Personality disorder symptoms predict declines in global functioning and quality of life in elderly depressed patients.

The authors evaluated personality disorder symptoms as predictors of change in global functioning and quality of life among elderly depressed patients. Treated elderly patients (N=40) who no longer met RDC criteria for major depression were assessed for personality disorders, depression, global functioning, and quality of life after treatment of the acute episode and at 1-year follow-up. In interaction with persisting or recurrent depression, Cluster B personality disorder symptoms contributed to declines in global functioning and quality of life over a 1-year period. Personality disorder symptoms in elderly patients appear to operate as co-factors that amplify or exacerbate the impact of residual depression on long-term functioning and quality of life.

Personality disorder symptoms and functioning in elderly depressed patients.

The authors evaluated the relationship of personality disorder symptoms to disability and social and interpersonal functioning in geriatric depression. Measures of personality disorder and cognitive, affective, social, interpersonal, medical, socioeconomic factors, and instrumental activities of daily living (IADL) status were administered to 47 elderly patients at various levels of remission from major depression. Total personality disorder scores were inversely associated with IADL, sociability, and presence of a satisfying relationship, both alone and in interaction with depression. The associations between personality disorder and functioning were most prominent in subjects with low residual depression. Symptoms of personality disorder in elderly patients may be associated with disability and impaired social and interpersonal functioning after an acute depressive episode; personality disorder symptoms may also have treatment implications for geriatric depression.

Personality disorder correlates of late and early onset depression.

OBJECTIVE: To compare the lifetime personality dysfunction of geriatric patients having late and early onset of major depression. DESIGN: Group comparisons. SETTING: Inpatient geriatric psychiatry unit and hospital-based geriatric psychiatry outpatient clinic. PATIENTS: Volunteer sample of recovered elderly depressives with history of early onset of major depression (age < 60) (n = 16) and history of late onset of major depression (age > 60) (n = 14). MAJOR OUTCOME MEASURE: Personality Disorder Examination, containing diagnostic and dimensional scores for DSM-III-R personality disorders. RESULTS: The two groups had similar demographic profiles and levels of depression after treatment. Early onset subjects had significantly higher mean dimensional scores in the avoidant, dependent, and not otherwise specified NOS personality disorders, and higher dimensional scores with a trend toward significance in 6 additional personality disorders. CONCLUSIONS: Early onset geriatric depressives may have more lifetime personality dysfunction than late onset subjects. Greater personality dysfunction in early onset subjects may reflect postdepressive changes, predisposition, or a low grade depressive subtype.

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)

Trait-state artifacts and the diagnosis of personality disorders.

The multiaxial nature of DSM-III has stimulated interest in the personality disorders. There are also indications that it has produced an increase in their diagnosis. However, there is clinical and psychometric evidence that a personality evaluation undertaken while a patient is in a dysphoric mental state may distort or misrepresent traits, the so-called trait-state problem in personality assessment. The present study appears to be the first to investigate this phenomenon with a clinical interview rather than with personality tests. It examined the effect of anxiety, depression, and level of global impairment on the diagnosis of personality disorder and the assessment of the criteria for the individual Axis II disorders. Eighty-four patients, most of whom had current Axis I diagnoses, were evaluated by seven experienced clinicians with a new semistructured interview, the Personality Disorder Examination. The sample evidenced a trend toward acknowledging fewer maladaptive personality traits at follow-up than at entry. There was no evidence, however, that anxiety or depression had affected either the diagnosis of a personality disorder or the criteria associated with most of the individual personality disorders.

Depression in Alzheimer's disease.

Alzheimer's disease involves cognitive and noncognitive manifestations including varying degrees of depression. The depressive syndromes of Alzheimer's patients are similar to those of nondemented patients and frequently are identified by patients themselves and their relatives. There is evidence that the depression of Alzheimer's disease is caused by familial and neurobiologic factors. The clinical importance in identifying depression in Alzheimer's disease lies in its responsiveness to antidepressant treatments.

Chronicity and relapse in geriatric depression.

Recent advances in the methodology of longitudinal investigations have permitted the identification of predictors of chronicity and relapse of depression. However, findings from mixed-age populations may not be directly applicable to geriatric depression. The effects of medical illness, cognitive dysfunction, and neuroradiological abnormalities on the outcome of geriatric depression merit further evaluation. Late-onset depression requires special attention, since medical and neurological disorders may be particularly important factors in these cases.

Late-onset depression.

Clinical and biologic studies of geriatric depression are reviewed to evaluate the role of age of onset as a distinguishing parameter. The findings suggest that late-onset depressives have a different presentation, more frequent relapses, and a greater association with medical disorders, dementia, and aging-related biologic changes than early-onset geriatric depressives. Careful clinical evaluation and follow-up of late-onset depressives are suggested. Longitudinal investigations of geriatric depressed patients are needed in order to study the frequency and time of occurrence of various clinical outcomes and identify predictors of outcome in late- and early-onset geriatric depression.

Use of the Cornell scale in nondemented patients.

The Cornell scale is a 19-item clinician-administered scale of depression that uses information from interviews with both patients and their caregivers. The Cornell scale has been validated in demented patients. In this study, the Cornell scale was psychometically tested in nondemented geriatric subjects by administering it to 15 depressed patients, 15 patients with other psychiatric diagnoses, and 15 normal control subjects. The Cornell scale had high interrater reliability (Cohen's kappa = 0.74), internal consistency (Kuder-Richardson's coefficient = 0.98), and sensitivity, and correlated significantly (Spearman's r = 0.81) with Research Diagnostic Criteria psychiatric diagnoses associated with various intensity of depression. To our knowledge, the Cornell scale is the only depression-rating instrument that has been validated in both demented and nondemented geriatric subjects.

Cornell Scale for Depression in Dementia.

The Cornell Scale for Depression in Dementia is introduced. This is a 19-item clinician-administered instrument that uses information from interviews with both the patient and a nursing staff member, a method suitable for demented patients. The scale has high interrater reliability (kw = 0.67), internal consistency (coefficient alpha: 0.84), and sensitivity. Total Cornell Scale scores correlate (0.83) with depressive subtypes of various intensity classified according to Research Diagnostic Criteria.

Geriatric depression and DSM-III-R personality disorder criteria.

The relationship between personality traits and late-life depression is not well established. The Personality Disorder Examination (PDE), a recently developed structured interview for diagnosing DSM-III-R* personality disorders, has provided a methodological advance for studies in this area. The PDE was administered to 36 cognitively intact elderly individuals. The sample consisted of 21 patients who had recovered from depression and 15 normal volunteers. Two of the patients met DSM-III-R criteria for personality disorder according to the PDE. The patient group received higher scores on PDE items related to each personality diagnosis (P less than .01) except antisocial personality disorder. These preliminary data suggest that elderly patients with a history of major depression have more lifetime personality dysfunction than normal elderly individuals, although no specific pattern could be identified.

A critique of the process-oriented approach to ward staff meetings.

Interdisciplinary staff meetings with a group-process orientation are a common feature of inpatient psychiatric wards. In these meetings an attempt is made to elicit and resolve intrastaff conflicts. Often the hierarchy of administrative structure is suspended and a setting reminiscent of a therapy or T-group is created. Insufficient attention has been paid to the potential hazards of and varying indications for this process-oriented approach to staff meetings. The authors reassess the usefulness of these meetings in improving staff relations and clinical performance and suggest guidelines for tailoring their use to fit the ward's therapeutic objectives.

Short first ray as a complication of multiple metatarsal osteotomies.

Multiple metatarsal osteotomy was performed in 50 children and found to be a reliable procedure for treatment of metatarsus adductus in a child. As a prerequisite to the operation, the epiphysis of the first ray should be ossified. During the operation, the epiphyseal plate must be identified and avoided. After the correction, displacement of the bony fragments may be prevented by wire fixation. The consequences of failure to observe these rules were noted in a patient who was observed for 13 years; despite premature arrest of the physis resulting in 2.5 cm shortening of the first ray, he is asymptomatic and gainfully employed; his foot is testimony to Harris and Beath's concept of the dynamic adaptability of the human foot.