American Journal of Geriatric Psychiatry.
Sunday, June 9, 2002
Outcome of Low-Level Depression In Elderly Patients Warrants Attention To Range of Depressive Disorders Study Considers Depressed Older People Who Need Help But Aren’t Sick Enough for Traditional Mental Care Facilities Low-levels of depression in the elderly are both frequent and persistent, underscoring the need to focus on depressive states in older patients that may fall below the clinical threshold for major depression, concludes a new study published today in the American Journal of Geriatric Psychiatry. With depression widely recognized as a major health problem, the study, conducted by researchers at the Program in Geriatrics and Neuropsychiatry at the University of Rochester Medical Center, considers the initial evaluation and the condition one-year later of depressed elderly patients treated in primary care settings. Of particular interest in the study was the rate and outcome for less severe but still important forms of depression: specifically, minor depression, in which patients suffer from two to four symptoms of depression that last most of the day, nearly every day, and a more variable condition called “subsyndromal depression” in which patients may suffer those same symptoms only a couple of hours a day or a few days a week. From an initial group of 247 subjects, the investigators followed 63 patients found to be suffering one of three different types of depression. Twenty-two had major (commonly known as “clinical”) depression, but the majority had the lesser forms, with 14 suffering minor depression and 27 subsyndromal depression. After one year, 36 of the 63 patients (57 percent) still had some level of depression, including about half of the patients initially suffering from minor and subsyndromal depression. Meanwhile, 27 or 43 percent were deemed nondepressed at one year. Of those still considered depressed at one year, some had improved. Ten patients initially diagnosed with major depression and three with minor depression were now suffering from the more variable, subsyndromal depression. At the same time, the study notes that “the minor and subsyndromal depression groups taken together were much more likely to develop major depression (at one year) than those initially in the nondepressed group.” Jeffrey M. Lyness, M.D., the lead author of the paper, said investigators were intrigued by the relative frequency and persistence of the less severe forms of depression because, while clearly associated with patient distress and disability, they are not often seen in traditional psychiatric care settings. As a result, clinicians have little in the way of definitive research to help them diagnose and treat such forms of depression. “It used to be that most psychiatric research was done with patients in psychiatric settings, which is why we know so much about how to treat major or ‘clinical’ depression,” Lyness said. “However, this type of research, because it dealt only with the more severe cases of depression, did not provide clinicians with information on how to treat people with other, less severe forms of depression. “Older people suffering from these symptoms usually don’t go to mental health facilities, but they do go to primary care doctors,” he added. “So we need to investigate in much more depth the rates and types of depression showing up in the ‘real world’ of primary care so that the primary care setting can become a place where we optimize treatment for all forms of depression.” The article points out that most elderly people who commit suicide suffer from depression, and most have seen their primary care provider shortly before death. Despite the limited data on effective treatments for people with conditions that fall short of severe depression, the authors conclude that they found the “risk” to patients “is sufficient that clinicians may choose to treat” the most chronic cases or those most likely to relapse. The results of the study also suggest “targeting treatment to those with previous episodes” of depression, with medical conditions (such as cardiovascular or neurological problems) known to have a relationship to depression, or with “personality vulnerabilities that lead to difficulty negotiating psychosocial” stress. Lyness said that while his study is the largest of its kind to date, the results—mainly the high percentage of patients who stayed depressed after one-year and the association of other medical conditions with outcomes—flagged enough issues to justify a more in-depth investigation. Lyness said research involving a much larger patient group followed over several years is needed to better identify those patients with depression who are at highest risk of persisting depression, a group of patients for whom treatments should be particularly targeted. For example, physicians need much more information with the prognosis for less severe forms of depression, chiefly, minor depression, which was only recently listed as a condition to be studied further in the appendix to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and so-called subsyndromal depression, Lyness said.