Subthreshold depression: characteristics and risk factors among vulnerable elders

Treatment resistant late-life depression: A narrative review of psychosocial risk factors, non-pharmacological interventions, and the role of clinical phenotyping

BACKGROUND

Treatment resistant depression (TRD) is a subset of major depressive disorder (MDD) in which symptoms do not respond to front line therapies. In older adults, the assessment and treatment of TRD is complicated by psychosocial risk factors unique to this population, as well as a relative paucity of research.

METHODS

Narrative review aimed at (1) defining TRLLD for clinical practice and research; (2) describing psychosocial risk factors; (3) reviewing psychological and non-pharmacological treatments; (4) discussing the role of clinical phenotyping for personalized treatment; and (5) outlining research priorities.

RESULTS

Our definition of TRLLD centers on response to medication and neuromodulation in primary depressive disorders. Psychosocial risk factors include trauma and early life adversity, chronic physical illness, social isolation, personality, and barriers to care. Promising non-pharmacological treatments include cognitive training, psychotherapy, and lifestyle interventions. The utility of clinical phenotyping is highlighted by studies examining the impact of comorbidities, symptom dimensions (e.g., apathy), and structural/functional brain changes.

LIMITATIONS

There is a relative paucity of TRLLD research. This limits the scope of empirical data from which to derive reliable patterns and complicates efforts to evaluate the literature quantitatively.

CONCLUSIONS

TRLLD is a complex disorder that demands further investigation given our aging population. While this review highlights the promising breadth of TRLLD research to date, more research is needed to help elucidate, for example, the optimal timing for implementing risk mitigation strategies, the value of collaborative care approaches, specific treatment components associated with more robust response, and phenotyping to help inform treatment decisions.

Promoting Personalized Reminiscence Among Cognitively Intact Older Adults Through an AI-Driven Interactive Multimodal Photo Album: Development and Usability Study

BACKGROUND

Reminiscence, a therapy that uses stimulating materials such as old photos and videos to stimulate long-term memory, can improve the emotional well-being and life satisfaction of older adults, including those who are cognitively intact. However, providing personalized reminiscence therapy can be challenging for caregivers and family members.

OBJECTIVE

This study aimed to achieve three objectives: (1) design and develop the GoodTimes app, an interactive multimodal photo album that uses artificial intelligence (AI) to engage users in personalized conversations and storytelling about their pictures, encompassing family, friends, and special moments; (2) examine the app's functionalities in various scenarios using use-case studies and assess the app's usability and user experience through the user study; and (3) investigate the app's potential as a supplementary tool for reminiscence therapy among cognitively intact older adults, aiming to enhance their psychological well-being by facilitating the recollection of past experiences.

METHODS

We used state-of-the-art AI technologies, including image recognition, natural language processing, knowledge graph, logic, and machine learning, to develop GoodTimes. First, we constructed a comprehensive knowledge graph that models the information required for effective communication, including photos, people, locations, time, and stories related to the photos. Next, we developed a voice assistant that interacts with users by leveraging the knowledge graph and machine learning techniques. Then, we created various use cases to examine the functions of the system in different scenarios. Finally, to evaluate GoodTimes' usability, we conducted a study with older adults (N=13; age range 58-84, mean 65.8 years). The study period started from January to March 2023.

RESULTS

The use-case tests demonstrated the performance of GoodTimes in handling a variety of scenarios, highlighting its versatility and adaptability. For the user study, the feedback from our participants was highly positive, with 92% (12/13) reporting a positive experience conversing with GoodTimes. All participants mentioned that the app invoked pleasant memories and aided in recollecting loved ones, resulting in a sense of happiness for the majority (11/13, 85%). Additionally, a significant majority found GoodTimes to be helpful (11/13, 85%) and user-friendly (12/13, 92%). Most participants (9/13, 69%) expressed a desire to use the app frequently, although some (4/13, 31%) indicated a need for technical support to navigate the system effectively.

CONCLUSIONS

Our AI-based interactive photo album, GoodTimes, was able to engage users in browsing their photos and conversing about them. Preliminary evidence supports GoodTimes' usability and benefits cognitively intact older adults. Future work is needed to explore its potential positive effects among older adults with cognitive impairment.

Understanding factors associated with the trajectory of subjective cognitive complaints in groups with similar objective cognitive trajectories

BACKGROUND

Cognitive complaints are often regarded as an early sign of Alzheimer's disease (AD) but may also occur in several other conditions and contexts. This study examines the correlates of cognitive complaint trajectories over a 5-year period in individuals who shared similar objective cognitive trajectories.

METHODS

We analyzed a subsample (n = 1748) of the MEMENTO cohort, consisting of individuals with subjective cognitive decline or mild cognitive impairment at baseline. Participants were stratified based on their latent MMSE trajectory over a 5-year period: "high and increasing," "subtle decline," and "steep decline." Within each of the three strata, we used a latent-class longitudinal approach to identify distinct trajectories of cognitive complaints. We then used multiple logistic regressions to examine the association between these complaint trajectories and several factors, including AD biomarkers (blood pTau/Aβ42 ratio, cortical thickness, APOE genotype), anxiety, depression, social relationships, a comorbidity-polypharmacy score, and demographic characteristics.

RESULTS

Among participants with high and increasing MMSE scores, greater baseline comorbidity-polypharmacy scores (odds ratio (OR) = 1.30, adjusted p = 0.03) were associated with higher odds of moderate and increasing cognitive complaints (as opposed to mild and decreasing complaints). Baseline depression and social relationships also showed significant associations with the complaint pattern but did not survive correction for multiple comparisons. Among participants with subtle decline in MMSE scores, greater baseline depression (OR = 1.76, adjusted p = 0.02) was associated with higher odds of moderate and increasing cognitive complaints (versus mild and decreasing). Similarly, baseline comorbidity-polypharmacy scores and pTau/Aβ42 ratio exhibited significant associations, but they did not survive correction. Among participants with a steep decline in MMSE scores, greater baseline comorbidity-polypharmacy scores increased the odds of moderate complaints (versus mild, OR = 1.38, unadjusted p = 0.03, adjusted p = 0.32), but this effect did not survive correction for multiple comparisons.

CONCLUSIONS

Despite similar objective cognitive trajectory, there is heterogeneity in the subjective perception of these cognitive changes. This perception was explained by both AD-related and, more robustly, non-AD-related factors. These findings deepen our understanding of the multifaceted nature of subjective cognitive complaints in individuals at risk for dementia and underscore the importance of considering a range of factors when interpreting cognitive complaints.

Hypnotherapy and IBS: Implicit, long-term stress memory in the ENS?

The association between irritable bowel syndrome (IBS) and psychiatric and mood disorders may be more fundamental than was previously believed. Prenatal, perinatal, postnatal, and early-age conditions can have a key role in the development of IBS. Subthreshold mental disorders (SMDs) could also be a significant source of countless diverse diseases and may be a cause of IBS development. We hypothesize that stress-induced implicit memories may persist throughout life by epigenetic processes in the enteric nervous system (ENS). These stress-induced implicit memories may play an essential role in the emergence and maintenance of IBS. In recent decades, numerous studies have proven that hypnosis can improve the primary symptoms of IBS and also reduce noncolonic symptoms such as anxiety and depression and improve quality of life and cognitive function. These significant beneficial effects of hypnosis on IBS may be because hypnosis allows access to unconscious brain processes.

The Relationship Between Loneliness and Positive Affect in Older Adults

OBJECTIVE

To establish whether positive affect (PA) is uniquely associated with loneliness and other social functioning variables beyond negative affect (NA) among older adults.

METHODS

Four hundred and twenty-eight participants (aged 60+ years old, 82% White, and 48% female) were recruited using random digit-dialing and completed scales for loneliness (UCLA Loneliness Scale), companionship (PROMIS scale), satisfaction with discretionary social activities (PROMIS scale), PA (Center for Epidemiologic Studies [CES] Happiness Scale), and NA (CES-Depression scale and Brief Symptom Inventory-Anxiety Subscale).

RESULTS

Multiple linear regression models found PA to be a significant predictor of lower loneliness where the effect of PA on loneliness is dependent on the level of NA; a large effect size at the mean level of NA, which becomes attenuated when NA increases. Although the direction of effect of PA on loneliness will change for NA > 5.10, which is 5 standard deviations away from 0, based on the model estimates, the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with lower loneliness, however this effect is attenuated for larger NA. Similarly, multiple linear regression models found that companionship was associated with PA and NA where the effect of PA is dependent on the level of NA; a medium effect size at the mean level of NA, which becomes attenuated when NA increases. As in the case of loneliness, the direction of effect of PA on companionship will change for NA > 3.52, which is 3.5 standard deviation away from 0, based on the model estimates, but the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with increased companionship, aand this effect is attenuated with greater NA. Satisfaction with social activities was associated with PA only (medium effect size).

CONCLUSION

Results suggest PA appears to be uniquely associated with social functioning among older adults. These findings support the potential for treatments that target PA to decrease loneliness among older adults, or vice versa.

Emotional and Mental Wellbeing Following COVID-19 Public Health Measures on People Living With Dementia and Carers

BACKGROUND

To date, there appears to be no evidence on the longer-term impacts caused by COVID-19 and its related public health restrictions on some of the most vulnerable in our societies. The aim of this research was to explore the change in impact of COVID-19 public health measures on the mental wellbeing of people living with dementia (PLWD) and unpaid carers.

METHOD

Semi-structured, follow-up telephone interviews were conducted with PLWD and unpaid carers between June and July 2020. Participants were asked about their experiences of accessing social support services during the pandemic, and the impact of restrictions on their daily lives.

RESULTS

20 interviews were conducted and thematically analyzed, which produced 3 primary themes concerning emotional responses and impact to mental health and wellbeing during the course of the pandemic: 1) Impact on mental health during lockdown, 2) Changes to mental health following easing of public health, and 3) The long-term effect of public health measures.

CONCLUSIONS

The findings from this research shed light on the longer-term psychological impacts of the UK Government's public health measures on PLWD and their carers. The loss of social support services was key in impacting this cohort mentally and emotionally, displaying a need for better psychological support, for both carers and PLWD.

Acceptability and effects of tele-delivered behavioral activation for depression in low-income homebound older adults: in their own words

OBJECTIVES

To examine experiences and perspectives of low-income homebound older adults (N = 90) who participated in tele-delivered behavioral activation (Tele-BA) treatment for depression by bachelor's-level lay counselors.

METHODS

We used the 11-item Treatment Evaluation Inventory (TEI) to measure participants' acceptability of Tele-BA. We used inductive thematic analysis to explore participants' Tele-BA session goals and activities and unsolicited and solicited comments about their Tele-BA experience.

RESULTS

Participant's TEI score averaged 70 out of maximum possible 77. The most frequently chosen Tele-BA goals were to improve self-care management of physical and mental health, engage in self-enrichment/self-enjoyment, improve living environment and daily routine, and to increase social connectedness. The themes that emerged from participants' comments about Tele-BA were: (1) benefits of psychoeducation; (2) importance of and gratitude for working with a counselor; (3) benefits of activity planning; (4) understanding of behavior and mood connection; (5) positive effects of increased activity on health and self-enjoyment; (6) sense of being productive and useful from accomplishing goals; (7) hope for the future; and (8) pride in tele-treatment.

CONCLUSION

Participants' comments show that Tele-BA aimed at reinforcing healthy behaviors that improve both physical functioning and mood is well aligned with these older adults' perception of what treatment should be. The findings also provide support for lay counselors' clinical capacity. Given geriatric mental health workforce shortages, lay counselors may be able to effectively supplement existing professional mental health service systems.

Late-Life Depression: A Narrative Review on Risk Factors and Prevention

After participating in this activity, learners should be better able to:• Identify risk factors for late-life depression• Evaluate strategies to prevent late-life depression ABSTRACT: Late-life depression (LLD) is one of the major sources of morbidity and mortality in the world. Because LLD is related to increased public health burden, excess health care costs and utilization, reduced quality of life, and increased mortality, prevention is a priority. Older adults differ from younger adults with respect to key features, such as their chronicity and lifetime burden of depression and their constellation of comorbidities and risk factors. LLD likely arises from a complex interplay of risk factors, including medical, physiologic, psychosocial, behavioral, and environmental factors. Thus, a comprehensive understanding of LLD risk factors is necessary to inform prevention strategies. In this narrative literature review, we address both the risk architecture of LLD and several potential strategies for prevention. Our description of LLD risk factors and prevention approaches is informed by the framework developed by the National Academy of Medicine (formerly, Institute of Medicine), which includes indicated, selective, and universal approaches to prevention.

Effect of depression on mortality in type 2 diabetes mellitus after 8 years of follow-up. The DIADEMA study

AIM

To assess the effect of depression on all-cause mortality in patients with type 2 diabetes mellitus (T2DM) followed up during 8 years in primary care in Spain.

METHODS

Depression was diagnosed according to MINI 5.0.0 questionnaire, physician-diagnosis or following antidepressant therapy for at least two months in 3923 people with T2DM. We analyzed mortality-rates/10,000 person-years. We compared survival according to baseline depression with Kaplan-Meier estimates and the log-rank test. We performed Cox proportional hazard model analyses.

RESULTS

Baseline depression was diagnosed in 22.1% of participants. Mortality was higher in patients with depression (31.9% vs. 26.9%; p = 0.003), who had a significantly poorer survival (median survival = 7.4 vs. 7.8 years, respectively; Log Rank = 15.83; p < 0.001). Depression showed an adjusted mortality hazard ratio (HR) = 1.40 (95%CI:1.20-1.65; p < 0.001). The strongest predictive factors were: age >75 years (HR = 6.04; 95%CI:4.62-7.91; p < 0.001), insulin use (HR = 2.37; 95%CI:1.86-3.00; p < 0.001), lower limb amputation (HR = 1.99; 95%CI:1.28-3.11; p = 0.002), heart failure (HR = 1.94; 95%CI:1.63-2.30; p < 0.001), and male gender (HR = 1.90; 95%CI:1.59-2.27).

CONCLUSION

In a Spanish cohort of older T2DM patients, depression was associated with a higher mortality risk. More efforts are needed to minimize the influence of depression on mortality in people with T2DM and to implement measures that allow its early diagnosis and effective treatment.

The effectiveness of Tai Chi on the depressive symptom of young adults with subthreshold depression: a study protocol for a randomized controlled trial

BACKGROUND

Depression is seriously affecting the physical and mental health of young people worldwide. Subthreshold depression, as an early stage of depression, is essential for early prevention and treatment of depression. Tai Chi, as a traditional Chinese mind-body therapy, may become an alternative intervention. However, the neurophysiological mechanism of Tai Chi for young people with subthreshold depression remains unclear, restricting its further promotion and application. Therefore, rigorous randomized clinical trials are needed to further observe the intervention effect of Tai Chi on young adults with subthreshold depression and explore the neurophysiological mechanism.

METHOD/DESIGN

This report describes a two-arm, randomized, parallel controlled trial with allocation concealment and assessor blinding. A total of 64 eligible participants are randomly allocated to the Tai Chi group and the waiting list group in a 1:1 ratio. Participants in the Tai Chi group receive 12 weeks of Tai Chi training, with a total of 36 times and each for 60 min. Specifically, the participants in the waiting list group are requested to maintain their routine lifestyle. In this study, the primary outcome measure is the mean change in scores on the PHQ-9 and HAMD-17 between baseline and 12 weeks; the secondary outcomes are the mean change in the scores on CES-D, CPSS, GAD-7, and PSQI. Besides, the saliva cortisol levels and fMRI are monitored to explore the mechanism of action of Tai Chi on subthreshold depression.

DISCUSSION

The protocol uses a randomized controlled trial to examine the effectiveness of Tai Chi for young adults with subthreshold depression and explore neurophysiological mechanisms. If the test results are positive, it can be verified that Tai Chi can promote the physical and mental health of young adults with subthreshold depression.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900028289 . Registered on 17 December 2019.

Prevalence of depression symptoms and associated sociodemographic and clinical correlates among Syrian refugees in Lebanon

BACKGROUND

Since the outbreak of the Syrian war in 2011, close to 6 million Syrian refugees have escaped to Syria's neighbouring countries, including Lebanon. Evidence suggests rising levels of mental health disorders among Syrian refugee populations. Yet, to the best of our knowledge, large-scale studies addressing the mental health of adult Syrian refugees in Lebanon are lacking. We examined the prevalence of depression symptoms, which represent a common and debilitating mental health disorder among Syrian refugee populations in Lebanon, along with their sociodemographic and clinical correlates.

METHODS

A cross-sectional survey design was conducted as part of a collaborative project-"Sijilli"- led by the Global Health Institute at the American University of Beirut (Beirut, Lebanon) across 4 informal tented settlements for refugees (Beirut, Bekaa, North, South) in Lebanon among adult Syrian refugees (≥18), over a period extending from 2018 to 2020. The survey inquired about participants' sociodemographic and clinical characteristics, and screened participants for symptoms of depression through sequential methodology using the Patient Health Questionnaire (PHQ-2 and PHQ-9).

RESULTS

A total of 3255 adult Syrian refugees were enrolled in the study. Of those refugees, 46.73% (n = 1521) screened positive on the PHQ-2 and were therefore eligible to complete the PHQ-9. In the entire sample (n = 3255), the prevalence of moderate to severe depression symptoms (PHQ-2 ≥ 2 and then PHQ-9 ≥ 10) was 22% (n = 706). Further analyses indicate that being ≥45 years of age (OR 1.61, 95% CI 1.13-2.30), a woman (OR 1.34, 95% CI 1.06-1.70), widowed (OR 2.88, 95% CI 1.31-6.32), reporting a neurological (OR 1.73, 95% CI 1.15-2.60) or a mental health condition (OR 3.98, 95% CI 1.76-8.97) are major risk factors for depression.

CONCLUSION

Our study suggests that an estimated one in four Syrian refugees in Lebanon shows moderate to severe depression symptoms, and our findings have important public health and clinical implications on refugee health. There is a need to enhance screening efforts, to improve access and referral to mental health services, and to improve post-migration factors among Syrian refugees in Lebanon.

Bi-directional association between depression and HF: An electronic health records-based cohort study

Objective:

To determine whether a bi-directional relationship exists between depression and HF within a single population of individuals receiving primary care services, using longitudinal electronic health records (EHRs).

Methods:

This retrospective cohort study utilized EHRs for adults who received primary care services within a large healthcare system in 2006. Validated EHR-based algorithms identified 10,649 people with depression (depression cohort) and 5,911 people with HF (HF cohort) between January 1, 2006 and December 31, 2018. Each person with depression or HF was matched 1:1 with an unaffected referent on age, sex, and outpatient service use. Each cohort (with their matched referents) was followed up electronically to identify newly diagnosed HF (in the depression cohort) and depression (in the HF cohort) that occurred after the index diagnosis of depression or HF, respectively. The risks of these outcomes were compared (vs. referents) using marginal Cox proportional hazard models adjusted for 16 comorbid chronic conditions.

Results:

2,024 occurrences of newly diagnosed HF were observed in the depression cohort and 944 occurrences of newly diagnosed depression were observed in the HF cohort over approximately 4–6 years of follow-up. People with depression had significantly increased risk for developing newly diagnosed HF (HR 2.08, 95% CI 1.89–2.28) and people with HF had a significantly increased risk of newly diagnosed depression (HR 1.34, 95% CI 1.17–1.54) after adjusting for all 16 comorbid chronic conditions.

Conclusion:

These results provide evidence of a bi-directional relationship between depression and HF independently of age, sex, and multimorbidity from chronic illnesses.

The effectiveness of reminiscence-based intervention on improving psychological well-being in cognitively intact older adults: A systematic review and meta-analysis

BACKGROUND

Aging is one of the most important public health issues. The World Health Organization (WHO) expects the number of older adults aged 65 and above to triple from 2010 to 2050. A major challenge would be to consider how functional ability and quality of life could be enhanced in older age. Reminiscence-based interventions are widely reported as having positive effects on psychological outcomes among older adults with dementia, but its effects on cognitively intact older adults have not been clearly evaluated.

OBJECTIVES

The aim of the current systematic review is to evaluate the existing evidence on the effects of reminiscence-based intervention on psychological outcomes in cognitively intact older adults.

REVIEW METHODS

Commonly used English databases, including CINAHL, EMBASE, MEDLINE and PsycINFO, were searched from inception till 31 Mar 2020. Studies were included if they examined the effects of reminiscence-based intervention on psychological outcomes among cognitively intact older adults aged 60 and above. Meta-analysis was conducted to synthesise the effects on different psychological outcomes.

RESULTS

Thirty-one studies involving 1,829 older adults were included. The pooled standardized mean difference for depressive symptoms and life satisfaction were -0.38 (95% CI: -0.69--0.07) and 0.33 (95% CI: 0.14-0.52) respectively. Positive effects were observed on self-esteem, psychological well-being and happiness, though meta-analysis could not be conducted.

CONCLUSION

Significant reduction of depressive symptoms and improvement of life satisfaction were revealed from the reminiscence-based intervention among cognitively intact older adults. In addition, reminiscence-based intervention has been effective in enhancing self-esteem, and promoting psychological well-being and happiness. Our results suggest that reminiscence-based intervention could be an effective solution to improve psychological well-being among cognitively intact older adults. Such non-pharmacological approach can be recommended for older adults at the community level.

Depressive role impairment and subthreshold depression in older black and white women: race differences in the clinical significance criterion

OBJECTIVES

We examined race differences in the DSM-IV clinical significance criterion (CSC), an indicator of depressive role impairment, and its impact on assessment outcomes in older white and black women with diagnosed and subthreshold depression.

DESIGN

We conducted a secondary analysis of a community-based interview study, using group comparisons and logistic regression.

SETTING

Lower-income neighborhoods in a Midwestern city.

PARTICIPANTS

411 community-dwelling depressed and non-depressed women ≥ 65 years (45.3% Black; mean age = 75.2, SD = 7.2) recruited through census tract-based telephone screening.

MEASUREMENTS

SCID interview for DSM-IV to assess major depression and dysthymia; Center for Epidemiologic Studies-Depression Scale to define subthreshold depression (≥16 points); Mini-Mental State Examination, count of medical conditions, activities of daily living, and mental health treatment to assess health factors.

RESULTS

Black participants were less likely than Whites to endorse the CSC (11.8% vs. 24.1%; p = .002). There were few race differences in depressive symptom type, severity, or count. Blacks with subthreshold depression endorsed more symptoms, though this comparison was not significant after adjustments. Health factors did not account for race differences in CSC endorsement. Disregarding the CSC-eliminated differences in diagnosis rate, race was a significant predictor of CSC endorsement in a logistic regression.

CONCLUSIONS

Race differences in CSC endorsement are not due to depressive symptom presentations or health factors. The use of the CSC may lead to underdiagnosis of depression among black older adults. Subthreshold depression among Blacks may be more severe compared to Whites, thus requiring tailored assessment and treatment approaches.

Ecological micro-expression recognition characteristics of young adults with subthreshold depression

The micro-expression (ME) processing characteristics of patients with depression has been studied but has not been investigated in people with subthreshold depression. Based on this, by adopting the ecological MEs recognition paradigm, this study aimed to explore ME recognition in people with subthreshold depression. A 4 (background expression: happy, neutral, sad and fearful) × 4 (ME: happy, neutral, sad, and fearful) study was designed; two groups of participants (experimental group with subthreshold depression vs. healthy control group, 32 participants in each group) were asked to complete the ecological ME recognition task, and the corresponding accuracy (ACC) and reaction time (RT) were analyzed. Results: (1) Under different background conditions, recognizing happy MEs had the highest ACC and shortest RT. (2) There was no significant difference in the ACC and RT between experimental and control groups. (3)In different contexts, individuals with subthreshold depression tended to misjudge neutral, sad, and fearful MEs as happy, while neutral MEs were misjudged as sad and fearful. (4) The performance of individuals with subthreshold depression in the ecological ME recognition task were influenced by the type of ME; they showed highest ACC and shortest RT when recognizing happy MEs (vs. the other MEs). Conclusions: (1) The performance of individuals’ ecological ME recognition were influenced by the background expression, and this embodied the need for ecological ME recognition. (2) Individuals with subthreshold depression showed normal ecological ME recognition ability. (3) In terms of misjudgment, individuals with subthreshold depression showed both positive and negative bias, when completing the ecological ME recognition task. (4) Compared with the other MEs, happy MEs showed an advantage recognition effect for individuals with subthreshold depression who completed the ecological ME recognition task.

Coping Resources, Loneliness, and Depressive Symptoms of Older Women With Chronic Illness

Chronic illness with its accompanying physical stressors poses a risk factor for loneliness and depression in later life. Testing a model of stress and coping, we examined the effects of three types of coping resources (religious coping; Selection, Optimization, and Compensation [SOC] adaptive strategies; and perceived social support) on the deleterious effects of chronic illness among older women. Community-dwelling older women (N = 138) with at least one chronic illness (M = 3.9, SD = 2.1) completed mailed questionnaires. Respondents reported multiple morbidities and 90% reported interference with daily life. Social support was associated with less loneliness and depression and mediated the relationship between physical health and loneliness. Our study demonstrates two distinct pathways to depressive symptoms: one through physical symptoms, pain, and disability, and another through the experience of loneliness. Findings support intervention approaches that address disability-related issues and loneliness, and assist older women with chronic illness in identifying and marshaling social support.

Subthreshold Depression Needs A Prime Time In Old Age Psychiatry? A Narrative Review Of Current Evidence

This study aims to carry out a narrative review, aiming to update the literature on subsyndromic depression (SD), which is the most prevalent depressive disorder in older adults, and no formal guidelines or consensus are dedicated to this topic. We carried out an electronic search for articles on SD. Relevant articles were retrieved from Pubmed, EMBASE and Web of Science using the search terms "subthreshold depression," "prevalence," "treatment" and "older adults" in several combinations. Original articles in English were included from inception to 1st March 2019. No clear consensus exists in the literature on its nosologic classification, diagnostic tools, causes, course, outcomes or management. SD diagnosis should base in depressive symptoms scales and DSM criteria. Treatment relies mainly on collaborative care and psychotherapy. SD is relevant in clinical practice and research in geriatric psychiatry. Given the negative outcomes and potential benefits of treatment, we recommend brief psychotherapy as first-line treatment and use of psychotropic agents in cases with greater severity and/or functional impairment in association with psychotherapy. SD can precede major depressive disorder, but it also may consist of a primary depressive disorder in older adults. Furthermore, adequate treatment of SD can prevent or reduce negative outcomes associated with depressive symptoms such as worsening of clinical comorbidities, loss of functionality, increased demand for health services, and increased mortality.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible.

SETTING

Sixty-nine general practices in the north of England.

PARTICIPANTS

A total of 485 participants aged ≥ 65 years with major depressive disorder.

INTERVENTIONS

A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months.

RESULTS

In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p  < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY).

LIMITATIONS

Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data).

CONCLUSION

Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant.

FUTURE WORK RECOMMENDATIONS

Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45842879.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

Computerized Cognitive Training to Improve Mood in Senior Living Settings: Design of a Randomized Controlled Trial

Purpose

This two-arm, randomized controlled trial was designed to evaluate a computerized cognitive speed of processing (SOP) training known as Road Tour in the generally older group of adults residing in assisted living (AL) and related senior housing. Study aims focused on depression-related outcomes that were observed in earlier SOP studies using Road Tour with younger, home-dwelling seniors. Study design and baseline outcomes are discussed.

Participants and methods

A community-based design engaged AL and related senior living settings as partners in research. Selected staff served as on-site research assistants who were trained to recruit, consent, and train a target of 300 participants from AL and independent living (IL) programs to use the intervention and attention-control computerized training. Ten hours of initial computerized training was followed by two booster sessions at 5 and 11 months. Outcome measures included Useful Field of View (UFOV), 9-item Patient Health Questionnaire (PHQ-9), 12-item Centers for Epidemiological Studies Depression scale (CESD-12), 7-item Generalized Anxiety Disorders GAD-7), Brief Pain Inventory (BPI) and SF-36 Health Survey. Assessments occurred before randomization (pre-training), post-training, 26 and 52 weeks.

Results

A total of 351 participants were randomized to the intervention (n=173) and attention-control (n=178) groups. There were no significant differences between groups in demographic characteristics with the exception of education and reported osteoporosis. There were no significant differences in study outcomes between groups at baseline. Participants in AL had significantly lower SOP and self-rated health, and significantly higher depression, anxiety and pain when compared to those in IL programs on the same campus.

Conclusions

Compared to earlier SOP training studies using Road Tour, this sample of senior living participants were older, reported more health conditions and poorer overall health, had lower UFOV scores and greater depressive symptoms at baseline. Moreover, participants in AL had greater health challenges than those in IL.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected.

SETTING

Thirty-two general practitioner (GP) practices in the north of England.

PARTICIPANTS

A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression.

INTERVENTIONS

Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months.

RESULTS

In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003).

CONCLUSIONS

Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02202951.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

Needs assessment with elder Syrian refugees in Lebanon: Implications for services and interventions

Currently, over 1 million Syrian and Palestinian refugees have fled Syria to take refuge in Lebanon. Among this vulnerable population, elder refugees warrant particular concern, as they shoulder a host of additional health and safety issues that require additional resources. However, the specific needs of elder refugees are often overlooked, especially during times of crisis. Our study used a semi-structured interview to survey the needs of elder refugees and understand their perceived support from Lebanese fieldworkers. Results indicate a high prevalence of depression and cognitive deficits in elder refugees, who expressed concerns surrounding illness, loneliness, war, and instability. Elders highlighted the importance of family connectedness in fostering security and normalcy and in building resilience during times of conflict. Elders spoke of their role akin that of the social workers with whom they interacted, in that they acted as a source of emotional support for their communities. Overall, this study clarifies steps to be taken to increase well-being in elder refugee populations and urges the response of humanitarian organisations to strengthen psychological support structures within refugee encampments.

Minor depression in older, long-term unemployed people seeking vocational support

BACKGROUND

Prevalence rates of minor and major depression vary from 0.7 to 6.8 (minor) and 3.8 to 10.9 (major) for the general population. Twenty-two percent of older, long-term unemployed people suffer from major depression. However, the prevalence rate of minor depression (depression on a subthreshold level with less than 5, but more than 1 depression symptom) in this population is unknown. The first aim of this study is to identify that prevalence rate, because we already know that minor depression increases the risk of developing a major depression and this in turn reduces the chances of reemployment what increases social and individual costs at the same time. The second aim is to find out whether there are symptoms that distinguish the different groups "no depression", "minor depression" and "major depression" in this population. In contrast to the general population, the most frequent symptoms within major and minor depression in older, long-term unemployed people are unknown so far.

METHODS

A total of 234 long-term unemployed people (response rate 59%) were included in a study within a project of the Department of Psychiatry and Psychotherapy at the University of Leipzig and an unemployment agency. Based on the results of the Patient Health Questionnaire, the participants were classified as non depressive, minor depressive or major depressive. Descriptive statistics and chi-square tests were performed to identify whether there are symptoms stated by the participants that are more frequent than others, and if the classified groups differ in this regard.

RESULTS

Fifty percent had no depression, 15.6% had a minor depression and 34.4% were suffering from major depression. Difficulty with concentration is the symptom that differentiated the last two groups the most. Fatigue, depressed mood and anhedonia were the symptoms that distinguished participants with minor depression the most from participants with no depression. Main limitations are: The sample was determined by programme conditions, e.g. not all potentially available people participated. The sample may therefore not be representative for the general long-term unemployed. Due to limited resources the PHQ 9 was used instead of a clinical interview to assess minor and major depression.

CONCLUSIONS

Results indicate that minor depression in older, long-term unemployed persons is significant, as, almost 16% of the participants were affected in the study. Especially when fatigue is present for a period of more than 2 weeks, people should be informed about the option to consult a primary care physician or professionals from the unemployment agency in order to prevent the possible onset of major depression.

The impact and measurement of social dysfunction in late-life depression: an evaluation of current methods with a focus on wearable technology

OBJECTIVE

Depression is known to negatively impact social functioning, with patients commonly reporting difficulties maintaining social relationships. Moreover, a large body of evidence suggests poor social functioning is not only present in depression but that social functioning is an important factor in illness course and outcome. In addition, good social relationships can play a protective role against the onset of depressive symptoms, particularly in late-life depression. However, the majority of research in this area has employed self-report measures of social function. This approach is problematic, as due to their reliance on memory, such measures are prone to error from the neurocognitive impairments of depression, as well as mood-congruent biases.

METHOD

Narrative review based on searches of the Web of Science and PubMed database(s) from the start of the databases, until the end of 2015.

RESULTS

The present review provides an overview of the literature on social functioning in (late-life) depression and discusses the potential for new technologies to improve the measurement of social function in depressed older adults. In particular, the use of wearable technology to collect direct, objective measures of social activity, such as physical activity and speech, is considered.

CONCLUSION

In order to develop a greater understanding of social functioning in late-life depression, future research should include the development and validation of more direct, objective measures in conjunction with subjective self-report measures. Copyright © 2016 John Wiley & Sons, Ltd.

Depression, Social Isolation, and the Lived Experience of Dancing in Disadvantaged Adults

This qualitative study described the lived experience of dancing as it related to depression and social isolation in 16 disadvantaged adults who completed a 12-week dance intervention. It is the first qualitative study to explore the experience of dance as an adjunct therapy, depression, and social isolation. A descriptive phenomenological framework consisted of two focus groups using semi-structured interviews. A Giorgian approach guided thematic analysis. Four themes emerged: (1) dance for myself and health, (2) social acceptance, (3) connection with others: a group, and (4) not wanting to stop: unexpected benefits from dancing. As the participants continued to dance, they developed a sense of belonging and group identity, which may have maintained group involvement and contributed to reducing depression and social isolation. Thus, dancing is a complementary therapy that should be considered when working with adults with depression and social isolation.

Systematic review of interventions addressing social isolation and depression in aged care clients

OBJECTIVE

A systematic review was undertaken of studies reporting interventions for reducing social isolation and depression in older people receiving aged care services (community or residential).

METHODS

Gray literature and relevant electronic databases were systematically searched for studies published in English between January 2009 and December 2013. Two reviewers independently screened studies for selection using predetermined inclusion and exclusion criteria and independently completed methodological quality review at study level. Studies of poor methodological quality were excluded. Data were extracted at study level by one reviewer and independently checked by a second reviewer, using a standardized form. The results across studies were qualitatively synthesized with outcomes described and summarized at last follow-up.

RESULTS

Although the original objective was to review rural studies, no intervention studies based in rural areas met criteria for inclusion in the review, and only urban studies could be reviewed. Of 403 articles, six articles representing five studies with moderate-to-low risk of bias were included for review. All study participants were older adults ranging in age from 77 to 86 years. All studies had small sample sizes, ranging from 26 to 113 participants. Three of the five included intervention studies successfully reduced social isolation; one also successfully reduced depression.

CONCLUSIONS

Only one intervention, group-based reminiscence therapy, was reported as successful in reducing both social isolation and depression in older people within an urban aged care setting. More research is needed to explore transferability of interventions across different aged care settings and into rural areas.

Associations of PER3 and RORA Circadian Gene Polymorphisms and Depressive Symptoms in Older Adults

BACKGROUND

Depressive symptoms are common in older adults and associated with poor outcomes. Although circadian genes have been implicated in depression, the relationship between circadian genes and depressive symptoms in older adults is unclear.

METHODS

A cross-sectional genetic association study of 529 single nucleotide polymorphisms (SNPs) representing 30 candidate circadian genes was performed in two population-based cohorts: the Osteoporotic Fractures in Men Study (MrOS; N=270, age: 76.58±5.61 years) and the Study of Osteoporotic Fractures (SOF) in women (N=1740, 84.05±3.53 years) and a meta-analysis was performed. Depressive symptoms were assessed with the Geriatric Depression Scale categorizing participants as having none-few symptoms (0-2), some depressive symptoms (>2 to <6), or many depressive symptoms (≥6).

RESULTS

We found associations meeting multiple testing criteria for significance between the PER3 intronic SNP rs12137927 and decreased odds of reporting "some depressive symptoms" in the SOF sample (odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.48-0.78, df=1, Wald χ2=-4.04, p=0.000054) and the meta-analysis (OR: 0.61, CI: 0.48-0.78, z=-4.04, p=0.000054) and between the PER3 intronic SNPs rs228644 (OR: 0.74, CI: 0.63-0.86, z=3.82, p=0.00013) and rs228682 (OR: 0.74, CI: 0.86-0.63, z=3.81, p=0.00014) and decreased odds of reporting "some depressive symptoms" in the meta-analysis compared to endorsing none-few depressive symptoms. The RORA intronic SNP rs11632098 was associated with greater odds of reporting "many depressive symptoms" (OR: 2.16, CI: 1.45-3.23, df=1, Wald χ2=3.76, p=0.000168) in the men. In the meta-analysis the association was attenuated and nominally significant (OR: 1.63, CI: 1.24-2.16, z=3.45, p=0.00056).

CONCLUSION

PER3 and RORA may play important roles in the development of depressive symptoms in older adults.

Depressive symptoms are independently associated with recurrent falls in community-dwelling older adults

BACKGROUND

Falls and depression are two major public health problems that affect millions of older people each year. Several factors associated with falls are also related to depressive symptoms such as medical conditions, sleep quality, use of medications, cognitive functioning, and physical capacities. To date, studies that investigated the association between falls and depressive symptoms did not control for all these shared factors. The current study addresses this issue by examining the relationship between falls and depression symptoms after controlling for several confounders.

METHODS

Eighty-two community-dwelling older adults were enrolled in this study. The Geriatric Depression Scale (GDS-30) was used to evaluate the presence of depressive symptoms, and the following question was used to assess falls: "Did you fall in the last 12 months, and if so, how many times?"

RESULTS

Univariate analyses indicated that the number of falls was significantly correlated with gender (women), fractures, asthma, physical inactivity, presence of depressive symptoms, complaints about quality of sleep, use of antidepressant drugs, and low functional capacities. Multivariate analyses revealed that depressive symptoms were significantly and independently linked to recurrent falls after controlling for confounders.

CONCLUSIONS

Results of the present study highlight the importance of assessing depressive symptoms during a fall risk assessment.

Relationship between depressive symptoms and cognition in older, non-demented African Americans

Knowledge of the relationship between depressive symptoms and cognition in older adults has primarily come from studies of clinically depressed, functionally impaired or cognitively impaired individuals, and in predominately White samples. Limited minority representation in depression research exposes the need to examine these associations in more ethnic/racially diverse populations. We sought to examine the relationship between depressive symptoms and cognition in a sample of non-demented older African Americans recruited from surrounding U.S. cities of New York, Greensboro, Miami, and Nashville (N=944). Depressive symptoms were evaluated with the Geriatric Depression Scale (GDS). Cognition was evaluated with a comprehensive neuropsychological battery. Test scores were summarized into attention, executive function, memory, language, and processing speed composites. Controlling for age, education, reading level, and sex, African American older adults who endorsed more symptoms obtained significantly lower scores on measures of memory, language, processing speed, and executive functioning. Further investigation of the causal pathway underlying this association, as well as potential mediators of the relationship between depressive symptoms and cognitive test performance among older African Americans, such as cardiovascular and cerebrovascular disease, may offer potential avenues for intervention.

Prevalence and correlates of depressive symptoms in a catchment-area based cohort of older community-living schizophrenia patients

BACKGROUND

Depressive symptoms frequently accompany schizophrenia. Older patients constitute the fastest growing segment of the schizophrenia population. With regard to the risk factors associated with depression, it is uncertain to which extent older schizophrenia patients differ from their age peers in the community.

METHODS

We assessed self-reported depressive symptoms in an epidemiological sample of older Dutch community-living patients with schizophrenia or schizoaffective disorder (N=99; mean age 67years). Demographic, clinical and social variables were evaluated for their predictive value on the level of depressive symptoms. A comparison group, proportionally matched for age and gender, was recruited from a community study.

RESULTS

In the schizophrenia group, 47.5% reported depressive symptoms at a level indicating clinically relevant depression, in contrast to 12.1% in their age peers (odds ratio 6.55; 95% CI, 3.19-13.48; p<0.001). This difference could not be explained by differential exposure to the evaluated general risk factors. In both groups, functional limitations were the strongest predictor of depressive symptoms. In the patient group, chronic physical disorders and lack of a confidant were predictors, while a diagnosis of schizoaffective disorder (vs. schizophrenia) was the only disorder-related risk factor that contributed to depressive symptoms, with marginal significance.

CONCLUSION

The high rate of depressive symptoms in this epidemiological sample of older schizophrenia patients confirms that these symptoms frequently accompany this severe mental illness in late life. With physical and social factors as important predictors of depressive symptoms, risk factors for depression are more comparable between older schizophrenia patients and their age peers than is often assumed.

Subjective and objective sleep disturbance and longitudinal risk of depression in a cohort of older women

OBJECTIVE

To investigate the longitudinal relationship between subjective and objective sleep disturbance and depressive symptoms.

DESIGN

Longitudinal.

SETTING

Three US clinical centers.

PARTICIPANTS

Nine hundred fifty-two community-dwelling older women (70 y or older).

MEASUREMENTS

At baseline, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and objective sleep measures were assessed with wrist actigraphy. Depressive symptoms were assessed with the Geriatric Depression Scale (GDS) at baseline and approximately 5 y later. The analysis was restricted to women with few (GDS 0-2) depressive symptoms at baseline.

RESULTS

There was an independent association between greater PSQI score (per standard deviation increase, indicating worse subjective sleep quality) at baseline and greater odds of worsening depressive symptoms (≥ 2-point increase in GDS) (Multivariate Odds Ratio [MOR] 1.19, confidence interval [CI] 1.01-1.40, P = 0.036). Higher scores specifically on the sleep quality (MOR 1.41, CI 1.13-1.77, P < 0.003) and sleep latency (MOR 1.21, CI 1.03-1.41, P = 0.018) PSQI subscales were also associated with greater odds for worsening depressive symptoms. Objective assessments revealed an association between baseline prolonged wake after sleep onset (WASO ≥ 60 min) and worsening depressive symptoms at follow-up (MOR 1.36, CI 1.01-1.84, P = 0.046). There were no associations between other objectively assessed sleep measures and worsening depressive symptoms.

CONCLUSIONS

In older women with few or no depressive symptoms at baseline, those with more subjectively reported sleep disturbance and more objectively assessed fragmentation of sleep at baseline had greater odds of worsening depressive symptoms 5 y later. Future studies investigating this relationship in more detail are indicated.

CITATION

Maglione JE, Ancoli-Israel S, Peters KW, Paudel ML, Yaffe K, Ensrud KE, Stone KL, Study of Osteoporotic Fractures Research Group. Subjective and objective sleep disturbance and longitudinal risk of depression in a cohort of older women.

Adapting manualized Behavioural Activation treatment for older adults with depression

There is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.

Depressive symptoms and circadian activity rhythm disturbances in community-dwelling older women

OBJECTIVES

Aging is associated with changes in circadian rhythms. Current evidence supports a role for circadian rhythms in the pathophysiology of depression. However, little is known about the relationship between depressive symptoms and circadian activity rhythms in older adults. We examined this association in community-dwelling older women.

METHODS

We performed a cross-sectional analysis of 3,020 women (mean age: 83.55 ± 3.79 years) enrolled in the Study of Osteoporotic Fractures. Depressive symptoms were assessed with the Geriatric Depression Scale categorizing participants as "normal" (0-2; referent group, N = 1,961), "some depressive symptoms" (3-5, N = 704), or "depressed" (≥6, N = 355). Circadian activity rhythm variables were measured using wrist actigraphy.

RESULTS

In age-adjusted and Study of Osteoporotic Fractures site-adjusted models, greater levels of depressive symptoms were associated with decreased amplitude (height; df = 3,014, t = -11.31, p for linear trend <0.001), pseudo F-statistic (robustness; df = 3,014, t = -8.07, p for linear trend <0.001), and mesor (mean modeled activity; df = 3014, t = -10.36, p for linear trend <0.001) of circadian activity rhythms. Greater levels of depressive symptoms were also associated with increased odds of being in the lowest quartile for amplitude (df = 1, χ(2) = 9240, p for linear trend <0.001), pseudo F-statistic (df = 1, χ(2) = 49.73, p for linear trend <0.001), and mesor (df = 1, χ(2) = 81.12, p for linear trend <0.001). These associations remained significant in multivariate models. Post-hoc analyses comparing mean amplitude, mesor, and pseudo F-statistic values pair-wise between depression-level groups revealed significant differences between women with "some depressive symptoms" and the "normal" group.

CONCLUSION

These data suggest a graded association between greater levels of depressive symptoms and more desynchronization of circadian activity rhythms in community-dwelling older women. This association was observed even for women endorsing subthreshold levels of depressive symptoms.

(The Feeling of) Meaning-as-Information

The desire for meaning is recognized as a central human motive. Yet, knowing that people want meaning does not explain its function. What adaptive problem does this experience solve? Drawing on the feelings-as-information hypothesis, we propose that the feeling of meaning provides information about the presence of reliable patterns and coherence in the environment, information that is not provided by affect. We review research demonstrating that manipulations of stimulus coherence influence subjective reports of meaning in life but not affect. We demonstrate that manipulations that foster an associative mindset enhance meaning. The meaning-as-information perspective embeds meaning in a network of foundational functions including associative learning, perception, cognition, and neural processing. This approach challenges assumptions about meaning, including its motivational appeal, the roles of expectancies and novelty in this experience, and the notion that meaning is inherently constructed. Implications for constructed meaning and existential meanings are discussed.

Late-life depression in older African Americans: a comprehensive review of epidemiological and clinical data

OBJECTIVE

The population of older African Americans is expected to triple by 2050, highlighting the public health importance of understanding their mental health needs. Despite evidence of the negative impact of late-life depression, less is known of how this disorder affects the lives of older African Americans. Lack of studies focusing on how depression presents in older African Americans and their subsequent treatment needs lead to a gap in epidemiologic and clinical knowledge for this population. In this review, we aim to present a concise report of prevalence, correlates, course, outcomes, symptom recognition, and treatment of depression for these individuals.

METHOD

We performed a literature review of English-language articles identified from PubMed and Medline published between January 1990 and June 2012. Studies included older adults and contained the key words 'geriatric depression in African Americans', 'geriatric depression in Blacks', and 'geriatric depression in minorities'.

RESULTS

Although in most studies, older African Americans had higher or equivalence prevalence of depression compared with Caucasian Americans, we also found lower rates of recognition of depression and treatment. Many studies reported worse outcomes associated for depression among older African Americans compared with older Caucasians.

CONCLUSIONS

Serious racial and ethnic disparities persist in the management of older African Americans with depression. Understanding their unmet needs and improving depression care for these individuals is necessary to reduce these disparities.

Depression treatment in assisted living settings: is an innovative approach feasible?

Depression is a common, disabling, and underrecognized problem among older adults in assisted living (AL) settings. The purpose of this study was to evaluate stakeholder perceptions of using a blended model of depression care that combines essential features of evidence-based collaborative care and older adult outreach for use in AL settings. A descriptive mixed-methods design was used to assess perceptions of the three main components of the depression model: onsite depression care management, staff development activities, and AL nurses as staff resources and liaisons to primary care providers. Quantitative and narrative responses were consistently positive and supportive of depression care approaches. Potential barriers included time constraints for staff and costs for residents. These data provide strong support for further evaluation of the blended depression model. Staff development activities may be implemented independent of the model to enhance depression recognition, assessment, and daily care approaches in AL.

Visual scanning patterns and executive function in relation to facial emotion recognition in aging

OBJECTIVE

The ability to perceive facial emotion varies with age. Relative to younger adults (YA), older adults (OA) are less accurate at identifying fear, anger, and sadness, and more accurate at identifying disgust. Because different emotions are conveyed by different parts of the face, changes in visual scanning patterns may account for age-related variability. We investigated the relation between scanning patterns and recognition of facial emotions. Additionally, as frontal-lobe changes with age may affect scanning patterns and emotion recognition, we examined correlations between scanning parameters and performance on executive function tests.

METHODS

We recorded eye movements from 16 OA (mean age 68.9) and 16 YA (mean age 19.2) while they categorized facial expressions and non-face control images (landscapes), and administered standard tests of executive function.

RESULTS

OA were less accurate than YA at identifying fear (p < .05, r = .44) and more accurate at identifying disgust (p < .05, r = .39). OA fixated less than YA on the top half of the face for disgust, fearful, happy, neutral, and sad faces (p values < .05, r values ≥ .38), whereas there was no group difference for landscapes. For OA, executive function was correlated with recognition of sad expressions and with scanning patterns for fearful, sad, and surprised expressions.

CONCLUSION

We report significant age-related differences in visual scanning that are specific to faces. The observed relation between scanning patterns and executive function supports the hypothesis that frontal-lobe changes with age may underlie some changes in emotion recognition.

Irritability and social isolation in dementia patients with and without depression

This study examined the prevalence of irritability and social isolation in veterans with dementia, with and without depression. Participants were diagnosed with dementia and enrolled in a dementia care-coordination and support-service intervention. Participants were interviewed and underwent assessment with the 10-item Center for Epidemiologic Studies Depression scale, a Patient Strain Measure and the Short Blessed Test. In all, of 294 participants completing interviews, 77 (26.2%) were depressed and 107 (36.4%) endorsed irritability; mean social isolation score was 1.59 ± 1.96. Irritability was significantly more likely to be present in depressed versus nondepressed participants (P < .0001), but this relationship was moderated by dementia severity. The mean social isolation score was also significantly more elevated in depressed rather than nondepressed patients (2.82 ± 1.96 vs 1.15 ± 1.76, respectively).

CONCLUSIONS

Depressed persons with dementia are significantly more likely to experience irritability and social isolation than those who are not depressed.

A randomised evaluation of CollAborative care and active surveillance for Screen-Positive EldeRs with sub-threshold depression (CASPER): study protocol for a randomized controlled trial

Background

Depression accounts for the greatest burden of disease among all mental health problems, and is expected to become the second-highest amongst all general health problems by 2020. By the age of 75, 1 in 7 older people meet formal diagnostic criteria for depression. Efforts to ameliorate the burden of illness and personal suffering associated with depression in older people have focussed on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/sub-threshold depressive syndromes but these patients also suffer impairments in their quality of life and level of functioning.

Methods/Design

The CASPER study has been designed to assemble an epidemiological cohort of people over 75 years of age (the CASPER cohort), from which we will identify those eligible to participate in a trial of collaborative care for sub-threshold depression (the CASPER trial).

We aim to undertake a pragmatic randomised controlled multi-centre trial evaluating the effectiveness and cost-effectiveness of collaborative care; a low intensity psychological intervention in addition to usual general practitioner care versus usual general practitioner care alone. General practitioners from practices based in the North of England will be asked to identify potentially eligible patients over the age of 75 years. Patients will be sent a letter inviting them to participate in the study.

We aim to recruit approximately 540 participants for the CASPER trial. A diagnostic interview will be carried out to ascertain trial eligibility with the major depressive episode module of the Mini International Neuropsychiatric Interview (M.I.N.I.), eligible participants randomised to either the intervention or usual care. The primary outcome will be measured with the Patient Health Questionnaire-9 (PHQ-9) and additional quality of life measures will be collected. Data will be collected at baseline, 4 and 12 months for both trial and cohort participants.

Trial Registration

ISRCTN: ISRCTN02202951

Aging and Late-Life Depression

Objectives: The objective of this study is to examine the relationship between age and depression among people aged 65 and older. Method: The study uses three waves of longitudinal data (1991, 1996, 2001) from a community and institutional sample of Canadians aged 65 and older. The study uses generalized linear mixed-model techniques to estimate the trajectories of depressive symptoms and major depression in late life. Results: There is a linear increase in depressive symptoms after age 65, but this occurs in the context of medical comorbidity and is not an independent effect of aging. There is a significant u-shaped relationship between age and major depression, after adjusting for selected covariates. Discussion: The relationship between age and late-life depression is complex, and it depends on how the dependent variable is measured. Late-life depression develops through a different set of risk factors than it does in earlier stages of the life course. The “fourth age” appears to be a period of psychiatric morbidity.

Do the GDS and the GDS-15 adequately capture the range of depressive symptoms among older residents in congregate housing?

BACKGROUND

In light of inconsistencies in cut points for identifying non-major depression, this study examined the classification efficiency of the Geriatric Depression Scale (GDS and GDS-15) total scores and individual items, and four additional depressive symptoms for identification of subthreshold, minor, or criterion depression among 166 vulnerable residents of congregate housing.

METHODS

Depression (combined categories of major depressive episode, minor, or subthreshold depression) was determined by the Mini-International Neuropsychiatric Interview (MINI) diagnostic interview depression module administered by telephone to 166 older residents of congregate housing facilities who also completed the 30-item GDS and four other yes/no potential indicators of geriatric depression. Classification agreement and ROC curve analysis for the full and 15-item GDS scale scores were calculated. Individual item hit rates for MINI criterion were calculated for GDS items and four new items.

RESULTS

GDS and GDS-15 at standard cut points had 70-75% agreement with MINI. Best sensitivity and specificity were obtained at lower than standard cut points. Some GDS Withdrawal, Apathy, lack of Vigor (WAV) and cognitive items obtained very low hit rates. New items "I just don't feel like myself" and "I feel I am a burden to others" better discriminated MINI depression than most GDS items and had good item-to-total correlations with the GDS.

CONCLUSIONS

Diagnostic criteria and GDS screen had partial agreement. Some GDS items did not adequately represent depression among functionally impaired or oldest old older adults. Feeling one is a burden and the sense of feeling "different" from usual may be useful indicators of depression among vulnerable older adults.

A tune in "a minor" can "b major": a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults

BACKGROUND

With emphasis on dimensional aspects of psychopathology in development of the upcoming DSM-V, we systematically review data on epidemiology, illness course, risk factors for, and consequences of late-life depressive syndromes not meeting DSM-IV-TR criteria for major depression or dysthymia. We termed these syndromes subthreshold depression, including minor depression and subsyndromal depression.

METHODS

We searched PubMed (1980-Jan 2010) using the terms: subsyndromal depression, subthreshold depression, and minor depression in combination with elderly, geriatric, older adult, and late-life. Data were extracted from 181 studies of late-life subthreshold depression.

RESULTS

In older adults subthreshold depression was generally at least 2-3 times more prevalent (median community point prevalence 9.8%) than major depression. Prevalence of subthreshold depression was lower in community settings versus primary care and highest in long-term care settings. Approximately 8-10% of older persons with subthreshold depression developed major depression per year. The course of late-life subthreshold depression was more favorable than that of late-life major depression, but far from benign, with a median remission rate to non-depressed status of only 27% after ≥1 year. Prominent risk factors included female gender, medical burden, disability, and low social support; consequences included increased disability, greater healthcare utilization, and increased suicidal ideation.

LIMITATIONS

Heterogeneity of the data, especially related to definitions of subthreshold depression limit our ability to conduct meta-analysis.

CONCLUSIONS

The high prevalence and associated adverse health outcomes of late-life subthreshold depression indicate the major public health significance of this condition and suggest a need for further research on its neurobiology and treatment. Such efforts could potentially lead to prevention of considerable morbidity for the growing number of older adults.