Residual symptoms in elderly major depression remitters
Gasto C, Navarro V, Catalan R, Portella MJ and Marcos T;
Commented by , 28 Jul 2003
Aim of the Study
To assess residual symptoms of depression in older adults following an index episode of major depression; to retrospectively analyse baseline clinical and sociodemographic factors that may predict subsequent residual symptom sufferers.
Method
The sample was all inpatients and outpatients over 60 attending Barcelona’s Hospital Clinic January 1998 – September 2001 with a diagnosis of unipolar depression (DSM-IV criteria) of at least one month’s duration. Diagnosis was confirmed by a trained Psychiatrist using the Schedule for Affective Disorders and Schizophrenia (SADS).
Exclusion criteria included abnormal thyroid function, history of bipolar illness, or non-affective psychosis, current substance dependence, and ECT within six months of recruitment.
Thirty patients over 60 with no history of substance abuse or psychiatric illness were recruited as a control group, from patients’ relatives and volunteers.
Detailed sociodemographic data was collected, supported by severity rating scales, including the 17-item Hamilton Rating Scale for Depression (HRSD), Mini-Mental State Examination (MMSE) and the Holmes-Rahe Readjustment Rating Scale.
At 9 month follow-up, subjects were classified as remitters (HRSD ≤ 7) or non-remitters (HRSD > 7). The continuous variables in the data were analysed using Student’s t-test, the Mann-Whitney U-test, and regression.
Results
108 patients were included, 79 of whom were remitters. There were no significant differences between remitters and controls in age, sex, vascular risk factors, medical illnesses, chronic stress or subjective social support. Remitters had statistically significant higher HRSD scores at follow up, ie., even in those classed as being in remission may have had some residual symptoms of depression.
Only 14/108 were completely symptom free. Depressed mood, reduced interest, insomnia and somatic anxiety were the most frequent residual symptoms in those classed as remitters.
Using linear regression, medical burden, subjective social support and chronic stress were the only factors that predicted severity of residual symptoms in remitters. Neither demographics nor clinical characteristics of patient predicted residual symptoms.
Discussion
Residual symptoms following partial recovery from depression is an under-researched area both in younger and older patients. (Interested readers are directed to articles in Psychological Medicine by Paykel et al. 1995; 25; 1171-1180, and the American Journal of Psychiatry by Mojtabai 2001; 158; 1645-1651.)
This study found that residual symptoms of depression effected 82 % of over 60s classified as “in remission” after an episode of unipolar depression. This begs two questions : firstly, should an HRSD score of < 8 equate with “remission”; secondly, should psychiatrists be trying more actively to treat these symptoms in older people, for example, by cognitive behavioural therapy?
There is insufficient data published in this paper to answer the first question completely, though residual symptoms were so widespread (only 14/108 subjects symptom-free) that an even lower cut-off on the HRSD for “remission” would have produced similar trends.
More data on the nature of how rigorously depressed patients in this study were treated is necessary to answer the second question.
The study is also limited by its sample size, sample characteristics, the uncontrolled nature of treatments used for depression, and the retrospective nature of the analysis. However, if the authors’ predictors of residual symptoms (medical burden, subjective continued stress, and subjective social support) are confirmed by future research, treatments targeted at these three areas could potentially reduce residual symptoms.
This paper serves to remind us that management of depression in individual older people is complex and ongoing.