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depression

Role of Physical Symptoms in Diagnosis of Depression in the Elderly

Role of Physical Symptoms in Diagnosis of Depression in the Elderly

Teaser: 

Dr. Marie-Josée Filteau, MSc, MD, FRCPC, Clinical Professor, Department of Psychiatry, Laval University, Clinical Researcher, Laval University-Robert-Giffard Research Centre, and Director, Clinique Marie Fitzbach, Quebec City, QC.

Patricia Gravel, BA, Department of Psychiatry, Laval University, Quebec City, QC.

Although depression is a highly prevalent psychiatric disorder and the focus of much research and discussion, it remains underdiagnosed and undertreated in the primary care setting. One of the key reasons for the underdiagnosis of depression is the tendency among physicians to focus on the emotional and psychological symptoms of the disorder at the expense of its physical symptoms. Although elderly patients with depression are more likely than their younger counterparts to present with physical rather than psychological symptoms, little emphasis is placed on physical symptoms in diagnostic tools and rating scales. Additionally, the understanding of the role and etiology of physical symptoms in depression remains poor.

Diagnosis can be especially challenging in the elderly population, since both patients and health care professionals often perceive depression to be a normal consequence of age-associated changes, such as physical illness or social or economic difficulties.

Detecting Depression in the Geriatric Primary Care Setting

Detecting Depression in the Geriatric Primary Care Setting

Teaser: 

Jennifer Pike, PhD, Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Michael Irwin, MD, Cousins Center for Psychoneuroimmunology, Neuropsychiatric Institute,
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), CA, USA.

Introduction
Depressive disorders are common in the geriatric primary care setting,1 and are associated with considerable costs and human suffering.2-4 In 1990, depression was ranked as the fourth leading cause of disability worldwide,5 with annual health care costs estimated at $44 billion in the United States alone. Much of this cost is a reflection of higher health care utilization rates in depressed individuals, irrespective of medical comorbidity and mental health visits.3

The prevalence of depressive disorders, defined by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; Table 1), in the elderly is high and ranges from 6.5-17% in the primary care setting.1,6 The rates for dysthymia, minor depression or subsyndromal depressions are roughly double those for major depression. The functional impairments and medical burden of these minor depressed geriatric patients are comparable to those of younger patients with major depression.

Depression in Idiopathic Parkinson’s Disease

Depression in Idiopathic Parkinson’s Disease

Teaser: 

Christopher Hyson MD, FRCPC, Clinical Fellow, Movement Disorders Program, London Health Sciences Centre, London, ON.

Mandar S Jog MD, FRCPC, Director, Movement Disorders Program, London Health Sciences Centre, London, ON.

Epidemiology
Idiopathic Parkinson's Disease (IPD), which results from degeneration of substantia nigra neurons, is characterized by the typical motor symptoms of rest tremor, rigidity, bradykinesia and postural instability. The estimated prevalence, which has been rising with the aging of the population, is 187/100,000 in the United States, with an annual incidence of 20/100,000. In addition to the well recognized motor disability, neuropsychiatric symptoms, such as depression, anxiety disorders and psychosis, are common, yet under-recognized in patients with IPD.1 It is, therefore, important that primary care physicians, internists and neurologists who care for patients with IPD be familiar with the occurrence and management of this important symptom.

Depression is the most common neuropsychiatric symptom seen in patients with IPD. It is estimated that approximately 40% of patients with IPD will experience depression at some point over the course of their illness. For 4-6% of these patients, the episode will meet the Diagnostic and Statistical Manual of Mental Disorders' (DSM-IV) definition of major depression. The remainder will meet the diagnostic criteria for minor depression.

Role of Venlafaxine and Bupropion in the Treatment of Depression in the Elderly

Role of Venlafaxine and Bupropion in the Treatment of Depression in the Elderly

Teaser: 

Kiran Rabheru, MD, CCFP, FRCPC, Active Staff, Geriatrics Psychiatry,London Psychiatric Hospital, London, ON.

Depression is the most common psychiatric disease in the elderly, and is a problem of major public health importance; however, it is underrecognized and undertreated, particularly in primary care and long-term care settings.1 Major depression may affect up to 20% of hospitalized elderly while up to 30% of older persons in the community suffer from milder forms of depression. In many, the symptoms are persistent or recurrent, resulting in increased disability, worsening of symptoms caused by other medical illness, greater health care utilization, and higher mortality from suicide as well as other medical causes such as vascular diseases.

Antidepressant medication, although not adequate or sufficient on its own, is often an essential part of the treatment plan for an older person who suffers from a significant burden of depressive symptoms. A dysregulation of the central neurotransmitters, norepinephrine (NE), serotonin (5-HT) and dopamine (DA), has been suggested to be part of the underlying mechanism in major depression.

In recent years, newer compounds have been introduced that have similar efficacy but far fewer side effects than do tricyclic antidepressants (TCA).

A Bigger Brain May be a Happier Brain

A Bigger Brain May be a Happier Brain

Teaser: 

Major depression has been shown to cause structural remodeling in the adult hippocampus, involving debranching and shortening of dendrites and suppression of neurogenesis. In fact, in some cases, major long-term depression can cause the hippocampus to shrink by almost 20%. This hippocampal atrophy may result from increased secretion of cortisol, which is found in almost half of seriously depressed patients.

A European group has tested the efficacy of a modified tricyclic antidepressant, tianeptine, in preventing hippocampal atrophy. The group used adult male tree shrews, a model considered to have high validity for studying the pathophysiology of major depression. Animals were subjected to a seven-day period of psychosocial stress to elicit stress-induced endocrine and central nervous alterations before they were given daily oral administration of tianeptine. The psychosocial stress continued over a period of 28 days. Interestingly, the physiological stress effects were prevented by the simultaneous administration of tianeptine. Not only does the study suggest that tianeptine may be useful for the treatment of major depression, it also provides a model for evaluating antidepressant treatments with regard to the possible reversal of structural changes in brain that have been reported in depressive disorders.

Source

  1. Boldizs C, Michaelis T, Watanabe T, et al. Stress-induced changes in cerebral metabolites, hippocampal volume, and cell proliferation are prevented by antidepressant treatment with tianeptine. Proc. Natl. Acad. Sci. USA, 10.1073/pnas.211427898.

The Sad Truth About Falls: Depression, Isolation and Increased Frailty all Common Consequences

The Sad Truth About Falls: Depression, Isolation and Increased Frailty all Common Consequences

Teaser: 

Brian E. Maki, PhD, PEng
Professor, Department of Surgery
and the Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

Hip fractures and other physical consequences of falls in older adults have received a great deal of attention, both in the scientific literature and the popular press. It is only recently, however, that the psychosocial consequences of falling, such as fear of falling, have begun to receive due recognition. The injuries due to falls may well prove to be the "tip of the iceberg", with the psychosocial sequelae incurring even greater societal costs.

Murphy and Isaacs1 first described the "post-fall syndrome" as an extreme fear of falling, characterized by a tendency to stagger, to clutch at objects, and to show hesitancy or alarm when asked to walk without assistance. Some researchers believe that such an anxiety syndrome can be viewed as a classic phobia, and in fact have coined the phrase "ptophobia" to refer to a phobic reaction to standing or walking.2 While such a severe reaction may be relatively uncommon, a more moderate fear of falling is very widespread among older adults, with reported prevalence ranging from 20-60%.3,4 The prevalence increases with age and is reportedly more common among women.4 One should note, however, that a gender-related bias in the willingness to report fear could confound the latter finding.

Drug-Induced Depression--Diagnosis and Management

Drug-Induced Depression--Diagnosis and Management

Teaser: 

Kathleen Jaques Bennett, BSc, MSc

Drug-induced depression is a type of depression that is caused by a drug or combination of drugs. It can be difficult to diagnose and manage, especially in the elderly. A depression must first be diagnosed and a temporal relationship with a drug or drugs must be identified in order to make an accurate diagnosis of drug-induced depression. While there are a number of treatment options, the management of drug-induced depression is complicated if the drug is an indispensable medication. The management of this type of depression is further complicated if there is no substitute for the offending medication. Elderly people consume large numbers of prescription and non-prescription drugs. This group of people is often taking several drugs concurrently and has less tolerance for medications.1 The elderly are particularly susceptible to drug interactions and adverse drug reactions (ADRs) which can lead to drug-induced depression.1 This group also presents more difficulty in terms of managing the condition.

The elderly are particularly susceptible to drug interactions and adverse drug reactions (ADRs) which can lead to drug-induced depression.

Is Depression an Early Sign of Alzheimer’s Disease?

Is Depression an Early Sign of Alzheimer’s Disease?

Teaser: 

depressed man imageIs Depression an Early Sign of Alzheimer's Disease?

In a 3-year study that followed 222 people aged 74 and older, Dr. Lars Backman and colleagues found that those who later developed Alzheimer's Disease were 50% more likely than other participants to have suffered symptoms of depression at the start of the investigation.

The study looked at two types of depression: "mood-related" symptoms such as unhappiness, guilt, and thoughts of death; and "motivated-related" symptoms which result in lack of energy and interest, and in concentration problems. The result showed that at the start of the study participants who would later develop Alzheimer's commonly had motivational-related symptoms. The researchers theorize that the symptoms may be related to changes in brain regions involved in regulating attention and energy levels.

The symptoms of depression that emerge in the study are common among the elderly and may easily be "over-looked" as early signs of Alzheimer's Disease.

Source: Neurology 1999;53:1996-2002.

Depression among the elderly affects quality of life

Depression among the elderly affects quality of life

Teaser: 

A highlight of opening day at the ninth International Psychogeriatric Association international congress was the recognition of outstanding research in the field of psychogeriatrics. First prize went to Jurgen Unutzer MD, MPH of Los Angeles, with Donald L Patrick PhD, MSPH, Paula Diehr PhD, Greg Simon MD, MPH, David Grembowski PhD and Wayne Katon MD, for a paper entitled: "Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders."

The researchers compared elderly victims of severe "depression" to those who had many other chronic and debilitating diseases. IPA president Dr. Barry Reisberg, who presented the award, said: "They found that depression had a greater effect on quality of life than such conditions as stroke, cancer diabetes, and high blood pressure."

Second prize was given to Sarvada Chandra Tiwari MD, MNAMS of Lucknow, India for a study of "Geriatric Psychiatric Morbidity in Rural Northern India--Implications for Future." Dr. Tiwari's study documents that there are almost 30 million psychogeriatrically ill persons in India, but few resources to treat the problem and little specialty training of the country's professionals, India has made astonishing strides in life expectancy. However, Dr. Tiwari says: "We have to realize that adding life to years is more important than adding years to life."

The Myths and Realities of ECT for Depression: A Scientific and Personal Perspective

The Myths and Realities of ECT for Depression: A Scientific and Personal Perspective

Teaser: 

David Heath, MB, ChB, FRCPC
Geriatric Psychiatrist
Program for Older Adults
Homewood Health Centre
Guelph, ON

You receive a call from Mrs. Roberts' daughter and she tells you, "They want to give mum shock treatment for her depression. I didn't think they still did that. What do you think doctor? Mum says she doesn't want to sign the consent form without first talking to you." Some physicians might feel put on the spot after such a conversation and are unsure how to respond. They may not have learned much about electroconvulsive therapy (ECT) in medical school and much of what they hear about it in the media is negative and often sensationalised. So, what are the facts about this widely misunderstood treatment?

ECT's voodoo image is not helped by the fact that its mechanism of action is still unknown. The induction of a seizure is universally accepted as necessary for its effectiveness, however, and its origins are quite scientifically respectable. Convulsion, induced by camphor, has been known to "cure insanity" since 1764. Von Meduna started treating schizophrenic patients this way using camphor and then Metrazol in the 1930's. In 1938, Cerletti used electrical stimulation as a less unpleasant convulsant.