Major Depression In Older Adults Research Articles

Usability of the Japanese Late-Stage Elderly Questionnaire for screening major depression.

Older adults with major depression are at risk of frailty and long-term care needs. Consequently, screening for major depression is imperative to prevent such risks. In Japan, the Late-Stage Elderly Questionnaire was developed to evaluate older adults' holistic health, including mental well-being. It comprises one specific question to gauge life satisfaction, but the effectiveness of this question to screen for major depression remains unclear. Therefore, we aimed to assess the usability of this question to screen for major depression. This retrospective cohort study used a large, commercially available claims database in Japan. Participants were older adults aged ≥75 years who completed the Late-Stage Elderly Questionnaire and were classified with and without new major depression within 1 year. We evaluated the questionnaire's ability to screen for major depression using C-statistics, developing three models to assess the cut-off value based on responses to the life satisfaction question ('Satisfied', 'Somewhat satisfied', 'Somewhat unsatisfied', or 'Unsatisfied'), estimating the sensitivity and specificity of each model. Among 11 117 older adults, 77 newly experienced major depression within 1 year. The C-statistic for screening major depression was 0.587. The model setting the cut-off between 'Somewhat unsatisfied' and 'Unsatisfied' the demonstrated lowest sensitivity and highest specificity, while the model setting the cut-off between 'Satisfied' and 'Somewhat satisfied' demonstrated highest sensitivity and lowest specificity. Our results suggest that due to its poor screening ability and high rate of false negatives, the question assessing life satisfaction in the Late-Stage Elderly Questionnaire may not be useful for screening major depression in older adults and may require modification.

FC35: Depressive symptom transitions in older adults: effects of psychosocial, behavioral, and clinical factors

Objective:Depression evolves dynamically in old age. Studies of natural history of major depression in older adults suggest that 19–34% recover, 27%–32% remain chronically ill, and approximately 40% experience a fluctuating course. Another way of approaching depression from a longitudinal point of view is by adopting a symptom-based approach, that in addition to the evolution of clinically manifested diagnostic entities, also focuses on transitions involving subclinical/subsyndromal states, although few studies have attempted it. We examined psychosocial, behavioral, and clinical determinants of transitions across states that include no depression, subsyndromal-, and clinical depression.Methods:We used data on 3086 adults aged 60+ from the Swedish National Study on Aging and Care in Kungsholmen, followed for 15 years. Markov-state transition models were used to capture transition patterns, as well as their associated determinants. Death and dropout constituted absorbing states. Depression was diagnosed in accordance with DSM-5; SSD was based on having at least 2 symptoms in the absence of DSM diagnosis. Determinants of transition patterns included index of social connections and support (i.e., psychosocial determinants); smoking, alcohol consumption, and physical activity (behavioral determinants); somatic disease burden and history of depression (clinical determinants).Results:At baseline, 10% of the study population exhibited clinically relevant levels of depressive symptoms. Over a 15-year period, a total of 11,489 transitions were observed. Preliminary results indicate that behavioral factors (primarily smoking) were mostly associated with transitions from no depression to clinical depression, as well as from clinical depression to death. Mostly the same pattern was seen for clinical determinants, although higher burden of chronic diseases and previous depression also increased the likelihood of transition from no depression to SSD. Notably, of high baseline values of social connection and support were found to: 1) lower the likelihood of transitioning from no depression to either SSD or clinical depression; 2) lower the likelihood of transitioning from SSD to clinical depression; and 3) increase the likelihood of transitioning from clinical depression to no depression.Conclusion:Clinical and behavioral factors are mostly implicated in lowering the occurrence of depression, whereas psychosocial factors may also be implicated in recovery.

Depression in older adults. What are the differences in clinical practice?

Management of depression in the elderly is a growing public health issue in France. The objective of this study was to compare practitioners' perception of depression severity (i.e., intensity and suicidal risk) and clinical practice (i.e., clinical assessment and medication choice) in elderly versus younger adult patients with major depression. The method consisted of an online questionnaire completed by general practitioners and psychiatrists. Respondents'answers to a fictive case of a patient with major depression were randomized according to the patient's age, if the patient'age was either 40 or 70 years old. We assessed the perceived intensity of the depression, the perceived suicidal risk, the prescription of biological tests and cerebral imaging, and of antidepressive or other psychotropic medications. 102 completed forms were included. Data indicate that there were no significant differences in terms of perceived depression intensity and suicidal risk according to the patients'age. The prescription of biological tests was systematic in both groups, but a significant difference was observed in terms of prescription of brain imaging (71% of respondents for the 70-year-old patient versus 43% for the 40-year-old patient, p <0.005), use of tetracyclic antidepressant (33% if aged 70years versus 2% if aged 40 years, p <0.001) and other psychotropic non-antidepressant medications (69% if aged 70 years versus 85% if aged 40 years, p<0.05). This study did not show any significant difference in the perception of depression according to age. However, it highlights differences in terms of practical care according to age. These results suggest a partial gap between clinical practice and guidelines for the management of major depression in older adults, reflecting the need to favor the dissemination of guidelines and strengthen research for this population.

Indigenous population and major depressive disorder in later life: a study based on the data from Longitudinal Ageing Study in India

BackgroundExisting evidence suggests that the indigenous older population who live with their families and friends might experience lesser depressive symptoms due to better emotional support and well-being. The present study aimed to investigate the differentials in the prevalence of the major depressive disorder among tribal and non-tribal older populations in India and to explore the contribution of socio-demographic, health-related, and household factors in such disparities.MethodsA cross-sectional study was conducted using data from the Longitudinal Aging Study in India (2017–18). The analytical sample included 30,637 older adults, among whom 5,025 and 25,612 belonged to the Scheduled Tribe (ST) and non-Scheduled Tribe (non-ST) social groups, respectively. Major depressive disorder assessed by the Composite International Diagnostic Interview short-form (CIDI-SF) scale was the outcome variable. Descriptive statistics, bivariate and multivariable regression and, decomposition analyses were conducted.ResultsAbout 4.8% and 8.9% of older adults from the ST and non-ST social groups had major depression. For both tribal and non-tribal groups, older adults who were unmarried, dissatisfied with living arrangements, and those who faced lifetime discrimination were at increased risk of major depression. Findings from differences due to characteristics (E) revealed that if the regional differences were minimized, it would decrease the ST-non-ST gap in major depression by about 19.6%. Similarly, equal self-rated health status and chronic conditions among ST and non-ST groups would decrease the gap in major depression by almost 9.6% and 7.9%, respectively. Additionally, an equal status of Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL) among older adults would decrease the gap in major depression by about 3.8% and 3% respectively. Also, findings from differences due to coefficients (C) revealed that if older adults from the ST group had the same status of ADL as of older adults from the non-ST group, it would decrease the gap in major depression by about 11.8%.ConclusionThe findings revealed a greater prevalence of major depression in older adults belonging to the non-ST group than the ST group. For both tribal and non-tribal groups, older adults who were unmarried, dissatisfied with living arrangements, and those who faced lifetime discrimination were at increased risk of major depression and these factors along with health-related variables contributed to significant ST-non-ST gap in depression, advantageous to tribal population; suggesting further research on the coping mechanisms of mental illnesses among indigenous population in India.

Reliable Cognitive Decline in Late-Life Major Depression.

Major depression in older adults increases the statistical likelihood of dementia. It is challenging to translate statistical evidence of cognitive decline at the group level into knowledge of individual cognitive outcomes. The objective of the current study is to investigate 2-year reliable cognitive change in late-life depression (LLD), which will enhance understanding of cognitive changes in LLD and provide a means to assess individual change. In a sample of non-depressed cognitively normal older adults or NDCN (n = 113), we used linear regression to predict tests of global cognition, processing speed-executive functioning, and memory administered 1 and 2 years later. Stepwise regression was used to select covariates among demographics and raw test scores (either baseline or year 1) and we cross-validated the final models using the predicted residual error sum of squares (PRESS). We then derived a z-change score from the difference between actual and predicted follow-up scores and investigated the proportion of LLD patients (n = 199) and NDCN adults who experienced reliable "decline" (a z-score < -1.645), "stability" (z-scores between + - 1.645), and "improvement" (z scores > +1.645). A greater proportion LLD compared with NDCN experienced cognitive decline in processing speed/executive functioning and global cognition over 2 years. When compared to NDCN, a greater proportion of LLD also significantly improved on one test of processing speed over 2 years. Older adults with LLD are at risk of meaningful cognitive decline over a relatively short period, particularly in the domain of executive functioning and processing speed. This study provides a series of reliable change equations for common neuropsychological tests that can be applied clinically.

Brief CBT Interventions May Stop Depression Before It Starts

Brief CBT Interventions May Stop Depression Before It Starts

Diffusion kurtosis imaging and comparison of microstructural change between older adults with Alzheimer's disease and major depressive disorder

<h3>Introduction</h3> Alzheimer's disease and major depression in older adults share common clinical presentations of cognitive dysfunction. Diffusion kurtosis imaging (DKI), an extension of diffusion tensor imaging, had shown a potential to detect better microstructural changes than conventional imaging. The authors hypothesized that DKI technique can differentiate the microstructural abnormalities in these two diseases. The aim of the current study was to compare microstructural changes among older treatment naïve participants with Alzheimer's disease (AD), major depressive disorder (MDD), and healthy controls using diffusion kurtosis imaging whole-brain analysis with tract-based spatial statistics (TBSS). <h3>Methods</h3> Participants aged 60 years or older were recruited from Psychiatric and Geriatrics Clinics at Siriraj Hospital in Bangkok, Thailand. Forty-seven participants were included in this pilot study (16 AD, 11 MDD, and 20 healthy age-matched controls; mean age 70.5 years). All participants underwent an MRI study including institutional dementia protocol and DKI sequence. Post-processing analysis of images was obtained using FMRIB Software Library and Diffusion Kurtosis Estimator software with TBSS method focusing on Fractional Anisotropy (FA) parameter. <h3>Results</h3> Participants with AD showed significantly smaller values of FA in subcortical white matter of the bilateral frontal lobe, the genu, the body, and the splenium of the corpus callosum, the inferior longitudinal fasciculus, the superior longitudinal fasciculus, the pons, and the cerebellar peduncle compared to controls. There were no significant differences in FA parameters between participants with MDD and controls. This study detected a smaller in FA values in the subcortical white matter of the bilateral frontal regions in participants with MDD compared to AD. <h3>Conclusions</h3> Diffusion kurtosis imaging is a promising approach to differentiate MDD from AD participants by detection of reduction in FA values especially at subcortical areas of bilateral frontal regions. Further analysis with other diffusional parameters and a larger group of participants will expand the knowledge about pathophysiology related to microstructural changes among the elderly with AD and MDD. <h3>This research was funded by</h3> Faculty of Medicine Siriraj Hospital, Mahidol University.

Prevention of Incident and Recurrent Major Depression in Older Adults With Insomnia

Older adults with insomnia have a high risk of incident and recurrent depression. Depression prevention is urgently needed, and such efforts have been neglected for older adults. To examine whether treatment of insomnia disorder with cognitive behavioral therapy for insomnia (CBT-I) compared with an active comparator condition, sleep education therapy (SET), prevents major depressive disorder in older adults. This assessor-blinded, parallel-group, single-site randomized clinical trial assessed a community-based sample of 431 people and enrolled 291 adults 60 years or older with insomnia disorder who had no major depression or major health events in past year. Study recruitment was performed from July 1, 2012, to April 30, 2015. The trial protocol was modified to extend follow-up from 24 to 36 months, with follow-up completion in July 2018. Data analysis was performed from March 1, 2019, to March 30, 2020. Participants were randomized to 2 months of CBT-I (n = 156) or SET (n = 135). The primary outcome was time to incident major depressive disorder as diagnosed by interview and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria. Secondary outcome was sustained remission of insomnia disorder before depression event or duration of follow-up. Among 291 randomized participants (mean [SD] age, 70.1 [6.7] years; 168 [57.7%] female; 7 [2.4%] Asian, 32 [11.0%] Black, 3 [1.0%] Pacific Islander, 241 [82.8%] White, 6 [2.1%] multiracial, and 2 [0.7%] unknown), 156 were randomized to CBT-I and 135 to SET. A total of 140 participants (89.7%) completed CBT-I and 130 (96.3%) participants completed SET (χ2 = 4.9, P = .03), with 114 (73.1%) completing 24 months of follow-up in the CBT-I group and 117 (86.7%) in the SET group (χ2 = 8.4, P = .004). After protocol modification, 92 (59.0%) of the CBT-I participants and 86 (63.7%) of the SET participants agreed to extended follow-up (χ2 = 0.7, P = .41), with 81 (51.9%) of the CBT-I participants and 77 (57.0%) of the SET group completing 36 months of follow-up (χ2 = 0.8; P = .39). Incident or recurrent major depression occurred in 19 participants (12.2%) in the CBT-I group and in 35 participants (25.9%) in the SET group, with an overall benefit (hazard ratio, 0.51; 95%, CI 0.29-0.88; P = .02) consistent across subgroups. Remission of insomnia disorder continuously sustained before depression event or during follow-up was more likely in CBT-I participants (41 [26.3%]) compared with the SET participants (26 [19.3%], P = .03). Those in the CBT-I group with sustained remission of insomnia disorder had an 82.6% decreased likelihood of depression (hazard ratio, 0.17; 95%, CI 0.04-0.73; P = .02) compared with those in the SET group without sustained remission of insomnia disorder. The findings of this randomized clinical trial indicate that treatment of insomnia with CBT-I has an overall benefit in the prevention of incident and recurrent major depression in older adults with insomnia disorder. Community-level screening for insomnia concerns in older adults and wide delivery of CBT-I-based treatment for insomnia could substantially advance public health efforts to treat insomnia and prevent depression in this vulnerable older adult population. ClinicalTrials.gov Identifier: NCT01641263.

The importance of social activity to risk of major depression in older adults.

Several social determinants of health (SDoH) have been associated with the onset of major depressive disorder (MDD). However, prior studies largely focused on individual SDoH and thus less is known about the relative importance (RI) of SDoH variables, especially in older adults. Given that risk factors for MDD may differ across the lifespan, we aimed to identify the SDoH that was most strongly related to newly diagnosed MDD in a cohort of older adults. We used self-reported health-related survey data from 41 174 older adults (50-89 years, median age = 67 years) who participated in the Mayo Clinic Biobank, and linked ICD codes for MDD in the participants' electronic health records. Participants with a history of clinically documented or self-reported MDD prior to survey completion were excluded from analysis (N = 10 938, 27%). We used Cox proportional hazards models with a gradient boosting machine approach to quantify the RI of 30 pre-selected SDoH variables on the risk of future MDD diagnosis. Following biobank enrollment, 2073 older participants were diagnosed with MDD during the follow-up period (median duration = 6.7 years). The most influential SDoH was perceived level of social activity (RI = 0.17). Lower level of social activity was associated with a higher risk of MDD [hazard ratio = 2.27 (95% CI 2.00-2.50) for highest v. lowest level]. Across a range of SDoH variables, perceived level of social activity is most strongly related to MDD in older adults. Monitoring changes in the level of social activity may help identify older adults at an increased risk of MDD.

Childhood adversity and major depression in later life: A competing-risks regression analysis.

This study examined the relationship between childhood adversities and major depression in older adults over 8 years. The study sample consisted of 16 946 participants aged 51 years and older from the US Health and Retirement Study. Major depression was assessed using the Composite International Diagnostic Interview. Competing-risks regression analysis was conducted to examine the impact of each childhood adversity on late-life major depression and the potential moderation effects of sex, race/ethnicity, and adulthood trauma. After controlling for covariates, childhood adversities including physical abuse by a parent (subdistribution hazard ratio [SHR] = 1.67, 95% confidence interval [CI] = 1.49-1.89, P < .001), trouble with the police (SHR = 1.31, 95% CI = 1.13-1.54, P = .001), receiving help because of financial difficulties (SHR = 1.17, 95% CI = 1.05-1.31, P = .006), and parental substance abuse (SHR = 1.11, 95% CI = 1.01-1.23, P = .037) were associated with a higher rate of major depression in later life. The association of physical abuse and major depression was stronger for men than women (SHR = 1.46, 95% CI = 1.15-1.85, P = .002), despite an overall lower risk of major depression among men. Potential adulthood trauma had a weaker association with late-life major depression in the presence of childhood physical abuse (SHR = 0.91, 95% CI = 0.85-0.98, P = .015). There was a significant dose-response relationship (SHR = 1.20, 95% CI = 1.16-1.24, P < .001). Childhood adversities increase the risk of major depression in later life, particularly for those who experienced physical abuse and trouble with the police. Men may be more susceptible to the mental health detriments of childhood adversities.

Effects of transient and chronic loneliness on major depression in older adults: A longitudinal study.

The number of older adults is rapidly rising globally. Loneliness is a common problem that can deteriorate health. The aims of this work were to identify different types of loneliness (transient and chronic) and to assess their association with depression over time. A nationally representative sample from the Spanish population comprising 1190 individuals aged 50+ years was interviewed on three evaluations over a 7-year period. The UCLA Loneliness Scale was used to measure loneliness. While chronic loneliness was defined as the presence of loneliness across all three waves, transient loneliness expressed the presence of loneliness in one wave only. A 12-month major depressive episode was assessed at each interview. After confirming the cross-sectional relationship, a multilevel mixed-effects model was used to examine the association between loneliness and depression. Almost a quarter of individuals felt lonely and one out of 10 presented depression at baseline. Of the sample, 22.78% showed transient loneliness, while 6.72% presented the chronic type. People experiencing chronic loneliness were at a higher risk of presenting major depression (OR = 6.11; 95% CI = 2.62, 14.22) than those presenting transient loneliness (OR = 2.22; 95% CI = 1.19, 4.14). This association varied over time and was stronger at the first follow-up than at the second one. Focusing on loneliness prevention could reduce the risk of depression. Chronic loneliness is a public health problem that should be addressed through the full participation of the political, social, and medical sectors.

Examining associations of food insecurity with major depression among older adults in the wake of the Great Recession.

As a psychosocial stressor, the degree to which food insecurity impacts major depression may be dependent on macro-level context, which can be examined in the wake of the Great Recession. The objective of this study was to determine (1) whether food insecurity transition status (i.e. initially food insecure, becoming food insecure, and remaining food insecure vs. not food insecure) was associated with major depression in older adults and; (2) whether this association was moderated by macro-level context. Data came from the United States Health and Retirement Study, 2008-2016. Multivariable logistic regression across all years revealed that major depression was associated with any exposure to food insecurity, however; this association was moderated by time period. Remaining food insecure was associated with major depression during all time periods. In contrast, becoming food insecure was associated with major depression in the years during and immediately following the Recession, but not in later time periods. Findings suggest that associations of food insecurity with major depression among older adults are moderated by macro-level context, consistent with theories of social comparison and relative disadvantage. Food insecurity may represent an important risk factor for major depression and mental health disparities across socioeconomic strata in old age. Thus, policies that increase access to food assistance programs or improve the quality of local food environments may buffer against the impact of food insecurity on depression and associated complications among older adults.

TREATMENT PARAMETERS AND RATIONALE FOR THE USE OF ELECTROCONVULSIVE THERAPY FOR THE MANAGEMENT OF TREATMENT-REFRACTORY AGITATION IN ALZHEIMER'S DISEASE

TREATMENT PARAMETERS AND RATIONALE FOR THE USE OF ELECTROCONVULSIVE THERAPY FOR THE MANAGEMENT OF TREATMENT-REFRACTORY AGITATION IN ALZHEIMER'S DISEASE

THE IMPACT OF SSRI TREATMENT OF MAJOR DEPRESSION ON GAIT AND POSTURAL STABILITY IN OLDER ADULTS: A PILOT FEASIBILITY STUDY

Introduction Falls are a common and potentially catastrophic event in older adults, and mortality due to falls is increasing. Older adults with psychiatric and cognitive disorders are at particularly high risk of falls and are at high risk for the negative consequences of falls, including fear of falling, functional decline, injury and dependence. Geriatric psychiatrists are confronted with a tension between the treatment of distressing psychiatric symptoms and disorders in older adults, and the concern about increasing the risk for falls. In particular, antidepressants are among the most commonly prescribed drugs in older adults, and the relationship between these drugs and falls events has been established through epidemiological studies. However, these studies are confounded by indication, in that depression itself is a known risk factor for falls. To date, little is known about the specific mechanisms of SSRI-related falls. The objective of this study was to determine the feasibility of a longitudinal study of the impact of sertraline treatment on gait and postural stability, and to establish the effect sizes for a fully powered study. Methods We completed a 12-week open label pilot observational study of sertraline for major depression in older adults. This study used instrumented walkway to measure features of gait stability and FallsLab (a 2-D motion platform) to measure postural stability and balance recovery reactions. Gait and dynamic stability of older adults with depression (n=12) at baseline and 3,6, and 12 weeks after initiation of sertraline was compared to the performance of a group of healthy controls (n=8). Results There were consistent baseline differences between depressed and control participants in their gait and postural stability, which persisted despite improvement in depressive symptoms. Short-term changes in gait stability were observed at 3 weeks after starting sertraline, which resolved by 6 weeks. Depressed individuals on sertraline became less cautious in their gait over time, as measured by decreased double stance time, and had worse standing postural sway. There were no changes over time with treatment in standing or dynamic postural stability. Healthy control and depressed participants showed some degree of practice effect in assessments over time. From the perspective of feasibility, depressed older adults with fear of falling did not tolerate the perturbations, with a high withdrawal rate in that group. Conclusions There are subtle changes in gait and stability observable after treatment with antidepressants, but important methodological issues need to be addressed, including practice effects with repeated assessments and development of an adequately challenging balance recovery paradigm which is acceptable to depressed older adults. This research was funded by: Dean's Fund, University of Toronto; UHN psychiatric consultants research grant; Walter and Maria Schroeder Institute for Brain Innovation and Recovery.

Review: In older adults with acute major depression, SNRIs, but not SSRIs, increase adverse events vs placebo.

Source Citation Sobieraj DM, Martinez BK, Hernandez AV, et al. Adverse effects of pharmacologic treatments of major depression in older adults. J Am Geriatr Soc. 2019;67:1571-81. 31140587

Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults.

To assess adverse effects of pharmacologic antidepressants for treatment of major depressive disorder (MDD) in adults 65 years of age or older. Systematic review and meta-analysis. Specialist or generalist outpatient setting, rehabilitation facility, and nursing facilities. Persons 65 years and older with MDD. Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, trazodone, vilazodone, or vortioxetine compared with another antidepressant, placebo, or nonpharmacologic therapy. Adverse events, arrhythmias, cognitive impairment, falls, fractures, hospitalization, mortality, QTc prolongation, serious adverse events, and withdrawals due to adverse events. Nineteen randomized controlled trials and two observational studies were included. Most studies evaluated treatment of the acute phase (<12 wk) of MDD of moderate severity. SSRIs led to a statistically similar frequency of overall adverse events vs placebo (moderate strength of evidence [SOE]), but SNRIs caused more overall adverse events vs placebo (high SOE) during the acute treatment phase. Both SSRIs and SNRIs led to more study withdrawals due to adverse events vs placebo (SSRIs low SOE; SNRIs moderate SOE). Duloxetine led to a more falls vs placebo (moderate SOE) during 24 weeks of acute and continuation treatment of MDD. In patients 65 years of age or older with MDD, treatment of the acute phase of MDD with SNRIs, but not SSRIs, was associated with a statistically greater number of overall adverse events vs placebo. SSRIs and SNRIs led to a greater number of study withdrawals due to adverse events vs placebo. Duloxetine increased the risk of falls that as an outcome was underreported in the literature. Few studies examined head-to-head comparisons, most trials were not powered to evaluate adverse events, and results of observational studies may be confounded. Comparative long-term studies reporting specific adverse events are needed to inform clinical decision making regarding choice of antidepressants in this population. J Am Geriatr Soc 67:1571-1581, 2019.

Chapter 23 - Assessment and treatment of major depression in older adults

Late life depression is a significant public health problem as well as a burden on patients, their families, and caregivers. There are significant associations of late life depression with medical disorders and cognitive impairment, the latter due to effects of the depression itself or association with dementia. Diagnostic criteria and screening tests have continued to evolve and provide structure and guidelines for assessment. Accurate diagnosis and treatment are of utmost importance to improve quality of life, alleviate suffering, and prevent suicide. A number of effective antidepressant medications are available; combination therapy with these medications and cognitive behavioral therapy appear most efficacious, and maintenance therapy can decrease the chances of remission. A sequence for treatment of late life depression is provided, with strategies for treatment-resistant depression. The relationship of dementia to depression and the interaction of depression with mechanisms of aging are major foci of research.

Effect of a Lay Counselor Intervention on Prevention of Major Depression in Older Adults Living in Low- and Middle-Income Countries

Preventing depression in older adults living in low- and middle-income countries is important because of the scarcity of treatment resources and the risk of disability, suicide, and dementia. To assess whether an intervention for depression prevention provided by lay counselors is effective in older adults from low- and middle-income countries. This parallel-group randomized clinical trial with masked outcome assessment was performed in 181 older adults (≥60 years) with subsyndromal depressive symptoms at rural and urban primary care clinics in Goa, India. The first participant entered the trial on March 31, 2015, and the last exited on June 2, 2017. Data analysis used the intention-to-treat approach. Lay counselors provided problem-solving therapy, brief behavioral treatment for insomnia, education in self-care of common medical disorders such as diabetes, and assistance in accessing medical and social programs. The main outcome was incidence of major depressive episodes. The study also assessed symptom change during 12 months (12-item General Health Questionnaire [GHQ-12]; score range of 0 to 12, with higher scores indicating greater symptoms of depression and anxiety), functional status (World Health Organization Disability Assessment Schedule 2.0; score range of 12 to 60, with higher scores indicating greater disability), cognition (Hindi Mini-Mental State Examination; score range of 0 to 30, with higher scores indicating better cognitive functioning), blood pressure, and body mass index to provide further clinical context. The study enrolled 181 participants (mean [SD] age, 69.6 [7.2] years; 114 [63.0%] female): 91 to the intervention arm (depression in later life [DIL] intervention) and 90 to care as usual (CAU). Incident episodes of major depression were lower in the DIL intervention than in the CAU group (4.40% vs 14.44%; log-rank P = .04; number needed to treat, 9.95; 95% CI, 5.12-182.43). The 12-month Kaplan-Meier estimates of percentage of depression-free participants were 95.1% (95% CI, 90.5%-99.9%) in the DIL group vs 87.4% (95% CI, 80.4%-95.1%) in the CAU group. The incidence of depressive symptoms (GHQ-12) was also less (12-month mean difference, -1.18; 95% CI, -2.03 to -0.31; group × time interaction P < .001). There were no changes in measures of disability or cognition. The DIL intervention was associated with a significantly greater lowering of systolic blood pressure (12-month mean difference, -6.98; 95% CI, -11.96 to -2.01; group × time interaction P < .001) and change in body mass index (12-month mean difference, 0.23; 95% CI, -0.97 to 1.43; P = .04). The DIL intervention is effective for preventing episodes of major depression in older persons with subsyndromal symptoms. If replicated, the DIL intervention may be effective in older adults living in low- and middle-income countries. ClinicalTrials.gov Identifier: NCT02145429.

State of the Science of Neural Systems in Late-Life Depression: Impact on Clinical Presentation and Treatment Outcome.

Major depression in older adults, or late-life depression (LLD), is a common and debilitating psychiatric disorder that increases the risk of morbidity and mortality. Although the effects of LLD make it important to achieve a diagnosis and start treatment quickly, individuals with LLD are often inadequately or unsuccessfully treated. The latest treatment developments suggest that interventions targeting executive dysfunction and neuroticism, constructs associated with poor response to antidepressants in older adults, are successful in treating LLD. Specific behavioral interventions (computerized cognitive training, mindfulness meditation, aerobic exercise) appear to decrease depressive symptoms and ameliorate executive dysfunction and neuroticism, but we do not fully understand the mechanisms by which these treatments work. We review recent research on neural network changes underlying executive dysfunction and neuroticism in LLD and their association with clinical outcomes (e.g., treatment response, cognitive functioning).

Factors associated with brain volume in major depression in older adults without dementia: results from a large autopsy study.

We examined brain volume and atrophy in individuals with major depressive disorder (MDD) without dementia that were referred to a large autopsy service. We also examined potential risk factors for brain atrophy, including demographics and clinical variables. In this study, 1373 participants (787 male) aged 50 years or older who died from natural causes were included. Participants with no reliable informant, with cognitive impairment or dementia, with a medical history of severe chronic disease, or with prolonged agonal state were excluded. Presence of MDD at least once in their lifetime was defined according to the Structured Clinical Interview for DSM. Brain volume was measured immediately after removal from the skull. Mean age at death was 68.6 ± 11.6, and MDD was present in 185 (14%) individuals. Smaller brain volume was associated with older age (p < 0.001), lower education (years; p < 0.001), hypertension (p = 0.001), diabetes (p = 0.006), and female gender (p < 0.001). In the multivariate analysis adjusted for sociodemographics and cardiovascular risk factors, smaller brain volume was not associated with major depression (β = -0.86, 95% CI = -26.50 to 24.77, p = 0.95). In this large autopsy study of older adults, MDD was not associated with smaller brain volumes. Regardless of the presence of MDD, in this sample of older adults without dementia, we found that smaller brain volumes were associated with risk factors for brain neurodegeneration such as older age, diabetes, hypertension, and lower education. Copyright © 2017 John Wiley & Sons, Ltd.