Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

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Depression in Late Life: Review and Commentary

CONTEXT Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment. OBJECTIVE To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI. DESIGN, SETTING, AND PATIENTS Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. INTERVENTION Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. MAIN OUTCOME MEASURES Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months. RESULTS Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients). CONCLUSIONS The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.

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Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.

Objective
To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.

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Case-Finding Instruments for Depression: Two Questions Are as Good as Many

Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure

Clinical and health services relationships between major depression, depressive symptoms, and general medical illness

Objective:Although many investigators have studied mood disorders following myocardial infarction, the prevalence, severity, and persistence of depression have been disputed, and standard rating scales and criteria for depressive disorders have infrequently been utilized The authors' goal was to determine how frequently depressive disorders occur after myocardial infarction, and to investigate predisposing factors for such disordersMethod:Structured clinical interviews were administered to 129 inpatients within ten days of myocardial infarction Patients were also evaluated using standardized rating scales for depression, social function, cognition, and physical impairment DSM-III diagnoses were derived from the structured interviewResults:Major depressive syndromes were present in 19 percent (n = 25) of the patients and were associated with prior history of mood disorder, female sex, large infarcts, and functional physical impairmentConclusion:Major depression is common in the acute post-myocardial 

Depression following myocardial infarction.

A group of 60 patients with spinal cord injury was examined to assess mood disorders during the rehabilitation hospital admission and 6 months of follow-up. During the initial evaluations, 13 patients (22%) had major depression and 5 patients (8%) had minor depression. The development of mood disorders during the hospital admission appeared to be related to heterogeneous etiological factors, including previous psychiatric history and severity of impairment in activities of daily living. During the first 3 months after SCI, about half of the depressions resolved. Nonrecovery from depression may be related to lack of adequate social support. Language: en

Prospective longitudinal study of depression following spinal cord injury.

Sixty patients with spinal cord injury were examined to assess major depression during the in-hospital period and at 3- and 6-month follow-up. Thirteen patients had depression during the initial in-hospital evaluation (acute onset depression) and eight had depression first diagnosed at either 3- or 6-month follow-up (delayed onset depression). Acute onset depression was related to the severity of impairment and premorbid history of psychiatric disorder, suggesting a psychological reaction to impairment or premorbid vulnerability as a possible mechanism for developing depression. Delayed onset depression was not related to severity of physical impairment but was associated with more rostral spinal injury, suggesting the possibility that neurophysiological response to injury more proximal to the brain may play a role in delayed onset depression. These data also suggest that the etiology and pathophysiology of these two types of depression may be different. Language: en

Alfred W. Forrester

Papers

Depression following myocardial infarction.

Prospective longitudinal study of depression following spinal cord injury.

Comparison between acute and delayed onset major depression after spinal cord injury.