Depression is a treatable illness that disproportionately places older adults at increased risk for mortality.
We sought to examine whether there are patterns of course of depression severity among older primary care patients that are associated with increased risk for mortality.
DESIGN AND SETTING
Our study was a secondary analysis of data from a practice-based randomized controlled trial within 20 primary care practices in New York, New York, and Philadelphia and Pittsburgh, Pennsylvania.
The study sample consisted of 599 adults aged 60 years and older recruited from primary care settings. Participants were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients. Severity of depression was assessed using the 24-item Hamilton Depression Rating Scale (HDRS).
Longitudinal analysis via general curve mixture modeling was carried out to classify patterns of course of depression severity across 12 months. Vital status at 5 years was ascertained via the National Death Index Plus.
Three patterns of change in course of depression severity over 12 months were identified: (1) persistent depressive symptoms, (2) high but declining depressive symptoms, (3) low and declining depressive symptoms. After a median follow-up of 52.0 months, 114 patients had died. Patients with persistent depressive symptoms were more likely to have died compared with patients with a course of high but declining depressive symptoms (adjusted hazard ratio 2.32, 95% confidence interval (CI) [1.15, 4.69]).
Persistent depressive symptoms signaled increased risk of dying in older primary care patients, even after adjustment for potentially influential characteristics such as age, smoking status, and medical comorbidity (244 words).
Aged; Primary health care; Geriatric depression; Mortality
Medication use among Medicare beneficiaries has increased and adherence has improved since the implementation of the Medicare Part D prescription drug benefit in 2006. However, the structure of the benefit, particularly, the coverage gap, is still problematic. It is critical to understand how beneficiaries with coexisting conditions respond to the coverage gap and whether their response differs by type of medications.
Aims of the Study
The paper aims to evaluate the effects of Medicare Part D’s coverage gap on drug regimens among beneficiaries with coexisting depression and heart failure (HF).
Drug utilization patterns of a 5% random sample of Medicare Part D beneficiaries with depression and HF in 2007 were observed. We compared drug use pattern pre and post coverage gap among three groups: no coverage, generic coverage, and full coverage due to low-income subsidies (LIS) and used propensity score weighting to adjust for difference across groups.
Beneficiaries with some drug coverage in the gap were more likely to enter the gap: 82% for LIS, 79% for generic-only and 58% for no coverage. Beneficiaries without drug coverage reduced their use of antidepressants by 5.0% (95% CI 1.7%-8.2%), and HF drugs by 9.4% (95% CI 7.2%-11.5%) after they entered the coverage gap. Those with generic coverage cut their brand-name drugs more than generic drugs but did not shift to generic drugs. However, adherence to antidepressants did not change; adherence to HF drugs reduced slightly, 2.5% (95% CI 1.2%-3.7%) in the no-coverage group and 2.6% (95% CI 1.3%-3.9%) in the generic-coverage group.
The coverage gap was associated with a modest reduction in number of prescriptions filled for depression and HF but it was not associated with a significant effect on adherence.
Implications for Health Policy
We found that beneficiaries with coexisting depression and HF were less likely to reduce their drug use than beneficiaries in general. In addition, the gap was not associated with a large reduction in adherence. It suggests that concerns about the coverage gap’s harmful effects on medication adherence, or comorbidities might be overstated.
Implications for Further Research
Further studies on how people make medication use decisions in the face of changes in benefits and how the coverage affects non-drug medical outcomes are warranted.
Although the epidemiology of insomnia in the general population has received considerable attention in the past 20 years, few studies have investigated the prevalence of insomnia using operational definitions such as those set forth in the ICSD and DSM-IV, specifying what proportion of respondents satisfied the criteria to reach a diagnosis of insomnia disorder.
This is a cross-sectional study involving 25,579 individuals aged 15 years and over representative of the general population of France, the United Kingdom, Germany, Italy, Portugal, Spain and Finland. The participants were interviewed on sleep habits and disorders managed by the Sleep-EVAL expert system using DSM-IV and ICSD classifications.
At the complaint level, too short sleep (15.8%), light sleep (16.6%), and global sleep dissatisfaction (8.5%) were reported by 37% of the subjects. At the symptom level (difficulty initiating or maintaining sleep and non-restorative sleep at least 3 nights per week), 34.5% of the sample reported at least one of them. At the criterion level, (symptoms + daytime consequences), 9.8% of the total sample reported having them. At the diagnostic level, 6.6% satisfied the DSM-IV requirement for positive and differential diagnosis. However, many respondents failed to meet diagnostic criteria for duration, frequency and severity in the two classifications, suggesting that multidimensional measures are needed.
A significant proportion of the population with sleep complaints do not fit into DSM-IV and ICSD classifications. Further efforts are needed to identify diagnostic criteria and dimensional measures that will lead to insomnia diagnoses and thus provide a more reliable, valid and clinically relevant classification.
Insomnia; Epidemiology; classifications; mental disorders
Converging evidence implicates basal ganglia alterations in impulsivity and suicidal behavior. For example, D2/D3 agonists and subthalamic nucleus stimulation in Parkinson’s disease trigger impulse control disorders and possibly suicidal behavior. Further, suicidal behavior has been associated with structural basal ganglia abnormalities. Finally, low-lethality, unplanned suicide attempts are associated with increased discounting of delayed rewards, a behavior dependent upon the striatum. Thus, we tested whether, in late-life depression, changes in the basal ganglia were associated with suicide attempts and with increased delay discounting.
Fifty-two persons aged ≥60 underwent extensive clinical and cognitive characterization: 33 with major depression (13 suicide attempters [SA], 20 non-suicidal depressed elderly), and 19 non-depressed controls. Participants had high-resolution T1-weighted MPRAGE MRI scans. Basal ganglia gray matter voxel counts were estimated using atlas-based segmentation, with a highly-deformable automated algorithm. Discounting of delayed rewards was assessed using the Monetary Choice Questionnaire, and delay aversion with the Cambridge Gamble Task.
SA had lower putamen but not caudate or pallidum gray matter voxel counts, compared to the control groups. This difference persisted after accounting for substance use disorders and possible brain injury from suicide attempts. SA with lower putamen gray matter voxel counts displayed higher delay discounting on the MCQ, but not delay aversion on the CGT. Secondary analyses revealed that SA had lower voxel counts in associative and possibly ventral, but not sensorimotor striatum.
Our findings, while limited by small sample size and case-control design, suggest that striatal lesions could contribute to suicidal behavior by increasing impulsivity.
suicide; basal ganglia; corpus striatum; globus pallidus; putamen; decision making; reward
This study tests whether or not the structural white matter lesions that are characteristic of late-life depression are associated with alterations in the functional affective circuits of late-life depression. This study used an emotional faces paradigm that has been shown to engage the affective limbic brain regions.
Thirty-three elderly depressed patients and 27 nondepressed comparison subjects participated in this study. The patients were recruited through the NIMH-sponsored Advanced Center for Interventions and Services Research for the Study of Late-Life Mood Disorders at the University of Pittsburgh Center for Bioethics and Health Law. Structural and functional MRI was used to assess white matter hyperintensity (WMH) burden and functional magnetic resonance imaging (fMRI) blood-oxygen-level-dependent (BOLD) response on a facial expression affective-reactivity task in both elderly participants with nonpsychotic and non-bipolar major depression (unmedicated) and nondepressed elderly comparison subjects.
As expected, greater subgenual cingulate activity was observed in the depressed patients relative to the nondepressed comparison subjects. This same region showed greater task-related activity associated with a greater burden of cerebrovascular white matter change in the depressed group. Moreover, the depressed group showed a significantly greater interaction of WMH by fMRI activity effect than the nondepressed group.
The observation that high WMH burden in late-life depression is associated with greater BOLD response on the affective-reactivity task supports the model that white matter ischemia in elderly depressed patients disrupts brain mechanisms of affective regulation and leads to limbic hyperactivation.
We sought to examine whether there are patterns of evolving depression symptoms among older primary care patients that are related to prognostic factors and long-term clinical outcomes.
Primary care practices were randomly assigned to Usual Care or to an intervention consisting of a depression care manager offering algorithm-based depression care. In all, 599 adults 60 years and older meeting criteria for major depression or clinically-significant minor depression were randomly selected. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients according to the patterns of depression symptoms across 12 months. Depression diagnosis determined after a structured interview at 24 months was the long-term clinical outcome.
Three patterns of change in depression symptoms over 12 months were identified: high persistent course (19.1% of the sample), high declining course (14.4% of the sample), low declining course (66.5% of the sample). Being in the intervention condition was more likely to be associated with a course of high and declining depression symptoms than high and persistent depression symptoms (OR = 2.53, 95% CI [1.01, 6.37]). Patients with a course of high and persistent depression symptoms were much more likely to have a diagnosis of major depression at 24 months compared with patients with a course of low and declining depression symptoms (adjusted OR = 16.46, 95% CI [7.75, 34.95]).
Identification of patients at particularly high risk of persistent depression symptoms and poor long-term clinical outcomes is important for the development and delivery of interventions.
clinicaltrials.gov registration number: NCT00000367.
Aged; Primary health care; Geriatric depression
Anticipatory grief is the process of experiencing normal phases of bereavement in advance of the loss of a significant person. To date, anticipatory grief has been examined in family caregivers to individuals who have had Alzheimer’s Disease (AD) an average of 3 to 6 years. Whether such grief is manifested early in the disease trajectory (at diagnosis) is unknown. Using a cross-sectional design, we examined differences in the nature and extent of anticipatory grief between family caregivers of persons with a new diagnosis of mild cognitive impairment (MCI, n=43) or AD (n=30). We also determined whether anticipatory grief levels were associated with caregiver demographics, caregiving burden, depressive symptoms and marital quality. Mean anticipatory grief levels were high in the total sample, with AD caregivers endorsing significantly more anticipatory grief than MCI caregivers. In general, AD caregivers endorsed difficulty functioning whereas MCI caregivers focused on themes of “missing the person” they once knew. Being a female caregiver, reporting higher levels of objective caregiving burden and higher depression levels each bore independent, statistically significant relationships with anticipatory grief. Given these findings, family caregivers of individuals with mild cognitive deficits or a new AD diagnosis may benefit from interventions specifically addressing anticipatory grief.
Anticipatory grief; dementia caregiving; mild cognitive impairment
Given the association of depression with poorer cardiac outcomes, an American Heart Association Science Advisory has advocated routinly screening cardiac patients for depression using the two-item Patient Health Questionnaire (PHQ-2) “at a minimum.” Yet, the prognostic value of the PHQ-2 among HF patients is unknown.
Methods and Results
We screened hospitalized HF patients (ejection fraction (EF) <40%) that staff suspected may be depressed with the PHQ-2, and then determined vital status at up to 12-months follow-up. At baseline, PHQ-2 depression-screen positive patients (PHQ-2 (+); N=371) compared to PHQ-2 screen-negative patients (PHQ-2 (−); N=100) were younger (65 vs. 70), and more likely to report NYHA class III/IV than class II symptoms (67% vs. 39%) and lower levels of physical and mental health-related quality of life (all p ≤ 0.002), but were similar on other characteristics (65% male, 26% mean EF). At 12-months, 20% of PHQ-2 (+) vs. 8% of PHQ-2 (−) patients had died (p=0.007) and PHQ-2 status remained associated with both all-cause (hazard ratio (HR): 3.1 (95% CI: 1.4–6.7); p=0.003) and cardiovascular mortality (HR: 2.7 (1.1–6.6); p=0.03) even after adjustment for age, gender, EF, NYHA class, and a variety of other covariates.
Among hospitalized HF patients, a positive PHQ-2 depression screen is associated with an elevated 12-month mortality risk.
Depression; heart failure; Patient Health Questionnaire; mortality
To describe the methodology of the first NIH-funded clinical trial for seniors with comorbid depression and chronic low back pain.
Randomized controlled effectiveness trial using stepped care methodology. Participants are ≥ 60 years old. Phase 1 (6 weeks) is open treatment with venlafaxine xr 150 mg/day and supportive management (SM). Response is two weeks of PHQ-9 ≤ 5 and at least 30% improvement in the average numeric rating scale for pain. Non-responders progress to phase 2 (14 weeks) in which they are randomized to high-dose venlafaxine xr (up to 300 mg/day) with Problem Solving Therapy for Depression and Pain (PST-DP) or high-dose venlafaxine xr and continued SM. Primary outcomes are the univariate pain and depression response and both observed and self-report disability. Survival analytic techniques will be used, and the clinical effect size will be estimated with NNT. We hypothesize that self-efficacy for pain management will mediate response for subjects randomized to venlafaxine xr and PST-DP.
The results of this trial will inform the care of these complex patients and further understanding of comorbid pain and depression in late-life.
clinical trial; geriatrics; depression; back pain; survival analysis
Bipolar disorder (BD) and major depressive disorder (MDD) are associated with cognitive dysfunction in older age during both acute mood episodes and remitted states. The purpose of this report is to investigate for the first time the similarities and differences in cognitive function of older adults with BD and MDD that may shed light on mechanisms of cognitive decline.
A total of 165 subjects with BD (n = 43) or MDD (n = 122) ages ≥65 years [mean (SD) 74.2 (6.2)] were assessed when euthymic using comprehensive measures of cognitive function and cognitive-instrumental activities of daily living (C-IADLs). Test results were standardized using a group of mentally healthy individuals (n = 92) of comparable age and education level.
Both subjects with BD and MDD were impaired across all cognitive domains compared to controls, most prominently in Information Processing Speed/Executive Function. Despite the protective effects of having higher education and lower vascular burden, BD subjects were more impaired across all cognitive domains compared with MDD subjects. Subjects with BD and MDD did not differ significantly in C-IADLs.
In older age, patients with BD have worse overall cognitive function than patients with MDD. Our findings suggest that factors intrinsic to BD appear to be related to cognitive deterioration and support the understanding that BD is associated with cognitive decline.
aged; bipolar disorder; cognition; IADLs; major depressive disorder
This study sought to examine whether ethnic differences occur in the presentation of patients with complicated grief or their treatment outcome.
Analyses of a randomized controlled trial comparing a novel psychotherapy for complicated grief with interpersonal psychotherapy contrasted the clinical presentation, treatment alliance, and rates of treatment completion and response for 19 African Americans with complicated grief and 19 Caucasian Americans with complicated grief matched by sex, age, and baseline grief severity. Participants were randomly assigned to receive 16 sessions of either standard interpersonal psychotherapy or interpersonal psychotherapy enhanced with focused complicated grief components.
No differences were found in any clinical or treatment-related measure.
African Americans and Caucasian Americans with complicated grief did not differ significantly in clinical presentation, treatment alliance, treatment completion, and outcome. The results suggest that standard treatment for complicated grief can be provided successfully for different racial and economic groups.
Identifying predictors of late-life depression that are amenable to change may lead to interventions that result in better and faster remission. Thus, authors investigated the impact of two different strategies for coping with physical illness on depression in older, primary care patients. Health-oriented goal engagement strategies involve the investment of cognitive and behavioral resources to achieve health goals. Conversely, disengagement strategies involve the withdrawal of these resources from obsolete or unattainable health goals, combined with goal restructuring.
Participants were 271 adults aged >59 who took part in a two-year randomized clinical trial for treating depression in the elderly (PROSPECT -- Prevention of Suicide in Primary Care Elderly: Collaborative Trial). The use of engagement and disengagement strategies, along with other risk factors for depression, were included in a tree-structured survival analysis to identify subgroups of individuals at risk for not achieving depression remission.
Greater use of disengagement strategies predicted earlier remission of depression, particularly among more severely depressed elderly. Use of engagement strategies did not predict earlier remission.
Interventions that encourage disengagement from unattainable health goals may promote remission from depression in older, primary care patients.
aging; depression; health; control
To explore how insomnia symptoms are hierarchically organized in individuals reporting daytime consequences of their sleep disturbances.
This is a cross-sectional study conducted in the general population of the states of California, New York and Texas. The sample included 8,937 individuals aged 18 years or older representative of the general population. Telephone interviews on sleep habits and disorders were managed with the Sleep-EVAL expert system and using DSM-IV and ICSD classifications. Insomnia symptoms and Global Sleep Dissatisfaction (GSD) had to occur at least three times per week for at least three months.
A total of 26.2% of the sample had a GSD. Individuals with GSD reported at least one insomnia symptom in 73.1% of the cases. The presence of GSD in addition to insomnia symptoms considerably increased the proportion of individuals with daytime consequences related to insomnia. In the classification trees performed, GSD arrived as the first predictor for daytime consequences related to insomnia. The second predictor was nonrestorative sleep followed by difficulty resuming sleep and difficulty initiating sleep.
Classification trees are a useful way to hierarchically organize symptoms and to help diagnostic classifications. In this study, GSD was found to be the foremost symptom in identifying individuals with daytime consequences related to insomnia.
The aim of this exploratory study is to examine the default-mode network (DMN) functional connectivity pattern in elderly depressed subjects with and without comorbid anxiety.
Functional MRI data were collected for 11 elderly depressed subjects with high comorbid anxiety and 8 elderly depressed subjects with low anxiety. We analyzed the resting connectivity patterns of the posterior cingulate cortex. We compared the DMN activity in the elderly depressed subjects with high versus low comorbid anxiety.
Depressed elderly with high comorbid anxiety had increased functional connectivity in the posterior regions of the DMN and decreased functional connectivity in the anterior regions of the DMN.
Elderly depressed subjects with high anxiety display a dissociative pattern of connectivity in the DMN when compared with elderly depressed subjects with low anxiety. These results suggest a unique biological signature of the anxiety symptoms in the context of late-life depression.
The brain's default-mode network has been the focus of intense research. This study characterizes the default-mode network activity in late-life depression and the correlation of the default-mode network activity changes with the white-matter hyperintensities burden. We hypothesized that elderly depressed subjects would have altered default-mode network activity, which would correlate with the increased white-matter hyperintensities burden. Twelve depressed subjects (mean Hamilton Depression Rating Scale 19.8±4.1, mean age 70.5±4.9) and 12 non-depressed, comparison subjects (mean age 69±6.5) were included. Functional MRI data were collected while subjects performed a low cognitive load, event-related task. We compared the default-mode network activity in these groups (including depressed subjects pre and post antidepressant treatment). We analyzed the resting connectivity patterns of the posterior cingulate cortex. Deconvolution was used to evaluate the correlation of resting-state connectivity scores with the white-matter hyperintensities burden. Compared with non-depressed elderly, depressed subjects pretreatment had decreased connectivity in the subgenual anterior cingulate cortex and increased connectivity in the dorsomedial prefrontal cortex and the orbitofrontal cortex. The abnormal connectivity was significantly correlated with the white-matter hyperintensities burden. Remitted elderly depressed subjects had improved functional connectivity compared to pretreatment, although alterations persisted in the anterior cingulate and the prefrontal cortex when remitted elderly depressed subjects were compared with non-depressed elderly. Our study provides evidence for altered default-mode network connectivity in late-life depression. The correlation between white-matter hyperintensities burden and default-mode network connectivity emphasizes the role of vascular changes in late-life depression etiopathogenesis.
Late-life depression; resting state; connectivity; white matter burden
To determine the nature of telephone-delivered collaborative care intervention provided patients below and above age 60 experiencing clinically significant depressive symptoms following coronary artery bypass graft (CABG) surgery, and whether patient age is related to response and remission rates and delivery of care at 8-month follow-up.
Exploratory post-hoc analysis of data collected in a randomized controlled trial.
Seven Pittsburgh-area general hospitals.
58 depressed post-CABG patients below age 60 and 92 comparable patients age 60 and above randomized to the RCT's intervention arm.
Components of collaborative care provided patients over the 8-month study period, and HRS-D scores at 8-month follow-up to determine response and remission status.
There were no differences in the cumulative 8-month rates at which the components of collaborative care were delivered to the two age groups. Similar response and remission rates were also achieved by these groups.
Older and younger patients experiencing clinical depression following CABG surgery can be treated with comparable components of collaborative care and both age groups will achieve clinical outcomes that do not differ significantly from each other.
Collaborative care; coronary artery bypass graft surgery; depression
The decision to commit suicide may be impulsive, but lethal suicidal acts often involve planning and forethought. People who attempt suicide make disadvantageous decisions in other contexts, but nothing is known about the way they decide about the future. Can the willingness to postpone future gratification differentiate between individuals prone to serious, premeditated and less serious, unplanned suicidal acts?
Four groups of depressed participants aged 60+ made choices between smaller immediate and larger delayed monetary rewards: 15 who made high-lethality suicide attempts, 14 who made low-lethality suicide attempts, 12 who seriously contemplated suicide, and 42 people with depression but no history of suicidal thoughts. The reference group was 31 psychiatrically healthy elders.
Individuals who had made low-lethality attempts displayed an exaggerated preference for immediate rewards compared to non-suicidal depressed and healthy controls. Those who had carried out high-lethality suicide attempts were more willing to delay future rewards, compared to low-lethality attempters. Better planned suicide attempts were also associated with willingness to wait for larger rewards. These effects were unchanged after accounting for education, global cognitive function, substance use disorders, psychotropic medications, and possible brain injury from attempts. Discount rates were correlated with having debt but were not significantly associated with income, hopelessness, depressive severity, premorbid IQ, age at first attempt, or choice of violent means.
While clinicians often focus on impulsivity in patients at risk for suicide, these data suggest that identifying biological characteristics and treatments for non-impulsive suicidal older people may be even more important.
suicide; cognition; decision making; reward; depressive disorder; aged; time perception; executive function; choice behavior
Prevention; Selective/Indicated; Depression; Later life
Adolescents, elderly persons, African Americans, and rural residents with bipolar disorder are less likely than their middle-aged, white, urban counterparts to be diagnosed, receive adequate treatment, remain in treatment once identified, and have positive outcomes. The Bipolar Disorder Center for Pennsylvanians (BDCP) study was designed to address these disparities. This report highlights the methods used to recruit, screen, and enroll a cohort of difficult-to-recruit individuals with bipolar disorder.
Study sites included three specialty clinics for bipolar disorder in a university setting and a rural behavioral health clinic. Study operations were standardized, and all study personnel were trained in study procedures. Several strategies were used for recruitment.
It was possible to introduce the identical assessment and screening protocol in settings regardless of whether they had a history of implementing research protocols. This protocol was also able to be used across the age spectrum, in urban and rural areas, and in a racially diverse cohort of participants. Across the four sites 515 individuals with bipolar disorder were enrolled as a result of these methods (69 African Americans and 446 non–African Americans). Although clinical characteristics at study entry did not differ appreciably between African Americans and non–African Americans, the pathways into treatment differed significantly.
Rigorous recruitment and assessment procedures can be successfully introduced in different settings and with different patient cohorts, thus facilitating access to high-quality treatment for individuals who frequently do not receive appropriate care for bipolar disorder.
Chronic insomnia is a common health problem with substantial consequences in older adults. Cognitive behavioral treatments are efficacious but not widely available. The aim of this study was to test the efficacy of brief behavioral treatment for insomnia (BBTI) vs an information control (IC) condition.
A total of 79 older adults (mean age, 71.7 years; 54 women [70%]) with chronic insomnia and common comorbidities were recruited from the community and 1 primary care clinic. Participants were randomly assigned to either BBTI, consisting of individualized behavioral instructions delivered in 2 intervention sessions and 2 telephone calls, or IC, consisting of printed educational material. Both interventions were delivered by a nurse clinician. The primary outcome was categorically defined treatment response at 4 weeks, based on sleep questionnaires and diaries. Secondary outcomes included self-report symptom and health measures, sleep diaries, actigraphy, and polysomnography.
Categorically defined response (67% [n=26] vs 25% [n=10]; χ2=13.8) (P<.001) and the proportion of participants without insomnia (55% [n=21] vs 13% [n=5]; χ2=15.5) (P<.001) were significantly higher for BBTI than for IC. The number needed to treat was 2.4 for each outcome. No differential effects were found for subgroups according to hypnotic or antidepressant use, sleep apnea, or recruitment source. The BBTI produced significantly better outcomes in self-reported sleep and health (group × time interaction, F5,73=5.99, P<.001), sleep diary (F8,70= 4.32, P<.001), and actigraphy (F4,74=17.72, P<.001), but not polysomnography. Improvements were maintained at 6months.
We found that BBTI is a simple, efficacious, and durable intervention for chronic insomnia in older adults that has potential for dissemination across medical settings.