Development of Adaptive Coping From Mid to Late Life: A 70-Year Longitudinal Study of Defense Maturity and Its Psychosocial Correlates.

The present study examines changes in defense maturity from mid to late life using data from an over 70-year longitudinal study. A sample of 72 men was followed beginning in late adolescence. Participants' childhoods were coded for emotional warmth. Defense mechanisms were coded by independent raters using the Q-Sort of Defenses (, Ego mechanisms of defense: A guide for clinicians and researchers 217-233) based on interview data gathered at approximately ages 52 and 75. We examined psychosocial correlates of defenses at midlife, late life, and changes in defense from mid to late life. Overall, defenses grew more adaptive from midlife to late life. However, results differed on the basis of the emotional warmth experienced in the participants' childhoods. In midlife, men who experienced warm childhoods used more adaptive (mature) defenses; yet by late life, this difference in defensive maturity had disappeared. Men who experienced less childhood warmth were more likely to show an increase in adaptive defenses during the period from mid to late life.

A pilot study of the efficacy and safety of paroxetine augmented with risperidone, valproate, buspirone, trazodone, or thyroid hormone in adult Chinese patients with treatment-resistant major depression.

To compare the efficacy and safety of augmenting paroxetine with risperidone, buspirone, valproate, trazodone, or thyroid hormone in patients with treatment-resistant depression (TRD), 225 patients with retrospectively and/or prospectively identified stage II TRD were randomly assigned to receive an 8-week treatment of paroxetine 20 mg/d augmented with risperidone 2 mg/d (n = 45), sodium valproate 600 mg/d (n = 39), buspirone 30 mg/d (n = 46), trazodone 100 mg/d (n = 47), or thyroid hormone 80 mg/d (n = 48). The primary outcome was the remission rate defined as the 17-item Hamilton Rating Scale for Depression score of 7 or less at the end of study. Secondary outcomes included remission rate based on the Self-rating Depression Scale score of 50 or less at the end of study, response rate based on 17-item Hamilton Rating Scale for Depression total score of 50% improvement or greater from baseline, and the change in scores of Clinical Global Impression-Improvement scale, the Short Form 36 Health Survey, and the Life Satisfaction Rating Scale. The remission rates were 26.7% for risperidone, 48.7% for valproate, 32.6% for buspirone, 42.6% for trazodone, and 37.5% for thyroid hormone. There was no statistical significance among treatment arms in remission rates, secondary outcome measures, and adverse events. Risperidone, valproate, buspirone, trazodone, or thyroid hormone augmentation to paroxetine 20 mg/d was effective and well tolerated in Chinese patients with TRD. Large-sample studies are warranted to support or refute these findings.

Comparisons of the efficacy and tolerability of extended-release venlafaxine, mirtazapine, and paroxetine in treatment-resistant depression: a double-blind, randomized pilot study in a Chinese population.

To compare the efficacy and tolerability of antidepressants switch with extended-release venlafaxine (venlafaxine-XR), mirtazapine, and paroxetine in Chinese patients with major depressive disorder who had 2 consecutive unsuccessful antidepressant trials. One hundred fifty adult patients with treatment-resistant depression according to their medical records and/or response to current treatments were randomly assigned to receive fixed-dosage treatment of venlafaxine-XR 225 mg/d (n = 50), mirtazapine 45 mg/d (n = 55), or paroxetine 20 mg/d (n = 45) for 8 weeks. The primary outcome was the remission rates that were defined as a score 7 or lower on the 17-item Hamilton Rating Scale for Depression (HRSD-17). Secondary outcomes included the remission rate defined by the Self-Rating Depression Scale of 50 or lower and the response rate defined by a 50% reduction or greater on the HRSD-17 total score, and the improvement of patients' general health functions. The completion rates were 82% for venlafaxine-XR, 81.8% for mirtazapine, and 82.2% for paroxetine. Only one patient in paroxetine arm discontinued the study owing to an adverse event. The remission rates based on the HRSD-17 were 42.0% for venlafaxine-XR, 36.4% for mirtazapine, and 46.7% for paroxetine. There were no statistical significances between treatment arms in remission rates. Similarly, there were also no significant differences between groups in secondary outcome measure. Venlafaxine-XR, mirtazapine, and paroxetine were equally effective in the treatment of Chinese patients with major depressive disorder who failed at least 2 previous antidepressant treatments. Selecting any of these 3 antidepressants as a third-step antidepressant is a reasonable choice for this group of patients.

Depression predicts cognitive disorders in older primary care patients.

OBJECTIVE: To investigate whether depression is independently associated with increased risk of incident dementia or cognitive disorder not otherwise specified (NOS) in an older primary care population. METHOD: This was a prospective 3-year cohort study of 470 patients aged >or= 65 years without baseline cognitive disorders who were recruited from primary care offices. Annual assessments completed from March 2003 through December 2005 included the use of the Structured Clinical Interview for DSM-IV to diagnose major depressive disorder (MDD) and minor depression (MinD) and the Hamilton Depression Rating Scale (HDRS) for depressive symptom severity. The Mini-Mental State Exam, Mattis Dementia Rating Scale-initiation/perseveration subscale, and the Trail Making Tests A and B informed diagnoses of dementia and cognitive disorder NOS. RESULTS: 36 subjects, representing a cumulative incidence of 13%, developed dementia or cognitive disorder NOS over 3 years. Using Cox proportional hazard survival models to calculate the risk ratio of depression for development of cognitive disorders, MDD and MinD (HR = 3.68; 95% CI, 2.1-6.42 and HR = 1.84; 95% CI, 1.05-3.21, respectively) and HDRS scores (HR = 1.07; 95% CI, 1.02-1.12) predicted new onset dementia or cognitive disorder NOS, when covarying age, gender, and education. CONCLUSIONS: Depressive disorders pose increased risk of incident dementia or cognitive disorder NOS in older primary care patients. Clinicians treating depressed older adults should monitor for development of cognitive disorders.

Outcomes and predictors of late-life depression trajectories in older primary care patients.

OBJECTIVES: The naturalistic outcomes of depression in older primary care patients have been poorly characterized. The authors sought to identify depressive trajectories over 2 years and to examine specified outcome predictors. DESIGN: Two-year observational cohort study. SETTING: University-based and independent practice primary care practices in greater Rochester. PARTICIPANTS: All patients aged >65 years presenting for care on selected recruitment days were eligible to participate. Of 392 subjects enrolled, 316 (80.6%) completed study measures over a 2-year follow-up. MEASUREMENTS: Depression trajectories were derived by applying longitudinal cluster analysis to weekly depression status from the Longitudinal Interval Follow-up Evaluation. RESULTS: The authors identified six distinct trajectory clusters that followed clinically intuitive patterns. Although subjects initially nondepressed or in the subsyndromal to minor depression range had a range of possible outcomes over 2 years, the cluster initially near the major depression level remained at that level over time. Consistent predictors of depression trajectory were baseline depressive symptom severity, medical burden, and psychiatric functional status; for some clusters, previous history of depression and perceived social support also had prognostic significance. CONCLUSION: The "real-world" outcomes of patients with more severe depressive symptoms are strikingly poor. Given the diverse outcomes of those with subsyndromal to mild forms of minor depression, clinicians might focus treatments on those at highest risk of poor outcome, i.e., those with greater depressive symptoms and medical burden and lower psychiatric functioning and social support. Preventive interventions research might focus on developing treatments to mitigate potentially modifiable risks such as deficits in social support.

Does depression precede or follow executive dysfunction? Outcomes in older primary care patients.

OBJECTIVE: The authors sought to test the potentially reciprocal relationships between depression and executive dysfunction in older patients over time. METHOD: In this prospective 2-year cohort study, the authors enrolled 709 patients age 65 years and older who presented for primary care on selected days and gave informed consent. Of these, 431 and 284 patients completed follow-up interviews at 1 year and 2 years, respectively. The main outcome measures included depression diagnosis, and measures assessing selected components of executive functions: the initiation-perseveration subscale of the Mattis Dementia Rating Scale, Trail Making tests A and B, and D Trails (Trails B time minus Trails A time). RESULTS: No cognitive measure was significantly independently associated with depression diagnosis concurrently or in 1-year lagged outcomes. A diagnosis of depression was independently associated with concurrent poorer Trails B time and with both Trails B and D Trails times in 1-year lagged models. In path analyses testing 2-year competing dynamic models, no baseline executive function measure predicted the score on the Hamilton Depression Rating Scale (HAM-D), but HAM-D score independently predicted poorer Trails B and D Trails times. Overall medical burden also independently predicted both depressive and cognitive outcomes, but cerebrovascular risk factors only predicted Trails B time. CONCLUSIONS: Older persons with depression are at risk of subsequent decline in at least some aspects of executive functioning. The study's findings leave open the possibility that either neurobiological or psychosocial factors play prominent roles in the mechanisms underlying the course of geriatric depression.

Pathways through adolescent smoking: a 7-year longitudinal grouping analysis.

This study examined longitudinal patterns of smoking among students (N = 852) followed from 6th through 12th grades using longitudinal grouping analysis. Six patterns (clusters) were identified: nonsmokers, quitters, experimenters, early escalators, late escalators, and continuous smokers. Baseline (6th-grade) differences in associated risk factors were examined. Growth curve modeling revealed meaningful intercluster differences in risk factor trends over the study period. In general, nonsmokers had the fewest baseline risk factors and slowest increase in risk factors, whereas continuous smokers had higher baseline and more rapidly increasing trends in risk factors. Results suggest that some clusters may respond to population-based antismoking interventions, whereas others (early escalators and continuous smokers) will probably require more focused interventions.

Science-based policy for psychosocial interventions in refugee camps: a Cambodian example.

No longer are the high rates of psychiatric morbidity associated with mass violence in refugee populations invisible to the humanitarian assistance community. However, identification of mental health risk and protective factors that can be utilized by policy planners is still lacking. The objective of this report is to provide an analytic approach to determining these factors. A description is provided from the first large-scale epidemiological study of Cambodian refugees confined to the Thailand-Cambodian border in the 1980s and 1990s. The original data from this study are reanalyzed to evaluate the mental health impact of psychosocial factors subject to the influence of camp authorities, such as opportunities in the refugee camp environment and personal behaviors, in addition to trauma. The results suggest the extraordinary capacity of refugees to protect themselves against mental illness despite horrific life experiences. The recommendation emerges for refugee policy makers to create programs that support work, indigenous religious practices, and culture-based altruistic behavior among refugees. As refugee mental health policy receives increasing attention from the international community, it must consist of recommendations and practices based on scientific analysis and empirical evidence.