Journal of the American Geriatrics Society, Mar 1, 2005
Callahan et al., investigators with the Improving Mood: Promoting Access to Collaborative Treatme... more Callahan et al., investigators with the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) study, present findings in this issue of the Journal of the American Geriatrics Society that support the improvement of physical functional status in older adults experiencing major depression or dysthymia after the intervention of depression clinical specialists (DCSs) located in primary care practices. Despite the focus on improving function in the practice of geriatric medicine, few interventional studies of depression have included physical function as an outcome. The findings from this study should be of importance to primary care practitioners treating older adults for at least three reasons; (1) depression is frequent in older adults, especially those who attend primary care clinics, (2) depression in late life is often associated with impairment in physical function, and (3) the interventions prescribed in the IMPACT study are not only efficacious but can reasonably be implemented within the primary care setting. Readers should reflect on four factors as they review this study. First, self-assessment of physical function must be recognized as a proxy for actual functional status. Second, the severity of the physical disability may modify the effectiveness of the DCS intervention. Third, the role of social support may be a key component of the DCS intervention apart from the specific intervention strategies. Finally, repeated measures analyses, as performed by these investigators, should be considered the standard for future analyses, especially when multiple assessments of primary and secondary outcomes are evaluated. Most studies of functional status, especially in community samples, use self-report measures as performed in this study. Such self-report is probably the only feasible assessment in busy primary care offices, although more specialized geriatric assessment programs may complement such self-assessment with actual tests of performance. For example, it has been found that self-report of disability at widely spaced intervals leads to significant underestimation of disability, especially episodes of short-term disability. Another study found only moderate agreement between the Late Life Function and Disability Instrument and actual physical measures of gait speed, standing balance, and chair stands. During intervention, depression status may also influence self-assessment, (The depressed may report their disability more negatively than the nondepressed.) Low mood may help people to disengage from pursuing a goal that is perceived to be unattainable. Low mood may also suggest alternative strategies when the distance from the goal does not reduce at a fast enough pace. When depressed, older adults may not only view themselves as less capable physically, they may also be less likely to engage in activities, such as shopping, paying bills, and perhaps even self-care activities. In the treatment setting when the depressed mood is lifting, older patients may desire to please the DCS, especially if they experience an improvement in symptoms and they have appreciated the work of the DCS. Therefore, they may overestimate their capacities and activities. In addition, the measurement of functional status is multidimensional. The IMPACT investigators explore physical function and instrumental activities of daily living (ADLs). A recent study found in a community sample that depression status predicted changes in instrumental ADLs but not more basic physical ADLs, such as are measured using the Katz scale. In addition, depression is multidimensional, as illustrated by the factor structures of depressive rating scales, such as the Center for Epidemiologic Studies Depression Scale (CES-D). Another study found that low positive affect and somatic complaints, but not negative affect (the typical core symptoms of depression), predicted functional decline in mobility. Severity of disability may affect the perceived effectiveness of the intervention of the DCS. As noted above, more severe physical ADL impairment may be less responsive to improvement in depressive symptoms, especially if these physical impairments are comorbid with severe chronic diseases. Because most older adults attending primary care clinics are not severely impaired, the value of the DCS is not substantially diminished. Yet interpretation of results at the other extreme presents a methodological problem. If the older patient has few physical function impairments, then the investigator faces a ‘‘ceiling effect,’’ namely improvement can be assessed over a relatively short interval and the disappearance of one impairment may be substituted for the appearance of another, neither being of grave consequence. Given that most of the subjects were relatively free of physical impairment in this study, the findings of improvement are impressive. The DCS had available a number of intervention strategies, and some activities were prescribed.…
Major depression can affect up to 10% of older adults in clinical samples. Longitudinal studies o... more Major depression can affect up to 10% of older adults in clinical samples. Longitudinal studies of older adults with major depression report that a significant proportion of patients do not fully recover. Partial remission or symptoms of major depression that do not meet criteria for major depression, is predicted by 1) clinical factors, such higher number of symptoms at diagnosis, presence of comorbid dysthymia, and health problems; 2) social variables, such as high levels of perceived stress and low levels of perceived social support; and 3) perceived health/well-being variables, such as limitations in mobility or instrumental activities of daily living, poorer self-perceived health, finding life not satisfying, and looking back over life and finding it unhappy. Treatment options include antidepressants (alone or in combination) and psychotherapy.
American Journal of Geriatric Psychiatry, May 1, 2002
The authors investigated the increased risk of mortality from subthreshold depression and examine... more The authors investigated the increased risk of mortality from subthreshold depression and examined differences in risk by gender. Data from the Duke University Established Populations for Epidemiologic Studies of the Elderly (EPESE) longitudinal study of 4,162 community-dwelling adults age 65 or older were used for these analyses. Depression was measured with a modified version of the Center for Epidemiologic Studies Depression Scale (CES-D). Three follow-up periods were assessed, 1986-1989, 1989-1992, and 1992-1996. Using logistic regression, they determined the odds of mortality from both CES-D depression (> or =9 symptoms) and subthreshold depression (6-8 symptoms) by sex for each follow-up period, controlling for sociodemographic factors, physical and cognitive health and functioning, and health behaviors. CES-D depression was not associated with mortality in either men or women. Subthreshold depression was also not associated with mortality in men; in women, however, subthreshold depression was negatively related to mortality (OR=0.60; p=0.002) across the three periods. Subthreshold depression may result in different outcomes in women, possibly mediating against mortality.
Journal of the American Geriatrics Society, Mar 1, 2005
Callahan et al., investigators with the Improving Mood: Promoting Access to Collaborative Treatme... more Callahan et al., investigators with the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) study, present findings in this issue of the Journal of the American Geriatrics Society that support the improvement of physical functional status in older adults experiencing major depression or dysthymia after the intervention of depression clinical specialists (DCSs) located in primary care practices. Despite the focus on improving function in the practice of geriatric medicine, few interventional studies of depression have included physical function as an outcome. The findings from this study should be of importance to primary care practitioners treating older adults for at least three reasons; (1) depression is frequent in older adults, especially those who attend primary care clinics, (2) depression in late life is often associated with impairment in physical function, and (3) the interventions prescribed in the IMPACT study are not only efficacious but can reasonably be implemented within the primary care setting. Readers should reflect on four factors as they review this study. First, self-assessment of physical function must be recognized as a proxy for actual functional status. Second, the severity of the physical disability may modify the effectiveness of the DCS intervention. Third, the role of social support may be a key component of the DCS intervention apart from the specific intervention strategies. Finally, repeated measures analyses, as performed by these investigators, should be considered the standard for future analyses, especially when multiple assessments of primary and secondary outcomes are evaluated. Most studies of functional status, especially in community samples, use self-report measures as performed in this study. Such self-report is probably the only feasible assessment in busy primary care offices, although more specialized geriatric assessment programs may complement such self-assessment with actual tests of performance. For example, it has been found that self-report of disability at widely spaced intervals leads to significant underestimation of disability, especially episodes of short-term disability. Another study found only moderate agreement between the Late Life Function and Disability Instrument and actual physical measures of gait speed, standing balance, and chair stands. During intervention, depression status may also influence self-assessment, (The depressed may report their disability more negatively than the nondepressed.) Low mood may help people to disengage from pursuing a goal that is perceived to be unattainable. Low mood may also suggest alternative strategies when the distance from the goal does not reduce at a fast enough pace. When depressed, older adults may not only view themselves as less capable physically, they may also be less likely to engage in activities, such as shopping, paying bills, and perhaps even self-care activities. In the treatment setting when the depressed mood is lifting, older patients may desire to please the DCS, especially if they experience an improvement in symptoms and they have appreciated the work of the DCS. Therefore, they may overestimate their capacities and activities. In addition, the measurement of functional status is multidimensional. The IMPACT investigators explore physical function and instrumental activities of daily living (ADLs). A recent study found in a community sample that depression status predicted changes in instrumental ADLs but not more basic physical ADLs, such as are measured using the Katz scale. In addition, depression is multidimensional, as illustrated by the factor structures of depressive rating scales, such as the Center for Epidemiologic Studies Depression Scale (CES-D). Another study found that low positive affect and somatic complaints, but not negative affect (the typical core symptoms of depression), predicted functional decline in mobility. Severity of disability may affect the perceived effectiveness of the intervention of the DCS. As noted above, more severe physical ADL impairment may be less responsive to improvement in depressive symptoms, especially if these physical impairments are comorbid with severe chronic diseases. Because most older adults attending primary care clinics are not severely impaired, the value of the DCS is not substantially diminished. Yet interpretation of results at the other extreme presents a methodological problem. If the older patient has few physical function impairments, then the investigator faces a ‘‘ceiling effect,’’ namely improvement can be assessed over a relatively short interval and the disappearance of one impairment may be substituted for the appearance of another, neither being of grave consequence. Given that most of the subjects were relatively free of physical impairment in this study, the findings of improvement are impressive. The DCS had available a number of intervention strategies, and some activities were prescribed.…
Major depression can affect up to 10% of older adults in clinical samples. Longitudinal studies o... more Major depression can affect up to 10% of older adults in clinical samples. Longitudinal studies of older adults with major depression report that a significant proportion of patients do not fully recover. Partial remission or symptoms of major depression that do not meet criteria for major depression, is predicted by 1) clinical factors, such higher number of symptoms at diagnosis, presence of comorbid dysthymia, and health problems; 2) social variables, such as high levels of perceived stress and low levels of perceived social support; and 3) perceived health/well-being variables, such as limitations in mobility or instrumental activities of daily living, poorer self-perceived health, finding life not satisfying, and looking back over life and finding it unhappy. Treatment options include antidepressants (alone or in combination) and psychotherapy.
American Journal of Geriatric Psychiatry, May 1, 2002
The authors investigated the increased risk of mortality from subthreshold depression and examine... more The authors investigated the increased risk of mortality from subthreshold depression and examined differences in risk by gender. Data from the Duke University Established Populations for Epidemiologic Studies of the Elderly (EPESE) longitudinal study of 4,162 community-dwelling adults age 65 or older were used for these analyses. Depression was measured with a modified version of the Center for Epidemiologic Studies Depression Scale (CES-D). Three follow-up periods were assessed, 1986-1989, 1989-1992, and 1992-1996. Using logistic regression, they determined the odds of mortality from both CES-D depression (> or =9 symptoms) and subthreshold depression (6-8 symptoms) by sex for each follow-up period, controlling for sociodemographic factors, physical and cognitive health and functioning, and health behaviors. CES-D depression was not associated with mortality in either men or women. Subthreshold depression was also not associated with mortality in men; in women, however, subthreshold depression was negatively related to mortality (OR=0.60; p=0.002) across the three periods. Subthreshold depression may result in different outcomes in women, possibly mediating against mortality.
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