CLASSIFICATION & EPIDEMIOLOGY

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1 DEPRESSION IN ELDERLY CLASSIFICATION & EPIDEMIOLOGY NIH Consensuses on Depression in Late Life Elderly depressive disorders are underdiagnosed and undertreated. Only 11% of depressed patients in primary care received adequate treatment. 34% received inadequate treatment. 55% received no treatment. 24 months outcomes 33% - improved 33% - depressed 13% - hospitalized 21% - died BARRIERS TO DIAGNOSIS AND TREATMENT Social stereotypes about aging: depression is understandable in older person. Depression occurs in a complex medical and psychosocial context. Denial of psychological symptoms. Age-inappropriate diagnostic criteria. Criteria for depression remain the same regardless of age.

2 What is depression? Normal emotion- response to loss or disappointment Accompanying symptom common in variety of physical condition Clinical psychiatric disorder What is a mood disorder? DEPRESSION IS A LARGE GROUPE OF PSYCHIATRIC DISORDERS IN WHICH PATOLOGICAL MOOD AND RELATED VEGETATIVE AND PSYCHOMOTOR DISTURBANCES DOMINATE IN THE CLINICAL PICTURE. DIAGNOSTIC CRITERIA PYRAMID Etiology Pathogenesis Syndrome Symptom CLASSIFICATION OF DEPRESSION PRINCIPAL MODELS Binary model Continuum model Hierarchical model

3 DICHOTOMIES OF AFFECTIVE DISORDER Binary Model From God Endogenous Psychotic Manic-depressive Autonomous Biological Of the world Exogenous Neurotic Psychogenic Reactive Characterological Continuum Model Classifications of depression are nothing more than attempts to distinguish between acute and chronic, mild and severe Aubrey Lewes, 1934 HIERARCHICAL MODEL Mania

4 CLASSIFICATION OF DEPRESSION Ancient Greek: depression resulted from imbalance in the body's four humours: blood, phlegm, yellow bile and black bile Melancholia Major depression Melancholic temperament dysthymia or depressive personality Etiological factor - black bile Emil Kraepelin (1921) Manic depressive insanity/paranoia Kurt Schneider (1920): Endogenous depression Reactive depression DSM-1(1952) 106 disorders depressive reaction of the personality to psychological, social and biological factors DSM 2 (1968) 182 disorder psychodynamic formulation, depressive neurosis and depressive psychosis DSM 3 (1980) 265 disorder nonetiological paradigm, nosologic criteria major depressive disorder DSM 4 (1994) 297 disorder DSM 5 (May 2013 ) Depression in DSM-5 1/ Disruptive mood dysregulation disorder 2/ Major depressive disorder 3/ Persistent depressive disorder (dysthymia) 4/ Premenstrual dysphoric disorder 5/ Substance/medication-induced depressive disorder 6/ Depressive disorder due to another medical condition 7/ Other specified depressive disorder 8/ Unspecified depressive disorder MENTAL DISORDER THAT COMMONLY HAVE DEPRESSIVE FEATURES Schizophrenia Schizoaffective Disorder Bipolar disorder Post traumatic stress disorder Adjustment disorder Anxiety disorders Somatoform disorder Substance-related disorder Dementia

5 Diagnostic Criteria for Major Depressive Episode DSM-5 A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). Diagnostic Criteria for Major Depressive Episode DSM-5 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Diagnostic Criteria for Major Depressive Episode DSM-5 B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Diagnostic Criteria for Major Depressive Episode DSM-5 Specify: With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern (recurrent episode only)

6 Diagnostic Criteria for Major Depressive Episode DSM-5 Severity specifier Mild Moderate Severe With psychotic features Unspecified Course specifier Single episode Recurrent episode In partial remission In full remission Persistent Depressive Disorder (Dysthymia) A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness. Persistent Depressive Disorder (Dysthymia) C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanie episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Persistent Depressive Disorder (Dysthymia) Specify if With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With peripartum onset

7 Persistent Depressive Disorder (Dysthymia) Specify if (for most recent 2 years of persistent depressive disorder): With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least the preceding 2 years. With persistent major depressive episode: Full criteria for a major depressive episode have been met throughout the preceding 2-year period. With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode. With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years. Persistent Depressive Disorder (Dysthymia) Specify if: In partial remission In full remission Specify if: Early onset: If onset is before age 21 years. Late onset: If onset is at age 21 years or older. Specify current severity: Mild Moderate Severe Depressive Disorder Due to Another l\/ledical Condition A. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. C. The disturbance is not better explained by another mental disorder (e.g., adjustment disorder, with depressed mood, in which the stressor is a serious medical condition). D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Depressive Disorder Due to Another Medical Condition Specify if: (F06.31) With depressive features: Full criteria are not met for a major depressive episode. ' (F06.32) With major depressive-like episode: Full criteria are met (except Criterion C) for a major depressive episode. (F06.34) With mixed features: Symptoms of mania or hypomania are also present but do not predominate in the clinical picture.

8 Persistent Complex Bereavement Disorder A.The individual experienced the death of someone with whom he or she had a close relationship. B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: 1. Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure. 2. Intense sorrow and emotional pain in response to the death. 3. Preoccupation with the deceased. 4. Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them. Persistent Complex Bereavement Disorder C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: Reactive distress to the death 1. Marked difficulty accepting the death. In children, this is dependent on the child s capacity to comprehend the meaning and permanence of death. 2. Experiencing disbelief or emotional numbness over the loss. 3. Difficulty with positive reminiscing about the deceased. 4. Bitterness or anger related to the loss. 5. Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame). 6. Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased). Persistent Complex Bereavement Disorder Social/identity disruption 7. A desire to die in order to be with the deceased. 8. Difficulty trusting other individuals since the death. 9. Feeling alone or detached from other individuals since the death. 10. Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased. 11. Confusion about one s role in life, or a diminished sense of one s identity (e.g., feeling that a part of oneself died with the deceased). 12. Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities). Persistent Complex Bereavement Disorder D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms. Specify if: With traumatic bereavement: Bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death (often in response to loss reminders), including the deceased s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death.

9 Classification of Mental and Behavioral Disorders ICD-10 F32 Depressive episode F32.0 Mild depressive episode.00 Without somatic syndrome.01 With somatic syndrome F32.1 Moderate depressive episode.10 Without somatic syndrome.11 With somatic syndrome F32.2 Severe depressive episode without psychotic symptoms F32.3 Severe depressive episode with psychotic symptoms F32.8 Other depressive episodes F32.9 Depressive episode, unspecified The World Health Organization's International Classification of Diseases (ICD-10) At least two weeks Two of the three core symptoms Two of the seven secondary symptoms Classification of Mental and Behavioral Disorders ICD-10 F33 Recurrent depressive disorder F33.0 Recurrent depressive disorder, current episode mild.00 Without somatic syndrome.01 With somatic syndrome F33.1 Recurrent depressive disorder, current episode moderate.10 Without somatic syndrome.11 With somatic syndrome F33.2 Recurrent depressive disorder, current episode severe Without psychotic symptoms F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms F33.4 Recurrent depressive disorder, currently in remission F33.8 Other recurrent depressive disorders F33.9 Recurrent depressive disorder, unspecified Classification of Mental and Behavioral Disorders ICD-10 F34 Persistent mood [affective] disorders F34.0 Cyclothymia F34.1 Dysthymia F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F38 Other mood [affective] disorders

10 Late-onset depression Late-onset depression Symptoms overlapping 1. Abnormal depressed mood 2. Abnormal loss of all interest and pleasure 3. Appetite or weight disturbance, either: Abnormal weight loss (when not dieting) or decrease in appetite. Abnormal weight gain or increase in appetite 4. Sleep disturbance, either abnormal insomnia or abnormal hypersomnia. 5. Activity disturbance, either abnormal agitation or abnormal slowing (observable by others). 6. Abnormal fatigue or loss of energy. 7. Abnormal self-reproach or inappropriate guilt. 8. Abnormal poor concentration or indecisiveness. 9. Abnormal morbid thoughts of death (not just fear of dying) or suicide. Relationship between depression and dementia EPIDEMIOLOGY OF DEPRESSION IN DEMENTIA 1. Depression treatment is a risk factor for dementia 2. Depression and dementia share common risk factors. 3. Depression is a prodrom of dementia 4. Depression is an early reaction to cognitive decline 5. Depression is a causal factor in dementia 6. Affective disorders lower the threshold for the clinical manifestation of dementia. Depressive symptoms Dementia suffers Mean rate 0 83% 19%

11 CONCEPT OF PSEUDODEMENTIA Kiloh (1961) reported on 10 cases of 'pseudodementia The concept of 'pseudodementia' was based on three elements: 1/ The syndrome of dementia in patients with 'pseudodementia' did not progress but was reversed in relation to the clinical state of' functional' psychiatric illness. 2/ The cause of the dementia was the ' functional' psychiatric illness. 3/ Distinctions between' pseudodementia and dementia: reversibility irreversibility lack of progression progression ' functional' causation - degenerative brain disease "The picture of dementia may be very closely mimicked and (patients) may be in danger of therapeutic neglect and perhaps of unnecessary neurosurgical investigations. It is to such cases that the term pseudodementia may be applied," Diagnostic definition of pseudo-dementia Evidence of depression accompanied by intellectual impairment Clinical features resemble degenerative brain disorders Intellectual deficit reverses with antidepressants No evidence of primary neuro-degenerative process Caine (1981) Risk of all-cause dementia in participants with late-life depression N-51 - Most of the studies found an increased risk for developing dementia in individuals with depression. - A quarter of the studies did not show a statistical significance - History of depression approximately doubled the risk of developing Alzheimer s disease or dementia in general. - The risk for dementia is proportional to symptoms severity, lifetime duration and number of depressive episodes. -The evidence is contradictory regarding whether there is a difference in risk in people with early- or late-onset depression. Diniz B S et al. BJP 2013;202: Dementia Depression spectrum

12 Dementia Depression spectrum National Institute of Mental Health Criteria for Diagnosis Depression in Alzheimer s Disease Major depression without Dementia Depressive dementia Dementia with Depressive symptoms Dementia without depression 1. 3 of the following must be present during the same 2 week period and represent a change from previous functioning. At least one symptom must be either depressed mood or loss of pleasure. a. Depressed mood b. Loss of pleasure c. Social isolation or withdraw d. Disruption in appetite e. Disruption in sleep f. Psychomotor changes g. Irritability h. Fatigue or loss of energy i. Feeling or worthlessness, hopelessness, or excessive or inappropriate guilt j. Recurrent thoughts of death, suicidal ideation, plan, or attempt 2. All criteria are met for Dementia of the Alzheimer Type (DSM IV) 3. The symptoms cause clinically significant distress or disrupt functioning 4. The symptoms do not occur exclusively in the course of delirium 5. The symptoms are not due to the physiological effect of a substance 6. The symptoms are not accounted for by other psychiatric conditions Epidemiology of old age depression At a global level, 322 million people are estimated to suffer from depression, equivalent to 4.4% of the world s population. The total estimated number of people living with depression increased by 18.4% between 2005 and Fewer than half of those affected in the world (in many countries, fewer than 10%) receive treatments Major depression was the fourth most important disorder in 1990 and would become the second most important by the year 2020 in terms of the global burden of disease as indicated by both disability and mortality.

13 Epidemiology of depression (US Epidemiological Catchment Area survey) 5.8% 7.9% Antidepressants 3.1% 2.7% 3.6% 1.7% 0.6% 1.5% Psychiatric disorders are infrequent in elderly individuals. Prevalence of depression in elderly subjects is low. Weissman et al (1988) Epidemiological Catchments Area study (1988) Prevalence of late-life depression in Europe The EURODEP consortium GMS / AGECAT Depression Prevalence (one-year) MDD Dysthymic disorder man 0,6% 1% >65 women 1,5% 2,3% overall 1% 2% Prévalence of dépression (%) centers subjects Prevalence of depression 8,8-23.6% Overall prevalence 12.3% (w/m 14.1/8.6) Mood disorders 1,4% 3,3% 4% 5 0 Depressive symptoms 15%

14 The prevalence of depression in older people using criteria from the DSM METAANALISIS OF EPIDEMIOLOGICAL STUDIES ( ) N-34 RANGE AVERAGE RATE Study Country Diagnosis Age (years) Men % Women % Total % Lobo et al Zaragoza, Spain All (1995) Kivelä et al Ähtäri, Finland All (1988) Bland et al Edmonton, Canada MDS (1988) Regier et al ECA, USA MDS (1993) Kramer et al USA MDS (1985) MDD Minor depression All depressive syndromes National comorbidity survey replication Life time prevalence of MDE-22.9% in females and 15.1% in males

15 ??? Do persons became less depressed as they grow older? Is depression more difficult to identify in the older adult? Epidemiology Prevalence In a meta-analysis, the prevalence of clinically significant depression among older people living in the community was 13.5% (Beekman et al 1999). The prevalence of depressive episode was much lower, at around 2%. Many older people may have depressive symptoms that do not fulfill the strict criteria for depressive disorder in a given classification system like DSM or ICD, even though they suffer from clinically significant depression and require treatment. Another review found that the prevalence of depressive symptoms ranged 26-40% among community dwelling older people in Europe (Copeland et al 2004). Conservative estimate of the prevalence of depression in cognitively intact nursing home residents is 10-20%; for cognitive impaired patients the prevalence rises to 50-60% (Parmelee et al 1989) Epidemiology Epidemiological Misconception Incidence Rorsman et al (1990) estimated the incidence of major depression in Lundby County, Sweden, to be 4.3% for men and 7.6% for women of all ages (with very little age variation). Norton et al (2006) assessed 2,877 nondemented elderly (ages 65 to 100 years) residents of Cache County, Utah. They found that individuals with no history of depression had rates for major depression of 7.88 per 1,000 person-years for men and 8.75 for women; minor depression rates were for men and for women. Luijendijk et al (2008) assessed 5653 participants free of dementia (aged 56 or above) in Rotterdam. For depressive syndromes, the incidence rate was 7.0 per 1000 person-years during the follow-up period of 8 years on average. Social stereotypes about aging: depression is understandable in older person. Depression occurs in a complex medical and psychosocial context. Exclusion due to severe comorbidity and institutionalization Symptoms under or over reporting Different phenomenological presentation Age-inappropriate diagnostic criteria Diagnostic instruments are inappropriate 59 Copyright World Psychiatric Association

16 Symptoms overlapping 1. Abnormal depressed mood 2. Abnormal loss of all interest and pleasure 3. Appetite or weight disturbance, either: Abnormal weight loss (when not dieting) or decrease in appetite. Abnormal weight gain or increase in appetite 4. Sleep disturbance, either abnormal insomnia or abnormal hypersomnia. 5. Activity disturbance, either abnormal agitation or abnormal slowing (observable by others). 6. Abnormal fatigue or loss of energy. 7. Abnormal self-reproach or inappropriate guilt. 8. Abnormal poor concentration or indecisiveness. 9. Abnormal morbid thoughts of death (not just fear of dying) or suicide. Subsyndromal depression (Subthreshold depression, Minor depression, Non-major depression) Systematic review of 181 studies ( ) Median point prevalence: Community: 9.8% Primary care: 25% Inpatients: 30% Long term care: 45-50% 8-10% of older person with minor depression developed major depression per year Median remission rate: 27% after 1 year T. Meeks J Affect Disorder 2011 Depression in older people in community care: effect of setting In older people, the setting has a major influence on depression prevalence Prevalence rate (%) Out-patient clinics Emergency rooms Nursing homes Long-stay institutions

17 EPIDEMIOLOGY OF DEPRESSION EPIDEMIOLOGY OF DEPRESSION Population Major depression Depressive symptoms Total elderly population Prevalence (%) Long term care Major depression Dysthymia Depressive symptoms Prevalence (%) Depressive symptoms Outpatients Depressive symptoms Depressive symptoms Dementia suffers 0 83% Hospitalized patients The Natural History of Late Life Depression (Beekman, 2002; A 6-year Prospective Study) Remissions: 23% Remission with recurrence: 12% Chronic intermittent course: 33% Chronic course: 32% CONCLUSIONS Depression is one of the most prevalent psychiatric condition in later life. Mood disorders are a continuum rather than a case / non-case dichotomy The standard criteria for depression may be difficult to apply to older adults. Most older patients with symptoms of depression do not meet the full criteria for major depression

18 CONCLUSIONS There is no consensus about epidemiology of late-life depression. Both prevalence and incidence studies that rely on DSM-based diagnosis of major depression suggest a decline with age. Symptom-based assessment studies show increased rates of depression Subsyndromal depressive disorder is separate and legitimate entity, that at least 2-3 times more frequent than major depression.

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