Clinical and phenomenological comparisons of late-onset and early-onset depression

Risk of conversion to bipolar disorder in patients with late-onset major depression

To evaluate the impact of age at onset on late-life depression course and on risk of conversion to bipolar disorder (BD). A retrospective chart review of 100 elderly patients (age ≥ 65 years) diagnosed with a moderate-to-severe depressive episode and followed up for at least 18 months was conducted. Among patients affected by major depressive disorder ( N = 57), follow-up morbidity differences between those with typical onset depression (TOD) (<60 years) and those with late-onset depression (LOD) (≥60 years) were investigated using Wilcoxon rank-sum test and Cox proportional hazard model. Patients belonging to the LOD group had a significantly lower percentage of follow-up time spent with depressive symptoms compared with patients with TOD ( r = 0.36; P = 0.006), but significantly more time spent with (hypo)manic episodes ( r = -0.31; P = 0.021). Moreover, LOD was significantly associated with a faster conversion to BD (hazard ratio = 3.05; P = 0.037). Depression first emerging in late life may represent an unstable condition with a high risk to convert to BD. Given the potential clinical implications, further studies on the course of LOD are required.

Network structure of time-varying depressive symptoms through dynamic time warp analysis in late-life depression

OBJECTIVES

Late-life major depressive disorder (MDD) can be conceptualized as a complex dynamic system. However, it is not straightforward how to analyze the covarying depressive symptoms over time in case of sparse panel data. Dynamic time warping (DTW) analysis may yield symptom networks and dimensions both at the patient and group level.

METHODS

In the Netherlands Study of Depression in Older People (NESDO) depressive symptoms were assessed every 6 months using the 30-item Inventory of Depressive Symptomatology (IDS) with up to 13 assessments per participant. Our sample consisted of 182 persons, aged ≥ 60 years, with an IDS total score of 26 or higher at baseline. Symptom networks dimensions, and centrality metrics were analyzed using DTW and Distatis analyses.

RESULTS

The mean age was 69.8 years (SD 7.1), with 69.0% females, and a mean IDS score of 38.0 (SD = 8.7). DTW enabled visualization of an idiographic symptom network in a single NESDO participant. In the group-level nomothetic approach, four depressive symptom dimensions were identified: "core symptoms", "lethargy/somatic", "sleep", and "appetite/atypical". Items of the "internalizing symptoms" dimension had the highest centrality, whose symptom changes over time were most similar to those changes of other symptoms.

CONCLUSIONS

DTW revealed symptom networks and dimensions based on the within-person symptom changes in older MDD patients. Its centrality metrics signal the most influential symptoms, which may aid personalized care.

Influences of dopaminergic system dysfunction on late-life depression

Deficits in cognition, reward processing, and motor function are clinical features relevant to both aging and depression. Individuals with late-life depression often show impairment across these domains, all of which are moderated by the functioning of dopaminergic circuits. As dopaminergic function declines with normal aging and increased inflammatory burden, the role of dopamine may be particularly salient for late-life depression. We review the literature examining the role of dopamine in the pathogenesis of depression, as well as how dopamine function changes with aging and is influenced by inflammation. Applying a Research Domain Criteria (RDoC) Initiative perspective, we then review work examining how dopaminergic signaling affects these domains, specifically focusing on Cognitive, Positive Valence, and Sensorimotor Systems. We propose a unified model incorporating the effects of aging and low-grade inflammation on dopaminergic functioning, with a resulting negative effect on cognition, reward processing, and motor function. Interplay between these systems may influence development of a depressive phenotype, with an initial deficit in one domain reinforcing decline in others. This model extends RDoC concepts into late-life depression while also providing opportunities for novel and personalized interventions.

Depression and Dementia in Older Adults: A Neuropsychological Review

Depression and dementia are the most common neuropsychiatric disorders in the older adult population. There are a certain number of depressed patients who visit outpatient clinics because they suspect dementia due to similarities in the clinical symptoms in both disorders. Depressive symptoms associated with dementia may be diagnosed with depression, and treatment with antidepressants is continued for a long time. Depression and dementia differ in their treatment approaches and subsequent courses, and it is necessary to carefully differentiate between the two in the clinical practice of dementia treatment. In this review, I describe the similarities between depression and dementia and how to differentiate depression in dementia treatment based on the differences and emphasize that there is a significant potential to cure depression, in contrast to dementia, for which there is currently no fundamental therapy. Therefore, it is important to recognize that depression and dementia may present with common symptoms and to appropriately differentiate depressed patients who are suspected of having dementia. Dementia is a disorder in which cognitive dysfunction is caused by a variety of causative diseases and conditions, resulting in impairment of activities of daily living. However, current medical science has had difficulty finding a cure for the causative disease. Based on clinical findings, it has also been shown that the degree of symptoms for preexisting psychiatric disorders is alleviated as the brain ages. In the presence of dementia, the speed of the alleviation will increase. The importance of focusing on the positive aspects of aging is also discussed.

The association of phasic irritability (aggressive outbursts) and tonic irritability (irritable mood) to depression occurrences, symptoms, and subtypes

BACKGROUND

Research among adults has rarely differentiated between tonic irritability (i.e., irritable mood) and phasic irritability (i.e., aggressive outbursts) with respect to multiple dimensions of depression. The current study explored both tonic and phasic irritability in relation to depression severity, depression chronicity, age of depression onset, individual depressive symptom, and depression subtypes.

METHODS

The study included participants (N = 5692) from the National Comorbidity Survey - Replication (NCS-R) part two. The NCS-R used lay-administered, fully standardized diagnostic interviews. The current study implemented linear models, generalized linear models, Cox proportional hazard model, and latent class regression.

RESULTS

Both types of irritability were significantly associated with greater risk for MDD diagnosis, as well as risk for having at least one depressive symptom, early MDE onset, and MDE chronicity. Both phasic and tonic irritability were associated with greater odds of specific depressive symptoms and were differentially related to distinct depressive symptom constellations. Phasic irritability related only to severe depression. Lastly, both phasic and tonic irritability was associated with suicidal ideation, but only phasic irritability was associated with a suicide plan and attempt, above and beyond depression subtypes.

CONCLUSIONS

Both phasic and tonic irritability differentially related to almost all aspects of depression in adults. Specifically, tonic irritability showed overall stronger associations with various depressive features, whereas phasic irritability marked higher depressive severity.

Prevalence of medical comorbidity in early onset versus late-onset depression in Vindhya region

BACKGROUND

Late-onset depression differs significantly from early-onset depression according to clinical features, physical comorbidities, cognitive impairment, and cerebrovascular abnormalities, which suggest that these might have differing etiopathological pathways toward the depressive phenotype.

AIM

The aim of the study was to identify comorbid physical disorders with late-onset depression.

METHODS

The present cross-sectional study was conducted in inpatients of the Department of Psychiatry during a period of 18 months. A study consisted of 60 patients of first depressive episode diagnosed using International Classification of Diseases-10 criteria, segregated 2 different groups of Early onset depression (between 40 and 65 years) and late-onset depression (LOD) (>65 years) with 30 patients each.

RESULTS

In LOD group, predominant comorbidities were hypertension 56.6%, cerebrovascular disease 36.6%, diabetes 33.3%, cardiovascular disease 23.3%, and anaemia 23.3%, followed by respiratory illnesses, arthritis, benign prostatic hyperplasia and cirrhosis. While, in early-onset depression group, common comorbidities were hypertension (13.3%), anemia (10%), arthritis (10%), and diabetes (6.6%).

CONCLUSIONS

Hypertension cerebrovascular disease, diabetes, and cardiovascular disease were the predominant comorbidities in late-onset as well as early onset depression.

Different Sides of Depression in the Elderly: An In-depth View on the Role of Aβ Peptides

BACKGROUND

Late-onset depression (LOD) is the most common neuropsychiatric disorder associated with Alzheimer's disease (AD), often associated with structural and functional brain changes, neuropsychological impairments and negative family history for affective disorders. LOD could be a risk factor or a prodromal phase of AD; this has led to the investigation of the link between depression and amyloid-β (Aβ) peptides by measuring Aβ levels in plasma, cerebrospinal fluid (CSF) and brains of elderly depressed subjects.

OBJECTIVE

Clarify the complex relationship between depression, Aβ peptides and AD.

METHOD

We evaluated all articles published up to 2019 in PubMed in which Aβ was measured in serum (or plasma), CSF or brain in elderly with Major Depressive Disorder or depressive symptoms evaluated with standard scales.

RESULTS

Low plasma Aβ42 levels are strongly associated with depression severity. Plasma Aβ40 levels are higher in younger depressed, drug-resistant and those with more severe symptoms. CSF Aβ42 levels are lower in depressed than controls. PET-detected global and region-specific increases in Aβ deposition are sometimes associated with LOD, cognitive impairment, anxiety but not with Cardiovascular Diseases (CVDs)/CVD risk factors. Elderly depressed with CVDs/CVD risk factors have more frequently high plasma Aβ40 levels and drug-resistance; those without these co-morbidities have low plasma Aβ42 levels and a greater cognitive impairment.

CONCLUSION

Two specific Aβ profiles emerge in elderly depressed. One is associated with Aβ42 reductions in plasma and CSF, possibly reflecting increased brain amyloid deposition and prodromal AD. The other one is characterized by high plasma Aβ40 levels, cerebrovascular disease and clinically associated with increased AD risk.

Experiences of falling and depression: Results from the Korean Longitudinal Study of Ageing

OBJECTIVE

This study estimates the association between fall experiences during the last two years and risk of depression.

METHODS

Data from 9,355 subjects of the Korean Longitudinal Study of Ageing from 2006 to 2016 were included with baseline at 2006. To analyze the association between fall experiences during the last two years and depression, a generalized estimating equation (GEE) model and chi-square tests were used.

RESULTS

At baseline 2006, the odds ratio (OR) of depressive symptoms in those with fall experiences was 1.36 times higher (p < .0001) than those with non-fall experience. In those 64 years or younger and 65 years or older, the OR of depressive symptoms in fall experience was 1.45 times higher (p =0.003) and 1.34 times higher (p =0.000) than those with non-fall experience, respectively. In males and females, the OR of depressive symptoms in those with fall experience was 1.47 times higher (p 0.008) and 1.34 times higher (p =0.000) than those with non-fall experience, respectively.

CONCLUSION

Fall experiences during the last two years are associated with depressive symptoms. Therefore, self-reported screening for fall experiences might aid in population-based prevention strategies for depressive symptoms.

Are Apathy and Depressive Symptoms Related to Vascular White Matter Hyperintensities in Severe Late Life Depression?

OBJECTIVE

Apathy symptoms are defined as a lack of interest and motivation. Patients with late-life depression (LLD) also suffer from lack of interest and motivation and previous studies have linked apathy to vascular white matter hyperintensities (WMH) of the brain in depressed and nondepressed patients. The aim of this study was to investigate the relationship between apathy symptoms, depressive symptoms, and WMH in LLD. We hypothesize that late-onset depression (LOD; first episode of depression after 55 years of age) is associated with WMH and apathy symptoms.

METHODS

Apathy scores were collected for 87 inpatients diagnosed with LLD. Eighty patients underwent brain magnetic resonance imaging. Associations between depressive and apathy symptoms and WMH were analyzed using linear regression.

RESULTS

All 3 subdomains of the 10-item Montgomery-Åsberg Depression Rating Scale correlated significantly with the apathy scale score (all P < .05). In the total sample, apathy nor depressive symptoms were related to specific WMH. In LOD only, periventricular WMH were associated with depression severity (β = 5.21, P = .04), while WMH in the left infratentorial region were associated with apathy symptoms (β coefficient = 5.89, P = .03).

CONCLUSION

Apathy and depressive symptoms are highly overlapping in the current cohort of older patients with severe LLD, leading to the hypothesis that apathy symptoms are part of depressive symptoms in the symptom profile of older patients with severe LLD. Neither apathy nor depressive symptoms were related to WMH, suggesting that radiological markers of cerebrovascular disease, such as WMH, may not be useful in predicting these symptoms in severe LLD.

Fatigue, sleep and depression: An exploratory interRAI study of older adults

An association between fatigue and depression was reported for older adults. We examined the association between fatigue, sleep and depression from interRAI-HC assessments of community dwelling older people (65+ years). Interview data from 5,950 participants who completed their first interRAI-HC assessment was analysed (mean age, 81.3 ± 7.1 years; 60.2% female). Only 873 (15%) reported "severe" fatigue. Nearly half reported minor sleep problems. Depression was diagnosed in 693 participants (11.6%). Depression explained only 0.2% of fatigue. This calls for further studies that may help in understanding the relationship between fatigue and depression across the life-cycle.

Aspirin and Risk of Dementia in Patients with Late-Onset Depression: A Population-Based Cohort Study

Background

Late onset depression (LOD) often occurs in the context of vascular disease and may be associated with risk of dementia. Aspirin is widely used to reduce the risk of cardiovascular disease and stroke. However, its role in patients with LOD and risk of dementia remains inconclusive. Materials and Methods. A population-based study was conducted using data from National Health Insurance of Taiwan during 1996–2009. Patients fulfil diagnostic criteria for LOD with or without subsequent dementia (incident dementia) and among whom users of aspirin (75 mg daily for at least 6 months) were identified. The time-dependent Cox proportional hazards model was applied for multivariate analyses. Propensity scores with the one-to-one nearest-neighbor matching model were used to select matching patients. Cumulative incidence of incident dementia after diagnosis of LOD was calculated by Kaplan–Meier Method.

Results

A total of 6028 (13.4%) and 40,411 (86.6%) patients were defined as, with and without diagnosis of LOD, among whom 2,424 (41.9%) were aspirin users. Patients with LOD had more comorbidities such as cardiovascular diseases, diabetes, and hypertension comparing to those without LOD. Among patients with LOD, aspirin users had lower incidence of subsequent incident dementia than non-users (Hazard Ratio = 0.734, 95% CI 0.641–0.841, p < 0.001). After matching aspirin users with non-users by propensity scores-matching method, the cumulative incidence of incident dementia was significantly lower in aspirin users of LOD patients (p < 0.001). After matching aspirin users with non-users by propensity scores-matching method, the cumulative incidence of incident dementia was significantly lower in aspirin users of LOD patients (

Conclusions

Aspirin may be associated with a lower risk of incident dementia in patients with LOD. This beneficial effect of aspirin in LOD patients needs validation in prospective clinical trials and our results should be interpreted with caution.

Vascular Effects on Depressive Symptoms in Cognitive Impairment

Late life depression is related to pathologic burdens, such as cerebral small vascular disease (CSVD) and amyloid, which are associated with brain network changes and cortical thinning. To examine the associations of various CSVD imaging markers, amyloid, and network changes with depression in cognitively impaired patients, we prospectively recruited 228 cognitively impaired patients having various degrees of amyloid and CSVD who underwent diffuse tensor image and PiB PET. Greater CSVD burden was associated with greater Geriatric Depression Scale (GDS) (white matter hyperintensities, WMH: p = 0.025, lacunes: p < 0.001) but not with amyloid (p = 0.095), and cortical thinning (p = 0.630) was not associated with greater GDS. The changes in white matter networks were related to GDS with decreasing integration (global efficiency: p < 0.001) and increasing segregation (clustering coefficient: p = 0.009). The network changes mediated the relationships of WMH and lacunes with GDS. Our findings provide insight to better understand how CSVD burdens contribute to depression in cognitively impaired patients having varying degrees of amyloid and vascular burdens.

Vascular risk factors in older patients with depression: outcome of electroconvulsive therapy versus medication

OBJECTIVE

Research suggests that in depression, vascular burden predicts a lower efficacy for medication (MED) and a more favourable outcome for electroconvulsive therapy (ECT). Therefore, we investigated the influence of the following vascular risk factors (VRF): hypercholesterolemia, hypertension, smoking, diabetes mellitus, cardiovascular disease, and cerebral vascular accident/transient ischemic attack, on remission from major depression after ECT versus MED.

METHODS

The study sample consisted of 81 inpatients with a DSM-IV unipolar major depression diagnosis (mean age 72.2 years, SD = 7.6, mean Montgomery-Åsberg Depression Rating Scale score 32.9, SD = 6.2) participating in a randomized controlled trial comparing nortriptyline versus venlafaxine and 43 inpatients (mean age 73.7 years, SD = 7.5, mean Montgomery-Åsberg Depression Rating Scale score 30.6, SD = 7.1) from an randomized controlled trial comparing brief pulse versus ultrabrief pulse ECT. The presence of VRF was established from the medical records. The remission rate of patients with VRF was compared with those of patients without VRF.

RESULTS

The remission rate was 58% (19/33) in the ECT group with ≥1 VRF and 32% (23/73) in the MED group with ≥1 VRF (χ²  = 6.456, p = 0.011). Comparing patients with no VRF versus ≥1 VRF, the remission rate decreased from 80 to 58% (χ²  = 1.652, p = 0.276) in ECT patients and from 38 to 32% (χ²  = 0.119, p = 0.707) in MED patients. Applying different cut-offs for the number of VRFs yielded the same trends. Logistic regression revealed no interaction between VRF and treatment condition.

CONCLUSION

The superior efficacy of ECT over pharmacotherapy in major depression in older age was independent of the presence of VRF. Copyright © 2017 John Wiley & Sons, Ltd.

Early Symptom Trajectories as Predictors of Treatment Outcome for Citalopram Versus Placebo

OBJECTIVES

The high percentage of failed clinical trials for anti-depressant medications, especially in elderly populations, obscures the fact that some patients may benefit greatly from treatment. Early detection of patients who may benefit most from antidepressant medication may improve treatment decisions. We examined whether depressed patients in a large clinical trial exhibit distinct trajectories of early symptom change that predict differential response to medication or placebo.

METHODS

We reanalyzed data of 174 patients aged 75 years and older with unipolar depression who were randomly assigned to citalopram or placebo. We used growth mixture modeling to identify trajectories of early change (weeks 1-4) on the Hamilton Rating Scale for Depression in the citalopram and placebo conditions.

RESULTS

In the citalopram condition, two distinct trajectories of early change were detected that were associated with significantly different symptom reduction, but only one trajectory was detected for the placebo condition. One of the early trajectories of patients receiving citalopram (N = 33) showed significantly better symptomatic change than placebo; the other trajectory (N = 51) did not differ significantly from placebo. Poor baseline functional scores predicted trajectory membership, so that individuals with a score below 4.5 on baseline instrumental activities of daily living showed a higher tendency to be in the trajectory that outperformed placebo.

CONCLUSIONS

The subgroup of citalopram-treated patients exhibiting better symptom trajectory early in a trial are likely to have beneficial outcomes relative to placebo. Future research should focus on developing reliable pre-treatment clinical and biological measures to identify this subgroup.

Apathy is related to reduced activation in cognitive control regions during set-shifting

Apathy is a prominent and influential symptom in several neurological and psychiatric disorders, but it also occurs in the healthy population. It has considerable impact on daily life functioning, in clinical as well as healthy samples. Even though cognitive control is thought to be disrupted in people with apathy, the exact neural underpinnings of apathy remain unclear. Because flexible shifting between behaviors (set-shifting) is crucial for goal-directed behavior, disruptions in set-shifting may underlie apathy. In this study, the neural correlates of apathy during set-shifting were studied in 34 healthy participants with varying levels of apathy, measured by the Apathy Evaluation Scale. During functional MRI scanning participants performed a set-shifting task, distinguishing between behavioral switches (a change in response to different stimuli), cognitive switches (a change in response rule), and salience decoupling (detecting a change in relevant stimuli). Regression analysis was used to assess the relationship between apathy and brain activation. Results showed that higher apathy scores were related to reduced activation in the medial superior frontal gyrus and cerebellum (Crus I/II) during cognitive set-shifting, but not behavioral shifting and salience decoupling. No relationship between apathy and accuracy or response time was found. These results support the idea that alterations in the neural basis of cognitive control, especially cognitive set-shifting, may contribute to apathy. Hum Brain Mapp 38:2722-2733, 2017. © 2017 Wiley Periodicals, Inc.

Biological Aging and the Future of Geriatric Psychiatry

Advances in understanding the biological bases of aging have intellectually revitalized the field of geriatric psychiatry and broadened its scope to include promoting successful aging and studying resilience factors in older adults. To describe the process by which this paradigm shift has occurred and illustrate its implications for treatment and research of late-life brain disorders, late-life depression is discussed as a prototype case. Prior phases of geriatric psychiatry research were focused on achieving depressive symptom relief, outlining pharmacokinetic and pharmacodynamic differences between older and younger adults, and identifying moderators of treatment response. Building on this work, current geriatric psychiatry researchers have begun to disentangle the etiologic complexity in late-life depression by focusing on the causative aging-related processes involved, identifying both neurobiological and behavioral intermediates, and finally delineating depression subtypes that are distinguishable by their underlying biology and the treatment approach required. In this review, we discuss several age-related processes that are critical to the development of late-life mood disorders, outline implications of these processes for the clinical evaluation and management of later-life psychiatric disorders, and finally put forth suggestions for better integrating aging and developmental processes into the National Institute of Mental Health's Research Domain Criteria.

Daily-Living Skills and Habits of Older Women with Depression

This study used a prospective, within-group comparison design to examine differences in the severity of disability in a community-based sample of 59 older women being treated for depression. The independent variables were three constructs: perceived skills, perceived habits, and demonstrated skills. The dependent variables were functional mobility, personal care, and instrumental activities of daily living. Results indicated that the expression of overall disability differed significantly among the three constructs. Participants' perceptions of their skill independence were greater than their ability to demonstrate independence in those skills, and their demonstrated skills of task independence were greater than their perceived ability habitually to use those skills independently. Objective, performance-based skill measures indicated greater disability than subjective, self-report skill measures, and supported the view that in older adults, depression-related disability reflects a combination of skill and habit deficits. Item analyses revealed five distinct patterns of relationships among perceived skills, perceived habits, and demonstrated skills. Practitioners need to be aware of the constructs being used to measure disability because the severity of disability may depend on the construct being used. Furthermore, the types of interventions appropriate for disability related to each construct or pattern of constructs may vary.

Strategies to improve anxiety and depression in patients with COPD: a mental health perspective

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by progressive and only partially reversible symptoms. Worldwide, the incidence of COPD presents a disturbing continuous increase. Anxiety and depression are remarkably common in COPD patients, but the evidence about optimal approaches for managing psychological comorbidities in COPD remains unclear and largely speculative. Pharmacological treatment based on selective serotonin reuptake inhibitors has almost replaced tricyclic antidepressants. The main psychological intervention is cognitive behavioral therapy. Of particular interest are pulmonary rehabilitation programs, which can reduce anxiety and depressive symptoms in these patients. Although the literature on treating anxiety and depression in patients with COPD is limited, we believe that it points to the implementation of personalized strategies to address their psychopathological comorbidities.

Statins Reduces the Risk of Dementia in Patients with Late-Onset Depression: A Retrospective Cohort Study

Objective

Patients with late-onset depression (LOD) have been reported to run a higher risk of subsequent dementia. The present study was conducted to assess whether statins can reduce the risk of dementia in these patients.

Methods

We used the data from National Health Insurance of Taiwan during 1996–2009. Standardized Incidence Ratios (SIRs) were calculated for LOD and subsequent dementia. The criteria for LOD diagnoses included age ≥65 years, diagnosis of depression after 65 years of age, at least three service claims, and treatment with antidepressants. The time-dependent Cox proportional hazards model was applied for multivariate analyses. Propensity scores with the one-to-one nearest-neighbor matching model were used to select matching patients for validation studies. Kaplan-Meier curve estimate was used to measure the group of patients with dementia living after diagnosis of LOD.

Results

Totally 45,973 patients aged ≥65 years were enrolled. The prevalence of LOD was 12.9% (5,952/45,973). Patients with LOD showed to have a higher incidence of subsequent dementia compared with those without LOD (Odds Ratio: 2.785; 95% CI 2.619–2.958). Among patients with LOD, lipid lowering agent (LLA) users (for at least 3 months) had lower incidence of subsequent dementia than non-users (Hazard Ratio = 0.781, 95% CI 0.685–0.891). Nevertheless, only statins users showed to have reduced risk of dementia (Hazard Ratio = 0.674, 95% CI 0.547–0.832) while other LLAs did not, which was further validated by Kaplan-Meier estimates after we used the propensity scores with the one-to-one nearest-neighbor matching model to control the confounding factors.

Conclusions

Statins may reduce the risk of subsequent dementia in patients with LOD.

In depressed older persons higher blood pressure is associated with symptoms of apathy. The NESDO study

BACKGROUND

In older persons, a relationship between both higher and lower blood pressure and depression has inconsistently been reported. Blood pressure may be differentially associated with distinct symptom domains of depression. We examined the cross-sectional relation of current systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) with different depressive symptom domains among depressed older persons.

METHODS

In the Netherlands Study of Depression in Older Persons (NESDO), 270 participants aged 60 years and above were diagnosed with depression in the past month. Using the three corresponding subscales of the Inventory of Depressive Symptoms-Self Report (IDS-SR), motivational, mood and somatic symptom domains were assessed. Additionally, symptoms of apathy were determined with the Apathy Scale. Multiple linear regression was used to examine the cross-sectional relationship between current SBP, DBP and MAP with both IDS-SR subscale and Apathy Scale scores. Unstandardized betas were calculated per 10 mmHg increase in blood pressure measures.

RESULTS

Mean age of participants was 70.4 years (standard deviation 7.3). Higher SBP (Beta 0.33, t (254) = 2.01, p = 0.045), higher DBP (Beta 0.68, t (254) = 2.15, p = 0.03) and higher MAP (Beta 0.63, t (254) = 2.33, p = 0.02) were associated with higher Apathy Scale scores in the fully adjusted model. Furthermore, a higher SBP was associated with higher IDS-SR mood subscale scores (Beta 0.25, t (254) = 2.13, p = 0.03).

CONCLUSIONS

Depressed older people with higher blood pressure measures had particularly more symptoms of apathy. To disentangle the relationship of blood pressure with late-life depression, it is important to pay attention to the role of apathy symptoms.

Apathy in late-life depression: common, persistent, and disabling

OBJECTIVE

The aims of this study were to examine: (1) the relationship between apathy and disability in late-life depression, and (2) the functional significance of improvement in apathy following escitalopram treatment in terms of its relationship to disability.

METHODS

Subjects were 71 non-demented elderly with non-psychotic major depression. After a 2-week single-blind placebo period, subjects who had Hamilton Depression Rating Scale (HDRS) ≥ 18 received escitalopram 10 mg daily for 12 weeks. Apathy and disability were assessed with the Apathy Evaluation Scale (AES) and the World Health Organization Disability Assessment Scale II (WHODAS), respectively. These measures and the HDRS were administered at baseline and again following 12 weeks of treatment.

RESULTS

At baseline, 38% of depressed subjects had significant apathy (AES ≥ 36.5). Severity of apathy at baseline significantly correlated with severity of disability. In a multivariate regression model, baseline severity of apathy, but not the overall depressive syndrome (HDRS), significantly correlated with baseline disability. Following escitalopram treatment, improvement in apathy significantly correlated with improvement in disability measures, while change in the rest of the depressive syndrome did not. The overall change in apathy and disability in response to escitalopram treatment was significant but small.

CONCLUSION

Apathy is common in late-life depression and is associated with disability above and beyond the influence of other depressive symptoms. Given the strong relationship between apathy and disability, understanding the neurobiology of apathy and developing treatments for apathy may improve the functional outcomes of late-life depression.

Sub-regional volumes changes of the corpus callosum in the drug naive patients with late-onset depression

Although sub-regional analysis methods of the corpus callosum (CC) have been developed, there has been no in vivo magnetic resonance imaging (MRI) study on a sub-regional volume analysis of the CC of late-onset depression (LOD). The aim of this study was to investigate the CC volume differences between LOD subjects and healthy elderly controls using a sub-regional analysis technique. Forty subjects with LOD and thirty nine group-matched healthy control subjects underwent 3T MRI scanning, and sub-regional volumes of the CC were measured and compared between the groups. The volumes of total (F=5.8, p=0.001), the anterior (F=5.2, p=0.001) and the posterior CC (F=5.1, p=0.001) were significantly reduced in the LOD group as compared to the control group. We measured cognitive functions in several different domains (language functions, verbal learning, visuospatial functions, delayed recall, memory consolidation, recognition memory, and executive functions) through the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease. The anterior CC volume in the LOD group showed significant positive correlation with the Verbal Fluency scores. The posterior CC volume in the LOD group was positively correlated significantly with the Word List Memory, the Word List Recall and the Constructional Praxis scores. This study is the first to elaborate the sub-regional volume differences of the CC between controls and LOD patients. These structural changes in the CC might be at the core of the underlying neurobiological mechanisms in LOD.

Reward-related decision making in older adults: relationship to clinical presentation of depression

OBJECTIVE

Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: (1) to use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression; and (2) to examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to older, healthy subjects, depressed, older patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients.

METHODS

We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, older patients with non-psychotic major depression and 36 older, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy, whereas 42 participants did not have apathy.

RESULTS

Older adults with depression and healthy comparison participants did not differ in their performance on the Iowa Gambling Task. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared with non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task.

CONCLUSIONS

This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals.

The salience network in the apathy of late-life depression

OBJECTIVE

Apathy is prevalent in late-life depression and predicts poor response to antidepressants, chronicity of depression, disability, and greater burden to caregivers. However, little is known about its neurobiology. Salience processing provides motivational context to stimuli. The aim of this study was to examine the salience network (SN) resting-state functional connectivity (rsFC) pattern in elderly depressed subjects with and without apathy.

METHODS

Resting-state functional MRI data were collected from 16 non-demented, non-MCI, elderly depressed subjects and 10 normal elderly subjects who were psychotropic-free for at least 2 weeks. The depressed group included 7 elderly, depressed subjects with high comorbid apathy and 9 with low apathy. We analyzed the rsFC patterns of the right anterior insular cortex (rAI), a primary node of the SN.

RESULTS

Relative to non-apathetic depressed elderly, depressed elderly subjects with high apathy had decreased rsFC of the rAI to dorsal anterior cingulate and to subcortical/limbic components of the SN. Depressed elderly subjects with high apathy also exhibited increased rsFC of the rAI to right dorsolateral prefrontal cortex and right posterior cingulate cortex when compared to non-apathetic depressed elderly.

CONCLUSIONS

Elderly depressed subjects with high apathy display decreased intrinsic rsFC of the SN and an altered pattern of SN rsFC to the right DLPFC node of the central executive network when compared to elderly non-apathetic depressed and normal, elderly subjects. These results suggest a unique biological signature of the apathy of late-life depression and may implicate a role for the rAI and SN in motivated behavior.

Comparison of brain structural variables, neuropsychological factors, and treatment outcome in early-onset versus late-onset late-life depression

OBJECTIVE

To compare differences in gray matter volumes, white matter and subcortical gray matter hyperintensities, neuropsychological factors, and treatment outcome between early- and late-onset late-life depressed (LLD) subjects.

METHODS

We conducted a prospective, nonrandomized, controlled trial at the outpatient clinics at Washington University and Duke University on 126 subjects, aged 60 years or older, who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression, scored 20 or more on the Montgomery-Asberg Depression Rating Scale (MADRS), and received neuropsychological testing and magnetic resonance imaging. Subjects were excluded for cognitive impairment or severe medical disorders. After 12 weeks of sertraline treatment, subjects' MADRS scores over time and neuropsychological factors were studied.

RESULTS

Left anterior cingulate thickness was significantly smaller in the late-onset depressed group than in the early-onset LLD subjects. The late-onset group also had more hyperintensities than the early-onset LLD subjects. No differences were found in neuropsychological factor scores or treatment outcome between early-onset and late-onset LLD subjects.

CONCLUSION

Age at onset of depressive symptoms in LLD subjects are associated with differences in cortical thickness and white matter and subcortical gray matter hyperintensities, but age at onset did not affect neuropsychological factors or treatment outcome.

Neuroanatomical correlates of apathy in late-life depression and antidepressant treatment response

BACKGROUND

Apathy is a prominent feature of geriatric depression that predicts poor clinical outcomes and hinders depression treatment. Yet little is known about the neurobiology and treatment of apathy in late-life depression. This study examined apathy prevalence in a clinical sample of depressed elderly, response of apathy to selective serotonin reuptake inhibitor (SSRI) treatment, and neuroanatomical correlates that distinguished responders from non-responders and healthy controls.

METHODS

Participants included 45 non-demented, elderly with major depression and 43 elderly comparison individuals. After a 2-week single-blind placebo period, depressed participants received escitalopram 10mg daily for 12 weeks. The Apathy Evaluation Scale (AES) and 24-item Hamilton Depression Rating Scale (HDRS) were administered at baseline and 12 weeks. MRI scans were acquired at baseline for concurrent structural and diffusion tensor imaging of anterior cingulate gray matter and associated white matter tracts.

RESULTS

35.5% of depressed patients suffered from apathy. This declined to 15.6% (p<0.1) following treatment, but 43% of initial sufferers continued to report significant apathy. Improvement of apathy with SSRI was independent of change in depression but correlated with larger left posterior subgenual cingulate volumes and greater fractional anisotropy of left uncinate fasciculi.

LIMITATIONS

Modest sample size, no placebo control, post-hoc secondary analysis, use of 1.5T MRI scanner

CONCLUSIONS

While prevalent in geriatric depression, apathy is separable from depression with regards to medication response. Structural abnormalities of the posterior subgenual cingulate and uncinate fasciculus may perpetuate apathetic states by interfering with prefrontal cortical recruitment of limbic activity essential to motivated behavior.

First episode psychosis in an adult area mental health service-a closer look at early and late-onset first episode psychosis

OBJECTIVES

To review the characteristics of all patients presenting with a first episode of psychosis between the ages of 16 and 65 years to an adult area mental health service.

METHODS

The early psychosis programme at St Vincent's Hospital Melbourne treats all patients presenting in the early stages of psychosis between the ages of 16 and 65 years. A database was developed to capture the demographic and diagnostic characteristics of the group. The characteristics of those with an onset under 26 years were compared with those with a later onset.

RESULTS

A large proportion (55%) of those presenting with first episode psychosis presented after the age of 25 years. There were a higher number of cases of depression with psychotic features in the older onset patients (notably so for those over 40) and a trend towards greater metabolic morbidity.

DISCUSSION

Older patients presenting with a first episode of psychosis are relatively understudied but appear to have certain distinguishing qualities. Understanding the needs of these patients is important in tailoring optimal treatment packages and service responses.

Soluble amyloid-β levels and late-life depression

Late-Life Major Depression (LLMD) is a complex heterogeneous disorder that has multiple pathophysiological mechanisms such as medical comorbidity, vascular-related factors and Alzheimer's disease (AD). There is an association between LLMD and AD, with LLMD possibly being a risk factor for, or early symptom of AD and vascular dementia. Whether depression is an etiologic risk factor for dementia, or part of the dementia prodrome remains controversial. AD has a long prodromal period with the neuropathologic features of the disease preceding the onset of clinical symptoms by as much as 15-20 years. Clinicopathological studies have provided robust support for the importance of Aβ42 in the pathogenesis of AD, but several other risk factors have also been identified. Given the relationship between Aβ42 and AD, a potential relationship between Aβ42 and LLMD would improve the understanding of the association between LLMD and AD. We reviewed 15 studies that analyzed the relationship between soluble Aβ42 and LLMD. For studies looking at plasma and/or cerebrospinal fluid (CSF) levels of Aβ42, the relationship between LLMD and soluble Aβ42 was equivocal, with some studies finding elevated Aβ42 levels associated with LLMD and others finding the opposite, decreased levels of Aβ42 associated with LLMD. It may be that there is poor reliability in the diagnosis of depression in late life, or variability in the criteria and the scales used, or subtypes of depression in late life such as early vs. late onset depression, vascular-related depression, and preclinical/comorbid depression in AD. The different correlations associated with each of these factors would be causing the inconsistent results for soluble Aβ42 levels in LLMD, but it is also possible that these patterns derive from disease stage-dependent differences in the trajectory of CSF Aβ42 during older age, or changes in neuronal activity or the sleep/wake cycle produced by LLMD that influence Aβ42 dynamics.

A systematic review comparing clinical features in early age at onset and late age at onset late-life depression

BACKGROUND

Although evidence suggests that there are neurobiological differences between unipolar depression in younger versus older adults, conflicting evidence exists about whether these manifest as clinically identifiable differences.

METHOD

We conducted a systematic review of aetiological, phenomenological and outcome studies to examine the evidence for a distinction between early onset (EOD) and late onset (LOD) depression. A literature search was completed using the computer databases MEDLINE, EMBASE, PSYCHINFO and PUBMED for papers published between January 1982 and December 2012 which compared groups with EOD and LOD. Studies were included if they were of older people and compared symptoms, aetiological factors or outcomes. We conducted a quality assessment of included articles.

RESULTS

We identified 23 articles which met entry criteria. The only clinical feature which was different between the groups was a higher frequency of a family history of mood disorders in EOD.

LIMITATIONS

The number of studies identified was low and their quality was generally poor.

CONCLUSIONS

Although neurobiological studies have reported differences between EOD and LOD, generally these do not appear to translate into identifiable distinguishing clinical features.

Functional connectivity in apathy of late-life depression: a preliminary study

BACKGROUND

Apathy is common in late-life depression and is associated with disability and poor antidepressant response. This study examined whether resting functional connectivity (FC) of the nucleus accumbens (NAcc) and the dorsal anterior cingulate (dACC) with other structures can distinguish apathetic depressed older patients from non-apathetic depressed patients and normal subjects.

METHODS

Twenty-six non-demented, non-MCI older adults were studied. Of these, 16 had major depression (7 also had apathy) and 10 had no psychopathology. Resting state fMRI was performed prior to treatment in subjects who were psychotropic-free for at least two weeks. FC was determined by placing seeds in the NAcc and the dACC bilaterally.

RESULTS

Apathetic depressed patients had lower FC of the NAcc with the amygdala, caudate, putamen, globus pallidus, and thalamus and increased FC with the dorsomedial prefrontal cortex, the superior frontal cortex, and the insula than non-apathetic patients. Further, apathetic patients had lower FC of the dACC with dorsolateral and ventrolateral prefrontal cortices and higher FC with the insula and the orbitofrontal cortex than non-apathetic patients.

LIMITATIONS

Small number of subjects, lack of random sampling, use of a 1.5T MRI scanner.

CONCLUSIONS

This preliminary study suggests that FC between the NAcc and the dACC and structures related to reward and related behavioral responses constitute the functional topography of abnormalities characterizing apathy of late life depression. However, replication is needed.

Comparison of major depressive disorder and subthreshold depression among older adults in community long-term care

OBJECTIVES

This study extends existing knowledge regarding the continuum between major depression (MD) and subthreshold depression (SD) by examining differences in symptomology and associative factors for a subpopulation of older adults with functional disability.

METHOD

Our sample consisted of clients age 60 and above entering public community long term care derived from the baseline survey of a longitudinal study (315 non-depressed, 74 MD, and 221 SD). We used the Diagnostic Interview Schedule to establish diagnoses of MD, the Center for Epidemiological Studies Depression Scale (CES-D) to assess SD, and other self-report measures to explore potential associative factors of demographics, comorbidity, social support, and stressors.

RESULTS

No differences in CES-D identified symptoms occurred between the two groups. MD and SD were both associated with lower education, poorer social support, more severe medical conditions, and higher stress when compared to non-depressed older adults. Younger age and being female were associated solely with MD; whereas, worse perceived health and more trouble affording food were associated solely with SD. The only associative factor significantly different between MD and SD was age. Those with MD were more likely to be younger than those with SD.

CONCLUSION

Our findings of symptom profiles and associative factors lend support to the continuum notion of depression. Identification of only older adults within the community long-term care service system who meet criteria for MD would leave many older adults, who also face multiple comorbidities, high levels of stress and social isolation, and substantial depressive symptoms undiagnosed and untreated.

Manipulating the sleep-wake cycle and circadian rhythms to improve clinical management of major depression

BACKGROUND

Clinical psychiatry has always been limited by the lack of objective tests to substantiate diagnoses and a lack of specific treatments that target underlying pathophysiology. One area in which these twin failures has been most frustrating is major depression. Due to very considerable progress in the basic and clinical neurosciences of sleep-wake cycles and underlying circadian systems this situation is now rapidly changing.

DISCUSSION

The development of specific behavioral or pharmacological strategies that target these basic regulatory systems is driving renewed clinical interest. Here, we explore the extent to which objective tests of sleep-wake cycles and circadian function - namely, those that measure timing or synchrony of circadian-dependent physiology as well as daytime activity and nighttime sleep patterns - can be used to identify a sub-class of patients with major depression who have disturbed circadian profiles.

SUMMARY

Once this unique pathophysiology is characterized, a highly personalized treatment plan can be proposed and monitored. New treatments will now be designed and old treatments re-evaluated on the basis of their effects on objective measures of sleep-wake cycles, circadian rhythms and related metabolic systems.

Reversal alterations of amplitude of low-frequency fluctuations in early and late onset, first-episode, drug-naive depression

BACKGROUND

It is unclear how patients with early onset depression (EOD) and late onset depression (LOD) differ at the neural level. Using amplitude of low-frequency fluctuations (ALFF) approach, we are to test the hypothesis of the different abnormal neural activities between patients with EOD and LOD.

METHODS

Fifteen patients with EOD, 15 patients with LOD, 15 young healthy subjects (HS) and 15 old HS were enrolled in the study. ALFF approach was employed to analyze the images.

RESULTS

ANOVA analysis revealed widespread differences in ALFF values among the four groups throughout frontal, parietal, temporal, occipital cortex, cerebellum and limbic regions. Compared to LOD group, EOD group had higher ALFF in bilateral precuneus, superior medial frontal gyrus and superior frontal gyrus, and lower ALFF in left brainstem and left superior temporal gyrus. Compared to young HS, lower ALFF in left superior/inferior temporal gyrus, left lingual gyrus and right middle occipital gyrus and higher ALFF in left medial frontal gyrus and bilateral superior frontal gyrus were seen in the EOD group; in contrast, in the LOD group, lower ALFF in bilateral superior frontal gyrus and higher ALFF in left superior temporal gyrus were observed. Further ROC analysis suggested that the mean ALFF values in the bilateral superior frontal gyrus and left superior temporal gyrus could serve as markers to separate patients with EOD from individuals with LOD.

CONCLUSIONS

Patients with EOD and LOD exhibit reversal pattern of abnormal ALFF in bilateral superior frontal gyrus and left superior temporal gyrus.

Association of five-factor model personality domains and facets with presence, onset, and treatment outcomes of major depression in older adults

OBJECTIVES

To assess the relationship of multiple domains and facets of the five-factor model of personality with presence, onset, and severity of late-life depression.

DESIGN

Cross-sectional analysis of depression status, and age of onset. Retrospective analysis of baseline severity. Longitudinal analysis of severity after 3 and 12 months of psychiatric treatment.

SETTING

Private university-affiliated medical center in the Southeastern United States.

PARTICIPANTS

One hundred twelve psychiatric patients with a current episode of unipolar major depression, and 104 nondepressed comparison subjects, age 60 and older (mean: 70, SD: 6).

MEASUREMENTS

Revised NEO Personality Inventory, Diagnostic Interview Schedule, and Montgomery-Åsberg Depression Rating Scale.

RESULTS

Binary logistic regression found that depression was related to higher neuroticism (and all its facets) and to lower extraversion (and facets of assertiveness, activity, and positive emotionality) and conscientiousness (and facets of competence, order, dutifulness, and self-discipline). Multinomial logistic regression found some of these relationships held only for depression with onset before age 50 (hostility, self-consciousness, extraversion, assertiveness, positive emotions, order, and dutifulness). Linear regression found that personality was unrelated to depression severity at the beginning of treatment, but improvement after 3 months was related to lower neuroticism (and facets depressiveness and stress-vulnerability) and higher warmth and competence. Improvement after 12 months was related to lower neuroticism, depressiveness, and stress-vulnerability.

CONCLUSIONS

Specific personality facets are related with depression and treatment outcomes. Screening for certain personality traits at the start of treatment may help identify patients at risk of worse response to treatment after 3 months.

Early and late onset, first-episode, treatment-naive depression: same clinical symptoms, different regional neural activities

BACKGROUND

Patients with early onset depression (EOD) and late onset depression (LOD) have distinctive risk factors and clinical pictures. Using regional homogeneity (ReHo) approach, we were to test the hypothesis of the different abnormal neural activity between patients with EOD or LOD.

METHODS

Fifteen patients with EOD, 15 patients with LOD, 15 young healthy subjects (HS) and 15 old HS participated in the study. ReHo approach was employed to analyze the scans.

RESULTS

ANOVA analysis revealed widespread differences in ReHo values among the four groups throughout frontal, parietal, temporal, occipital cortex, cerebellum and limbic regions. Compared to LOD group, EOD group had higher ReHo in right precuneus (PCu) and bilateral superior frontal gyrus, and lower ReHo in left superior temporal gyrus. Compared to young HS, lower ReHo in left parahippocampal gyrus and higher ReHo in left fusiform gyrus and bilateral superior frontal gyrus were seen in EOD group; in contrast, in LOD group, lower ReHo in right PCu and higher ReHo in left superior temporal gyrus and left Crus I of the cerebellum were observed. Further ROC analysis suggested that the mean ReHo values in right PCu and bilateral superior frontal gyrus could serve as markers to identify patients with EOD from individuals with LOD.

LIMITATION

The large age gap may limit the translational value of our findings.

CONCLUSIONS

Patients with EOD and those with LOD have abnormal neural activities in different brain regions, although the two groups share the same symptoms.

The role of glia in late-life depression

Late-life depression (LLD) has a complex and multifactoral etiology. There is growing interest in elucidating how glia, acting alone or as part of a glial-neuronal network, may contribute to the pathophysiology of depression. In this paper, we explore results from neuroimaging studies showing gray-matter volume loss in key frontal and subcortical structures implicated in LLD, and present the few histological studies that have examined neuronal and glial densities in these regions. Compared to results in younger people with depression, there appear to be age-dependent differences in neuronal pathology but the changes in glial pathology may be more subtle, perhaps reflecting a longer-term compensatory gliosis to earlier damage. We then consider the mechanisms by which both astrocytes and microglia may mediate and modulate neuronal dysfunction and possible degeneration in depression. These include a critical role in the response to peripheral inflammation and central microglial activation, as well as a key role in glutamate metabolism. Advances in our understanding of glia are highlighted, including the role of microglia as "electricians" of the brain and astrocytes as key communicating cells, an integral part of the tripartite synapse. Finally, implications for clinicians are discussed, including the consideration of glia as biomarkers for LLD and incorporation of glia into future therapeutic strategies.

Latent class-derived subgroups of depressive symptoms in a community sample of older adults: the Cache County Study

OBJECTIVE

We sought to identify possible subgroups of elders that varied in depressive symptomatology and to examine symptom patterns and health status differences between subgroups.

METHODS

The Cache County memory study is a population-based epidemiological study of dementia with 5092 participants. Depressive symptoms were measured with a modified version of the diagnostic interview schedule-depression. There were 400 nondemented participants who endorsed currently (i.e., in the past 2 weeks) experiencing at least one of the three "gateway" depressive symptoms and then completed a full depression interview. Responses to all nine current depressive symptoms were modeled using the latent class analysis.

RESULTS

Three depression subgroups were identified: a significantly depressed subgroup (62%), with the remainder split evenly between a subgroup with low probability of all symptoms (21%), and a subgroup with primarily psychomotor changes, sleep symptoms, and fatigue (17%). Latent class analysis derived subgroups of depressive symptoms and Diagnostic and statistical manual of mental disorders, fourth edition depression diagnostic group were nonredundant. Age, gender, education, marital status, early or late onset, number of episodes, current episode duration, and functional status were not significant predictors of depression subgroup. The first subgroup was more likely to be recently bereaved and had less physical health problems, whereas the third subgroup were less likely to be using antidepressants compared with the second subgroup.

CONCLUSIONS

There are distinct subgroups of depressed elders, which are not redundant with the Diagnostic and statistical manual of mental disorders, fourth edition classification scheme, offering an alternative diagnostic approach to clinicians and researchers. Future work will examine whether these depressive symptom profiles are predictive of incident dementia and earlier mortality.

Lifetime romantic attachment style and social adaptation in late-onset depression

BACKGROUND

Measuring social adjustment (including attachment style and current social adaptation) in late-life depression may support planning secondary prevention, rehabilitation, and treatment. Insecure attachment style is a risk factor for developing new depression, and social adjustment may constitute a problem after symptoms abatement. Few studies have examined attachment style and social adjustment in late-onset depression.

DESIGN

Subjects 50 years of age and older with early-onset (n = 35), late-onset DSM-IV unipolar depression (n = 38), and never-depressed volunteers (n = 47) were assessed with a widely used measure of attachment style (the Experiences in Close Relationship Scale). Social adjustment was measured using the Social Adjustment Scale.

RESULTS

Both early-onset and late-onset patients with depression showed greater insecure attachment and poorer social adaptation compared with never-depressed volunteers. No difference was found between early-onset and late-onset patients with depression on attachment style or social adjustment. There were no significant differences between late-life depression in remission or current on attachment or social adaptation.

CONCLUSION

Insecure attachment style may be a risk factor for late-life depression irrespective of the age of onset. Social maladaptation may persist among individuals with late-life depression in remission.

Cellular abnormalities in depression: evidence from postmortem brain tissue

During the past two decades, in vivo neuroimaging studies have permitted significant insights into the general location of dysfunctional brain regions in depression. In parallel and often intersecting ways, neuroanatomical, pharmacological, and biochemical studies of postmortem brain tissue are permitting new insights into the pathophysiology of depression. In addition to long-recognized neurochemical abnormalities in depression, novel studies at the microscopic level support the contention that mood disorders are associated with abnormalities in cell morphology and distribution. In the past 6 years, cell-counting studies have identified changes in the density and size of both neurons and glia in a number of frontolimbic brain regions, including dorsolateral prefrontal, orbitofrontal, and anterior cingulate cortex, and the amygdala and hippocampus. Convergence of cellular changes at the microscopic level with neuroimaging changes detected in vivo provides a compelling integration of clinical and basic research for disentangling the pathophysiology of depression. The ultimate integration of these two research approaches will occur with premortem longitudinal clinical studies on well-characterized patients linked to postmortem studies of the same subjects.

Early and late onset depression in young and middle aged adults: differential symptomatology, characteristics and risk factors?

BACKGROUND

Early onset depression (EOD) and late onset depression (LOD) may be different phenomena. In this study, differences between EOD and LOD in symptomatology, psychiatric characteristics and psychosocial/somatic factors were examined.

METHODS

Baseline data were from 1104 participants with a current major depressive disorder participating in the Netherlands Study of Depression and Anxiety (age range 18-65 years). DSM-IV diagnoses, depressive symptoms and age of onset were assessed with the Composite International Diagnostic Interview. Analyses were performed by using a continuous as well as a dichotomous (cut-off 40 years) age of onset indicator.

RESULTS

Differences between EOD and LOD were observed: longer duration of symptoms (p<.001), a personal history of depressive episodes (p<.001), a serious suicide attempt (p<.001), childhood events (p<.001), a family history of depression (p=.03), and high neuroticism (p<.001) were more often present in EOD than in LOD. Also differences in symptomatology were observed: feelings of sadness (p<.001), diminished concentration (p=.02) and suicidal thoughts (p=.001) were significantly less prevalent at a higher age of onset, whereas decreased appetite/weight loss (p=.01) was more prominent at a higher age of onset.

LIMITATIONS

The age of first depression onset was asked retrospectively and might be biased by selective recall. However, participants can likely recall whether symptoms started earlier or later in life.

CONCLUSIONS

Despite similarities, our observed differential findings in symptoms, psychiatric characteristics, and psychosocial factors between EOD and LOD further support that EOD is associated with more frequent occurrence of some clinical features of depression. These differential findings are important factors to keep in mind for diagnostics, treatment, and prevention.

Regional cortical thickness and subcortical volume changes are associated with cognitive impairments in the drug-naive patients with late-onset depression

Previous studies have shown an association between late-onset depression (LOD) and cognitive impairment in older adults. However, the neural correlates of this relationship are not yet clear. The aim of this study was to investigate the differences in both cortical thickness and subcortical volumes between drug-naive LOD patients and healthy controls and explore the relationship between LOD and cognitive impairments. A total of 48 elderly, drug-naive patients with LOD and 47 group-matched healthy control subjects underwent 3T MRI scanning, and the cortical thickness was compared between the groups in multiple locations, across the continuous cortical surface. The subcortical volumes were also compared on a structure-by-structure basis. Subjects with LOD exhibited significantly decreased cortical thickness in the rostral anterior cingulate cortex, the medial orbitofrontal cortex, dorsolateral prefrontal cortex, the superior and middle temporal cortex, and the posterior cingulate cortex when compared with healthy subjects (all p<0.05, false discovery rate corrected). Reduced volumes of the right hippocampus was also observed in LOD patients when compared with healthy controls (p<0.001). There were significant correlations between memory functions and cortical thickness of medial temporal, isthmus cingulate, and precuneus (p<0.001). This study was the first study to explore the relationships between the cortical thickness/subcortical volumes and cognitive impairments of drug-naive patients with LOD. These structural changes might explain the neurobiological mechanism of LOD as a risk factor of dementia.

Subtypes of mild cognitive impairment among the elderly with major depressive disorder in remission

BACKGROUND

Cognitive impairment in remitted late-life depression varies and might be associated with greater risk of dementia in some individuals. This study aimed to classify the subtypes of mild cognitive impairment (MCI) in late-life major depressive disorder in remission and to examine their clinical correlates and structural magnetic resonance imaging (MRI) features.

METHODS

Elderly patients with major depressive disorder in remission and elderly comparisons were examined by a comprehensive battery of cognitive tasks. Proposed diagnostic criteria were used for MCI classification, and the degree of brain atrophy and white matter hyperintensity on MRI were evaluated.

RESULTS

We found information-processing speed and memory were independent cognitive domains associated with late-life remitted major depressive disorder. Of the study cohort, 52.3% met the definition of MCI, including 28.5% with amnestic MCI (aMCI) and 23.8% with nonamnestic MCI (naMCI). A clinical correlate of aMCI was the late-onset of disorder (OR = 4.76; 95% CI = 1.57, 14.40) and of naMCI was a higher score on the Framingham stroke risk scale (OR = 1.39; 95% CI = 1.12, 1.72). The odds ratio of highest quartile of ventricular atrophy for aMCI compared to the comparisons was 3.65 (95% CI = 1.22, 10.96).

CONCLUSIONS

The central cognitive impairments among the elderly with major depressive disorder in remission were memory and information-processing speed, and over half of the subjects met the MCI diagnostic criteria. Different risk factors existed for the subtypes of aMCI and naMCI. Later-age onset of first episode and ventricular atrophy were associated with aMCI, whereas vascular risk factor were associated with naMCI. We suggest there were different pathogeneses between aMCI and naMCI in late-life major depressive disorder.

Striatal Hypodensities, Not White Matter Hypodensities on CT, Are Associated with Late-Onset Depression in Alzheimer's Disease

This study examined whether there were neuroanatomical differences evident on CT scans of individuals with dementia who differed on depression history. Neuroanatomical variables consisted of visual ratings of frontal lobe deep white matter, subcortical white matter, and subcortical gray matter hypodensities in the CT scans of 182 individuals from the Study of Dementia in Swedish Twins who were diagnosed with dementia and had information on depression history. Compared to individuals with Alzheimer's disease and no depression, individuals with Alzheimer's disease and late-onset depression (first depressive episode at age 60 or over) had a greater number of striatal hypodensities (gray matter hypodensities in the caudate nucleus and lentiform nucleus). There were no significant differences in frontal lobe deep white matter or subcortical white matter. These findings suggest that late-onset depression may be a process that is distinct from the neurodegenerative changes caused by Alzheimer's disease.

Suicide in later life: a comparison between cases with early-onset and late-onset depression

BACKGROUND

Suicide rates are high in elderly people with depressive disorder. We compared behavioural, clinical and care characteristics of depressed elderly patients, aged 60years and over at the time of death by suicide, with an early-onset depression (EOD, onset before 60years) with those patients with a late age of onset (LOD).

METHOD

From a 10-year national clinical survey of all suicides in England and Wales (n=13066) we identified 549 LOD cases, and 290 EOD cases. EOD and LOD cases were compared by logistic regression adjusted for age at suicide.

RESULTS

Method of suicide did not differ by age of onset of depression. LOD cases were significantly less likely to have a history of psychiatric admissions (OR=0.2 [0.1-0.3]), alcohol misuse (OR=0.6 [0.4-0.9]) and self-harm (0.6 [0.4-0.8]). LOD cases also had a lower prevalence of a psychiatric co-morbid diagnosis (0.6 [0.4-0.7]) and a lower prescription rate for psychotropic drugs other than antidepressants. Furthermore, the number of recent life-events was significantly higher (OR=1.4 [1.0-1.9]) in LOD while the frequency of recent self-harm was similar to EOD.

CONCLUSION

Although our study suggests that psychopathology of suicide among elderly depressed patients differs between EOD and LOD, the final pathway (via recent self-harm) to suicide may be similar in up to a quarter of patients in both groups. Our results suggest that strategies to enhance coping abilities and provision of support to negate the effects of life-events might be especially important in the prevention of suicide in LOD.

Functional neuroimaging in geriatric depression

Abnormalities in specific cerebral networks likely confer vulnerability that increases the susceptibility for development of geriatric depression and affect the course of symptoms. Functional neuroimaging enables the in vivo identification of alterations in cerebral function that characterize disease vulnerability and contribute to variability in depressive symptoms and antidepressant response. Judicious use of functional neuroimaging tools can advance pathophysiologic models of geriatric depression. Furthermore, geriatric depression provides a logical context within which to study the role of specific functional abnormalities in both antidepressant response and key behavioral and cognitive abnormalities of mood disorders.

Gray matter volumes of pain-related brain areas are decreased in fibromyalgia syndrome

Fibromyalgia (FM) is a chronic, widespread musculoskeletal pain disorder that is very prevalent in the general population (approximately 5%). Accumulating evidence suggests that FM is associated with central pain processing abnormalities, ie, central sensitization. Several previous studies of chronic pain patients, including FM, have shown gray matter atrophy of brain areas associated with sensory and affective pain processing. These findings, however, have not been confirmed in all FM studies. In this study, we investigated gray matter volumes of brain areas associated with pain-related areas of FM patients identified by functional brain imaging. Using voxel-based morphometric (VBM) analysis of magnetic resonance brain images, we compared 19 pain-related brain areas of 14 female FM patients and 11 healthy controls (NC). We found that FM patients had significantly less gray matter volumes than NC in 3 of these brain regions, including the anterior and mid-cingulate, as well as mid-insular cortices. Importantly, FM patients demonstrated neither global gray matter atrophy nor gray matter changes associated with depression, as shown in some studies. Using a more stringent analysis than other VBM studies, we provide evidence for decreased gray matter volumes in a number of pain-related brain areas in FM. Although the mechanisms for these gray matter changes are presently unclear, they may contribute to some of the core features of this chronic disorder including affective disturbances and chronic widespread pain.

PERSPECTIVE

Increasing evidence supports the association of chronic pain with accelerated gray matter atrophy in pain disorders like low back pain, IBS, and FM syndrome. However, cause-effect relationships between chronic pain and decreased gray matter volumes have not been established yet and will require future prospective studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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