortality risk, respectively. These proportions remained substantially stable after reciprocal adjustments. INFLA-score showed significant additive (but not interactive) effects on both hospitalizations and mortality risk.

LIMITATIONS

Depression severity was defined using a sub-version of Patient Health Questionnaire 9, which was validated here. Directionality links among exposures could not be established since they were collected simultaneously.

CONCLUSIONS

These findings suggest a combined influence of depression and low-grade inflammation on health, which is partly intertwined and dependent on lifestyles and chronic conditions. This suggests the existence of pathways other than inflammation through which depression may play its detrimental effect.

Collaborative care for primary care treatment of late-life depression in Singapore: Randomized controlled trial

BACKGROUND

The effectiveness and portability of the collaborative care model in the primary care treatment of depression has not been demonstrated in many randomized controlled trials in healthcare settings across the world. We determined the effectiveness of collaborative care management of elderly depression in the primary care setting in Singapore.

METHOD

Eligible participants with depressive symptoms were randomized to 6-month duration usual care (UC, N = 112) or collaborative care (CC, N = 102). Outcome measures were HDRS-17, GDS, BDI and SF-12 MCS QOL measured at 3, 6, and 12-month, care satisfaction at 6-month, and also measured on 120 participants who refused referral (non-receipt of care, NC). Primary outcome was HDRS-17 measure of depression severity, response and remission at 6-month.

RESULTS

HDRS scores in CC group compared to UC group were reduced more at 6-month (1.5 points difference in change from baseline), and also at 3 and 12-month, with similar observations of differences for GDS and BDI. There was significantly greater improvement for both CC and UC groups compared to NC group. The CC group was about 1.5 times more likely to show HDRS treatment response and remission, and more than two times likely to show GDS treatment response and remission than the UC and NC groups, as well as better quality of life improvement (P < .001) and better care satisfaction (P < .001).

CONCLUSION

Collaborative care is effective for primary care treatment of older persons with depression and is portable in diverse health care settings.

Morbidity and mortality in very old individuals with subsyndromal depression: an 8-year prospective study

OBJECTIVES

Both morbidity and mortality are elevated for individuals with subsyndromal depression (SSD) compared to non-depression (ND) in those of younger ages, but scientific studies are scarce for very old individuals. The aim of this study was therefore to compare the morbidity and mortality in very old individuals with SSD and ND.

DESIGN AND SETTING

An 8-year prospective population-based study was undertaken on 85-year-old individuals in Sweden.

MEASUREMENTS

Data were collected from postal questionnaires and clinical assessments at baseline, after 1, 5, and 8 years. Depressive symptoms were measured with Geriatric Depression Scale and the results were classified into ND, SSD, and syndromal depression. Mortality was investigated using multivariable cox regressions, and variables of morbidity were investigated using linear mixed models.

RESULTS

Compared to ND, in people with SSD, mortality was elevated in the univariate regression, but this association vanished when controlling for relevant covariates. Morbidity was elevated with regard to basic activities of daily living (ADLs), instrumental ADLs, loneliness, self-perceived health, and depressive symptoms for individuals with SSD compared to ND, whereas cognitive speed, executive functions, and global cognitive function were not significantly impaired when adjusting for covariates.

CONCLUSIONS

SSD among very old individuals is longitudinally associated with elevated morbidity but not mortality, when controlling for relevant covariates. Considering the high prevalence of SSD and the demographic development of increasing numbers of very old people, the findings highlight the need to develop clinical and societal strategies to prevent SSD and associated negative outcomes.

Systolic blood pressure decline in very old individuals is explained by deteriorating health: Longitudinal changes from Umeå85+/GERDA

Declining systolic blood pressure (SBP) is common in very old age and is associated with adverse events, such as dementia. Knowledge of factors associated with SBP changes could explain the etiology of this decline in SBP. This study investigated longitudinal changes in socioeconomic factors, medical conditions, drug prescriptions, and assessments and their associations with SBP changes among very old followed individuals.The study was based on data from the Umeå85+/Gerontological Regional Database (GERDA) cohort study, which provided cross-sectional and longitudinal data on participants aged 85, 90, and ≥95 years from 2000 to 2015. Follow-up assessments were conducted after 5 years. The main outcome was a change in SBP. Factors associated with SBP changes were assessed using multivariate linear regression models.In the Umeå85+/GERDA study, 454 surviving individuals underwent follow-up assessment after 5 years. Of these, 297 had SBP measured at baseline and follow-up. The mean change ± standard deviation in SBP was -12 ± 25 mm Hg. SBP decline was associated independently with later investigation year (P = .009), higher baseline SBP (P < .001), baseline antidepressant prescription (P = .011), incident acute myocardial infarction during follow-up (P = .003), new diuretic prescription during follow-up (P = .044), and a decline in the Barthel Activities of Daily Living index at follow-up (P < .001).In conclusion, SBP declines among very old individuals. This decline seems to be associated with initial SBP level, investigation year, and health-related factors.

Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms

In 2 meta-analyses on gender differences in depression in nationally representative samples, we advance previous work by including studies of depression diagnoses and symptoms to (a) estimate the magnitude of the gender difference in depression across a wide array of nations and ages; (b) use a developmental perspective to elucidate patterns of gender differences across the life span; and (c) incorporate additional theory-driven moderators (e.g., gender equity). For major depression diagnoses and depression symptoms, respectively, we meta-analyzed data from 65 and 95 articles and their corresponding national data sets, representing data from 1,716,195 and 1,922,064 people in over 90 different nations. Overall, odds ratio (OR) = 1.95, 95% confidence interval (CI) [1.88, 2.03], and d = 0.27 [0.26, 0.29]. Age was the strongest predictor of effect size. The gender difference for diagnoses emerged earlier than previously thought, with OR = 2.37 at age 12. For both meta-analyses, the gender difference peaked in adolescence (OR = 3.02 for ages 13-15, and d = 0.47 for age 16) but then declined and remained stable in adulthood. Cross-national analyses indicated that larger gender differences were found in nations with greater gender equity, for major depression, but not depression symptoms. The gender difference in depression represents a health disparity, especially in adolescence, yet the magnitude of the difference indicates that depression in men should not be overlooked. (PsycINFO Database Record

Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms

In 2 meta-analyses on gender differences in depression in nationally representative samples, we advance previous work by including studies of depression diagnoses and symptoms to (a) estimate the magnitude of the gender difference in depression across a wide array of nations and ages; (b) use a developmental perspective to elucidate patterns of gender differences across the life span; and (c) incorporate additional theory-driven moderators (e.g., gender equity). For major depression diagnoses and depression symptoms, respectively, we meta-analyzed data from 65 and 95 articles and their corresponding national data sets, representing data from 1,716,195 and 1,922,064 people in over 90 different nations. Overall, odds ratio (OR) = 1.95, 95% confidence interval (CI) [1.88, 2.03], and d = 0.27 [0.26, 0.29]. Age was the strongest predictor of effect size. The gender difference for diagnoses emerged earlier than previously thought, with OR = 2.37 at age 12. For both meta-analyses, the gender difference peaked in adolescence (OR = 3.02 for ages 13-15, and d = 0.47 for age 16) but then declined and remained stable in adulthood. Cross-national analyses indicated that larger gender differences were found in nations with greater gender equity, for major depression, but not depression symptoms. The gender difference in depression represents a health disparity, especially in adolescence, yet the magnitude of the difference indicates that depression in men should not be overlooked. (PsycINFO Database Record

Severity of depressive symptoms as a predictor of mortality: the English longitudinal study of ageing

BACKGROUND

Major depressive disorder and subthreshold depression have been associated with premature mortality. We investigated the association between depressive symptoms and mortality across the full continuum of severity.

METHOD

We used Cox proportional hazards models to examine the association between depressive symptom severity, assessed using the eight-item Center for Epidemiological Studies Depression Scale (CES-D; range 0-8), and the risk of all-cause mortality over a 9-year follow-up, in 11 104 members of the English Longitudinal Study of Ageing.

RESULTS

During follow-up, one fifth of study members died (N = 2267). Depressive symptoms were associated with increased mortality across the full range of severity (p trend < 0.001). Relative to study members with no symptoms, an increased risk of mortality was found in people with depressive symptoms of a low [hazard ratio (HR) for a score of 2 was 1.59, 95% confidence interval (CI) 1.40-1.82], moderate (score of 4: HR 1.80, 95% CI 1.52-2.13) and high (score of 8: HR 2.27, 95% CI 1.69-3.04) severity, suggesting risk emerges at low levels but plateaus thereafter. A third of participants (36.4%, 95% CI 35.5-37.3) reported depressive symptoms associated with an increased mortality risk. Adjustment for physical activity, physical illnesses, and impairments in physical and cognitive functioning attenuated this association (p trend = 0.25).

CONCLUSIONS

Depressive symptoms are associated with an increased mortality risk even at low levels of symptom severity. This association is explained by physical activity, physical illnesses, and impairments in physical and cognitive functioning.

Serum insulin-like growth factor 1 and late-life depression: a population-based study

OBJECTIVE

Serum insulin-like growth factor 1 (IGF-1) concentration decreases, while the prevalence of depressive symptoms increases with advancing age. Although basic research indicates a link between low IGF-1 concentration and depression, this has scarcely been investigated in humans. This study investigates whether lower IGF-1 concentrations are associated with prevalent and incident late-life depression over a 3-year period.

METHODS

The study included 1188 participants, aged ≥ 65 years, from the Longitudinal Aging Study Amsterdam (LASA), an ongoing, population-based cohort study. Depression was assessed at baseline and after three years using the Center for Epidemiological Studies-Depression Scale (CES-D) and the Diagnostic Interview Schedule (DIS), and categorized into minor depression and major depression (MDD). Serum IGF-1 concentration was determined at baseline. Associations were adjusted for relevant confounders.

RESULTS

Serum IGF-1 concentrations were within the normal range (mean 13.9 nmol/l, standard deviation 5.3 nmol/l). At baseline, in men, as compared to high concentrations, mid concentrations decreased the probability of prevalent minor depression (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.15-0.82). In women, as compared to high concentrations, low concentrations tended to increase the probability of prevalent MDD (OR = 2.66, 95% CI = 0.89-7.89). At three-year follow-up, in men, no significant prospective associations were detected. In women, as compared to high concentrations, mid concentrations decreased the probability of incident minor depression (OR = 0.43, 95% CI = 0.19-0.95).

CONCLUSIONS

Several associations, which differed across the genders, were observed between IGF-1 and depression. Cross-sectional findings were not supported by longitudinal findings, which suggest that IGF-1 may not play an important predictive role in the development of depression in older persons over time. However, a more acute role of IGF-1 in current depression, as indicated by the cross-sectional results, may be possible. Further studies are needed to elucidate the complex relation between IGF-1 and late-life depression.

Impact of socioeconomic deprivation on rate and cause of death in severe mental illness

BACKGROUND

Socioeconomic status has important associations with disease-specific mortality in the general population. Although individuals with Severe Mental Illnesses (SMI) experience significant premature mortality, the relationship between socioeconomic status and mortality in this group remains under investigated. We aimed to assess the impact of socioeconomic status on rate and cause of death in individuals with SMI (schizophrenia and bipolar disorder) relative to the local (Glasgow) and wider (Scottish) populations.

METHODS

Cause and age of death during 2006-2010 inclusive for individuals with schizophrenia or bipolar disorder registered on the Glasgow Psychosis Clinical Information System (PsyCIS) were obtained by linkage to the Scottish General Register Office (GRO). Rate and cause of death by socioeconomic status, measured by Scottish Index of Multiple Deprivation (SIMD), were compared to the Glasgow and Scottish populations.

RESULTS

Death rates were higher in people with SMI across all socioeconomic quintiles compared to the Glasgow and Scottish populations, and persisted when suicide was excluded. Differences were largest in the most deprived quintile (794.6 per 10,000 population vs. 274.7 and 252.4 for Glasgow and Scotland respectively). Cause of death varied by socioeconomic status. For those living in the most deprived quintile, higher drug-related deaths occurred in those with SMI compared to local Glasgow and wider Scottish population rates (12.3% vs. 5.9%, p = <0.001 and 5.1% p = 0.002 respectively). A lower proportion of deaths due to cancer in those with SMI living in the most deprived quintile were also observed, relative to the local Glasgow and wider Scottish populations (12.3% vs. 25.1% p = 0.013 and 26.3% p = <0.001). The proportion of suicides was significantly higher in those with SMI living in the more affluent quintiles relative to Glasgow and Scotland (54.6% vs. 5.8%, p = <0.001 and 5.5%, p = <0.001).

CONCLUSIONS

Excess mortality in those with SMI occurred across all socioeconomic quintiles compared to the Glasgow and Scottish populations but was most marked in the most deprived quintiles when suicide was excluded as a cause of death. Further work assessing the impact of socioeconomic status on specific causes of premature mortality in SMI is needed.

Predictors of Treatments Acceptable to Patients for Late-Life Depression

Objectives. Describe older patients' perceptions about depression and characteristics associated with acceptance of treatments. Design. Cross-sectional study. Setting. Three primary care clinics in Iowa. Participants. Consecutive sample of 529 primary care patients. Measurements. Depression screening tool (a 9-item patient health questionnaire [PHQ-9]) and questionnaire including sociodemographic data, patient attitudes about depression, and acceptability of different treatments. Results. Mean age was 71.9 years (range 60–93 years), 314 (59%) female. Among the 529 participants, 93 (17.5%) had history of depression and 60 (11.3%) had PHQ-9 scores of 10 or greater. Participants believed depression is a disease for which they would use medication and counseling. Accepting medications from primary physicians was strongly associated with a past history of depression (P < 0.01) and with agreeing that depression needs treatment (P < 0.01). Counseling was not acceptable for those believing that they can control depression on their own (P < 0.01). Older patients (P < 0.001) and those with higher education levels (P < 0.01) were less likely to accept herbs or supplements as treatment options. Willingness to discuss treatments with family was associated with not using alcohol as a treatment and acceptance of all other treatment options (P < 0.001). Conclusions. Attitude that depression is a disease and the willingness to discuss depression with family may enhance treatment acceptance.