Clinical Practice Guidelines for Management of Depression in Elderly

The effectiveness of preventive home visits on resilience and health-related outcomes among community dwelling older adults: A systematic review

BACKGROUND

This research aimed to assess the effectiveness of preventive home visits (PHVs) in enhancing resilience and health-related outcomes among older adults living in the community.

METHODS

A comprehensive literature search was conducted in nine databases (PubMed, MEDLINE, CINAHL, Embase, Emcare, Web of Science (WOS), Scopus, PsycINFO and Cochrane Library. The search was undertaken between March 15 and 31, 2022 with subsequent updates performed on October 15, 2023 and April 10, 2024. This review also included grey literature sourced via Google, Google Scholar and backward citation searches.

RESULTS

Out of 5,621 records, 20 articles were found to meet the inclusion criteria with a total of 8,035 participants involved and the mean age ranged from 74.0 to 84.4 years. Using McMaster Critical Review Form for Quantitative Studies, we ascertained that the studies included in our analysis had moderate to high levels of quality. In addition to health-related outcomes, PHV interventions were also conducted to evaluate psychological effects (16 studies) and social outcomes (seven studies). Five studies conducted financial assessment to evaluate the costs of health and social care utilisation during PHV interventions. Regarding the results of the review, seven studies showed favourable outcomes, five indicated no effect and eight had equivocal findings. Only one study assessed resilience and determined that PHV had no effect on the resilience of the subjects.

CONCLUSION

This review found that the effectiveness of PHV interventions was uncertain and inconclusive. PHV interventions often prioritise health-related objectives. The incorporation of a holistic approach involving psychosocial health into PHV interventions is relatively uncommon. Due to the paucity of research on resilience as PHV outcome, we are unable to draw a conclusion on the effectiveness of PHV on resilience. Resilience should be prioritised as a psychological assessment in the future development of comprehensive PHV interventions, as it enables older adults to adapt, manage, and respond positively to adversities that may arise with age. Performing financial analysis such as costs and benefits analysis to incorporate the return on investment of PHV interventions is an added value for future research on this topic.

CLINICAL TRIAL REGISTRATION

PROSPERO registration number: CRD42022296919.

Tolerability of vortioxetine compared to selective serotonin reuptake inhibitors in older adults with major depressive disorder (VESPA): a randomised, assessor-blinded and statistician-blinded, multicentre, superiority trial

Background

Major depressive disorder (MDD) is prevalent and disabling among older adults. Standing on its tolerability profile, vortioxetine might be a promising alternative to selective serotonin reuptake inhibitors (SSRIs) in such a vulnerable population.

Methods

We conducted a randomised, assessor- and statistician-blinded, superiority trial including older adults with MDD. The study was conducted between 02/02/2019 and 02/22/2023 in 11 Italian Psychiatric Services. Participants were randomised to vortioxetine or one of the SSRIs, selected according to common practice. Treatment discontinuation due to adverse events after six months was the primary outcome, for which we aimed to detect a 12% difference in favour of vortioxetine. The study was registered in the online repository clinicaltrials.gov (NCT03779789).

Findings

The intention-to-treat population included 179 individuals randomised to vortioxetine and 178 to SSRIs. Mean age was 73.7 years (standard deviation 6.1), and 264 participants (69%) were female. Of those on vortioxetine, 78 (44%) discontinued the treatment due to adverse events at six months, compared to 59 (33%) of those on SSRIs (odds ratio 1.56; 95% confidence interval 1.01-2.39). Adjusted and per-protocol analyses confirmed point estimates in favour of SSRIs, but without a significant difference. With the exception of the unadjusted survival analysis showing SSRIs to outperform vortioxetine, secondary outcomes provided results consistent with a lack of substantial safety and tolerability differences between the two arms. Overall, no significant differences emerged in terms of response rates, depressive symptoms and quality of life, while SSRIs outperformed vortioxetine in terms of cognitive performance.

Interpretation

As opposed to what was previously hypothesised, vortioxetine did not show a better tolerability profile compared to SSRIs in older adults with MDD in this study. Additionally, hypothetical advantages of vortioxetine on depression-related cognitive symptoms might be questioned. The study's statistical power and highly pragmatic design allow for generalisability to real-world practice.

Funding

The study was funded by the Italian Medicines Agency within the "2016 Call for Independent Drug Research".

PROTOCOL: Non-pharmacological interventions for older people with a diagnosis of depression: An evidence and gap map

This is the protocol for an evidence and gap map. The objectives are as follows: To map available randomized control trials, economic evaluations, and systematic reviews that assess the effectiveness and cost-effectiveness of non-pharmacological interventions for older people with a diagnosis of depression and identify any existing gaps in the evidence that can inform future research.

Optimizing treatment for older adults with depression

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

Depression in Older Adults: Do Current DSM Diagnostic Criteria Really Fit?

OBJECTIVES

The great heterogeneity in symptoms and clinical signs of depression in older adults makes the current diagnostic criteria difficult to apply. This scoping review aims to provide an update on the relevance of each of the diagnostic criteria as defined in the DSM-5.

METHODS

In order to limit the risk of bias inherent in the study selection process, a priori inclusion and exclusion criteria were defined. Articles meeting these criteria were identified using a combination of search terms entered into PubMed, PsycINFO, PsycARTICLES and SocINDEX.

RESULTS

Of the 894 articles identified, 33 articles were selected. This review highlights a different presentation of depression in older adults. Beyond the first two DSM core criteria, some symptoms are more common in older adults: appetite change, sleep disturbance, psychomotor slowing, difficulty concentrating, indecisiveness, and fatigue.

CONCLUSIONS

This review provides an updated description of the clinical expression of depressive symptoms in the older population while highlighting current pending issues.

CLINICAL IMPLICATIONS

Somatic symptoms should be systematically considered in order to improve the diagnosis of depression in older adults, even if, in some cases, they may reflect symptoms of age-related illnesses.

The effect of mobile-based logotherapy on depression, suicidal ideation, and hopelessness in patients with major depressive disorder: a mixed-methods study

Major depressive disorder is one of the most common psychiatric disorders in the world. It is essential to study and use effective, available, and affordable psychotherapy methods along with drug therapy to manage the symptoms of this disease. Therefore, the current study aimed to determine the effect of mobile phone-based logotherapy on depression, suicidal ideation, and hopelessness in patients with major depressive disorder by using a mixed-methods approach. In the first phase of this mixed-methods study, 70 patients completed the quantitative phase (control group = 35, intervention group = 35). The intervention group received an 8-week mobile-based logotherapy program via WhatsApp (one 180-min module per week) combined with sertraline, while the control group received just sertraline plus education about pharmacotherapy. Data was collected before, immediately after the intervention, and 3 months later using the Beck depression inventory short form items (BDI-13), the Beck hopelessness scale (BHS), and the Beck scale for suicide ideation (BSSI). Then, a qualitative study on the intervention group was conducted to explain the findings of the quantitative phase. The repeated measure MANOVA revealed a significant interaction effect of time and group on the set of dependent variables (F(6,63) = 25.218, P < 0.001). Qualitative analysis confirmed the efficacy of sertraline plus mobile-based logotherapy on depression, suicidal ideation, and hopelessness in the intervention group. Three key themes extracted from the participants' experiences of mobile-based logotherapy were "efficient instruction", "user-friendly intervention" and "constructive change". Mobile-based logotherapy through WhatsApp was an effective psychotherapy method for decreasing depression, hopelessness, and suicidal ideation in patients with major depressive disorder. It is suggested that educational, institutional, and technological infrastructure for providing and using mobile-based logotheapy for patients with major depressive disorder be considered in the mental health care system.

Effectiveness of Repetitive Transcranial Magnetic Stimulation in the Treatment of Depression in the Elderly: A Retrospective Natural Analysis

INTRODUCTION

Depression in the elderly is an understudied condition. Psychopharmacological and psychotherapeutic approaches suffer from specific difficulties with this patient group. Brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a therapeutic alternative. rTMS remains understudied in this age group when compared with younger patients.

METHODS

A cohort of 505 patients with depression was analyzed in retrospect concerning their response to rTMS treatment. A total of 15.5% were 60 years old or older, defined as the elderly group of depressed patients. The majority of these were treated with high-frequency protocols over the left dorsolateral prefrontal cortex (DLPFC). For group comparisons, we used Student t-tests or chi-square-tests, depending on the scales of measurement. As measures for effect size, we used Cohen's d for the relative and absolute change in the HDRS total score.

RESULTS

Groups did not differ significantly with respect to baseline depression severity or treatment parameters. In the group of elderly patients, a higher number of females were present. Groups did not differ significantly with respect to treatment efficacy, as indicated by the absolute and relative changes in the HDRS-21 sum score. Elderly patients tended to take higher numbers of mood stabilizers. Elderly patients showed a significantly superior reduction for the item "appetite" and a superior reduction tending towards significance for the item "work and interests".

CONCLUSIONS

Antidepressant rTMS treatment showed comparable efficacy for patients above 60 years to that in younger patients. Differences between the age groups concerning amelioration of distinct HDRS single items deserve further investigation.

Predictors of depression among the elderly persons with disabilities in Indonesia

BACKGROUND

Depression is a major mental problem in the elderly, particularly those with disability. This study's aim was to identify variables that predict depression in the elderly with disabilities.

MATERIALS AND METHODS

This cross-sectional study was conducted in Gunungkidul Regency and Yogyakarta City from April to June 2021. The study participants were community-dwelling elderly aged 60 years and above with disabilities, who could communicate verbally without any apparent cognitive impairment. Data was collected by interviewing participants using structured questionnaire on following sections: Demographic characteristics, Mini-Mental State Examination (MMSE), Washington Group Short Set (WG-SS), Barthel Index of activities of daily living (ADL), Lawton Instrumental ADL (IADL) Scale, and Geriatric Depression Scale-30 (GDS-30). Multivariate linear regression analysis applied to identify variables significantly correlated with depression. Multinomial logistic regression analysis performed to obtain the odds ratio (OR).

RESULTS

Study included 115 elderly persons with disabilities. Most of them had mobility impairment. Higher independence in ADL and being married were related with lower risk of depression, whereas increased age at disability increased the risk of depression (P = 0.001). The elderly who had greater independence with daily activities were less likely to have depression (OR = 0.639 for mild depression and OR = 0.589 for severe depression). Those who were not married were more likely to have mild depression (OR = 3.203) and severe depression (OR = 29.119). compared to the married elderly. Age at acquiring disability was associated with higher risk for mild depression (OR = 1.025) and severe depression (OR = 1.053). Higher independence in ADL and being married were related with lower risk of depression, whereas increased age at disability increased the risk of depression (P = 0.001).

CONCLUSION

Independence in the ADL, being married, and being disabled as a young adult are negative predictors of depression in the elderly with disability.

Sertraline treatment influences [18F]FE-PE2I PET imaging for Parkinsonism

BACKGROUND

The dopamine transporter (DaT) PET ligand [¹⁸F]FE-PE2I is used to aid the diagnosis of Parkinson's disease. After encountering four patients with a history of daily sertraline use, who all showed atypical findings on [¹⁸F]FE-PE2I PET, we suspected that the selective serotonin reuptake inhibitor (SSRI), sertraline, might interfere with the results and lead to globally reduced striatal [¹⁸F]FE-PE2I binding due to sertraline's high affinity for DaT.

METHODS

We rescanned the four patients with [¹⁸F]FE-PE2I PET after a 5-day sertraline pause. Sertraline plasma concentration was estimated based on body weight and dose, and specific binding ratios (SBR) in caudate nucleus, known to be more preserved in Parkinson's, were used to estimate the effect on tracer binding. Comparison was made to a patient with [¹⁸F]FE-PE2I PET before and after a 7-day Modafinil pause.

RESULTS

We found a significant effect of sertraline on caudate nucleus SBR (p = 0.029). The effect showed a linear dose-dependent relationship that corresponds to a reduction in SBR by 0.32 or 0.44 for a 75 kg male or a 65 kg female, respectively, taking a daily dose of 50 mg sertraline.

CONCLUSION

Sertraline is one of the most commonly used antidepressants and in contrast to other SSRI's, sertraline show high affinity for DaT. We recommend that sertraline treatment is taken into account when patients are undergoing [¹⁸F]FE-PE2I PET especially in patients showing apparent globally reduced PE2I binding. If tolerable, pausing of the sertraline treatment should be considered, especially for doses above 50 mg/day.

Increased BDNF and hippocampal dendritic spine density are associated with the rapid antidepressant-like effect of iron-citalopram and iron-imipramine combinations in mice

Iron supplementation previously demonstrated antidepressant-like effects in post-partum rats. The present study evaluates the possible synergistic antidepressant effect of sub-therapeutic dose of iron co-administered with citalopram or imipramine in female Institute of Cancer Research mice. Depression-like symptoms were induced in the forced swim (FST), tail suspension (TST), and open space swim (OSST) tests while open field test (OFT) was used to assess locomotor activity. Mice (n=8) received iron (0.8- 7.2 mg/kg), citalopram (3-30 mg/kg), imipramine (3-30 mg/kg), desferrioxamine (50 mg/kg) or saline in the single treatment phase of each model and subsequently a sub-therapeutic dose of iron co-administered with citalopram or imipramine. Assessment of serum BDNF and dendritic spine density was done using ELISA and Golgi staining techniques respectively. Iron, citalopram and imipramine, unlike desferrioxamine, reduced immobility score in the TST, FST and OSST without affecting locomotor activity, suggesting antidepressant-like effect. Sub-therapeutic dose of iron in combination with citalopram or imipramine further enhanced the antidepressant-like effect, producing a more rapid effect when compared to the iron, citalopram or imipramine alone. Iron, citalopram and imipramine or their combinations increased serum BDNF concentration, hippocampal neuronal count and dendritic spine densities. Our study provides experimental evidence that iron has antidepressant-like effect and sub-therapeutic dose of iron combined with citalopram or imipramine produces more rapid antidepressant-like effect. We further show that iron alone or its combination with citalopram or imipramine attenuates the neuronal loss associated with depressive conditions, increases dendritic spines density and BDNF levels. These finding suggest iron-induced neuronal plasticity in the mice brain.

Discontinuation of Antidepressants in Older Adults: A Literature Review

Polypharmacy increases the risk of unbearable side effects, drug-drug interactions, and hospitalizations in geriatric patients. The iatrogenic risk of inadequate management of antidepressants is very important in this population. Therefore, primary care physicians and geriatricians have the responsibility of the optimization of antidepressants prescriptions. Our work is a literature review of the European and the international guidelines regarding the management of antidepressants. We reviewed the PubMed database and Google scholar for articles and reviews from 2015. We also screened relevant articles for more references and searched the web for available European guidelines relevant to our topic. We divided our findings into four main inquiries that are Indication, effectiveness, tolerability, and iatrogenic risks. Poor or absence of effectiveness should lead to a readjustment of the treatment plan. In case of unbearable side effects, antidepressants should be stopped, and alternative non-pharmacological therapies should be proposed. Doctors should look out for drug-drug interaction risks in this population and constantly adjust the prescription. Prescription of antidepressants is not always evidence based which leads to heavy iatrogenic consequences. We suggest a simple 4-questions-algorithm that aims to remind doctors of the basics of good practice and helps in the process of deprescribing an antidepressant in older adults.

Geriatric Depression

Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.

Late-life depression: Epidemiology, phenotype, pathogenesis and treatment before and during the COVID-19 pandemic

Late-life depression (LLD) is one of the most common mental disorders among the older adults. Population aging, social stress, and the COVID-19 pandemic have significantly affected the emotional health of older adults, resulting in a worldwide prevalence of LLD. The clinical phenotypes between LLD and adult depression differ in terms of symptoms, comorbid physical diseases, and coexisting cognitive impairments. Many pathological factors such as the imbalance of neurotransmitters, a decrease in neurotrophic factors, an increase in β-amyloid production, dysregulation of the hypothalamic-pituitary-adrenal axis, and changes in the gut microbiota, are allegedly associated with the onset of LLD. However, the exact pathogenic mechanism underlying LLD remains unclear. Traditional selective serotonin reuptake inhibitor therapy results in poor responsiveness and side effects during LLD treatment. Neuromodulation therapies and complementary and integrative therapies have been proven safe and effective for the treatment of LLD. Importantly, during the COVID-19 pandemic, modern digital health intervention technologies, including socially assistive robots and app-based interventions, have proven to be advantageous in providing personal services to patients with LLD.

Mediation effect of coping strategies on general psychological health among middle-aged and older adults during the COVID-19 pandemic

OBJECTIVE

In this study, we aim to assess general psychological health, associated factors, and the potential of coping strategies as a mediator for middle-aged and older Malaysian adults during the COVID-19 pandemic.

METHODS

A total of 535 individuals aged 52 years and above from the previous cohort and interventional studies in Peninsular Malaysia were contacted during the Movement Control Order (MCO) issued during the COVID-19 pandemic. Telephonic interviews were conducted to obtain participant information concerning socio-demography, physical activity, subjective well-being (SWB) as assessed using flourishing scale, coping strategies, and general psychological health (GHQ-12). Simple linear regression (SLR) and multiple linear regression (MLR) analyses were performed to identify the factors associated with GHQ-12. The associated factors were further analysed using mediation analysis to determine the potential of coping strategies as a mediator.

RESULTS

It was observed that participants had a low mean GHQ-12 score (M = 0.80, SD = 2.19), indicating good psychological health. Living arrangement, physical activity, and flourishing scale were associated with psychological health (R² = 0.412, p < 0.05) in MLR. Positive reinterpretation, emotional support, instrumental support, humour, denial, and self-blame appear to partially mediate the relationship between socio-demography, physical activity, flourishing scale and GHQ-12, with lower coefficient values.

CONCLUSION

Middle-aged and older adults in Malaysia had good psychological health during the COVID-19 pandemic, especially when living with family, physically active, and having good subjective well-being. These findings provide the initial evidence to help promote the ageing population's general well-being and mental health and enable them to cope with change during the COVID-19 pandemic.

Pharmacist Intervention in Portuguese Older Adult Care

Healthy ageing has become one of the most significant challenges in a society with an increasing life expectancy. Older adults have a greater prevalence of chronic disease, with the need for multiple medications to appropriately control these issues. In addition to their health concerns, ageing individuals are prone to loneliness, dependence, and economic issues, which may affect their quality of life. Governments and health professionals worldwide have developed various strategies to promote active and healthy ageing to improve the quality of life of older adults. Pharmacists are highly qualified health professionals, easily accessible to the population, thus playing a pivotal role in medication management. Their proximity to the patient puts them in a unique position to provide education and training to improve therapeutic adherence and identify medication-related problems. This paper aims to address the importance of Portuguese community pharmacists in the medication management of older adults, emphasising their intervention in health promotion, patient education, medication-related problems, deprescription, dose administration aids, and medication review and reconciliation. We also discuss home delivery services and medication management in long-term care facilities.

Fluoxetine increases astrocytic glucose uptake and glycolysis in corticosterone-induced depression through restricting GR-TXNIP-GLUT1 Pathway

Antidepressant fluoxetine can affect cerebral glucose metabolism in clinic, but the underlying molecular mechanism remains poorly understood. Here, we examined the effect of fluoxetine on brain regional glucose metabolism in a rat model of depression induced by repeated corticosterone injection, and explored the molecular mechanism. Fluoxetine was found to recover the decrease of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) signal in prefrontal cortex (PFC), and increased 2-[N-(7-Nitrobenz-2-oxa-1,3-diazol-4-yl) amino]-2-deoxy-D-glucose (2-NBDG, a fluorescent glucose analog) uptake in an astrocyte-specific manner in ex vivo cultured PFC slices from corticosterone-induced depressive rats, which were consistent with its improvement of animal depressive behaviors. Furthermore, fluoxetine restricted nuclear translocation of glucocorticoid receptor (GR) to suppress the transcription of thioredoxin interacting protein (TXNIP). Subsequently, it promoted glucose transporter 1 (GLUT1)-mediated glucose uptake and glycolysis of PFC astrocytes through suppressing TXNIP expression under corticosterone-induced depressive state. More importantly, fluoxetine could improve glucose metabolism of corticosterone-stimulated astrocytes via TXNIP-GLUT1 pathway. These results demonstrated that fluoxetine increased astrocytic glucose uptake and glycolysis in corticosterone-induced depression via restricting GR-TXNIP-GLUT1 pathway. The modulation of astrocytic glucose metabolism by fluoxetine was suggested as a novel mechanism of its antidepressant action.

Spotlight on the Challenges of Depression following Retirement and Opportunities for Interventions

As a major life transition characterized by changes in social, behavioral, and psychological domains, retirement is associated with numerous risk factors that can contribute to the development of depression in later life. Understanding how these risk factors intersect with overall health and functioning can inform opportunities for mental health promotion during this transition. The objective of this review is to summarize the literature on risk and protective factors for depression during retirement transitions, discuss challenges related to appropriate management of depression in later life, and describe opportunities for prevention and intervention for depression relating to retirement transitions, both within and beyond the health care system. Key implications from this review are that 1) the relationship between depression and retirement is multifaceted; 2) while depression is a common health condition among older adults, this syndrome should not be considered a normative part of aging or of retirement specifically; 3) the existing mental health specialty workforce is insufficient to meet the depression management needs of the aging population, and 4) therefore, there is a need for interprofessional and multidisciplinary intervention efforts for preventing and managing depression among older adults. In sum, both healthcare providers, public health practitioners, and community organizations have meaningful opportunities for promoting the mental health of older adults during such major life transitions.

Cognitive, behavioural or cognitive-behavioural self-help interventions for subclinical depression in older adults: A systematic review and meta-analysis

BACKGROUND

Subclinical depression is a risk factor for the development of major depression in older adults. We aimed to determine the effectiveness of pure self-help or self-help with minimal support to reduce depressive symptoms and to prevent the onset of major depression in this population.

METHODS

This was a systematic review and meta-analysis of trials that used self-administrated cognitive, behavioural or cognitive-behavioural interventions for older adults with subclinical depression compared to control groups. Medline, Embase, PsycInfo and Cochrane databases were searched for relevant studies.

RESULTS

We analysed eight trials involving 1449 participants. A small but significant effect favouring the intervention was found at short-term [d = 0.33; 95% CI (Confidence Interval): 0.20-0.47] and at long-term (d = 0.22; 95% CI: 0.04-0.40) for depressive symptoms. None of the studies looked at the preventive effect of self-help interventions in reducing the probability of a subsequent diagnosis of major depression.

LIMITATIONS

The low number of studies meant that it was not possible to test for publication bias. The absence of pre-published protocols for many of the studies meant that there is a possibility of selective reporting bias for some of the primary studies.

CONCLUSIONS

There is some evidence that cognitive-behavioural self-help interventions may reduce depressive symptoms in older adults with subclinical depression. However, no study examined whether the intervention had a preventative effect in reducing the likelihood of a subsequent diagnosis of major depression.

Quality of clinical practice guidelines for inadequate response to first-line treatment for depression according to AGREE II checklist and comparison of recommendations: a systematic review

OBJECTIVE

To assess similarities and differences in the recommended sequence of strategies among the most relevant clinical practice guidelines (CPGs) for the treatment of depression in adults with inadequate response to first-line treatment.

DATA SOURCES

We performed a systematic review of the literature spanning January 2011 to August 2020 in Medline, Embase, Cochrane Library and 12 databases recognised as CPGs repositories. CPGs quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

STUDY SELECTION

The eligibility criteria were CPGs that described pharmacological recommendations for treating depression for individuals aged 18 years or older in outpatient care setting. We included CPGs considered of high-quality (≥80% in domain 3 of AGREE II) or recognised as clinically relevant.

DATA EXTRACTION

Two independent researchers extracted recommendations for patients who did not respond to first-line pharmacological treatment from the selected CPGs.

RESULTS

We included 46 CPGs and selected 8, of which 5 were considered high quality (≥80% in domain 3 of AGREE II) and 3 were recognised as clinically relevant. Three CPGs did not define inadequate response to treatment and 3 did not establish a clear sequence of strategies. The duration of treatment needed to determine that a patient had not responded was not explicit in 3 CPGs and was discordant in 5 CPGs. Most CPGs agree in reassessing the diagnosis, assessing the presence of comorbidities, adherence to treatment, and increase dosage as first steps. All CPGs recommend psychotherapy, switching antidepressants, and considering augmentation/combining antidepressants.

CONCLUSION

Relevant CPGs present shortcomings in recommendations for non-responders to first-line antidepressant treatment including absence and divergencies in definition of inadequate response and sequence of recommended strategies. Overall, most relevant CPGs recommend reassessing the diagnosis, evaluate comorbidities, adherence to treatment, increase dosage of antidepressants, and psychotherapy as first steps.

PROSPERO REGISTRATION NUMBER

CRD42016043364.

Attitudes toward aging, active coping, and depressive symptoms among middle-aged and older Korean adults: How do they differ by age group?

BACKGROUND

Despite the adverse health outcomes of holding negative attitudes toward aging, little attention has been paid to these attitudes' role in mental health among the aging population.

OBJECTIVES

Drawing on the stress coping theory, this study examines whether negative attitudes toward aging and low levels of active coping are associated with greater depressive symptoms, and whether active coping attenuates the increased risk of depression caused by negative aging attitudes. We also investigate how these associations differ in middle-aged and older adults.

METHODS

A nationwide sample of 500 Koreans aged 55 or above was analyzed. Multivariate linear regression analyses were performed separately by age groups to investigate the independent effects of attitudes toward aging and active coping as well as their interactive effects on depressive symptoms.

RESULTS

Our findings showed that more negative attitudes toward aging were related to higher levels of depressive symptoms. There were age group differences in the independent and moderating effects of active coping. For the middle-aged, those with higher levels of active coping had fewer depressive symptoms, while no such significant association was found among older adults. On the contrary, active coping buffered the adverse effects of endorsing negative aging attitudes on depressive symptoms only for the older adult group.

LIMITATIONS

A causality cannot be inferred by our findings due to the cross-sectional design.

CONCLUSIONS

The findings provide some of the first insights into how one's aging attitudes and coping style may protect against the risk of depression and how it differs by age group.

Association between the consumption of omega-3-rich fish and depressive symptoms in older adults living in a middle-income country: EpiFloripa Aging cohort study

This study aimed to verify the association between the consumption of omega-3-rich (n-3) fish and depressive symptoms in older adults living in Southern Brazil. This is a cross-sectional analysis with data from the second wave of the EpiFloripa Aging cohort study (2013/2014) including 1,130 individuals aged 60 years or older. The presence of depressive symptoms was measured by the 15-items Geriatric Depression Scale (GDS-15), and the consumption of n-3-rich fish by a question of weekly frequency. The minimum set of variables for adjustment was defined using directed acyclic graph (DAG). Poisson regression with robust error variance was applied (adjusted by Model 1: demographic and socioeconomic variables, Model 2: added behavioral variables, Model 3: added health variables). We identified the prevalence of depressive symptoms in 19% of older adults and 51.8% reported eating n-3-rich fish once a week. Models 1 and 3 showed an inverse association between n-3-rich fish and depressive symptoms. However, the association was reduced when behavioral factors (leisure-time physical activity) were included in Model 2. These findings suggest that n-3-rich fish intake tends to be associated with depressive symptoms in older adults. However, other factors, such as physical exercise, are as pivotal as n-3 fatty acids in preventing the development of depressive symptoms.

Methylphenidate use in geriatric depression: A systematic review

OBJECTIVES

Geriatric depression is common and is often associated with coexisting medical illnesses, cognitive dysfunction, or both. Treatment with pharmacotherapy is usually required, and many patients may not respond to initial therapy. Thus, there is a need for adjunctive treatment options. The objective of this systematic review is to assess the efficacy and safety of methylphenidate (MPH) in the treatment of geriatric depression.

METHODS

PubMed (1946-December 2020) and Embase (1947-December 2020) were queried using the following search terms: geriatrics, aged, geriatric patient, or elderly and depressive disorder, depression, major depression or late-life depression, and MPH. Studies were included if they were a randomized-controlled trial or open-label trial that investigated use of MPH for treatment of depression in adults aged 60 years and older.

RESULTS

After screening per the inclusion criteria, five prospective trials were included. All studies found improvement in depressive symptoms with use of MPH or MPH combined with citalopram. Study durations ranged from 8 to 16 weeks and MPH dosing ranged from 5 to 90 mg per day.

CONCLUSIONS

Based on the reviewed literature, MPH appears to be most effective when combined with citalopram and used short-term. MPH should be initiated at a low dose and titrated up to 10 or 20 mg per day based on response. Larger, long-term trials are needed to further define the role of MPH in this population.

A Study of Older Adults' Mental Health across 33 Countries during the COVID-19 Pandemic

Despite older adults’ extremely high vulnerability to COVID-19 complications and death, few studies have examined how personal characteristics and the COVID-19 pandemic have impacted the mental health of older adults at the global level. The purpose of this study was to examine the relationships among demographics, COVID-19 life impacts, and depression and anxiety in adults aged 60 and older from 33 countries. A sample of 823 older adults aged 60–94 and residing in 33 countries completed a 10-min online survey following recruitment from mailing lists and social media. Being separated from and having conflicts with loved ones predicted both anxiety and depression, as did residing in a country with higher income. Getting medical treatment for severe symptoms of COVID-19 and having decreased work responsibilities predicted depression, but adjustment to working from home and younger age predicted both depression and anxiety. Participants from Europe and Central Asia reported higher depression than those from all other regions and higher anxiety than those from Latin America and the Caribbean. The COVID-19 pandemic has had serious deleterious effects on the mental health of older adults worldwide. The current findings have direct implications for mental health services that may be delivered to older adults to help facilitate healthy psychological adjustment.

Antidepressants and Risk of Sudden Cardiac Death: A Network Meta-Analysis and Systematic Review

Background: Antidepressants are one of the most prescribed medications, particularly for patients with mental disorders. Nevertheless, there are still limited data regarding the risk of ventricular arrhythmia (VA) and sudden cardiac death (SCD) associated with these medications. Thus, we performed systemic review and meta-analysis to characterize the risks of VA and SCD among patients who used common antidepressants. Methods: A literature search for studies that reported risk of ventricular arrhythmias and sudden cardiac death in antidepressant use from MEDLINE, EMBASE, and Cochrane Database from inception through September 2020. A random-effects model network meta-analysis model was used to analyze the relation between antidepressants and VA/SCD. Surface Under Cumulative Ranking Curve (SUCRA) was used to rank the treatment for each outcome. Results: The mean study sample size was 355,158 subjects. Tricyclic antidepressant (TCA) patients were the least likely to develop ventricular arrhythmia events/sudden cardiac deaths at OR 0.24, 0.028–1.2, OR 0.32 (95% CI 0.038–1.6) for serotonin and norepinephrine reuptake inhibitors (SNRI), and OR 0.36 (95% CI 0.043, 1.8) for selective serotonin reuptake inhibitors (SSRI), respectively. According to SUCRA analysis, TCA was on a higher rank compared to SNRI and SSRI considering the risk of VA/SCD. Conclusion: Our network meta-analysis demonstrated the low risk of VA/SCD among patients using antidepressants for SNRI, SSRI and especially, TCA. Despite the relatively lowest VA/SCD in TCA, drug efficacy and other adverse effects should be taken into account in patients with mental disorders.

Lower serum 25-hydroxycholecalciferol is associated with depressive symptoms in older adults in Southern Brazil

Background

Older adults are one of the most susceptible populations to depression, especially those living in low- and middle-income countries. As well, they are also considering a risk group for vitamin D deficiency. Low serum vitamin D has been associated with an increased risk of brain neuropsychiatry disorders. We aimed to investigate the association between serum 25-hydroxycholecalciferol concentrations and depressive symptoms in adults aged 60 years and over from southern Brazil.

Methods

A cross-sectional analysis was performed using data collected during 2013–2014 from the populational-based longitudinal EpiFloripa Aging Study (n = 1197). Serum 25-hydroxycholecalciferol concentrations were analyzed and classified according to the Endocrine Society reference values [sufficiency (≥ 30 ng/mL), insufficiency (21–29 ng/mL), and deficiency (≤ 20 ng/mL)]. Depressive symptoms were evaluated using the Geriatric Depression Scale (15-item GDS). Logistic regression was performed to assess depressive symptoms in each vitamin D category. The analysis was adjusted for sex, age, skin color, family income, leisure-time physical activities, social or religious groups attendance, morbidities, cognitive impairment, and dependence in activities of daily living.

Results

A total of 557 participants with complete data for exposure and outcome were enrolled in the analysis. Most of the sample participants were female (63.1%), age-range 60–69 years (42.2%), white skin color (85.1%), and vitamin D serum level samples were collected in autumn (50.7%). Depressive symptoms were present in 15.8% of the participants, and the prevalence was higher in individuals classified as deficient in vitamin D (23.2, 95% confidence interval [CI] = 15.6;32.9) and insufficiency (17.2, 95%CI = 11.0;25.9). The crude analysis showed that vitamin D deficient participants had 3.08 (CI = 1.53;6.20) times higher odds to present depressive symptoms compared to vitamin D sufficiency. After adjusting, the association was maintained [OR 2.27 (95%CI = 1.05;4.94).

Conclusions

Serum 25-hydroxycholecalciferol deficiency was positively associated with depressive symptoms in older adults from southern Brazil.

The Relationship between Muscular Strength and Depression in Older Adults with Chronic Disease Comorbidity

Older adults with disease and disability are particularly vulnerable to experiencing more severe consequences of depression. The purpose of the present study is to investigate the relationship between disease comorbidities (number of disease: ND0, 1 disease: ND1 and 2 or more diseases: ND ≥ 2), hand grip strength (low HGS and high HGS), and the prevalence of depression in Korean older adults. Data from the living profiles of older people survey that was conducted by the ministry of health and welfare in Korea were utilized. Data for 6107 females and 4347 males were appropriate for statistical tests. The results demonstrated that depression was more prevalent as ND increased (p < 0.01). In addition, HGS appeared lower as ND increased in both male (p < 0.01) and female subjects (p < 0.01). Furthermore, relative to ND0 and low HGS, ND0 and high HGS showed a ~65% reduction in the prevalence of depression (p < 0.01). After adjusting for age, the prevalence of depression was reduced by ~60% in the subgroup with ND0 and high HGS relative to ND0 and low HGS (p < 0.01). These data demonstrate that muscular strength indices such as HGS may be useful when assessing depression in older adults. Further research in this area is warranted.

Tolerability and efficacy of vortioxetine versus SSRIs in elderly with major depression. Study protocol of the VESPA study: a pragmatic, multicentre, open-label, parallel-group, superiority, randomized trial

Introduction

Depression is a highly prevalent condition in the elderly, with a vast impact on quality of life, life expectancy, and medical outcomes. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed agents in this condition and, although generally safe, tolerability issues cannot be overlooked. Vortioxetine is an antidepressant with a novel mechanism of action. Based on studies to date, it may have a promising tolerability profile in the elderly, as it does not adversely affect psychomotor or cognitive performance and does not alter cardiovascular and endocrine parameters. The present study aims to assess the tolerability profile of vortioxetine in comparison with the SSRIs considered as a single group in elderly participants with depression. The rate of participants withdrawing from treatment due to adverse events after 6 months of follow up will be the primary outcome.

Methods and analysis

This is a pragmatic, multicentre, open-label, parallel-group, superiority, randomized trial funded by the Italian Medicines Agency (AIFA - Agenzia Italiana del Farmaco). Thirteen Italian Community Psychiatric Services will consecutively enrol elderly participants suffering from an episode of major depression over a period of 12 months. Participants will be assessed at baseline and after 1, 3 and 6 months of follow up. At each time point, the following validated rating scales will be administered: Montgomery–Åsberg Depression Rating Scale (MADRS), Antidepressant Side-Effect Checklist (ASEC), EuroQual 5 Dimensions (EQ-5D), Short Blessed Test (SBT), and Charlson Age-Comorbidity Index (CACI). Outcome assessors and the statistician will be masked to treatment allocation. A total of 358 participants (179 in each group) will be enrolled.

Ethics and dissemination

This study will fully adhere to the ICH E6 Guideline for Good Clinical Practice. Participants’ data will be managed and safeguarded according to the European Data Protection Regulation 2016/679. An external Ethical Advisory Board will help guarantee high ethical standards.

Trial registration

Clinicaltrials.gov: NCT03779789, Registered on 19 December 2018. Submitted on 19 December. EudraCT number: 2018–001444-66.

Trial status

Protocol version 1.5; 09/06/2018. Recruitment started In February 2019 and it is ongoing. It is expected to end approximately on 30 September 2021.

Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association

INTRODUCTION

Present knowledge about depression in the elderly is still scarce and often controversial, despite its high frequency and impact. This article reports the results and most relevant conclusions of a Delphi-based consensus on geriatric depression promoted by the Spanish Psychogeriatric Association.

METHODS

A 78-item questionnaire was developed by 7 highly specialized geriatric psychiatrists and was evaluated using the Modified Delphi technique in two rounds answered by 35 psychiatrists with an extensive expertise in geriatric depression. The topics and number of questions (in brackets) covered were: concepts, clinical aspects, and risk factors (12); screening and diagnosis (7); psychotic depression (17); depression and dementia (5); antidepressant drug treatment (18); non-pharmacological biological treatments (5); psychotherapeutic treatments (4); comorbidity and preventive aspects (6); professional training needed (4). In addition, the expert panel's opinion on the antidepressants of choice in 21 common comorbid conditions and on different strategies to approach treatment-resistant cases in terms of both efficacy and safety was assessed.

RESULTS

After the two rounds of the Delphi process, consensus was reached for 59 (75.6%) of the 78 items. Detailed recommendations are included in the text. Considering pharmacological treatments, agomelatine was the most widely mentioned drug to be recommended in terms of safety in comorbid conditions. Desvenlafaxine, sertraline, and vortioxetine, were the most frequently recommended antidepressants in comorbid conditions in general. Combining parameters of efficacy and safety, experts recommended the following steps to address cases of treatment resistance: 1. Escalation to the maximum tolerated dose; 2. Change of antidepressant; 3. Combination with another antidepressant; 4. Potentiation with an antipsychotic or with lamotrigine; 5. Potentiation with lithium; 6. Potentiation with dopamine agonists or methylphenidate.

DISCUSSION AND CONCLUSIONS

Consensus was reached for a high number of items as well as for the management of depression in the context of comorbid conditions and in resistant cases. In the current absence of sufficient evidence-based information, our results can be used to inform medical doctors about clinical recommendations that might reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders.

Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial

INTRODUCTION

Depression is a common disorder among older people living in residential aged care facilities. Several trials have demonstrated the effectiveness of behavioural therapies in treating depressive symptoms in older adults living in the community and in residential aged care. Behavioural Activation is demonstrably effective even when delivered by non-specialists (staff without formal psychological training), although strategies for adapting its use in residential aged care facilities are yet to be explored. This study will determine whether training residential care staff in the use of a structured Behavioural Activation programme is more effective at decreasing depressive symptoms among older residents than internet-based training about depression recognition and management alone.

METHOD AND ANALYSIS

The behavioural activation in nursing homes to treat depression (BAN-Dep) trial is a pragmatic two-arm parallel clustered randomised controlled trial. It will recruit 666 residents aged 60 or older from 100 residential aged care facilities, which will be randomly assigned to the Behavioural Activation or control intervention. Staff in both treatment groups will be encouraged to complete the Beyondblue Professional Education to Aged Care e-learning programme to improve their recognition of and ability to respond to depression in older adults. Selected staff from intervention facilities will undergo additional training to deliver an 8-module Behavioural Activation programme to residents with subthreshold symptoms of depression-they will receive ongoing Mental support from trained Behavioural Activation therapists. Outcome measures will be collected by blind research officer at baseline and after 3, 6 and 12 months. The Patient Health Questionnaire-9 is the primary outcome measure of the study.

ETHICS AND DISSEMINATION

The trial will comply with the principles of the Declaration of Helsinki for Human Rights and is overseen by the University of Western Australia (reference RA/4/20/4234) and Melbourne Health (reference number HREC/18/MH/47) Ethics Committees. The results of this research project will be disseminated through publications and/or presentations in a variety of media to health professionals, academics, clinicians and the public. Only de-identified group data will be presented.

TRIAL REGISTRATION

ACTRN12618000634279.

Incidence and risk factors of depressive symptoms in 4 years of follow-up among mid-aged and elderly community-dwelling Chinese adults: findings from the China Health and Retirement Longitudinal Study

OBJECTIVES

The purpose of this study was to examine the incidence of depressive symptoms, and determine if baseline risk factors conferred a risk for incident depressive symptoms in nationally representative sample of mid-aged and elderly Chinese adults.

DESIGN

This study was a secondary analysis of a prospective cohort from a nationally representative sample.

SETTING

Community samples were recruited from the baseline survey of the China Health and Retirement Longitudinal Study. A four-stage, stratified, cluster probability sampling strategy was used, which included 10 257 households with members aged 45 years or older and their spouse.

PARTICIPANTS

A total of 11 533 participants free of depressive symptoms at baseline were identified, and 10 288 were re-examined in either the first and/or the second follow-up surveys. The current analysis was conducted among the 10 288 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale short form.

RESULTS

The findings showed that the incidence of depressive symptoms in a 4-year follow-up was as high as 22.3%. The incidence was much higher in rural areas (25.7%) and in women (27.9%). Furthermore, participants with 1 hour longer of night-time sleep had a 10% lower risk of developing depressive symptoms. Compared with individuals who perceived their health status as poor, those who perceived their health status as excellent had a 62% lower risk of developing depressive symptoms. In addition, having diabetes (OR=1.19), chronic kidney disease (OR=1.32), chronic digestive disorders (OR=1.15) and arthritis (OR=1.43) at baseline increased the risk of depressive symptoms. However, baseline body mass index was not associated with the subsequent depressive symptoms in this population.

CONCLUSIONS

This study highlights the importance of developing an appropriate screening test to identify depressive symptoms for those who are vulnerable and ensure these individuals can receive early interventions for depressive symptoms.

Young psychiatrists' opinion on the activities of Indian Psychiatric Society: A survey under the aegis of Research, Education, and Training Foundation of Indian Psychiatric Society

AIM

The aim of the study is to assess the opinion of young psychiatrists (aged ≤45 years) about the various scientific activities of Indian Psychiatric Society (IPS).

MATERIALS AND METHODS

An online survey using SurveyMonkey electronic platform was conducted. Data of 350 participants were available for analysis.

RESULTS

The mean age of the participants (spread across 115 institutes/medical colleges) was 33.61 (standard deviation [SD] - 5.32) years and their mean number of years of experience in psychiatry including the training period was 8.25 (SD - 5.5) years. About 70% of the participants (n = 243) rated the current format of the Annual National Conference of the IPS (ANCIPS) to be "good/very good," and more than half of the participants agreed that the conferences at the zonal and state level help in enhancing the academic knowledge of the participants as well as such activities help in enhancing the social interaction among fellow colleagues. Among the various scientific sessions of the ANCIPS, workshops and guest lectures were rated as very useful by three-fifth of the participants. Regarding opinion in terms of changes required in the current format of the ANCIPS and other conferences/continuing medical educations (CMEs) being conducted by IPS, more than half to about two-third of the participants reported that having more hands-on workshops, having sessions like meet the experts, having mentorship programs, and more expert speakers from India will "definitely" be useful. Majority of the participants expressed that reduction of concurrent sessions would be definitely be beneficial. In terms of modification of ongoing activities and introduction of new activities, about two-third of the participants expressed that having IPS supported travel fellowship programs within the country and abroad, having subject/topic-focused conferences, and starting online CMEs will be definitely be useful.

CONCLUSIONS

The present survey reflects that there is a need to have more subject/topic-focused conferences/CMEs, need to introduce online CME activities, reduction of concurrent sessions during the conferences and strengthening the travel fellowship programs. All these can be considered as expectations of the young generation of psychiatrists from the organization like IPS, which should be duly considered while planning future conferences and CMEs.