Assessing depression in Greek dementia patients: Which scale to use?

Depression in dementia is known to deteriorate patients' cognitive function and Quality of Life and to increase the burden of care. Although detecting depression in dementia is crucial, there is no gold standard for its screening and diagnosis. We examined the psychometric properties of 3 different scales in detecting depression in dementia. Results will be useful as community services for dementia in the country are developing and the need for reliable detection of depression in dementia patients is urgent. Our sample consisted of 136 Greek dementia patients who consulted a memory clinic. For the diagnosis of depression, DSM-IV criteria for major depression and 3 different depression measures were used: a self-assessment scale (Geriatric Depression Scale; GDS), a caregiver assessment scale (Neuropsychiatric Inventory-Depression; NPI-D) and a clinician rated scale (Cornell Scale for Depression in Dementia; CSDD). For the evaluation of the screening performance of the three depression scales receiver operating characteristic curve (ROC) analysis was applied. The DSMIV criteria served as the gold standard method for the diagnosis of major depression. CSDD showed the best psychometric properties for the diagnosis of depression in dementia. The ROC curve analysis revealed that among the three measures, the CSDD had the wider AUC (0.919), second in the width of the AUC was the GDS (0.871), and last was the NPI-D (0.812). The prevalence of depression ranged from 18.4% according to DSM-IV criteria to 42.6% using the NPI-D. Using the GDS (cut off point: 7/8) and the CSDD (cut off point: 6/7), depression was present in 26.9% and 33.1% of the patients, respectively. Correlations between scales used were significant (r from 0.432 to 0.660; p<0.001). Caregivers tend to report more depressive symptoms in dementia compared to patients' and clinicians' ratings. CSDD should be used in specialized centers, but GDS may be an alternative in patients able to complete the assessment. The need to establish valid criteria for the diagnosis of depression in dementia is urgent.

The burden of caring for patients with dementia and its predictors.

Dementia not only affects patients but also care providers. The assessment of Caregivers' Burden (CB) has grown exponentially in the dementia field, as studies have shown that it is higher in dementia than in other diseases. Dementia care in Greece is different compared to other developed countries, as most of the patients receive care at home from family members. The aim of the present study was to examine the level of burden in Greek caregivers who live in Athens, and its association with patient and caregiver factors. This was a cross-sectional study of 161 primary caregivers of dementia patients living in the community and attending a secondary clinic. CB was assessed with the Zarit Burden Interview (ZBI) and caregivers' depression with the Center for Epidemiological Studies Depression Scale (CES-D). Clinical characteristics of the patients were also assessed using validated scales (cognitive status, functional ability, neuropsychiatric symptoms). In order to find predictors of caregiver Burden, we conducted a 3-step hierarchical regression analysis. Most patients were suffering from Alzheimer's Dementia (n=101; 62.73%) and had moderate and severe dementia according to the MMSE score (mean MMSE=11.50), with patients being unable to perform 2 basic activities of daily living on average. 45 patients (27.95%) had depression according to the CSDD; only 5 patients didn't have any behavioral problem in the NPI, while patients had more than 5 behavioral problems on average. Caregivers were involved in their role for 3.6 years on average and the mean weekly caregiving time was more than 70 hours. Nearly half (n=80; 49.06%) of the 161 caregivers demonstrated high CB (ZBI>40) and nearly one fourth had depression according to the CES-D scale. All blocks of variables entered into the regression model independently predicted caregiver burden's variance (demographics, clinical factors and caregiving characteristics). Lower caregiver's age, high behavioral symptoms of dementia patients and caregivers' depression were found to be independently associated with CB. The final regression model explained 47.2% of the variance in CB. Dementia causes a great burden in caregivers. CB is a complex issue that is associated with several patients and caregivers' factors. The level of CB should be assessed in everyday dementia clinical practice.

Sex differences in the prevalence and detection of depressive and anxiety disorders in general health care settings: report from the World Health Organization Collaborative Study on Psychological Problems in General Health Care.

BACKGROUND: Understanding the relevance of biological and social factors to sex differences in the prevalence and detection of depressive and anxiety disorders has been impaired by the lack of standardized research methods across cultures. METHOD: Prevalence rates of depressive and anxiety disorders were assessed using a 2-stage design from 26,969 patients attending for primary care in 15 centers from 4 continents. Logistic regression analysis was used to examine sex differences in prevalence and detection across centers. RESULTS: Odds ratios for women compared with men of current depression (1.60; 95% confidence interval [CI], 1.37-1.86) and agoraphobia or panic (1.63; 95% CI, 1.18-2.20) were consistent across centers. The odds ratio for generalized anxiety varied among centers: 3 groups of centers were identified with odds ratios of 0.46 (95% CI, 0.27-0.78), 1.34 (95% CI, 1.08-1.66), and 3.09 (95% CI, 1.60-5.89). There was no sex difference in the detection of depressive and anxiety disorders by physicians across centers. CONCLUSIONS: The absence of a sex-by-center effect for current depression and agoraphobia or panic disorder is consistent with biological and psychosocial factors, either interacting or working alone, that have a similar final effect across cultures. It does not support the idea that sex differences in prevalence are caused by local psychosocial factors that vary from country to country. The variation in the odds ratio for generalized anxiety disorder offers some support to the idea that there are local differences between the centers contributing to the sex difference in rates. Patients' sex does not appear to affect the likelihood of current depression and anxiety being detected by primary care physicians.

Formal clinical characteristics of delusional beliefs.

We studied 13 formal clinical characteristics of delusions by means of observer-rated ordinal scales in a sample of 74 psychiatric inpatients with mainly schizophrenic or schizophreniform disorders. The interrater reliability of the scales was found to be satisfactory. High levels of conviction about their truth and to a lower extent lack of dismissibility and lack of resistance against them were found to be the hallmarks of delusional beliefs. The lack of strong intercorrelations among the scales items supports the hypothesis that the concept of delusions represents various aspects of delusional experience which are relatively independent of one another.

Clinical characteristics of auditory hallucinations.

We studied 25 clinical characteristics of auditory hallucinations by means of 3-point observer-rated scales in a sample of 60 inpatients with mainly schizophrenic or schizophreniform disorders. The interrater reliability of the scales was found to be satisfactory. High levels of conviction about the reality of the sensory stimuli, clarity of content, location of their source of origin and lack of volitional control were found to be the hallmarks of verbal hallucinations. This finding supports the hypothesis that the concept of auditory hallucinations represents many aspects of patients' hallucinatory experiences, which are relatively independent of one another.

Expressed Emotion in families of chronic schizophrenics and its association with clinical measures.

A controlled clinical study on the outcome of family intervention in chronic schizophrenics is being carried out in Athens. All subjects participating in the study reside with their families and attend a vocational rehabilitation unit. Those belonging to families characterized by high "Expressed Emotion" (EE) are randomly assigned to either the experimental or the control condition. The former receive family intervention combined with individual treatment, the latter individual treatment alone. 75 subjects have entered the study, and 121 relatives were interviewed with the Camberwell Family Interview. 40 patients (53.3%) were found to belong to high EE families. The present article presents the results of the baseline assessment. It was found that the EE status of the family was significantly associated with measures of psychopathology and social functioning (BPRS, GAS, DAS, number of residual symptoms). Further analyses revealed that these associations exist only when all key relatives express high EE. The implications of these findings are discussed.

Greeks, British Greek Cypriots and Londoners: a comparison of morbidity.

This paper reports the results of a comparison of the rates of psychiatric disorder from three general population surveys in which the PSE-ID-CATEGO system was used for case-definition. These surveys were of an English sample in Camberwell, London, and of two Greek samples, the first in Athens, the second of Greek Cypriot immigrants living in Camberwell. The results show that the rates of psychiatric disorders in both Greek samples were somewhat higher than those of the Camberwell population, the differences being accounted for by higher rates of anxiety disorders, especially in women. Comparisons in terms of syndrome profiles showed that Greeks reported more symptoms of generalized anxiety than their English counterparts who, in their turn, reported higher rates of obsessive symptoms, and symptoms of social anxiety. The higher rates in the Greek samples were possibly due to an increased frequency of non-specific neurotic symptoms like worrying and tension. The results of other European community surveys with the PSE suggest that there might be a genuine and general North-South difference in the expression of psychological distress. Cultural differences in terms of personality traits and culturally sanctioned child rearing practices might account for the findings.

Attempted suicide in psychiatric outpatients with concurrent physical illness.

Fifty outpatients with concurrent psychiatric and physical illness who were referred following a suicidal attempt to the Outpatient Psychiatric Department, University of Athens, during a period of 3 years (1979-1981) were compared with a random sample of 85 psychiatric outpatients without concurrent physical illness who had attempted suicide at the same time period. Attempters suffering from both mental and physical illness were more often of an older age, married, pensioners or housewifes, were living with their own family, were suffering from organic psychotic condition or major affective disorder (depressive type) and more frequently used violent methods for attempting suicide. Among attempters the commonest physical illnesses were neurological diseases (40%), cardiovascular diseases (26%) and cancer (10%).

Greece: the transition to community care.

The system of psychiatric care in Greece is described. It was based until recently on overcrowded, large asylums inhabited by chronic mental patients. The mental health system was highly centralized, with an uneven distribution of both facilities and manpower. Out-patient and rehabilitation facilities were particularly scarce. Recent reforms funded by both the Greek State and the Social Fund of the EC are outlined. These changes started in the late Seventies and are aimed at creating a comprehensive system of community-oriented mental health care. The new system is gradually being deployed, and it is expected that in the following years it will effectively cover the needs of the whole country.