Comparison of the standard and structured interview guide for the Hamilton Depression Rating Scale in depressed geriatric inpatients.

The interrater reliability of the standard Hamilton Depression Rating Scale (Ham-D) and a structured interview guide for the Ham-D (the SIGH-D) were compared in a sample of 20 elderly inpatients with major depression. Each patient was independently interviewed by four raters; two used the standard 24-item Ham-D, and the other two used a 24-item modified version of the Structured Interview Guide for the Ham-D. Systematic counterbalancing of raters and scales and a stringent evaluation schedule were used to counter position effects, spontaneous symptom change, or diurnal variation. The modified SIGH-D produced uniformly higher item- and summary-scale reliabilities than the unstructured Ham-D.

Predicting response to fluoxetine in geriatric patients with major depression.

No consensus exists regarding whether early response to an antidepressant strongly predicts a good outcome, what is the criterion for early response, or when to measure it. We hypothesized that early response (> or = 20% decrease in HAM-d21) after any of weeks 1, 2, or 3 of fluoxetine treatment of major depression in geriatric outpatients would predict a favorable outcome by week 6 or an earlier endpoint accurately enough for clinical use. We also hypothesized that the week 1, 2, and 3 percent changes in 21-item Hamilton Rating Scale for Depression (HAM-D21) would predict the percent change at week 6 (or endpoint) accurately enough for clinical use. We enrolled 671 elderly outpatients with unipolar DSM-III-R major depression in a double-blind, placebo-controlled trial of fluoxetine, 20 mg/day. For analysis, fluoxetine-treated patients were randomly divided into a development set (N = 154) for a preliminary test of our criteria and a validation set (N = 181) to validate the development data set's results. Early responders at weeks 1, 2, and 3 were statistically significantly more likely to experience marked improvement or remission than those lacking early response. However, at week 3, this criterion correctly classified only about three-fourths of patients with regard to marked improvement and only about two-thirds with regard to remission. Moreover, about one-third of patients predicted to experience marked improvement and about three-fifths of those predicted to remit did not. The continuous variable, percent change in HAM-D21, did not produce predictive results of any greater clinical utility. We believe that the sensitivity, specificity, false-positive rate, false-negative rate, and kappa of outcome predictions all should be reported in future studies. Without a full set of descriptive statistics, clinicians can be misled by statistically significant results.

Methylphenidate and nortriptyline in the treatment of poststroke depression: a retrospective comparison.

The hospital charts of elderly stroke patients with major depression, as determined by DSM-III-R criteria, who were treated with either methylphenidate (n = 28) or nortriptyline (n = 30) were retrospectively reviewed. Fifty-three percent of the methylphenidate patients experienced complete remission of depressive symptoms. Similarly, 43% of the patients in the nortriptyline group showed remission of depressive symptomatology. Whereas the response rates between the two treatment groups were not significantly different in the patients who did respond to treatment (chi 2 = .608, df = 1, p = NS), the speed of response was significantly better in the methylphenidate group (t[13] = 15.9, p < .001). The average peak response time for the methylphenidate patients was 2.4 days compared to 27 days for the nortriptyline group. This finding is consistent with previous reports suggesting a rapid response to methylphenidate and other psychostimulants, typically between 24 and 72 hours. Adverse side effects, such as cardiac changes, did not differ between groups, generally falling in the mild range of severity. These data suggest that the rapid effects of methylphenidate may be especially useful to speed recovery from depression so that patients can participate more fully in rehabilitation programs.

Efficacy and side effects of methylphenidate for poststroke depression.

BACKGROUND: Depression after stroke impedes the rehabilitation process and causes additional suffering to patient and family. Few studies have systematically examined pharmacologic treatments of poststroke depression. In the present paper, the use of the stimulant methylphenidate is studied in a depressed, elderly stroke population. METHOD: Ten subjects (mean age = 73.2 years) meeting DSM-III-R criteria for major depression were followed-up during a 3-week efficacy and side effect trial involving methylphenidate. Subjects were selected from rehabilitation patients referred for psychiatric consultation. RESULTS: A total of 80% (8 of 10) of the subjects showed either a full or partial response as measured by Hamilton Rating Scale for Depression scores. The incidence of problematic side effects was low, and no subjects had to be discontinued from the study. CONCLUSION: Results of this methylphenidate trial for poststroke depression in elderly patients suggest that it is a safe and effective treatment for poststroke depression. Future studies are called for in which methylphenidate is compared with placebo controls and antidepressant medication.

Psychotherapy with elderly depressed patients.

Although psychotherapy outcome research is not without controversy, available evidence suggests that elderly patients benefit from an active, structured relationship with a therapist who provides a helpful therapeutic setting for comprehending and mastering problems that contribute to depression. Until research can evaluate better the various types of therapies, it is reasonable to integrate aspects of different therapies in the clinician's approach to depressed elderly patients, depending on the clinician's understanding of the patient's diagnosis, ego strengths and weaknesses, and capacity to cope and change. The therapist can use psychodynamic, cognitive, behavioral, interpersonal, and supportive techniques in a flexible manner, individualizing therapy to meet the patient's specific needs. Antidepressants are helpful in conjunction with psychotherapy, particularly for patients with major depression and for patients with prominent neurovegetative signs of depression. A tailored, individualized approach that considers the patient's unique needs can strengthen the therapeutic relationship, which may be the primary "nonspecific factor" through which all psychotherapies appear to benefit patients.

Assessment and management of dementia in the nursing home.

Well over half of the nursing home residents in the United States suffer from dementia, and the absolute number of those affected is expected to increase dramatically. Dementia is a clinical syndrome for which physicians assess patients carefully to search for reversible etiologies and other factors which worsen cognitive function. Behavioral and affective symptoms are common and may be understood as having organic, environmental, psychological, and interpersonal components. Patients with dementia may benefit from judicious use of psychotropics but are often highly vulnerable to adverse effects. Specialized treatment units are showing early promise.

Methylphenidate in treating poststroke depression.

The authors retrospectively studied the charts of 25 patients with poststroke depression who were treated with methylphenidate. The 13 patients (52%) who recovered completely from their depression did not differ significantly from the 12 nonresponders on demographic characteristics, location of cerebrovascular accident, and other variables. Mood usually improved within 48 hours; only 3 (12%) patients had side effects. Rapid response to treatment and lack of significant side effects indicate that methylphenidate may be a valuable treatment for poststroke depression.

Use of the dexamethasone suppression test with depressed and demented elderly.

Although some researchers have suggested that the dexamethasone suppression test (DST) may be useful in differentiating between major depression and dementia in the elderly, recent reports of abnormal DST results in nondepressed, demented elderly have questioned the validity of the test in this population. This study compared the frequency of abnormal DST results in three groups of elderly inpatients: depressed/not demented; demented/not depressed; and depressed and demented. Two geropsychiatrists independently evaluated 33 patients for symptoms of depression and/or dementia and then assigned each patient to one of the three groups. Subjects in the demented/not depressed group had a significantly larger proportion of abnormal DSTs (P less than .01), and the mean postdexamethasone, 4 PM blood cortisol level of the demented/not depressed group was significantly greater than the means of the other two groups (P less than .005). In this sample, the DST was more likely to identify dementia than depression. Until further investigations clarify the parameters of DST use in the elderly, the diagnosis of depression and dementia should continue to be determined by sensitive interpretation of clinical findings, history, and other diagnostic tests.

Frequency and presentation of depressive symptoms in patients with primary degenerative dementia.

The authors examined the frequency and severity of depressive symptoms in elderly patients with presumed primary degenerative dementia and identified the signs and symptoms that provide a reliable basis for diagnosing depression. Forty-four patients and 42 control subjects were interviewed and rated on the Hamilton Rating Scale for Depression and the Sandoz Clinical Assessment-Geriatric Scale. Nine of the patients demonstrated symptoms suggestive of mild, four of moderate, and five of severe depression. Patients had significantly higher scores than control subjects on items that assess intrapsychic rather than vegetative symptoms of depression. These findings underline the importance of maintaining a high index of suspicion for concomitant depressive symptoms in patients with primary degenerative dementia.

Geriatric depression: a guide to successful therapy.

In the apathetic, withdrawn patient, tricyclic secondary amines such as desipramine and nortriptyline are as efficacious as tricyclic tertiary amines, and they offer the advantage of fewer anticholinergic and sedating side effects. Depressions usually have a sudden onset, whereas degenerative dementias such as Alzheimer's disease and multi-infarct dementia are manifested gradually. However, many elderly demented patients have concomitant depression, making assessment difficult.

Training in geropsychiatry: problems and process.

The introduction of substantive geropsychiatry training into the medical school curriculum and residency programs in medicine and family practice involves overcoming such obstacles as competition among specialties for curriculum time, "ageism" (negative attitudes toward the elderly), limited financial resources, and scarcity of specialized educators and model curricula. These obstacles can be overcome by developing educational alliances with chairpersons and training directors, recruiting charismatic teachers, providing varied clinical experiences with healthy and impaired elderly patients, and by providing formative as well as summative methods of trainee and program evaluation.