Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-029The Assessment of Depressive StatesThomas R. Thompson and William M. McDonaldEmory University School of Medicine, Atlanta, GA, USAThe diagnosis of depressive states in the elderly requires amulti-dimensional approach and should not be undertakenwithout a clear understanding of the normal aging process andthe psychosocial factors that are unique to the elderly. Theaccurate assessment of depressive disorders in the elderly isessential, since this population is often subject to more adverseside effects from pharmacotherapy, and concurrent depressioncan limit compliance with medical treatments and worsen thecognitive decline associated with dementia. Further, depressioncan adversely affect the clinical course of other medical illnessesand increase morbidity and mortality 1,2 . Depression in late lifeis not a normal part of aging and is not necessarily moredifficult to treat or chronic when compared to depression inyounger people 3,4 .A number of authors have drawn attention to the psychosocialstressors that must be taken into account in the diagnosis ofdepression in the older population and to the high levels ofdepressive symptoms in the elderly living in the community 5 .Although the prevalence of individuals with major depressionmay not be as high as for younger subjects in such settings 6,7 , theprevalence increases in elderly patients in long-term care facilitiesand the medically ill 8,9 . Depressive symptoms can lead toaccelerated cognitive decline, physical impairment and increasedhealth care costs. The elderly population maintains the highestsuicide rate 10,11 so that the social and economic consequences ofthis disorder are severe.THE SYNDROME OF LATE-LIFE DEPRESSIONTo accurately assess the depressed older adult, the clinician mustbe aware of the major syndrome encountered in older adults. Themajor categories of mood disorders outlined in the Diagnostic andStatistical Manual of Mental Disorders, 4th edn 12 , are majordepression, dysthymic disorder (dysthymia) and adjustmentdisorder (bipolar disorder is discussed elsewhere), which correspondroughly with the International Classification of Diseases 9(ICD-9) 13 for diagnoses of manic–depressive psychosis, neuroticdepression and brief depressive reaction, respectively. Therevision of the ICD (ICD-10) 14 has diagnoses of depressiveepisode and persistent affective state (with a subclassification ofdysthymia) that closely approximate the corresponding DSM-IVclassifications.Major depression is distinguished by the severity of symptoms,which may include significant weight loss or weight gain, insomniaor hypersomnia, psychomotor agitation or retardation, diminishedability to think or concentrate, feelings of worthlessness orexcessive inappropriate guilt and recurrent thoughts of death orsuicide 12 . A melancholic depression (DSM-IV) or severe depression(ICD-10) represents a subtype of major depression that is feltto be preferentially responsive to somatic therapy (i.e. antidepressantsand electroconvulsive therapy) and includessymptoms such as a lack of reactivity to pleasurable stimuli,diurnal variation in mood with depression worse in the morning,early morning awakening, psychomotor retardation or agitation,significant weight loss and other factors that may have a bearingon response, including no significant personality disturbancebefore the onset of a major depressive episode and a previoushistory of a major depressive episode that may have responded tosomatic treatment. In the DSM-IV, depression is sub-typedaccording to whether the mood disturbance is associated with aseasonal variation (e.g. a temporal relationship between a distinct60-day period of the year) or psychotic symptoms that are morelikely to be mood-congruent (i.e. delusions or hallucinations of adepressive nature). Psychotic depressions may be more commonin late life 15 .The DSM-IV now includes a research diagnosis of minordepression. The duration of the episode and the symptoms are thesame as major depression. However, in minor depression thenumber of symptoms required for diagnosis is less compared tomajor depression. Minor depression is important in the elderly asthere is evidence that these individuals have levels of cognitive andfunctional impairment similar to those who met full criteria formajor depression 16 .Dysthymic disorder (dysthymia) is defined as a chronic lowgradedepression, which lasts at least 2 years (DSM-IV), or‘‘several’’ years (ICD-10). Primary dysthymia may occur in olderadults due to changing roles and life conditions. Personalitystyles and the individual’s ability to cope with changing lifesituations may predispose the individual to develop a dysthymicdisorder (see Chapters 71, 74). Although certain severe personalitydisorders are less common in the elderly, long-standingpatterns of perfectionism and the need for external gratificationcan lead to chronic low self-esteem and dysphoria. Dysthymicdisorder may also develop secondary to a medical disorder,which leads to chronic debilitation or other psychiatric disorders,such as substance abuse, anxiety disorder or somatizationdisorder.The elderly patient may also have to adjust to severe changesin lifestyle and the loss of loved ones. In the DSM-IV, thepatient is not classified with an adjustment disorder unless his/her reaction is considered maladaptive and the level ofimpairment is significantly severe, so as to be greater thanwhat would be normally expected. The ICD-10 outlines similarsymptoms under the heading of mild depressive episodes. Severalcommon life events that prove to be stressors in the elderlyPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd