The reduction of stigma and discrimination against older people with mental disorders: a challenge for the future.

Aging of the world population risks to be accompanied by an increase of chronic health problems, and most particularly of mental health problems. To face these problems the organization of care and education in old age psychiatry is still quite low. If at inter -national level the body of knowledge and skills of the psychiatry of the elderly is today enough recognized it is very difficult to convince authorities at national and local level to recognize this discipline as a sub-specialty of psychiatry. Even when some resources exist at local level to support old people with mental disorders, very often these old persons do not look for care as consequence of the prevailing double stigma attached to mental disorders in general and to the end of life in particular. In order to promote changes of this situation, the World Health Organization (WHO) Collaborating Centre of Lausanne realized a WHO-World Psychiatric Association (WPA) consensus meeting and statement on how to reduce the stigma and the discrimination against old persons with mental disorders, as well it has realized a survey in Europe on this specific subject of stigma and discrimination against these old persons. As education is one of the most important components of the strategy to reduce stigma and discrimination, 3 recent developments were done to promote this. The first one is a survey conducted by the section of old age psychiatry of WPA. The second one is the consensus statement on education in psychiatry of the elderly jointly published by WHO and WPA, and finally was the recent publication of a skill -based objectives for the training in the discipline. These efforts will be completed by some actions to strengthen the impact of all these documents.

Rapid-cycling affective disorder in the elderly: clinical subtype or specific course of manic-depressive illness?

Rapid cycling is a relatively unusual presentation of bipolar affective disorder in the elderly. Four cases or rapid-cycling affective disorder (RCAD) in elderly women (aged 78-86 yr) are presented. Two patients began their bipolar illness in adulthood (aged 30 and 49 yr), and rapid cycles appeared secondarily in their elderly years (82 and 76 yr). The other two began their illness immediately with rapid cycles respectively at the age of 62 and 66. Added to the nine cases of RCAD in the elderly previously reported in the literature, a meta-analysis conducted on this small sample suggests that immediate entry in rapid cycles seems more likely to be associated with a late occurrence of bipolar illness (after 60 years of age)(P = .0035, Fisher's Exact Test, two-tailed), and that very short cycles (< 2 weeks each) are more likely to be associated with female gender (P = .0047, Fisher's Exact Test, two-tailed). Despite the small size of the sample, these results give some arguments to the hypothesis that RCAD is not a homogeneous syndrome but could be considered as a pattern of evolution, as well as clinical subtype, of the bipolar illness.

[Maprotiline versus fluvoxamine: comparison of their effects on the hypothalamo-hypophyseal-thyroid axis]. / Maprotiline versus fluvoxamine: comparaison entre leurs actions sur l'axe hypothalamo-hypophyso-thyroïdien.

The TRH test has been used in psychiatry these last 20 years. One of the most promising results is that concerning the possibility to use it to identify the best moment to stop a treatment after clinical recovery of the depressive episode. For that it is necessary to demonstrate an absence of intrinsic action of antidepressants on the HPT axis physiology. This overt, randomized study has compared the actions on T3, T4, basal TSH and its response to the TRH test after 75 mg/day of maprotiline and 100 mg/day of fluvoxamine, both administrated in depressed patients during 28 days. Forty patients (20 men and 20 women) were studied, 20 patients per treatment. The inclusion criteria were those of DSM III-R for major depression and dysthymia as well a minimum score of 25 at MADRS scale. Blood samples for T3, T4 and basal TSH dosages were made before TRH intranasal administration (2 mg) at days 1 and 28 of the treatment. We haven't observed any difference before treatment between the 2 groups for clinical and biological studied parameters. After treatment both antidepressants produced equivalent improvement of depression evaluated by MADRS (fluvoxamine:dMADRS = 16.95 +/- 7.11; maprotiline: dMADRS = 17.10 +/- 6.84. t = 0.07, NS). T3 and T4 variations between the beginning and the end of the study weren't also significantly different between the 2 groups. Basal TSH was increased in the maprotiline group but decreased in the fluvoxamine group resulting in a significant difference (fluvoxamine: dTSH = 0.31 +/- 0.76 mUI/l. Maprotiline : dTSH = -0.23 +/- 0.66 mUI/l. t = 2.40, p < 0.02). The TSH response to TRH was decreased in the fluvoxamine group (ddTSH = 0.24 +/- 6.65 mUI/l. dAUC = 103.98 +/- 596.84 mUI/l) while it was increased in the maprotiline group (ddTSH = -3.59 +/- 5.88 mUI/l. dAUC = -355.80 +/- 505.67 mUI.min/l). The difference between the 2 treatments was not significant when evaluated by ddTSH (t = 1.53, NS) but it became significant if evaluated by dAUC (t = 2.63, p < 0.01). As we could demonstrate an absence of influence of the clinical evolution between both groups in the hormonal variations observed, we concluded to a intrinsic difference action on HPT axis between fluvoxamine and maprotiline. This difference could be linked to the different aminergic action of these 2 antidepressants.

Are personality disorders more frequent in early onset geriatric depression?

This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square = 2.588, p = 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients.

[Thyroid function in depressed patients]. / Etude de la fonction thyroïdiene chez les déprimés.

This preliminary report compares the FT3, FT4, TSH basal levels and FT4/FT3 ration of depressed patients (DSM III-R criteria) with those of a healthy control group. Authors have also studied thyroid parameters in function of some clinical depression data (polarity, intensity and endogenous character) and other factors as age and sex. 81 depressed patients (31 men, 50 women), with mean age of 44.85 years were studied. 44 patients suffered of an endogenous depression and 37 of a non endogenous depression (Newcastle criteria). 60 patients had an unipolar depression while 21 patients had a bipolar depression. The control group was constituted of 36 healthy subjects (20 men, 16 women), with mean age of 40.94 years. There is no significant difference between the two groups for sex and age, besides the different size of the two groups. FT3 mean of depressed patients was 4.39 pmol/l. There was a significant difference between unipolar group FT3 mean (4.51 +/- 1.01 pmol/l) and bipolar FT3 mean (4.03 +/- 0.91 pmol/l; t = 2.02, p < 0.05). Depression intensity was correlated negatively to FT3 mean (r = -0.23; t = 2.10, p < 0.005). FT4 mean in the depressed group was 12.62 +/- 4.14 pmol/l. The only significative result for FT4 was its correlation to TSH levels (r = -0.36; t = 3.43, p < 0.001). TSH mean in depressed patients was 1.43 +/- 0.85 microIU/ml. When we have compared these results with those of control group we concluded that FT3 and TSH levels were significantly lower in the depressed group (FT3: t = 4.83, p < 0.0001; TSH; t = 2.44 p < 0.02) and that FT4 was slightly but not significantly increased in the depressed group. FT3 decrease and the slight FT4 increase in depression may be the consequence of a metabolic deviation of FT4 transformation into FT3. Its link with intensity and polarity of depression suggests that it can be considered as a biological marker of this disease.