The trajectory of non-depressed suicidal ideation in community-dwelling older people in a rural area in Japan: a prospective longitudinal study with a 3-year follow-up.

BACKGROUND: Suicidal ideation is closely related to severe suicidal behaviour and is an important predictor of suicide attempt and completion, including in older people. Older people tend to have many opportunities to be conscious of death, and may have vague suicidal ideation because of various loss experiences, even if they are not depressed. We hypothesised that suicidal ideation among older people might be a risk factor for later transition to depression. The present study aimed to clarify risk factors that predict the incidence of depression in older people 3 years post-baseline in a rural area of Japan, and to examine the subsequent course of depression among non-depressed older people with suicidal ideation. METHODS: In 2015 and 2018, survey questionnaires were mailed to residents aged 65 years and over living in a rural area in Japan. Participants were divided into a depression group and a non-depression group using 15-item Geriatric Depression Scale scores 3 years post-baseline. Logistic regression analysis was used to identify predictive factors of late-life depression 3 years post-baseline. RESULTS: We received 597 valid responses, with a 3-year follow-up rate of 78.8%. Regarding suicidal ideation, 6.7% of non-depressed older people exhibited suicidal ideation at baseline. Of these, 9.8% exhibited depression after 3 years post-baseline. Logistic regression analysis indicated that development of late-life depression is significantly associated with suicidal ideation, being female, and poor health-related quality of life (HRQOL). CONCLUSIONS: The results revealed that suicidal ideation, being female, and poor HRQOL were predictive factors of the development of late-life depression 3 years post-baseline in a rural area of Japan. These findings provide novel information regarding the transition to depression among community-dwelling older people who are not depressed but have suicidal ideation. Whereas suicidal ideation is considered to be a symptom of depression, the current results suggest that suicidal ideation may precede depression in some older people.

Guidelines for diagnosis and treatment of depression in older adults: A report from the Japanese Society of mood disorders.

The Committee for Treatment Guidelines of Mood Disorders, Japanese Society of Mood Disorders, published a Japanese guideline for the treatment of late-life depression in 2020. Based on that guideline, the present guideline was developed and revised to incorporate the suggestions of global experts and the latest published evidence. In the diagnosis of late-life depression, it is important to carefully differentiate it from bipolar disorders, depressive states caused by physical and organic brain disease, drug effects, and dementia, and to determine the comorbidity between late-life depression and dementia. It is necessary to fully understand the clinical characteristics and psychosocial background of late-life depression, evaluate the patient's condition, and provide basic interventions based on these factors. Problem-solving therapy, reminiscence therapy/life review therapy, and behavioral activation therapy, and other forms of psychotherapy can reduce depressive symptoms. In terms of pharmacotherapy, newer antidepressants or non-tricyclic antidepressants are recommended for late-life depression, and it is recommended that the efficacy of least the minimal effective dosage should first be determined. Switching antidepressants and aripiprazole augmentation can be used to treatment-resistant therapy. Electroconvulsive therapy and repetitive transcranial magnetic stimulation have demonstrated usefulness for late-life depression. Exercise therapy, high-intensity light therapy, and diet therapy also show some effectiveness and are useful for late-life depression. Continuation therapy should be maintained for at least 1 year after remission.

How university students changed their habits and developed mental disorders in the context of the coronavirus disease 2019 (COVID-19) pandemic in Japan: Three case reports.

Background: Since the COVID-19 pandemic reached Japan in 2020, the country has faced an unprecedented increase in suicide rate and school refusal among adolescents, as well as increased rates of depression and anxiety among young people. However, the effects of the COVID-19 pandemic on adolescents in terms of changes in habits, the development of mental disorders, social isolation, and suicidal ideation remain largely unclear. Case Presentation: We examined three cases of university students who changed their habits during the COVID-19 pandemic and developed mental disorders. All three cases had similar habitual changes, experienced loneliness, and developed depression and circadian rhythm sleep-wake disorder. Their habitual changes were delayed sleep and wake times, delayed first mealtime, a tendency to eat before sleeping, decreased social contact, increased digital media usage, and a tendency to use digital media before going to bed. We established a model of increasing mental health difficulties, school refusal, and suicidal ideation during the COVID-19 pandemic. Conclusion: This report suggests possible approaches for preventing a decline in mental health during the COVID-19 pandemic among university students.

Optimising first- and second-line treatment strategies for untreated major depressive disorder - the SUN☺D study: a pragmatic, multi-centre, assessor-blinded randomised controlled trial.

BACKGROUND: For patients starting treatment for depression, current guidelines recommend titrating the antidepressant dosage to the maximum of the licenced range if tolerated. When patients do not achieve remission within several weeks, recommendations include adding or switching to another antidepressant. However, the relative merits of these guideline strategies remain unestablished. METHODS: This multi-centre, open-label, assessor-blinded, pragmatic trial involved two steps. Step 1 used open-cluster randomisation, allocating clinics into those titrating sertraline up to 50 mg/day or 100 mg/day by week 3. Step 2 used central randomisation to allocate patients who did not remit after 3 weeks of treatment to continue sertraline, to add mirtazapine or to switch to mirtazapine. The primary outcome was depression severity measured with the Patient Health Questionnaire-9 (PHQ-9) (scores between 0 and 27; higher scores, greater depression) at week 9. We applied mixed-model repeated-measures analysis adjusted for key baseline covariates. RESULTS: Between December 2010 and March 2015, we recruited 2011 participants with hitherto untreated major depression at 48 clinics in Japan. In step 1, 970 participants were allocated to the 50 mg/day and 1041 to the 100 mg/day arms; 1927 (95.8%) provided primary outcomes. There was no statistically significant difference in the adjusted PHQ-9 score at week 9 between the 50 mg/day arm and the 100 mg/day arm (0.25 point, 95% confidence interval (CI), - 0.58 to 1.07, P = 0.55). Other outcomes proved similar in the two groups. In step 2, 1646 participants not remitted by week 3 were randomised to continue sertraline (n = 551), to add mirtazapine (n = 537) or to switch to mirtazapine (n = 558): 1613 (98.0%) provided primary outcomes. At week 9, adding mirtazapine achieved a reduction in PHQ-9 scores of 0.99 point (0.43 to 1.55, P = 0.0012); switching achieved a reduction of 1.01 points (0.46 to 1.56, P = 0.0012), both relative to continuing sertraline. Combination increased the percentage of remission by 12.4% (6.1 to 19.0%) and switching by 8.4% (2.5 to 14.8%). There were no differences in adverse effects. CONCLUSIONS: In patients with new onset depression, we found no advantage of titrating sertraline to 100 mg vs 50 mg. Patients unremitted by week 3 gained a small benefit in reduction of depressive symptoms at week 9 by switching sertraline to mirtazapine or by adding mirtazapine. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01109693 . Registered on 23 April 2010.

Effect of lamotrigine in the treatment of bipolar depression with psychotic features: a case report.

BACKGROUND: Major depressive episodes with psychotic features are more common in bipolar disorder than in major depressive disorder; however, there is little information on the optimal treatment for bipolar depression with psychotic features. CASE PRESENTATION: The patient was a 69-year-old man. At the age of 66, he was admitted to the hospital for the treatment of bipolar depression with psychotic features. He was treated with a combination therapy of antipsychotics and antidepressants during long-term hospitalization. At the age of 69, he relapsed and was admitted to the hospital again. He was initially treated with olanzapine and lithium for the treatment of bipolar depression with psychotic features. He partially responded to the combination therapy, and psychomotor retardation and delusion of guilt disappeared; however, he developed psychomotor agitation and delusion of persecution, which was a mood-incongruent psychotic feature. Finally, he fully recovered with an additional dosage of lamotrigine, and had no experience of relapse after discontinuation of olanzapine. CONCLUSIONS: This case report implicates the utility of lamotrigine for bipolar depression with psychotic features, and further studies are needed to establish the optimal treatment.

Mental health among younger and older caregivers of dementia patients.

AIM: Caregiver burden in dementia is an important issue, but few studies have examined the mental health of younger and older family caregivers by comparing them with age- and gender-matched community residents. We aimed to compare the mental health of dementia caregivers with that of community residents and to clarify factors related to mental health problems in younger and older caregivers. METHODS: We studied 104 dementia caregivers; 46 were younger (<65 years) and 58 were older (≥65 years). A total of 104 community residents who were matched for age and gender were selected. We compared depression (Center for Epidemiologic Studies Depression Scale for younger participants; Geriatric Depression Scale for older participants), health-related quality of life (QOL) short-form health survey (SF-8), sleep problems, and suicidal ideation between the caregivers and community residents by age. Behavioural and psychological symptoms of dementia, activities of daily living (ADL), and instrumental ADL were assessed among patients with dementia using the Neuropsychiatric Inventory, Physical Self-Maintenance Scale, and Lawton Instrumental ADL Scale, respectively. RESULTS: According to SF-8 results, both younger and older caregivers had significantly worse mental QOL than community residents (younger caregivers: 46.3 vs community residents: 49.7, P = 0.017; older caregivers: 48.2 vs community residents: 51.1, P = 0.024) but were not more depressive. Sleep problems were significantly more frequent in younger caregivers (39.1%) than in community residents (17.0%) (P = 0.017). Multiple regression analysis revealed that caregivers' deteriorated mental QOL was associated with patients' behavioural and psychological symptoms of dementia in younger caregivers and with dementia patients' instrumental ADL and female gender in older caregivers. CONCLUSIONS: Dementia caregivers had a lower mental QOL than community residents. To maintain caregivers' mental QOL, it is necessary to provide younger caregivers with skills or professional interventions for dealing with behavioural and psychological symptoms of dementia, and older caregivers must be offered adequate care support.

Malnutrition in Alzheimer's Disease, Dementia with Lewy Bodies, and Frontotemporal Lobar Degeneration: Comparison Using Serum Albumin, Total Protein, and Hemoglobin Level.

Malnutrition among dementia patients is an important issue. However, the biochemical markers of malnutrition have not been well studied in this population. The purpose of this study was to compare biochemical blood markers among patients with Alzheimer's disease (AD), dementia with Lewy bodies (DLB), and frontotemporal lobar degeneration (FTLD). A total of 339 dementia outpatients and their family caregivers participated in this study. Low serum albumin was 7.2 times more prevalent among patients with DLB and 10.1 times more prevalent among those with FTLD than among those with AD, with adjustment for age. Low hemoglobin was 9.1 times more common in female DLB patients than in female AD patients, with adjustment for age. The levels of biochemical markers were not significantly correlated with cognitive function. Family caregivers of patients with low total protein, low albumin, or low hemoglobin were asked if the patients had loss of weight or appetite; 96.4% reported no loss of weight or appetite. In conclusion, nutritional status was worse in patients with DLB and FTLD than in those with AD. A multidimensional approach, including blood testing, is needed to assess malnutrition in patients with dementia.

Comparisons of prevalence and related factors of depression in middle-aged adults between urban and rural populations in Japan.

BACKGROUND: Findings of urban-rural differences in the prevalence of depression have been controversial, and few reports have directly compared the related factors of depression between urban and rural areas. The present study aimed to investigate differences between urban and rural areas in Japan with regards to the prevalence of and related factors of depression in middle-aged adults, in order to further understanding of the features of depression in this demographic. METHODS: We used a multistage, random sampling procedure and mailing method. In total, 5000 participants were recruited from urban and rural areas in Kumamoto Prefecture (2500 in each area). Participants were aged from 40 to 64 years. Depression was assessed using the Center for Epidemiologic Studies Depression scale (CES-D). RESULTS: The prevalence of middle-aged depression was not different between the urban and rural areas. Logistic regression analysis found that being female, living alone, and having a chronic illness were significantly associated with depression in urban-dwelling middle-aged adults. Younger age, sleep disturbance, and financial strain were significantly associated with depression in both urban and rural areas. LIMITATIONS: The definition of depression was based on CES-D scores, without corroborating clinical evaluation. CONCLUSIONS: We found no marked differences in the prevalence of middle-aged depression between the urban and rural areas. Some related factors of depression in middle-aged adults differed between urban and rural areas in Japan. Effective intervention programs for middle-aged adults with depression should consider regional differences.

Suicidal ideation and related factors among dementia patients.

BACKGROUND: It is generally thought that people with dementia are not able to attempt suicide because of impaired executive function. Little research is available about suicidal ideation among dementia patients. The present study examines 1) the sociodemographic and clinical features of dementia patients with suicidal ideation and 2) the effect of suicidal ideation on caregiver burden. METHODS: A total of 634 dementia outpatients and their family caregivers participated in this study. Comparisons of variables were made among three groups: patients with suicidal ideation, patients with depression without suicidal ideation, and patients with neither suicidal ideation nor depression. Data were collected between April 2007 and July 2013. RESULTS: Suicidal ideation was seen in 64 patients (10.1%). Patients with suicidal ideation had a significantly higher rate of behavioural and psychological symptoms of dementia (BPSD) (P<0.001). Caregivers of patients with suicidal ideation felt a higher caregiver burden, even after adjusting for BPSD score (P<0.01). LIMITATIONS: Suicidal ideation was assessed by interview with caregivers, so we may have overlooked people who had suicidal ideation but did not express it to their caregivers. CONCLUSIONS: Suicidal ideation among dementia patients should receive greater attention. Adequate assessment of suicidal ideation and psychological support for both patients with suicidal ideation and their caregivers are needed.

Sleep duration and its association with sleepiness and depression in "ronin-sei" preparatory school students.

PURPOSES: The Japanese word "ronin-sei" refers to a student who has failed their university entrance examination and is preparing to re-take the examination in the following year. We aimed to determine how sleep duration is associated with daytime sleepiness or depression in ronin-sei because impaired daytime performance is known to result from sleep deprivation. METHODS: The participants in this cross-sectional study were 1075 ronin-sei and 285 university students. Sleepiness and depressive symptoms were assessed using the Epworth Sleepiness Scale (ESS) and the Center for Epidemiologic Studies Depression Scale (CES-D), respectively. RESULTS: Ronin-sei had significantly shorter sleep duration and earlier bed- and rise-times than university students. There was no significant difference in CES-D between the groups; however, the ESS score of university students was significantly higher than that of ronin-sei. Ronin-sei who slept for 5 to <6h had higher ESS scores than those who slept for 6 to <7h. The mean CES-D score in ronin-sei who slept <5h was significantly higher than in those who slept for 5 to <6h, from 6 to <7h, and from 7 to <8h. Ronin-sei who slept for more than 8h also had higher depression scores. CONCLUSIONS: Sleep deprivation appears to be common among ronin-sei. Furthermore, a U-shaped relationship was found between sleep duration and depressive symptoms, revealing that ronin-sei who had too little or too much sleep were more likely to exhibit an increase in depressive symptoms.

Item non-response on self-reported depression screening questionnaire among community-dwelling elderly.

BACKGROUND: In responses to self-reported depression screening questionnaires, item non-response, which refers to the absence of answers to specific questions, is problematic. The objective of this study were (1) to clarify the features of respondents with item non-response on a self-reported elderly depression screening questionnaire (15-item geriatric depression scale; GDS-15) as compared to respondents with full responses, and (2) to compare positive depression screening rates calculated using two methods: excluding respondents with item non-response (complete case analysis; CCA) and estimating by multiplying mean scores from valid responses by the total number of GDS-15 items for respondents with item non-response. METHODS: This was a cross-sectional study conducted from 2010 to 2012. Of 4794 elderly subjects (65 years and older) living in one town in Japan 2836 community-dwelling elderly people (59.2%) were included in the analysis. RESULTS: Item non-response was observed in 25.0% of respondents. Respondents with item non-response had a higher rate of depression and mental and physical problems. Respondents with depression (estimated GDS-15 score ≥6) and suicidal ideation both had a 1.6-times higher risk of item non-response on the GDS-15. The positive depression screening rate on GDS-15 by CCA was 16.5%, compared with 18.9% when calculated by the estimated GDS-15 score. LIMITATIONS: Our survey was conducted in one rural area and targeted only elderly people. CONCLUSION: The incidence of item non-response among community-dwelling elderly people was associated with depression of the respondent. Excluding subjects with item non-response when calculating positive depression screening rates in elderly individuals causes the rate to be underestimated.

[Apathy].

Apathy includes aspontaneous, indifferent behavior, with loss of motor and affective drive. Apathy is related to the disruption, at various anatomical sites, of frontosubcortical pathways, such as anterior cingulate and bithalamic lesions. Apathy was frequently reported in patients with Alzheimer's disease, post-stroke, and frontotemporal dementia. It is very important to distinguish apathy from depression by the therapeutic view point.

Usefulness of the coherence entrainment test for deep brain stimulation for a patient with atypical tremor.

A 40-year-old man with an anxiety disorder developed sudden-onset right-hand tremor after a fixation wire for a tibial bone fracture was removed. He manifested a resting and action tremor with an irregular pattern. A coherence entrainment test (CET) revealed that the peak power spectral frequency of the right finger tremor was not entrained by simultaneous voluntary left finger tapping, which indicated a non-psychogenic origin. Deep brain stimulation to the left thalamic ventral intermediate nucleus abolished the tremor. We concluded that CET can determine the surgical indications for an unusual tremor that must be differentiated from that of psychogenic origin.

Living alone is associated with depression among the elderly in a rural community in Japan.

AIM: This study aimed to investigate factors associated with depression in a sample of elderly Japanese individuals in a rural community and to examine differences among factors associated with individuals living alone or living with others. METHODS: Using a population-based sample from rural Japan, we assessed a total of 1552 participants aged 65 years or older by mailing a survey and evaluating responses based on the Geriatric Depression Scale. Factors associated with depression were also examined. RESULTS: We received 964 valid responses. Depressed subjects comprised 20.5% of the sample. Living alone was significantly related to depression. In individuals living alone, depression was associated with loss of appetite, suicidal ideation, financial strain, and worries in life. However, multiple linear regression analyses revealed that the influence of living alone was negated by having a good social support system. CONCLUSION: These findings confirm that living alone is an important factor in depression among the elderly in a rural part of Japan. Results also confirm what others have found in Western cultures: high levels of social support, awareness of receiving social support, and willingness to receive assistance may reduce the risk of depression.

[The relationship between depression and dementia in elderly].

It has been noted the relationship between depression and dementia in elderly. The prevalence of depression in Alzheimer's disease (AD) was reported 20 to 30% in population-based study. Apathy was more frequently observed than depression among demented outpatients in our study. Whereas the apathy has been considered to be a kind of depression traditionally, it has been found that the apathy is distinct from depression recently. In our clinical practice, we frequently realize the close relationship between depression and dementia. It has been reported that risk of AD was 1.71 (odds ratio) in the history of depression more than 25 years ago, and interval between diagnoses of depression and AD was positively related to increased risk of developing AD, suggesting that rather than a prodrome, depression may be a risk factor for AD. Furthermore, Rotterdam Scan Study reported recently that the risk of AD increased to 3.76 in the history of pre-senile depression, while 2.34 in the history of senile depression. On the other hand, it is interesting but still controversial whether depression is associated with the conversion from mild cognitive impairment (MCI) into dementia. The underlying neuropathological condition that causes MCI or dementia might also cause depressive symptoms.

Identification of an aging-related spherical inclusion in the human brain.

Inclusions, such as corpora amylacea, axonal spheroids and ubiquitin-positive granular structures, are present in aged brains. We found a phosphorylated tau-positive inclusion in brain tissues obtained from 13 non-demented subjects and five patients with Alzheimer's disease. This inclusion was spherical and 3-20 microm in size. It was most frequently detected in the hippocampal CA1 region and in the prosubiculum but was not present in the white matter. The density of this inclusion increased significantly with aging and decreased after the occurrence of neurofibrillary tangles. The presence of the inclusion was confirmed using immunoelectron microscopy. These findings show a possibility that the inclusion is a novel aging-related structure in the human brain.