Use of antidepressants by nonpsychiatrists in the treatment of medically ill hospitalized depressed elderly patients

Recognition and treatment of depression in older adults admitted to acute hospitals in England

Levels of awareness and treatment of depression in older adults admitted to acute hospitals are unclear. This study aims to examine the proportion of older adults diagnosed with depression in acute hospitals, treatment, referral, and communication between secondary and primary healthcare services following discharge. Retrospective examination of records of 766 older adults admitted to 27 acute hospitals in England was carried out. Ninety-eight (12.7%, 95% confidence interval (CI) = 10.6-15.3) records included a diagnosis of depression of which eight (1.0%, 95% CI = 0.5-2.0) had a new diagnosis made during their hospital admission. All newly diagnosed and 76 (84.4%, 95% CI = 75.5-90.5) of those with an existing diagnosis of depression were prescribed antidepressant medication. Six (75.0%, 95% CI = 40.9-92.8) of those with a new diagnosis, and 21 (23.3%, 95% CI = 15.8-33.0) with an existing diagnosis of depression were referred to liaison psychiatry. References to mental health were made in 50 (51.0%, 95% CI = 41.2-60.6) discharge letters sent to primary care. Very few older adults admitted to acute hospitals in this study were diagnosed with depression during their inpatient stay. Opportunities for improving the mental and physical health of such patients appear to be being missed.

Suicidal ideation in medical inpatients: psychosocial and clinical correlates

OBJECTIVE

To identify psychosocial and clinical correlates of suicidal ideation in medical inpatients.

METHOD

In a cross-sectional study, all adults consecutively admitted to the medical wards of a University Hospital had their names recorded and were randomized and evaluated during the first week of admission. Suicidal ideation was assessed using Item 9 of Patient Health Questionnaire-9. The Beck Depression Inventory, the Beck Anxiety Inventory, the WHO Subjective well-being scale, the Charlson Comorbidity Index and other numerical rating scales (pain and self-reported physical illness severity) were used. Patients with less than four confidants were considered with poor social support. The Student's t test, Mann-Whitney U test, chi-square test and stepwise logistic regression analysis were used.

RESULTS

Of the 1092 patients who composed the sample, 7.2% reported having suicidal ideation. After adjusting for psychosocial and clinical confounders, prior suicide attempts (OR: 4.41; 95% CI: 2.12-9.15; P<.001), depressive symptoms (OR: 1.11; 95% CI: 1.06-1.17; P<.001), severe anxiety symptoms (OR: 3.04; 95% CI: 1.47-6.26; P=.003) and poor social support (OR: 2.02; 95% CI:1.03-3.96; P=.04) were independently associated with suicidal ideation.

CONCLUSIONS

Three out of the four correlates of suicidal ideation in medical inpatients are potentially modifiable factors: severe anxiety, depressive symptoms and poor social support. The fourth variable, prior suicide attempts, is not modifiable but should serve as a red flag to suspect and investigate current suicide risk. These findings highlight the importance of suicidal ideation as a proxy for the distress that is incumbent upon physicians to manage if they wish to provide excellent and comprehensive inpatient care.

Which version of the geriatric depression scale is most useful in medical settings and nursing homes? Diagnostic validity meta-analysis

BACKGROUND

The Geriatric Depression Scale (GDS) has been evaluated in individual studies, but its validity and added value in medical settings and nursing homes is uncertain. Therefore, the authors conducted a meta-analysis, analyzing the diagnostic accuracy of long, short, and ultrashort versions of the GDS and stratified this into those with and without cognitive impairment.

METHODS

A comprehensive search identified 69 studies that measured the diagnostic validity of the GDS against a semistructured psychiatric interview, and of these, 43 analyses (in 36 publications) took place inmedical settings. Twenty-one studies examined the GDS₃₀, 12 studies examined the GDS₁₅, and 3 examined the GDS₄(/)₅. For comparison, the authors also summarized studies examining unassisted clinical judgment. Heterogeneity was moderate to high; therefore, random effects meta-analysis was used.

RESULTS

Across all studies, the prevalence of late-life depression was 29.2% (95% confidence interval [CI] = 24.7%–33.9%), with no difference between inpatients, outpatients, and nursing homes. Diagnostic accuracy of the GDS₃₀ aftermeta-analytic weighting was given by a sensitivity of 81.9% (95% CI = 76.4%–86.9%) and a specificity of 77.7% (95% CI = 73.0%–82.1%). For the GDS₁₅, sensitivity was 84.3% (95% CI = 79.7%–88.4%) and specificity was 73.8% (95% CI = 68.0%–79.2%). For the GDS₄(/)₅, the sensitivity and specificity were 92.5% (95% CI = 85.5%–97.4%) and 77.2% (95% CI = 66.6%–86.3%), respectively. Results were not significantly influenced by the presence of dementia. Concerning added value, when identification using the GDS was compared with routine clinicians’ ability to diagnose late-life depressions, at a prevalence of 30%, of every 100 attendees, the GDS₃₀ would help correctly identify an additional 22 people as depressed but at a cost of 13 additional false positives. The GDS₁₅ performed the same as GDS₃₀ but with 15 false positives. The ultrashort form would help identify an additional 25 true positives with only 10 false positives. Thus, the best option when choosing between versions of the GDS seems to be the GDS₄(/)₅.

CONCLUSION

All versions of the GDS yield potential added value in medical settings, but the GDS₄(/)₅ is the most efficient. In nursing homes, given an absence of data on the GDS₄(/)₅, the GDS₁₅ may be preferred until more studies are reported.

Prevalence of depression in a general hospital in Izhevsk, Russia

BACKGROUND

There are a lot of studies on depressive disorders in a general hospital done across the world, but no data from Russia on this subject was found in international psychiatric journals or MEDLINE.

AIMS

to determine the prevalence of depressive disorders in medical inpatients in Izhevsk, the capital of the Udmurt Republic, a region in Russia, and to identify associated factors.

METHOD

A sample of 323 adult medical inpatients was composed. The Russian version of the MINI 5.0.0 was used.

RESULTS

The prevalence of lifetime and current depressive disorders was 30% and 20.7%, respectively. Depression was more common in women, widowed or divorced, retired or disabled, with low income and bad family relationships, and among respondents with a chronic somatic illness. Depression had a high comorbidity with organic mental and anxiety disorders. Only 40.3% of the individuals with depression had referred for psychiatric consultations, most of them being treated with fluvoxamine.

CONCLUSIONS

Prevalence of depression was substantial but consistent with other studies. Taking into consideration associated factors, physicians can improve recognition and treatment of depression in medical inpatients.

Trends in antidepressant use in the older population: results from the LASA-study over a period of 10 years

BACKGROUND

In the past 15 years, antidepressant use in adults has increased, mainly due to a rise in SSRI-use. The question is if this is true for older adults as well.

METHODS

Data from the Longitudinal Aging Study Amsterdam were used to investigate trends in antidepressant use from 1992 through 2002 in a population-based sample aged 65-85 years.

RESULTS

Antidepressant use increased from 2% to 6%. In the group with major depressive disorder, treatment with antidepressants showed an increase from 15% to 30%. This increase was larger in the older-old than in the younger old. Also, the increase was mainly due to a rise in SSRI-use. Daily TCA-dosages often were too low; dosages of the other antidepressants seemed to be sufficient. However, rates of depression remained stable, in the treated as well as in the untreated group.

LIMITATIONS

Non-response was associated with depression, the indication for prescription of antidepressants was not known, and serum concentrations of antidepressants were not available.

CONCLUSIONS

Antidepressant use in older people increased over the past 15 years, mainly due to a rise in SSRI-use. Daily dosages of antidepressants had become more adequate. Still only a minority of the more severely depressed used antidepressants.

The increased need for liaison psychiatry in surgical patients due to the high prevalence of undiagnosed anxiety and depression

BACKGROUND

Depression is the most common mental disease in patients hospitalized with physical illness. Disorders of anxiety and depression in general hospitals are frequently underdiagnosed and inappropriately treated.

AIM

To assess the prevalence of undiagnosed anxiety and depression in surgical inpatients and assess the referral rate and utilization of liaison psychiatry services.

METHODS

A prospective study of surgical admissions (n = 96) to two surgical services at two separate institutions between 01/01/05 and 31/12/05. The Hospital Anxiety and Depression (HADS) scale was used to evaluate all patients.

RESULTS

About 12.5% of patients had significant depression, 18.75% had significant anxiety, and 8.3% had significant mixed anxiety and depression. About 22.9% of patients warranted referral to liaison psychiatry services for further assessment and management.

CONCLUSIONS

Anxiety and depression are highly prevalent in surgical inpatients. An increased awareness of the possibility of undiagnosed psychiatric disorders is required, along with prompt and appropriate use of liaison psychiatry services.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Physician attitudes toward treatment of depression in older medical inpatients

OBJECTIVES

To better understand low treatment (<50%) and psychiatry referral rates (<10%) of depressed older medical patients, we examined medical physicians' characteristics, attitudes and practices regarding treatment.

METHODS

Physicians caring for a consecutive series of 1000 depressed older patients during medical hospitalization and/or after discharge were asked about their general attitudes and behaviors related to the treatment of depression in older patients.

RESULTS

Of 422 physicians responding to questionnaires, less than half (48%) usually started more than two patients a month on antidepressants. Even fewer (14%) referred more than two patients a month for counseling; 37% usually referred none. Only 11% referred more than two patients a month to psychiatrists; nearly 40% usually referred none. Antidepressants, counseling, and psychiatric referral were seldom thought very effective. Physicians out of their training and those in primary care specialties (especially family practice) were more likely to treat patients. Common reasons for not treating these patients were perceived resistance to treatment (62.3%), lack of time (61.1%), uncertainty of depression diagnosis (56.2%), belief that patients couldn't afford treatment (50.5%), and concern about medication/disease interactions (58.8%). One-third (33.5%) emphasized that they were unsure about treatment effectiveness and one-third (34.4%) that they were poorly prepared to treat depression in older patients. Non-white physicians were more likely to refer to psychiatrists.

CONCLUSIONS

Many older depressed patients in medical settings are not treated or referred. Physician experience and specialty may affect the decision to treat, and physician race may affect the decision to seek consultation. Therapeutic nihilism may be influential.

Diagnosis and pharmacological treatment of depressive disorders in a general hospital

OBJECTIVE: To determine the point prevalence of depressive disorders in medical inpatients, to identify related sociodemographic and medical factors and to evaluate the psychotropic treatment given. METHOD: A cross-sectional study identifying the prevalence of depressive disorders and related factors combined with a prospective longitudinal study evaluating the psychopharmacological treatment were conducted. Medical inpatients, aged 18 years or older, presenting suitability to be interviewed and giving written informed consent were selected. The sample was composed of 125 subjects. The following instruments were used: a sociodemographic questionnaire; the Mini International Neuropsychiatric Interview; and the Beck Depression Inventory. Data related to medical, personal and family histories of psychiatric disorders and psychotropic use were collected by interview and from patient charts. The study took place at the Hospital Santa Isabel, in Blumenau, located in the state of Santa Catarina, Brazil, from January to July of 2002. RESULTS: The prevalence of depressive disorders was 26%. The factors that correlated with depressive disorders were being female, having an income lower than 3 times the minimum wage, having a personal history of depressive disorders, using psychotropic drugs, scoring higher than 13 on the Beck Depression Inventory and having been referred for a psychiatric consultation (p < 0.05). Only 43.8% of the individuals with depressive disorders received antidepressants. Most of the depressed patients were being treated with benzodiazepines (62.5%). The most frequently prescribed drugs were diazepam and fluoxetine. CONCLUSIONS: Approximately one-quarter of the medical inpatients had depressive disorders. However, antidepressants were prescribed for less than half of them. Women with a history of depression, using benzodiazepines and having a low income presented significantly higher rates of depressive disorders. Physicians should suspect depression in patients presenting such characteristics.

Minor depression and physical outcome trajectories in heart failure and pulmonary disease

We examined conjoint trajectories of depression-physical illness outcomes in elderly inpatients with minor depression and heart failure or pulmonary disease, and identified demographic, psychosocial, physical, and treatment predictors of trajectory. Consecutively admitted patients over age 50 with heart failure and/or chronic pulmonary disease were screened for minor depression using the Structured Clinical Interview for Depression. Follow-up evaluations were performed at 6 and 12 weeks using the Longitudinal Interview Follow-Up Evaluation, Hamilton Depression Scale, and Chronic Heart Failure-Chronic Respiratory Disease Questionnaire. Patients were placed into four depression-physical illness outcome trajectories: (T#1) depression better, illness better; (T#2) depression better, illness same; (T#3) depression same, illness better; and (T#4) depression same, illness same. Bivariate and multivariate predictors were examined. Minor depression was identified in 587 patients. Of these, 487 were evaluated at 6 weeks and 444 at 12 weeks. By 6 weeks, 39.4% of patients improved both on depression and physical illness (T#1), and 27.3% improved on neither (T#4). By 12 weeks, 49.6% had improved on both and 20.5% on neither. Race, admitting hospital, past psychiatric history, family psychiatric history, comorbid physical illnesses, and antidepressant drug treatment independently predicted outcome trajectory. Improvements in depression and physical illness track closely together in elderly inpatients with heart failure or pulmonary disease. Baseline patient characteristics predict which outcome trajectory they are likely to follow after hospital discharge, and may be useful in diagnosis and management.

Diagnosticando depressão em pacientes internados com doenças hematológicas: prevalência e sintomas associados

INTRODUÇÃO: Não encontramos estudos avaliando o diagnóstico e a prevalência de depressão em pacientes hematológicos aqui no Brasil. OBJETIVO: Verificar a prevalência dos sintomas depressivos e quais deles mais se associam à depressão em pacientes internados com doenças hematológicas. MÉTODOS: Num estudo transversal, 104 pacientes consecutivamente internados nos leitos da hematologia do Hospital Universitário da Universidade Federal de Santa Catarina (HU/UFSC) foram avaliados. Foram preenchidos questionários de variáveis sociodemográficas e de história psiquiátrica. O índice Charlson de co-morbidade (IC) foi usado para medir gravidade física. Foi aplicado, também, o inventário Beck de depressão (BDI). Aqueles que tiveram pontuação acima de 9 na soma dos 13 primeiros itens do BDI (BDI-13) foram considerados deprimidos. Também foi verificada a freqüência caso fosse utilizada a escala completa com 21 itens (BDI-21), com ponto de corte 16/17. RESULTADOS: As prevalências foram: BDI-13 = 25% e BDI-21 = 32,7%. Após controle para fatores de confusão, os sintomas que permaneceram no modelo da regressão logística, indicando que melhor detectavam os deprimidos, foram sensação de fracasso, anedonia, culpa e fadiga. CONCLUSÃO: Cerca de um quarto a um terço dos pacientes internados com doenças hematológicas tinham sintomas depressivos significativos, e os sintomas que melhor os discriminaram foram sensação de fracasso, anedonia, culpa e fadiga.

Diagnosticando e tratando depressão no paciente com doença clínica

Diagnosticar depressão em um doente clínico é uma tarefa difícil por vários motivos. Muito embora tristeza e humor depressivo possam indicar síndrome depressiva subjacente, eles também podem fazer parte da adaptação normal a uma doença que ameace a vida. Os sintomas somáticos e vegetativos incluídos nos critérios diagnósticos das classificações atuais não são específicos e podem de fato ser atribuíveis à hospitalização, aos tratamentos ou à própria doença clínica. Tratar a depressão no paciente clínico é também difícil devido à preocupação com a interação de drogas, assim como questões de eficácia e segurança nesse grupo. Nesta conferência clínica os autores discutem questões como que diagnósticos podem ser feitos em pacientes clínicos com sintomas depressivos; prevalência de depressão em diferentes ambientes; mecanismos de co-morbidade (fatores fisiológicos e comportamentais) que relacionam a depressão às doenças clínicas e o manuseio da depressão nesse grupo.

Systematic detection and multidisciplinary care of depression in older medical inpatients: a randomized trial

BACKGROUND

Major depression is a frequent and serious disorder in older medical inpatients. Because the condition goes undetected and untreated in most of these patients, we conducted a randomized clinical trial to evaluate the effectiveness of a strategy of systematic detection and multidisciplinary treatment of depression in this population.

METHODS

Consecutive patients aged 65 years or more admitted to general medical services in a primary care hospital between October 1999 and November 2002 were screened for depression with the Diagnostic Interview Schedule (DIS) within 48 hours after admission. Patients found to have major depression were randomly allocated to receive the intervention or usual care. The intervention involved consultation and treatment by a psychiatrist and follow-up by a research nurse and the patient's family physician. Research assistants, blind to group allocation, collected data from the patients at enrollment and at 3 and 6 months later using the Hamilton Depression Rating Scale (HAMD), the Medical Outcomes 36-item Short Form (SF-36), the DIS, the Mini-Mental State Examination (MMSE), the Older Americans Resources and Services (OARS) questionnaire to assess basic and instrumental activities of daily living (OARS-ADL and OARS-IADL) and the Rating Scale for Side Effects. Data on the severity of illness, length of hospital stay, health services and medication use, mortality and process of care were also collected. The primary outcome measures were the HAMD and SF-36.

RESULTS

Of 1500 eligible patients who were screened, 157 were found to have major depression and consented to participate (78 in the intervention group and 79 in the usual care group). At randomization, there were no clinically or statistically significant differences between the 2 groups. Sixty-four patients completed follow-up to 6 months, 57 withdrew, and 36 died. At 6 months, there were no clinically or statistically significant differences the 2 groups in HAMD or SF-36 scores or any of the secondary outcome measures.

INTERPRETATION

We were unable to demonstrate that systematic detection and multidisciplinary care of depression was more beneficial than usual care for elderly medical inpatients.

The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients

OBJECTIVE

To examine the concurrent validity of the Beck Depression Inventory-Short Form (BDI-SF) to detect moderate and severe depressive episodes according to the International Classification of Diseases, 10th edition (ICD-10) criteria in inpatients with heterogeneous medical conditions and to set cut-off scores for its use in medical wards.

METHODS

One hundred and fifty-five patients [53% female; mean age (+/- S.D.) = 49.5 (+/- 17) years; mean number of years of education (+/- S.D.) = 6 (+/- 4) years] consecutively admitted to the adult medical wards in a General Hospital were interviewed during the first 72 h of hospitalization. The Clinical Interview Schedule [CIS] was used to make ICD-10 psychiatric diagnoses. All patients completed the BDI-SF. A "receiver operating characteristics" (ROC) curve was obtained and the sensitivity, specificity, positive and negative predictive values were calculated for different cut-off points of the BDI-SF.

RESULTS

High sensitivity and negative predictive value (NPV) were obtained with a cut-off score of 9/10 (sensitivity = 100%, specificity = 83.1%, NPV = 100%). High sensitivity and positive predictive value (PPV) were obtained with a cut-off score of 13/14 (sensitivity = 93.5%, specificity = 96%, PPV = 85.3%). The area under the ROC curve was 98.4% (95% Confidence Interval = 0.97-1.00).

CONCLUSIONS

The BDI-SF is a valid instrument for detecting moderate and severe depression in medical inpatients. For screening purposes, a 9/10 cut-off score is indicated, but if a high specificity is desired, a 13/14 cut-off score is warranted.

The impact of medical issues in inpatient geriatric psychiatry

At an advanced age, serious medical and psychiatric illnesses frequently coalesce. Often, the need for admission to inpatient geriatric psychiatric care arises from coexisting medical problems. While cognitive and behavioral interventions are important, the complexity of physical comorbidities usually becomes the focus of hospitalization and requires intensive medical treatments. This paper describes adaptations made in one metropolitan geriatric psychiatry unit in order to better treat complex patients who experience both medical and psychiatric illness. The need for all members of the interdisciplinary team to expand their practice and the importance of complementary approaches of psychiatry and medicine are emphasized.

Screening for depression in a geriatric rehabilitation sample

OBJECTIVE

To examine the utility of a short depression inventory (SDI) for use with elderly medical inpatients.

METHOD

Subjects were 132 consecutive admissions to the inpatient geriatric rehabilitation unit at MetroHealth Medical Center, a general medical teaching hospital in Cleveland, Ohio. Sixty of the original sample qualified for inclusion in the final sample. Within the first five days of admission, all subjects were administered the Mini-Mental Status Examination (MMSE). Ss who scored 20 or above were asked to complete the SDI and the GDI. A clinical interview used DSM-III-R criteria to establish the diagnosis of major depression. The order of presentation of questionnaire or interview was varied to control for the effects of presentation order.

RESULTS

When an optimal cut-off score of 4 or above on the SDI was used, the sensitivity and specificity were 100% and 85% respectively. Using the GDS, sensitivity and specificity were 100% and 90%.

CONCLUSIONS

Using the SDI, impressive sensitivity and specificity were achieved. The SDI was also essentially equivalent to the GDI psychometrically. The SDI appears to have good promise as a depression screen in medical populations.

Complexity in late-life depression: impact of confounding factors on diagnosis, treatment, and outcomes

Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.

Drug treatment in depressed elderly in the Dutch community

OBJECTIVES

In older people, a diagnosis of depression is frequently missed, and proper treatment is subsequently hampered. We investigated antidepressant and benzodiazepine use in an older community sample, and assessed possible risk factors associated with non-treatment in depressed elderly.

METHODS

Data were used from the baseline measurements of the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified community sample of 3107 older Dutch people (55 to 85 years), respondents were screened on depression with the Center for Epidemiologic Studies Depression Scale (CES-D). In the depressed subsample depressive disorder according to DSM-III was assessed using the Diagnostic Interview Schedule (DIS). The use of antidepressants and anxiolytics (benzodiazepines) in the depressed subsample was measured, and associations with age, sex, cognitive impairment, physical health and anxiety symptoms were investigated.

RESULTS

Only 16% of the respondents with a major depressive disorder used antidepressants. More than half of them used non-therapeutic dosages. Lower antidepressant use was associated with cognitive impairment. Benzodiazepine use was more likely than antidepressant use, which was especially evident in females in the major depressive disorder group.

CONCLUSIONS

Depressed older people were undertreated, particularly when they were cognitively impaired. A high rate of benzodiazepine use was found, particularly in females.

Psychotropic prescription in non-psychiatric hospital settings

A study was conducted to assess differences in psychotropic prescription (PP) in various non-psychiatric hospital settings. After adjustment for demographic, medical and psychological status, rates of PP were significantly lower for surgical, intensive care and outpatients and higher for geriatric patients than for patients in other settings, suggesting inadequate consideration of psychiatric problems in certain contexts, in particular intensive care units.

Sertraline: a review of its use in the management of major depressive disorder in elderly patients

Sertraline is a selective serotonin reuptake inhibitor (SSRI) with well established antidepressant and anxiolytic activity. Results from several well designed trials show that sertraline (50 to 200 mg/day) is effective in the treatment of major depressive disorder in elderly patients (> or =60 years of age). Primary endpoints in most studies included the Hamilton Depression Rating Scale (HDRS), Clinical Global Impression (CGI) score and the Montgomery-Asberg Depression Rating Scale (MADRS). Sertraline was significantly more effective than placebo, and was as effective as fluoxetine, nortriptyline and imipramine in elderly patients. During one trial, amitriptyline was significantly more effective than sertraline [mean reduction from baseline on one of six primary outcomes (HDRS)], although no quantitative data were provided. Subgroup analysis of data from a randomised, double-blind trial in elderly patients with major depressive disorder suggests that vascular morbidity, diabetes mellitus or arthritis does not affect the antidepressant effect of sertraline. Secondary endpoints from these clinical trials suggest that sertraline has significant benefits over nortriptyline in terms of quality of life. In addition, significant differences favouring sertraline in comparison with nortriptyline and fluoxetine have been recorded for a number of cognitive functioning parameters. Sertraline is generally well tolerated in elderly patients with major depressive disorder, and lacks the marked anticholinergic effects that characterise the adverse event profiles of tricyclic antidepressants (TCAs). The most frequently reported adverse events in patients aged > or =60 years with major depressive disorder receiving sertraline 50 to 150 mg/day were dry mouth, headache, diarrhoea, nausea, insomnia, somnolence, constipation, dizziness, sweating and taste abnormalities. The tolerability profile of sertraline is generally similar in younger and elderly patients. Sertraline has a low potential for drug interactions at the level of the cytochrome P450 enzyme system. In addition, no dosage adjustments are warranted for elderly patients solely based on age.

CONCLUSION

Sertraline is an effective and well tolerated antidepressant for the treatment of major depressive disorder in patients aged > or =60 years. Since elderly patients are particularly prone to the anticholinergic effects of TCAs as a class, SSRIs such as sertraline are likely to be a better choice for the treatment of major depressive disorder in this age group. In addition, sertraline may have advantages over the SSRIs paroxetine, fluoxetine and fluvoxamine in elderly patients because of the drug's comparatively low potential for drug interactions, which is of importance in patient groups such as the elderly who are likely to receive more than one drug regimen.

Epidemiology of psychiatric medication use in patients recovering from critical illness at a long-term acute-care facility

STUDY OBJECTIVES

To describe the pharmacoepidemiology of psychotropic medication prescription in patients recovering from life-threatening medical and surgical illness.

DESIGN

Retrospective analysis of a random sample of medical records.

SETTING

Regional referral center.

PATIENTS

Eighty-nine randomly selected patients transferred from an ICU to the study facility.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Patients had been treated at the referring ICU for 33 +/- 24 days (mean +/- SD) and remained at the study hospital for 64 +/- 52 days. Most of the patients had prolonged respiratory failure. Nearly half of the patients (47%) received an antidepressant medication while at the facility, and 48% received at least one dose of a benzodiazepine on the first day after transfer. In the sample of 75 patients not prescribed an antidepressant before transfer, 37% were started on therapy with an agent, usually within 3 weeks and predominantly in the selective serotonin reuptake inhibitor or psychostimulant class. Younger patients and those evaluated by a mental health specialist were more likely to be prescribed an antidepressant, compared to other patients. Forty percent of patients were still receiving at least one dose of a benzodiazepine in a 24-h period after their third week at the facility.

CONCLUSION

Although the efficacy of antidepressant pharmacotherapy in patients with comparable severity of medical illness has not been established, a substantial proportion of patients recovering from critical illness at a specialized facility are prescribed antidepressant medications. Benzodiazepine exposure is frequent after transfer, and the prevalence in patients who remain at the facility minimally decreases over time.

The effectiveness of old age psychiatry services

The objective of this study was to review outcomes of acute service delivery in old age psychiatry. Sources of data included Medline, PsycINFO and Cochrane Collaboration databases of English language papers to 1998 on service delivery evaluation in 'old age psychiatry', 'psychogeriatrics' and 'geriatric psychiatry', supplemented by a manual search of references from relevant literature. All controlled trials, audits, and surveys of the outcomes of service delivery in old age psychiatry located in acute hospitals and community settings were included. Service delivery by medical, adult psychiatry and consultation/liaison services were included. With the exception of outreach services to nursing homes, long term institutional care was excluded. All data were extracted by the author. Data quality was assessed by applying an evidence hierarchy. Evaluation strategies were qualitatively reviewed. Controlled trials, audits and surveys were each found to provide important data in the evaluation of service delivery. There is better quality evidence to support the effectiveness of components of old age psychiatry services than other service types. The majority of studies indicate that old age psychiatry services have positive acute treatment outcomes, particularly with depression. There is insufficient evidence to determine which processes of care are associated with better outcomes. Pluralistic evaluations indicate that carers often have unmet needs and are not as positive about outcomes. There have been no controlled comparisons of service delivery provided by other services. In conclusion, controlled trials and audits indicate that old age psychiatry services are effective. Further pluralistic evaluations and comparisons with other services are required.

Pharmacodynamics of milnacipran in young and elderly volunteers

AIMS

To investigate the pharmacodynamics of milnacipran in healthy young and elderly volunteers.

METHODS

Randomized double-blind crossover designs were employed and a standardized psychometric battery was administered pre and post dose for both studies. In the first study 10 healthy young volunteers received milnacipran 12.5 mg, 25 mg, 50 mg, 100 mg as a single dose or matched placebo. The test battery was administered at baseline and at 1, 2, 4 and 6 h post dose. The second study compared the effects of milnacipran 75 mg (50 mg+25 mg) per day, amitriptyline 50 mg (25 mg+25 mg) per day and placebo for 3 days' dosing in healthy volunteers aged over 65 years. The test battery was administered at baseline and at 2, 10 and 24 h post dose. The psychometric battery included critical flicker fusion (CFF), choice reaction time (CRT), compensatory tracking (CTT) and tests of short-term memory (STM), subjective sedation (LARS) and subjective sleep (LSEQ).

RESULTS

Milnacipran produced no significant dose related effects in the young volunteers. For the elderly, milnacipran significantly (P<0.05) raised CFF scores compared with placebo but had no significant effects on any of the other measures used. Amitriptyline, in contrast, significantly (P<0. 05) lowered CFF threshold, lengthened CRT and increased error on the CTT. On the subjective variables, LARS and LSEQ, amitriptyline increased ratings both of sedation and of difficulty in waking from sleep.

CONCLUSIONS

The results showed that milnacipran at single doses of up to 100 mg in healthy young volunteers is free from disruptive effects on cognitive function and psychomotor performance. In addition, milnacipran 75 mg (50+25 mg) appears to be free of negative effects on cognitive function in elderly volunteers, where it seemingly improves performance on CFF. In contrast, the tricyclic antidepressant amitriptyline, used here as a positive internal control, significantly impaired performance in the elderly on the majority of psychometric measures used in this study. This finding not only validated the sensitivity of this current test battery but also indicates the potential behavioural toxicity of amitriptyline in clinical use in the elderly.

Suboptimal use of antidepressants in the elderly: a population-based study in Nova Scotia

This descriptive, retrospective, population-based study assessed patterns of antidepressant medication use in elderly patients in Nova Scotia during fiscal years 1993 through 1996. Individuals > or =65 years of age who were registered with Nova Scotia's Seniors Pharmacare program and filled a prescription for an antidepressant medication during the specified period were included in the study. We determined the number of individuals who filled > or =1 prescription for an antidepressant, the number whose prescription for an antidepressant could be matched with a diagnosis of depression in the physician's billing database, the number who used antidepressants that were judged inappropriate based on published criteria for medication prescribing in the elderly, the number who used a therapeutic antidepressant dose based on published dosing guidelines for the elderly, and the number who used antidepressants for > or =6 months. A total of 12,048, 12,317, and 13,419 individuals filled prescriptions for antidepressants during the 1993 to 1994, 1994 to 1995, and 1995 to 1996 fiscal years, respectively. In each fiscal year, approximately 70% had received a diagnosis of depression based on the International Classification of Diseases, Ninth Revision, Clinical Modification, making it likely that 70% of antidepressant users were receiving these drugs for a primary diagnosis of depression. The number of antidepressant prescriptions that were classified as inappropriate for use in the elderly was 67% in 1993 to 1994, 61% in 1994 to 1995, and 55% in 1995 to 1996. These decreases over time were statistically significant (P < 0.001). Among those using serotonin reuptake inhibitors, secondary tricyclic antidepressants, or tertiary tricyclic antidepressants, 79%, 45%, and 31%, respectively, appeared to be using therapeutic doses. Of 23,553 antidepressant treatment courses, 11,028 (47%) were for < or =180 days. During the study, a significant number of elderly individuals were prescribed antidepressant medications that are judged by expert consensus to be inappropriate for use in this population because of an unfavorable toxicity profile, although the number declined significantly from year to year (P < 0.001 for year-to-year comparisons). Many individuals also appeared to be using antidepressant doses that are probably subtherapeutic, but this finding seemed heavily dependent on the class of antidepressant used. Nearly half of the individuals studied appeared to be treated for inadequately short periods.

The "new VA": a national laboratory for health care quality management

In 1995, the Veterans Health Administration (VHA) initiated the most radical redesign of the veterans health care system since the system was formally created in 1946. One of the goals of this reengineering effort has been to ensure the consistent and predictable provision of high-quality care everywhere in the system. To accomplish this goal, the VHA has organized more than 100 different quality improvement activities according to a structure-, process-, and outcomes-focused quality management accountability framework (QMAF) that targets 10 interrelated dimensions of quality management (QM). Each of these dimensions utilizes a defined strategy and employs a menu of quality assessment and assurance tactics. Organizing these many different quality improvement activities into an accountability framework should facilitate the development of policies and procedures that will systematize the VHA's QM. The VHA's new operational structure and its approach to quality improvement provide a unique national laboratory for health care QM.

Compliance with PASARR recommendations for Medicaid recipients in nursing homes. Preadmission Screening and Annual Resident Review

OBJECTIVE

To determine the rate of compliance with placement and mental health recommendations of the preadmission screening and annual resident review (PASARR) program.

DESIGN

A retrospective observational study using PASARR screening forms to identify recommendations of inpatient psychiatric care for people needing more care than nursing homes provide, alternate disposition for individuals needing less than nursing home level care, and recommendations for new mental health services when needed but not provided. Service use as indicated in Medicaid billing data during the following year was used to determine receipt of service.

PARTICIPANTS

All Washington state Medicaid recipients screened from 1992 through 1993.

MAIN OUTCOME MEASUREMENTS

Compliance rates for placement and service recommendations.

RESULTS

Inpatient psychiatric care was recommended for four of the 523 Medicaid recipients (0.8%), all of whom received it. Screeners recommended alternate dispositions in 131 (25%) subjects, and compliance occurred in 29% of these. Recommendations for new services were made in 310 (59%) cases. Compliance rates averaged 35%, ranging from 73% for medication recommendations to 7% for consultation. Depressed individuals were less likely to receive recommended services.

CONCLUSIONS

Many individuals needed additional mental health services but did not receive them, and a significant minority of patients could have been given an alternate disposition but rarely were.

Religious attitudes and practices of hospitalized medically ill older adults

OBJECTIVES

To examine the prevalence of religious beliefs and practices among medically ill hospitalized older adults and relate them to social, psychological and health characteristics.

METHODS AND PROCEDURES

Consecutive patients age 60 or over admitted to the general medicine cardiology and neurology services of Duke University Medical Center were evaluated for participation in a depression study. As part of the evaluation, information on religious affiliation, religious attendance, private religious activities, intrinsic religiosity and religious coping was collected. Demographic, social, psychological and physical health characteristics were also assessed. Bivariate and multivariate correlates of religious belief and activity were examined using Pearson correlation and linear regression.

RESULTS

Of the 542 patients evaluated, detailed information on religious beliefs and behaviors was collected on 455 cognitively unimpaired patients. Over one-half (53.4%) of the sample reported attending religious services once per week or more often; 58.7% prayed or studied the Bible daily or more often; over 85% of patients held intrinsic religious attitudes; and over 40% spontaneously reported that their religious faith was the most important factor that enabled them to cope. Religious variables were consistently and independently related to race (Black), lower education, higher social support and greater life stressors, and religious attendance was associated with less medical illness burden. Religious attendance was also related to lower depressive symptoms, although the association weakened when other covariates were controlled.

CONCLUSIONS

Religious practices, attitudes and coping behaviors are prevalent among hospitalized medically ill older adults and are related to social, psychological and physical health outcomes. Implications for clinical practice are discussed.

Depression in hospitalized older patients with congestive heart failure

The objectives of this study were to examine the prevalence of depression in hospitalized, medically ill, older patients with and without congestive heart failure (CHF), and examine correlates, course, predictors of outcome, and treatment of depression in patients with CHF. A consecutive sample of 542 patients age 60 or over admitted to inpatient services of Duke University Medical Center were systematically screened by a psychiatrist for depression using the Diagnostic Interview Schedule; 342 depressed cases and nondepressed controls were identified. Of these, 107 had a primary or secondary diagnosis of CHF. Among patients with CHF, major depression was identified in 36.5%, a rate that was significantly higher than for patients without CHF (25.5%); the difference was largely explained by low rates of major depression in cardiac patients without CHF (17.0%) who had less severe physical illness. Minor depression was also present in 21.5% of CHF patients, but was not more prevalent than in patients without CHF (17.0%). Compared with nondepressed CHF patients, those with depression were more likely to have comorbid psychiatric disorder, severe medical illness, and severe functional impairment. Depressed patients used more outpatient and inpatients medical services, although this was largely due to the severity of their health problems. Patients often remained depressed for a prolonged period, and over 40% failed to remit during the year following discharge. Factors predicting slower remission included nonhealth-related, stressful life events and low social support; physical health factors at baseline had little effect. The majority of depressed CHF patients did not receive treatment for their depression with either antidepressants or psychotherapy, and did not see mental health specialists any more frequently than did the nondepressed. These findings are of concern and have important implications for the diagnosis and treatment of depression in older patients with heart failure.