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Millions of Elderly Could Be Quietly Sliding into
Major Depression
Lesser depressions
often lead to major depression but goes undiagnosed in elderly
April 4, 2006 – Elderly patients with any form of
depression less than major depression are more than five times as likely
as healthy seniors to descend into major depression within a year,
according to a study published today in the Annals of Internal Medicine.
The study's authors believe that perhaps millions of elderly patients
who do not meet the criteria for a diagnosis of major depression are
indeed depressed, suffering and not being treated for it.
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Researchers are focusing on depression in elderly
patients because the number of persons aged 65 years or older (about 36
million) is expected to double in the next 25 years, with a third of
them expected to struggle with a mental disorder at some point.
While major depression among the elderly is an
important problem, it has overshadowed related disorders that are less
serious, but that leave many more people with suffering from painful
emotions, disinterest in their surroundings, and thoughts of
worthlessness. As a result, this group is more functionally disabled,
less able to feed and groom themselves, or to go shopping.
The current study is the first to carefully
reexamine the definitions of certain depression types in older patients
seen in primary care settings, and to compare outcomes in different
types of depression.
According to the Diagnostic and Statistical Manual
for Mental Disorders 4th Edition (DSM-IV), minor depression is
officially defined using the exact same symptoms as major depression,
but including fewer of them. To be precise, persons suffering from minor
depression experience 2 to 4 symptoms of depression for most of the day
nearly every day, while those with major depression experience five or
more symptoms.
Patients with the same symptoms, but experiencing
them less frequently – perhaps only several days per week, or for only a
few hours each day -- fall within the "subsyndromal" depression
category.
Among patients in the current study, 20 percent
were found to meet the criteria for minor or subsyndromal depression,
compared to just five percent that met the definition of major
depression.
Projecting the percentages out to the U.S.
population over aged 65, researchers estimate that about 7 million
experience minor or subsyndromal depression, often undiagnosed and
untreated, compared to 1.75 million senior citizens with major or
so-called clinical depression.
"Our study makes the point that the lines drawn
between major and minor depression, while useful in some ways, are
arbitrary, and may need to be redrawn to put an end to a great deal of
suffering in this country," said Jeffrey M. Lyness, M.D., director of
the Program in Geriatrics and Neuropsychiatry at the University of
Rochester Medical Center, and lead author of the article.
"The less severe the depression, the less it has
been studied, regardless of how significant its impact might be."
Study Details
The current study followed 622 patients who were at
least 60 years of age and came in for treatment in primary care
practices in greater New York City, Philadelphia and Pittsburgh. The
current study sought to measure minor depression, not by studying
patients that report to psychiatrist's office, but instead by measuring
depression among those who visited their primary care doctors' offices.
Most elderly persons never see mental a health
specialist, but instead may tell their primary care physician about
feeling down or nervous or otherwise unwell during a regular check-up.
Of the 441(70.9%) patients who completed one year
of follow-up, 122 had major depression, 205 had minor or subsyndromal
depression, and 114 did not have depression at the beginning of the
study. One year after a baseline evaluation, data were collected using
standard questionnaires and measurements of depression (e.g., Hamilton
Depression Rating Scale).
The study found that patients with minor or
subsyndromal depression were five and one-half times more likely to be
diagnosed with major depression within a year than those who were not
depressed at the start of the study.
The group with minor and subsyndromal depression
also suffered greater functional disability at one year than patients
without depression, although not as severe as those with major
depression. As shown in other studies, the level of a patient's medical
illness to start with (medical burden) and patients' beliefs about their
health and support from others such as families or friends were
significant, independent predictors of depression outcome.
Beginnings of A Solution
Lyness has also co-authored a separate study, now
in press in The American Journal of Psychiatry, which may hold part of
the answer for these oft-neglected patients with minor and subsyndromal
depression.
In short, the second study, a statistical analysis
of previously published clinical studies, found that patients with less
severe forms of depression may on average experience 40 percent more
improvement from psychotherapy (i.e., counseling) than from treatment
with antidepressant drugs. In addition, a greater proportion of patients
receiving psychotherapy improved than did those receiving drug
treatment, Lyness said.
"There is an urgent need for all of us in the field
to redraw the definitions and standards in minor and subsyndromal
depression, but that will not happen until we prove what works for these
patients in particular, as opposed to what works for patients with major
depression," Lyness said. "In the near future we will seek to identify
those patients most in need and most likely to respond to specific
therapy or medications. To do so, my colleagues and I are currently
analyzing information collected over the past five years from over 750
older persons in the Rochester area."
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