The depression-dementia conundrum: integrating clinical and epidemiological perspectives.
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Adult↗
Biomedical subjects
M L Bruce
Publications and source records attributed to M L Bruce.
Trends over a decade for a general hospital psychiatry unit.
This study examines the composition and delivery of services in a general hospital inpatient psychiatry unit during a 10-year period. Multiple regression techniques were used to assess the association of clinical, insurance, and demographic data with length of stay and likelihood of readmission for all admissions from 1985-1993. Two variables became progressively associated with readmission--Medicaid and psychotic diagnosis. The results indicate that: (1) the hospital is increasingly treating a poorer, sicker group of patients with shorter lengths of stay and more readmissions, and (2) the rise in readmissions, particularly within vulnerable populations, could represent an inadequate length of initial treatment. Future research should further investigate the generalizability of these results and implications for quality of inpatient care.
Adult↗
Physical health, depressive symptoms, and managed care enrollment.
OBJECTIVE: This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs). METHOD: The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables. RESULTS: In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics. CONCLUSIONS: This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.
Adult↗
Diagnosis and treatment of depression in late life. Consensus statement update.
OBJECTIVE: To reexamine the conclusions of the 1991 National Institutes of Health Consensus Panel on Diagnosis and Treatment of Depression in Late Life in light of current scientific evidence. PARTICIPANTS: Participants included National Institutes of Health staff and experts drawn from the Planning Committee and presenters of the 1991 Consensus Development Conference. EVIDENCE: Participants summarized relevant data from the world scientific literature on the original questions posed for the conference. PROCESS: Participants reviewed the original consensus statement and identified areas for update. The list of issues was circulated to all participants and amended to reflect group agreement. Selected participants prepared first drafts of the consensus update for each issue. All drafts were read by all participants and were amended and edited to reflect group consensus. CONCLUSIONS: The review concluded that, although the initial consensus statement still holds, there is important new information in a number of areas. These areas include the onset and course of late-life depression; comorbidity and disability; sex and hormonal issues; newer medications, psychotherapies, and approaches to long-term treatment; impact of depression on health services and health care resource use; late-life depression as a risk factor for suicide; and the importance of the heterogeneous forms of depression. Depression in older people remains a significant public health problem. The burden of unrecognized or inadequately treated depression is substantial. Efficacious treatments are available. Aggressive approaches to recognition, diagnosis, and treatment are warranted to minimize suffering, improve overall functioning and quality of life, and limit inappropriate use of health care resources.
Age Factors↗
The influence of psychological and social factors on accuracy of self-reported blood pressure.
The data reported here document levels of accuracy in reports of blood pressure and identify correlates of inaccurate reporting. The data come from a long-term follow-up of a cohort of African-American women who registered for antepartum care between September, 1967 and June, 1969. At the follow-up interview, these women were asked whether they had ever received a diagnosis of hypertension from a physician. The self-reports of hypertension were compared with information contained in the medical records of these women. Twenty-five percent reported having high blood pressure but 53% of these reports were unconfirmed by their medical records (overall misreporting rates was 15.9% with 2.5% underreporting and 13.4% overreporting). The factors related to misreporting included a psychiatric diagnosis (based on the Diagnostic Interview Schedule) of major depressive disorder or drug and/or alcohol abuse and a small social network. The conjunction of these three variables significantly affected accuracy of reporting (100% misreporting with all three variables). These results suggest that, using currently standard methodology, there is an unreliable subpopulation of respondents in health surveys that may require the collection of data on health status from a second source to confirm data from self-reported health measures.
Adult↗
Subjective ratings of emotional health as a risk factor for major depression in a community sample.
BACKGROUND: Although subjective ratings of health have been shown to be accurate predictors of physical health outcomes, there is little research on the association between subjective emotional health (SEH) and psychiatric outcomes. METHOD: This paper utilises data from the Epidemiologic Catchment Area study to explore the relationship between baseline SEH and the risk for major depression in the next year. Both recurrent and incident episodes of depression are outcomes of interest. RESULTS: The age- and gender-adjusted relationship between SEH and depression is quite significant, and remains so after adjusting for other factors associated with major depression. The more positive the SEH rating, the lower the risk of an episode of depression in the next year. CONCLUSIONS: Some possible explanations for this association are explored, including possible confounders that were not accounted for and the possibility that SEH ratings pose an independent risk for major depression.
Affective Symptoms↗
Outcomes for antidepressant trials in late-life depression.
Most randomized controlled trials of antidepressant efficacy in older depressive patients use outcome measures similar to those applied in younger patients. Defining subjects as geriatric based on chronological age alone misses the opportunity to study relationships among efficacy, safety, and the range of impairments associated with aging. Assessment of outcomes related to the medical comorbidities and disabilities associated with late-life depression is needed to understand the broad range of treatment effects. Assessment of changes in subjective and objective measures of functioning can address relationships between clinical state and health-related quality of life. Sensitive measurement of the number and severity of comorbid medical illnesses can precisely characterize the study sample and assess the impact of efficacious treatment on medical illnesses. In long-term studies of heterogeneous geriatric samples, use of appropriate outcome measures can determine the effect of efficacious treatment on changes in health status and functional independence.
Age Factors↗
Depression in former school-age mothers and community comparison subjects.
This paper examines the lifetime prevalence and correlates of major depressive disorder in a cohort of former school-age mothers and compares the prevalence and correlates to those found in women of the same age, ethnicity, and geographical location as the school-age mothers. The sociodemographic characteristics show some striking differences. The former young mothers were less likely to be on public assistance (19% vs 42%), but were more likely to be working (78% vs. 55%), to have completed high school or college and to meet the DSM-III criteria for depression (10.7% vs. 4.9%) than the sample of community women. The only factor related to depression in the former school-age mothers was a diagnosis of drug/alcohol abuse or dependence.
Adolescent↗
Social network characteristics and onset of ADL disability: MacArthur studies of successful aging.
The relationship between social network structural and support characteristics and onset of new or recurrent activities of daily living (ADL) disability was examined in a cohort of older men and women. No significant protective effects were found for network structural or support characteristics. However, greater frequency of instrumental support was associated with significantly increased risk of ADL disability among men; a similar though nonsignificant pattern was seen among women. These findings indicate that receipt of more instrumental support may not have uniformly beneficial effects on functional status. They serve to underscore the need for more comprehensive research, examining both the positive and negative effects of social interactions on health and functioning.
Activities of Daily Living↗
Depression and medical illness in late life: report of a symposium.
The high comorbidity of medical illnesses and late life depression poses both challenges and opportunities. Challenges in assessment techniques, diagnosis, and specific prognosis affect clinical care and research methodology alike. However, investigations that turn this vexing "confound" into research questions may prove fruitful. For clinicians working with older persons, recognizing the prognostic import of comorbid medical illnesses in late-life depression is essential to treatment planning. This comorbidity also poses difficulties in diagnosing depression inasmuch as symptoms of the medical conditions may overlap with those of an affective disorder. Symptom assessments must strike a balance between overly inclusive (e.g., mistakenly treating the psychomotor slowing of Parkinson's disease as depression) and overly exclusive (e.g., erroneously dismissing the patient's mood symptoms as "understandable"). Clinicians also should be sensitive to the broad range of symptomatic presentations with varying severities of both mood and medical disorders, as exemplified by variability across treatment settings. For researchers, similar issues are of relevance in planning investigative strategies. Consideration should be given to the following: 1. Case identification is a crucial first step; the approach to depressive symptoms potentially confounded by medical illnesses must be defined explicitly. Choice of an inclusive approach avoids premature exclusion of relevant phenomena; exploratory analyses can examine the effects of other approaches to the relationships of interest. 2. The use of similar research instruments across sample sites would greatly facilitate comparisons of results. Each subject group offers its own "leverage" for answering particular questions. Psychiatric inpatients will highlight the contributions of severe psychopathology (useful, for example, in identifying biologic markers). Medical inpatients are well suited to studies examining validity of different approaches to case identification, investigating health service utilization, or highlighting the contribution of acute, severe, life-threatening medical disorders to affective illness. Long-term care residents lend themselves to issues that benefit from compression of health processes over time. Medical outpatients have many advantages regarding generalizability and public health significance. Community samples are needed to determine the biases of all the above groups, which are each defined by service utilization. 3. Study of the relationships between depression and medical illness may further understanding of pathogenic mechanisms in late life mood disorders. Research questions might be guided by the biopsychosocial conceptual context described above. On the one hand, this context demands multidimensional study methodology to identify the routes by which medical illness influences depression in particular patient groups. Multivariate models should examine direct and indirect effects of medical illness on depression while, at the same time, considering intervening variables such as functional disability, personality, and social support. Guided multiple regressions or structural equation modeling will allow for determination of strengths of associations. 4. At the same time, and of particular importance if complex multivariate analyses are used, specific theoretic models should help direct focused investigations. The development and testing of such models is a major challenge that should be addressed by current research. Finally, from a societal perspective, the comorbidity of depression and medical illness likely has a tremendous impact on both health and health care delivery for older adults. Further study is needed to identify more specific approaches to treatment. Yet existing data clearly support a policy of routine psychiatric assessment of older people in general medical settings...
Age Factors↗
Training and experience of psychiatric residents in identifying domestic violence.
Of 221 psychiatric residents at four U.S. medical schools, 145 responded to a survey about their training and clinical experience in recognizing domestic violence and providing referrals and treatment. Only 28 percent reported receiving training in this area. Almost half reported that they asked about domestic violence in less than a quarter of their cases involving female patients. Fifty-nine percent of respondents did so "only when a problem was suspected." Eighty-seven percent had seen at least one case of domestic violence in the previous year. Those with training in recognizing domestic violence identified significantly more cases. Sixty-five percent of all residents surveyed were unable to list a local agency for referral.
Adult↗
Cognitive impairment and depression in the oldest old in a German and in U.S. communities.
Data on cognitive impairment in the oldest old is reported comparing two different samples, one in Munich, Germany, and the other in the United States (Epidemiologic Catchment Area [ECA] study). In both studies the Mini Mental State Examination (MMSE) was used for assessing cognitive impairment. The Munich sample consisted of 402 and the ECA sample of 827 very old people aged 85 years and above. The results indicate that approximately 40% of each sample scored below 24 points in the MMSE indicating at least mild cognitive impairment. Severe cognitive impairment was found in 13.4% of the Munich and in 14.6% of the American sample. The prevalence of major depression was 1.4% in Munich and 2.0% in the ECA study, and dysthymia was found in 5.1% in the Munich and in 2.0% in the ECA sample aged 85 years and above. Persons living in institutions in both studies more frequently showed signs of cognitive impairment than those living in private households. The ECA sample, but not the Munich sample, showed a significantly higher prevalence of cognitive impairment for females and for the oldest age cohort above 90 years of age. Major depression was more frequent in Munich in persons living in institutions and in the ECA study among the oldest age cohort above 90 years of age. Dysthymia in both studies did not show any association with sociodemographic factors. Most of the excess comorbidity (cognitive impairment and depression) was observed among subjects with mild (and not with severe) cognitive impairment.(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
The effects of cognitive impairment on 9-year mortality in a community sample.
Using 9-year mortality data on a community sample of 3,560 adults aged 40 and over, this study assessed the effects of cognitive functioning and one-year declines in cognitive functioning on mortality controlling for comorbid chronic medical illness, physical disability, and psychiatric illness. The study determined the 9-year vital status and, among the decreased, date of death of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area Study. Mortality risk by cognitive functioning, as assessed by the Mini-Mental State Examination (MMSE), was estimated using Cox Proportional Hazards Models controlling for baseline assessments of physical and mental health. For both men and women, lower scores on the MMSE decreased the risk of survival, although the effect was stronger for younger respondents than older respondents. Decline in MMSE scores over the course of one year had no additional effect on mortality beyond the resulting MMSE score. Cause-specific mortality was also examined.
Adult↗
Social and physical health risk factors for first-onset major depressive disorder in a community sample.
Using prospective data on 3,170 respondents aged 18 years and over who were at risk for a first-onset major depression from the New Haven site of the Epidemiologic Catchment Area (ECA) study, these analyses assessed the effects of social status, physical health status, and social isolation on first-onset depression in a 1-year period, controlling for demographic characteristics and baseline psychiatric factors. Among the assessed potential risk factors, poverty status [odds ratio (OR = 2.034, P < 0.05)] and confinement to a bed or chair (OR = 4.015, P < 0.05) were independently associated with an increased risk for a first-onset depressive episode when controlling for gender, age, past history of substance abuse, and subclinical depressive symptoms. The effects of poverty, and to a lesser degree homebound status, were substantially reduced when controlling for degree of isolation from friends and family, suggesting that social isolation mediates some of the relationships between social and physical statuses and major depression.
Adolescent↗
Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study.
OBJECTIVE: This study examined the effects of nine axis I psychiatric disorders, as assessed by the Diagnostic Interview Schedule, on the risk of mortality over a 9-year period among a community sample of 3,560 men and women aged 40 and older. METHOD: The study identified the vital status as of Oct. 1, 1989, of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area study. Mortality risk by psychiatric status was estimated by using Cox proportional hazards models. RESULTS: Nine years after the baseline interview, it was confirmed that 1,194 (33.5%) of the respondents were deceased and 2,344 (65.8%) survived; the vital status of 22 (0.6%) remained unknown. When the relative risk of mortality was adjusted for age, several disorders--major depression, alcohol abuse or dependence, and schizophrenia--increased the likelihood of mortality. CONCLUSIONS: These data are further evidence of the negative outcome of some psychiatric problems even when assessed in community samples. The relatively high prevalence of depression and alcohol disorders indicates the far-reaching impact that these problems have on community health in general.
Adult↗
The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging.
OBJECTIVES: The purpose of these analyses was to test the hypothesis that depressive symptomatology affects the risk of onset of physical disability in high-functioning elderly adults. METHODS: The data come from the MacArthur Study of Successful Aging, a community-based cohort of high-functioning adults aged 70 through 79 years who were assessed twice at a 2.5-year interval. Physical and cognitive status was assessed by performance as well as by self-report measures. RESULTS: In gender-stratified logistic regression models, high depressive symptoms as measured by the depression subscale of the Hopkins Symptom Checklist were associated with an increased risk of onset of disability in activities of daily living for both men and women, adjusting for baseline sociodemographic factors, physical health status, and cognitive functioning. CONCLUSIONS: Joined with evidence that physical disability is a potential risk factor for depression, these findings suggest that both depressive symptoms and physical disability can initiate a spiralling decline in physical and psychological health. Given the important impact of activities-of-daily-living functioning on utilization of medical services and quality of life, prevention or reduction of depressive symptoms should be considered an important point of intervention.
Activities of Daily Living↗
Psychiatric status among the homebound elderly: an epidemiologic perspective.
OBJECTIVE: To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors. DESIGN: Survey. SETTING: Epidemiologic Catchment Area (ECA) project in New Haven, CT. PARTICIPANTS: 2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area. INTERVENTION: None MAIN MEASURES: Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination. RESULTS: Cognitive impairment (21.8% vs 11.0%, P less than 0.001), depression (2.3% vs 0.7%, P less than 0.01), dysthymia (3.9% vs 1.7%, P less than 0.01), and anxiety disorders (2.2% vs 0.4%, P less than 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P less than 0.01) was significantly more prevalent among elders confined to a bed or chair. CONCLUSIONS: The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.
Aged↗
Effects of age and alcoholism on the prevalence of panic disorder.
Findings are reported evaluating the effects of aging and alcoholism histories on the 6-month prevalence rates of panic disorder. The data were collected in 5 communities as part of the Epidemiologic Catchment Area (ECA) study: New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; and Los Angeles, CA. Reanalysis of ECA data provided additional support for a decline in the prevalence of panic disorder among elderly people. In addition, the presence of a history of alcohol abuse or dependence was associated with significantly elevated panic disorder rates in younger individuals, but an earlier decline in panic disorder prevalence with age, regardless of gender. These findings offer preliminary support for neurodevelopmental hypotheses for the onset and outgrowing of panic disorder. They also highlight the impact of alcoholism on the course of panic disorder.
Adolescent↗