Brief interventions to prevent depression in older subjects: a systematic review of feasibility and effectiveness

Prevalence of depression in patients with type 2 diabetes mellitus in Spain (the DIADEMA Study) : results from the MADIABETES cohort

OBJECTIVE

To estimate the prevalence of depression in patients diagnosed with type 2 diabetes mellitus (T2DM), and to identify sociodemographic, clinical and psychological factors associated with depression in this population. Additionally, we examine the annual incidence rate of depression among patients with T2DM.

METHODS

We performed a large prospective cohort study of patients with T2DM from the Madrid Diabetes Study. The first recruitment drive included 3443 patients. The second recruitment drive included 727 new patients. Data have been collected since 2007 (baseline visit) and annually during the follow-up period (since 2008).

RESULTS

Depression was prevalent in 20.03% of patients (n=592; 95% CI 18.6% to 21.5%) and was associated with previous personal history of depression (OR 6.482; 95% CI 5.138 to 8.178), mental health status below mean (OR 1.423; 95% CI 1.452 to 2.577), neuropathy (OR 1.951; 95% CI 1.423 to 2.674), fair or poor self-reported health status (OR 1.509; 95% CI 1.209 to 1.882), treatment with oral antidiabetic agents plus insulin (OR 1.802; 95% CI 1.364 to 2.380), female gender (OR 1.333; 95% CI 1.009 to 1.761) and blood cholesterol level (OR 1.005; 95% CI 1.002 to 1.009). The variables inversely associated with depression were: being in employment (OR 0.595; 95% CI 0.397 to 0.894), low physical activity (OR 0.552; 95% CI 0.408 to 0.746), systolic blood pressure (OR 0.982; 95% CI 0.971 to 0.992) and social support (OR 0.978; 95% CI 0.963 to 0.993). In patients without depression at baseline, the incidence of depression after 1 year of follow-up was 1.20% (95% CI 1.11% to 2.81%).

CONCLUSIONS

Depression is very prevalent among patients with T2DM and is associated with several key diabetes-related outcomes. Our results suggest that previous mental status, self-reported health status, gender and several diabetes-related complications are associated with differences in the degree of depression. These findings should alert practitioners to the importance of detecting depression in patients with T2DM.

Prevention Strategies in Post-TBI Depression in Older Adults: A Case Study

PURPOSE

The purpose of this study was to describe a theoretically focused intervention aimed toward chronic stress and depressive symptom management that is coordinated by a case manager and delivered within a home environment by the caregiver.

PRIMARY PRACTICE SETTING

Home care, community setting.

METHODS

A case study of an older adult with traumatic brain injury (TBI) secondary to a fall who had significant allostatic load at the time of his injury. "Allostatic load" is a theoretical construct that suggests the brain is experiencing chronic strain on its systems that flexibly respond to stressors. Sustained allostatic load can contribute to chronic conditions and poor outcomes.

FINDINGS

Through actions with the family as caregivers, the case manager was able to coordinate a structured home setting and gradual resumption of social activities for this older adult. Focus was on establishing structure, meaningful social interactions, and positive home experiences that maximized the older adult's interests and capacity and mitigated chronic stress. Gradually, the older adult returned to his preinjury capacity and lives independently within the family home.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The case management process has the potential to mitigate stressors and improve depression management through family-focused care. Although there is limited guidance on prevention of depression, this approach resulted in attainment of safe home care, no hospital readmissions, and return to previous lifestyle for the older adult. This could be useful in the prevention of post-TBI depression.

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT

BACKGROUND

Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression.

OBJECTIVES

(1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT).

DESIGN

Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation.

INTERVENTION DEVELOPMENT

Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation.

FEASIBILITY RCT

Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU).

SETTING

Community settings in London and Hertfordshire, UK.

PARTICIPANTS

A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty.

MAIN OUTCOME MEASURES

Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs.

RESULTS

We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding.

CONCLUSIONS

Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible.

FUTURE WORK

A large, definitive RCT of the HomeHealth service is warranted.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672.

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. 73. See the NIHR Journals Library website for further project information.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Influence of Serotonin Transporter Gene Polymorphisms and Adverse Life Events on Depressive Symptoms in the Elderly: A Population-Based Study

Background

Depression is common in the elderly. The role of genetic and environmental factors in modulating depressive symptoms is not clear.

Methods

We evaluated the influence of serotonin transporter gene polymorphisms and recent adverse life events on depressive symptoms in an elderly Italian population. We used data from “InveCe.Ab”, a population-based study of 1321 subjects aged 70–74 years. We used the 15-item Geriatric Depression Scale (GDS) to assess depressive symptoms–a GDS score ≥5 points (GDS≥5) indicated the presence of clinically relevant symptoms–and performed 5-HTTLPR and rs25531 genotyping to obtain the triallelic polymorphism of the serotonin transporter. We used the Geriatric Adverse Life Events Scale to measure adverse life events, and logistic regression models to evaluate the role of genotype and recent adverse life events in depressive symptoms, controlling for potential confounders and independent predictors.

Results

Two hundred subjects (15.76%) had a GDS≥5. The 5-HTTLPR triallelic polymorphism was significantly associated with GDS≥5. Only S′S′ carriers showed an increased risk of depressive symptoms (OR_adj = 1.81, p = .022); one extra adverse life event increased this risk by 14% (p = .061) independently of genotype. Other factors significantly related to GDS≥5 were: female gender (OR_adj = 2.49, p < .001), age (OR_adj = 1.19, p = .007), a history of depression (OR_adj = 4.73, p < .001), and comorbidity (OR_adj = 1.23, p = .001). One extra adverse life event increased the risk of depressive symptoms by 57% (p = .005) only in the L′L′ carriers, while antidepressant intake was directly related to GDS≥5 in the L′S′ carriers (OR_adj = 2.46, p = .036) and borderline significant in the S′S′ carriers (OR_adj = 2.41, p = .081).

Discussion

The S′S′ genotype and recent exposure to adverse life events were independently associated with depressive symptoms. The S′S′ genotype, compared with the environment, exerted a predominant effect on depressive symptoms, suggesting that it reduces the efficacy of antidepressant therapy. We conclude that genetics may be an important risk factor for depressive symptoms in late adulthood.

Postcard intervention for depression in community-dwelling older adults: A randomised controlled trial

Depression in older adults erodes their health, quality of life and the economy. Existing interventions are not feasible for broad application at the community. Postcard intervention only requires a few resources, and previous studies have shown its effectiveness for patients following drug overdose, self-harm and hospitalisation for major depression. The purpose of the present study is to evaluate the effectiveness of a postcard intervention. Participants were community-dwelling individuals, aged 65 or older, who eat meals alone and with the score of 4 or higher on the 15-item Geriatric Depression Scale (GDS-15). We enrolled 184 eligible participants, with 93 in the intervention and 91 in the control arm. Postcards were sent to participants once a month for eight months. Primary outcome was the GDS-15 score at post-intervention. Secondary outcomes were quality of life and activities of daily living. There was no significant difference in primary and secondary outcomes between completers of the intervention and the control arm. However, most of the participants who received intervention thought the intervention was effective. The postcard intervention for depression in community-dwelling elderly people in Japan is neither feasible nor effective. However, the descriptive results suggest that the intervention may be effective given different parameters.

Supported depression self-care may prevent major depression in community-dwelling older adults with chronic physical conditions and co-morbid depressive symptoms

Self-care programs for depression use educational and cognitive-behavioral techniques (e.g. written information, audiotapes, videotapes, computerized, or group courses) to assist patients in the management of depressive symptoms (Morgan and Jorm, 2008). In the UK, these interventions are recommended as step 1 in a stepped care program for treating depression in primary care (National Institute for Health and Clinical Excellence, 2007). One meta-analysis suggests that supported self-care (self-care with coaching) is more effective than unsupported self-care (Gellatly et al., 2007).

Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: a randomized controlled trial

OBJECTIVE

Interventions directed at the mental health of family dementia caregivers may have limited impact when focused on caregivers who have provided care for years and report high burden levels. We sought to evaluate the mental health effects of problem-solving therapy (PST), designed for caregivers of individuals with a recent diagnosis of Mild Cognitive Impairment (MCI) or early dementia.

METHOD

Seventy-three (43 MCI and 30 early dementia) family caregivers were randomly assigned to receive PST or a comparison condition (nutritional education). Depression, anxiety, and problem-solving orientation were assessed at baseline and at 1, 3, 6, and 12 months post intervention.

RESULTS

In general, the PST caregiver intervention was feasible and acceptable to family caregivers of older adults with a new cognitive diagnosis. Relative to nutritional education, PST led to significantly reduced depression symptoms, particularly among early dementia caregivers. PST also lowered caregivers' anxiety levels, and led to lessening of negative problem orientation.

DISCUSSION

Enhanced problem-solving skills, learned early after a loved one's cognitive diagnosis (especially dementia), results in positive mental health outcomes among new family caregivers.

An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms

Background

Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services.

Methods

A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation.

Results

Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period.

Conclusions

Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms.

Trial registration

Clinicaltrials.gov identifier: NCT01407926.

The postcard intervention against depression among community-dwelling older adults: study protocol for a randomized controlled trial

Background

Depression in older adults deteriorates quality of life and increases morbidity, mortality, and medical expenses. Medicine and social policy should work together to decrease this burden. Existing prevention studies are often based on time-consuming psychotherapies, which therefore are not feasible for a wide application at the community level. Postcard interventions have been shown to be effective for patients after hospitalization for major depression, drug overdose, or self-harm. This paper describes the protocol of a pragmatic, randomized controlled trial designed to examine the efficacy of a postcard intervention for depression among community-dwelling individuals aged 65 years or older.

Methods/Design

This is a pragmatic, non-blinded, parallel comparison, randomized controlled trial using Zelen’s design in a community setting. Participants will include community-dwelling older adults (aged 65 years or older) with limited social support (indicated by eating meals alone) and with symptoms of depression (scoring 4 or higher on the 15-item Geriatric Depression Scale (GDS)). The intervention will consist of sending postcards with handwritten messages and seasonal reports from a historical city to participants once a month for eight consecutive months. Self-addressed, stamped envelopes will be enclosed to facilitate non-obligatory replies. Primary outcomes will be changes in the GDS scores that are administered to all elderly inhabitants of the community every year as part of annual health checks. Secondary outcomes include quality of life as measured by a visual analogue scale, and self-rated basic and advanced activities of daily living. We will also examine the subjective sense of effectiveness of the intervention, recollection of the number of intervention mailings received, and the number of mailed replies as the index of the acceptability of the postcard intervention. The time × group interaction for two consecutive years will be analyzed using a generalized linear mixed model. To detect an effect size of 0.5 at alpha error of 0.05 and statistical power of 0.80, 63 participants per group are required. Based on an estimated consent and dropout rate of 70%, a total of 180 subjects will be recruited.

Trial registration

UMIN000010529

Preventing the onset of major depression based on the level and profile of risk of primary care attendees: protocol of a cluster randomised trial (the predictD-CCRT study)

BACKGROUND

The 'predictD algorithm' provides an estimate of the level and profile of risk of the onset of major depression in primary care attendees. This gives us the opportunity to develop interventions to prevent depression in a personalized way. We aim to evaluate the effectiveness, cost-effectiveness and cost-utility of a new intervention, personalized and implemented by family physicians (FPs), to prevent the onset of episodes of major depression.

METHODS/DESIGN

This is a multicenter randomized controlled trial (RCT), with cluster assignment by health center and two parallel arms. Two interventions will be applied by FPs, usual care versus the new intervention predictD-CCRT. The latter has four components: a training workshop for FPs; communicating the level and profile of risk of depression; building up a tailored bio-psycho-family-social intervention by FPs to prevent depression; offering a booklet to prevent depression; and activating and empowering patients. We will recruit a systematic random sample of 3286 non-depressed adult patients (1643 in each trial arm), nested in 140 FPs and 70 health centers from 7 Spanish cities. All patients will be evaluated at baseline, 6, 12 and 18 months. The level and profile of risk of depression will be communicated to patients by the FPs in the intervention practices at baseline, 6 and 12 months. Our primary outcome will be the cumulative incidence of major depression (measured by CIDI each 6 months) over 18 months of follow-up. Secondary outcomes will be health-related quality of life (SF-12 and EuroQol), and measurements of cost-effectiveness and cost-utility. The inferences will be made at patient level. We shall undertake an intention-to-treat effectiveness analysis and will handle missing data using multiple imputations. We will perform multi-level logistic regressions and will adjust for the probability of the onset of major depression at 12 months measured at baseline as well as for unbalanced variables if appropriate. The economic evaluation will be approached from two perspectives, societal and health system.

DISCUSSION

To our knowledge, this will be the first RCT of universal primary prevention for depression in adults and the first to test a personalized intervention implemented by FPs. We discuss possible biases as well as other limitations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01151982.

Preventing major depression in older medical inpatients: innovation or flight of fancy?

Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007).

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention

BACKGROUND

Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services.

METHODS/DESIGN

This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation.

DISCUSSION

Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01407926.

Prevention of late-life anxiety and depression has sustained effects over 24 months: a pragmatic randomized trial

OBJECTIVE

Depressive and anxiety disorders in later life have a high incidence and are associated with reduced quality of life. Elsewhere, we demonstrated that a stepped-care prevention approach was successful in halving the incidence of these disorders over a period of 12 months. As a decreasing effect over time is to be expected, our aim was to investigate the longer-term effects.

DESIGN

Randomized controlled trial.

SETTING

Thirty-three primary care practices in the Netherlands.

PARTICIPANTS

One hundred seventy consenting individuals, age 75 years and older, presenting with subthreshold depression or anxiety, not meeting the diagnostic criteria.

INTERVENTION

Participants were randomized to a preventive intervention or usual care. In the first 12 months, the preventive intervention entailed watchful waiting, minimally supported CBT-based self-help intervention, problem-solving treatment, and referral to a primary care physician for medication, if required. In the last 12 months, 95% of the participants ceased to receive such support.

MEASUREMENTS

Mini International Neuropsychiatric Interview.

RESULTS

The cumulative incidence rate of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression or anxiety disorder over a period of 24 months was halved by the intervention, from 33 of 84 (39.3%) in the usual care group to 17 of 86 (19.8%) in the intervention group (odds ratio = 0.38; 95% confidence interval = 0.19–0.76), which was significant (z = 2.75; p = 0.006). The corresponding number needed to treat was 5 (95% confidence interval = 3–16).

CONCLUSIONS

A stepped-care approach to the prevention of depression and anxiety in late life was not only successful in halving the incidence of depressive and anxiety disorders after 1 year, but these favorable effects were also sustained over 24 months.

Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life

BACKGROUND

The association between depression and functional disability in late life remains unclear. This study aimed to explore the relationship between depressive symptoms and daily functioning through the mediation of cognitive abilities, measured by memory, reasoning, and speed of processing.

METHODS

The authors recruited 2,832 older adults (mean age = 73.6 years, standard deviation = 5.9) participating in the Advanced Cognitive Training for Independent and Vital Elderly Study. Structural equation modeling was applied to illustrate the relationship between depressive symptoms and everyday problem-solving ability through the mediation of cognitive abilities.

RESULTS

Depressive symptoms were associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning. Although depressive symptoms were associated with speed of processing, speed of processing was not significantly related to everyday problem-solving ability.

CONCLUSIONS

This study conceptualizes the possible relationships between depressive symptoms and daily functioning with mediation of cognitive abilities and provides a feasible model for the prevention of functional impairment related to geriatric depressive symptoms.

Major depression during interferon-alpha treatment: vulnerability and prevention

Major Depressive Disorder (MDD) during interferons (IFN-α) treatment can occur within a few months of therapy, and shares many homologies with other forms of MDD, Most patients are resilient to the side effect ofinterferon-induced depression (IFN-MDD), but 15% to 40% are vulnerable. Several studies have employed antidepressants to prevent the incidence of an IFN-MDD episode, and the results suggest that prophylactic antidepressants may be specifically useful in those with pre-existing subthreshold depressive symptoms andlor a history of prior MDD episodes. Several other potential markers of vulnerability for IFN-MDD have been implicated in assessments of nondepressed patients before they start IFN-α These include poor sleep quality, premorbid elevations in inflammatory cytokines, genetic polymorphisms in the serotonin system, personality, and social support. The interplay of these factors strongly predicts who is at risk for IFN-MDD, and indicates several potentially modifiable targets for the personalized prevention of IFN-MDD,

Academic psychiatry's responsibility for increasing the recognition of mood disorders and risk for suicide in primary care

PURPOSE OF REVIEW

The authors seek solutions to better meet the healthcare needs of depressed patients in primary care by improving the recognition of depression, other mood disorders and of a risk for suicide.

RECENT FINDINGS

For 25 years academic psychiatry and primary care have known that only 10-50% of depressed patients are adequately treated, primarily because of the failure to recognize depression. There are substantial negative consequences including suicide. Suicide occurs during depression so the recognition of depression is the critical first step to preventing suicide. Recently noted is that one barrier to recognition is the traditional, comprehensive, psychiatric interview taught in academic departments of psychiatry that is impractical in primary care settings because it takes too much time. Some brief, initial psychiatric techniques have been developed but these typically have been introduced in primary care training programs and not by departments of psychiatry.

SUMMARY

A verbal four-question, 90 s screen for depression may be acceptable for routine use in primary care because it typically requires only seconds to a few minutes. Introduction of such a screening instrument to medical students on psychiatry and primary care clerkships could increase the recognition of depression and reduce death by suicide.

Onset of anxiety and depression in the aging population: comparison of risk factors in a 9-year prospective study

OBJECTIVES

To study the onset and compare risk factors for pure depression (DEP), pure anxiety (ANX), and comorbid anxiety-depression (ANXDEP) in the aging population.

DESIGN

Prospective study with 3-year intervals over a 9-year period.

SETTING

Data of the Longitudinal Aging Study Amsterdam were used, which is a population-based study among older adults (55-85 years at baseline).

PARTICIPANTS

Older adults free of depression and anxiety at baseline (N = 1,712).

MEASUREMENTS

Clinically relevant levels of depression and anxiety were measured with the Center for Epidemiologic Studies Depression scale> or =16 and Hospital Anxiety and Depression Scale > or =7, respectively. A broad range of potential sociodemographic, health, and psychosocial risk factors for anxiety and/or depression were examined by using polytomous logistic regression analyses.

RESULTS

Within 9 years, 184 subjects (10.8%) developed DEP, 93 (5.4%) ANX, and 103 (6.0%) ANXDEP. Concerning sociodemographics, higher age and lower educational level were predictors for DEP. Health indicators were predictive for DEP and ANXDEP but not for ANX. Depressive symptoms at baseline were predictive for DEP, whereas initial anxiety symptoms were predictive for ANX and ANXDEP. Neuroticism increased the risk of DEP and ANXDEP. Mixed effects of psychosocial variables were found: DEP was associated with recent widowhood, whereas ANX and ANXDEP were associated with other life events such as having an ill partner.

CONCLUSION

Although onset of ANXDEP demonstrated communality in risk factors, comparing risk factors associated with DEP and ANX revealed more differences than similarities. This underlines the need to distinguish anxiety from depression in preventive strategies.

The moderation of an early intervention program for anxiety and depression by specific psychological symptoms

The current study examined the influence of a number of psychological factors on the effectiveness of an early intervention program targeting anxiety and depression in a non-clinical sample of college students. The early intervention program comprised elements of the cognitive-behavioral analysis system of psychotherapy (McCullough, 2000) delivered in a 2-hour computer-based educational program. Participants completed measures of depression, anxiety, and general distress prior to the intervention program and then again 8 weeks later. Additionally, participants were assessed for past major depression, sleep related difficulties, a number of anxiety disorders, and suicide ideation. Moderation of the effectiveness of the early intervention program by these factors depended on the dependent variable of interest, specifically: the effectiveness of the intervention program on symptoms of depression was moderated by insomnia; symptoms of anxiety by past post-traumatic stress disorder (PTSD) and specific phobia as well as sleep problems related to nightmares; and symptoms of general negative affect by social phobia and suicide ideation. Implications are discussed.

Depressive symptoms moderate the influence of the apolipoproteine epsilon4 allele on cognitive decline in a sample of community dwelling older adults

OBJECTIVES

The apolipoproteinE epsilon4 (APOE epsilon4) allele and a history of depression are each separate risk factors for cognitive decline (CD). However, little research has investigated whether a history of depression influences the relationship between APOE epsilon4 and CD. The present study examined whether depressive symptoms had greater influence on subsequent CD among participants with APOE epsilon4 than those without the allele.

DESIGN

Prospective 6-year longitudinal study.

SETTING

Community in-home interviews.

PARTICIPANTS

A biracial sample of community dwelling older adults (N = 1,992) from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).

MEASUREMENTS

Data were drawn from Waves 1 to 3 of the EPESE, which were conducted 6 years apart. Cognitive functioning and depressive symptoms were assessed at both waves, and APOE genotyping was completed during the Wave 3 assessment.

RESULTS

Regression analyses revealed that depressive symptoms and the APOE epsilon4 allele independently predicted CD. Importantly, the influence of depressive symptoms on CD was greater for individuals with the APOE epsilon4 allele compared with those without the allele.

CONCLUSION

Depressive symptoms and the APOE epsilon4 allele are independent contributors to CD. Moreover, the influence of depressive symptoms on CD is greater among individuals with the APOE epsilon4 allele. Depression and the APOE epsilon4 allele may act together in disrupting neurological functioning, which may in turn lower an individual's cognitive reserve capacity. Given the efficacious treatments currently available for depression, future research should investigate the extent to which interventions for depression may reduce the risk for subsequent CD.

Depression in older adults

Depression is less prevalent among older adults than among younger adults, but it can have serious consequences. More than half of cases represent a first onset in later life. Although suicide rates in the elderly are declining, they are still higher than in younger adults and are more closely associated with depression. Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are depressed younger adults. Risk factors leading to the development of late-life depression likely comprise complex interactions among genetic vulnerabilities, cognitive diathesis, age-associated neurobiological changes, and stressful events. Insomnia is an often overlooked risk factor for late-life depression. We suggest that a common pathway to depression in older adults, regardless of which predisposing risks are most prominent, may be curtailment of daily activities. Accompanying self-critical thinking may exacerbate and maintain a depressed state. Offsetting the increasing prevalence of certain risk factors in late life are age-related increases in psychological resilience. Other protective factors include higher education and socioeconomic status, engagement in valued activities, and religious or spiritual involvement. Treatments including behavioral therapy, cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and life review/reminiscence therapy are effective but are too infrequently used with older adults. Preventive interventions including education for individuals with chronic illness, behavioral activation, cognitive restructuring, problem-solving skills training, group support, and life review have also received support.