The symptomatology of depression in the elderly.

Older people may have a different pattern of depressive symptoms to that found earlier in life, in particular having more somatic symptoms and less overt low mood symptoms. Few attempts have been made to relate such differences to more general aspects of cognitive or emotional processing, such as the presence of dysfunctional attitudes or of alexithymia. Symptom differences within depression in old age have also received relatively little study, as has the ability of individual symptoms to distinguish between depressed and non-depressed elderly populations. These issues have been examined in two studies. In the first, a random sample of 700 subjects aged 65 years and over were identified through door-knocking in randomized enumeration districts in Islington, a socially deprived region of inner city London, and evaluated using a shortened version of the Comprehensive Assessment and Referral Evaluation (Short-CARE), which incorporates a depression subscale (DPDS). All 18 DPDS items distinguished significantly between depressed and non-depressed subjects (P < 0.0001). Depressed men were significantly more pessimistic than depressed women (63 versus 40%; P < 0.05); non-significant trends suggested that depressed women are more worried (39 versus 22%) and more restless (50 versus 31%), and depressed men more likely to be 'not very happy' or 'not happy at all' (53 versus 36%). There were no significant differences between older (age > 74 years) and younger subjects. Several other Short-CARE items, predominantly addressing subjective memory and disability, also distinguished significantly between the depressed and non-depressed groups. Logistic regression analysis identified eight items of the DPDS contributing significantly to the predictive ability of the total scale. In the second study, the Toronto Alexithymia Scale (TAS) and the Dysfunctional Attitudes Scale (DAS; 3) were administered to primary-care attenders aged > 64 years, and those with significant depressive symptoms were matched by age and sex to a depression-free control group. Depressed subjects had higher scores on both the TAS (Mann-Whitney U-test z = -4.71, P < 0.0001) and on the DAS (z = -2.49, P < 0.02).

Moclobemide and nortriptyline in elderly depressed patients. A randomized, multicentre trial against placebo.

Moclobemide and nortriptyline were compared with placebo in a double-blind randomized multinational (Canada, Denmark and UK) trial comprising 109 patients of > 60 years of age with major depression (DSM-III-R). Patients were randomized to 7 weeks of treatment with doses of 400 mg/day moclobemide, 75 mg/day nortriptyline or placebo. It was necessary to adjust nortriptyline dosage in < 20% of patients to maintain serum levels within the postulated therapeutic window of 50-170 ng/ml. At end of treatment, the remission rates were 23% for moclobemide, 33% for nortriptyline and 11% for placebo. Anticholinergic and orthostatic events occurred more often with patients on nortriptyline than either moclobemide or placebo.

Attitudes to community psychiatry among urban and rural general practitioners.

General practitioners' requirements for community psychiatric services may differ according to the area in which they practise. A questionnaire survey of general practitioners' attitudes to community psychiatric services is reported from three contrasting areas: an inner city urban area, a new town and a rural area. General practitioners in all areas wanted more consultation with psychiatrists, and 53-68% wanted regular psychiatric outpatient clinics in their surgeries. There was enthusiasm for community psychiatric nurses and for help with psychotherapy. In the rural area general practitioners favoured surgery based psychiatric outpatient clinics and arranging emergency hospital admissions themselves; in urban areas domiciliary visits from psychiatrists to help with emergencies were favoured. These results appear to reflect the greater geographical distance between primary and hospital based secondary care in rural as opposed to urban areas. Overall, general practitioners wanted more support from community psychiatric services in carrying out their primary therapeutic role especially in rural areas far from hospital-based psychiatric services.