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 0-470-84641-0416 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYOutcome of Depression in FinlandSirkka-Liisa Kivela¨University of Turku, FinlandIn the early 1980s, an epidemiological study of depression wascarried out among the population aged 60 years or over (n=1529)living in the municipality of A¨ hta¨ri in south-western Finland.DSM-III criteria were used to diagnose depression in interviewsand examinations and 264 depressed persons (91 men and 173women) were discovered; 42 met the criteria for major depression,199 for dysthymic disorder, 21 for atypical depression and two forcyclothymic disorder.The depressed persons were intensively treated in a primarycare setting for about 2 years after the epidemiological study. Thetreatment consisted of individual psychological support by ageneral practitioner, antidepressive medication, counselling aboutnutrition and physical exercise and social support from thefamilies, relatives, neighbours and home care personnel. Later, aless intensive treatment schedule, consisting of psychologicalsupport by a general practitioner and antidepressive medication,was arranged for those who had not recovered.1 YEAR AND 5 YEAR CLINICAL OUTCOMESNearly half of both major depressive and dysthymic patients werenon-depressed after 1 year (Table 1). The proportion of depressedsubjects tended to be higher among the dysthymic patients, whilethe proportions of demented subjects and deaths tended to behigher among the major depressive patients. After 5 years, theproportion of recoveries was higher among the dysthymic patients,and the death rate was higher among the major depressive patients.Every fourth subject was depressed in both groups.FACTORS RELATED TO RELAPSESOR LONG-TERM COURSEMajor depression had a definite tendency for a relapsing courseduring the 5 year follow-up, even without any special stressors inlife or physical illnesses after recovery. The depressed patientswho developed a physical disease and whose physical healthdeteriorated during the treatment had a high risk for non-recoveryand a long-term course of depression. Many of these patients hadsuffered from poor self-appreciation and diurnal variation ofsymptoms at the onset of the treatment.The results support the following proposals for clinical practice.Major depressive patients should be followed up after recovery inorder to detect their possible relapse and to increase theprobability of recovery. Intensive antidepressant and psychotherapeutictreatment and adequate treatment of physical diseasesshould be arranged for depressed patients who develop a physicaldisease or whose somatic condition deteriorates due to a previousphysical disease. Cooperation between psychiatrists and generalpractitioners is needed in the above two cases.MORTALITYMajor depressive patients had a high death rate, which was notexplained by their poor physical health. These results suggest thatthere may be biological factors associated with major depression thatincrease the risk of death or the risk of the development of physicaldiseases leading to death. The mortality of dysthymic patients wasTable 1 One year and 5 year outcomes of major depressive anddysthymic older patients treated in primary health care1 Year outcome 5 Year outcomen (%) n (%)Major depressive patientsNon-depressed 19 (45) 5 (12)Depressed 11 (26) 11 (26)Demented 6 (14) 5 (12)Dead 6 (14) 19 (45)Refused to participate 2 (5)Total 42 (100) 42 (100)Dysthymic patientsNon-depressed 79 (40) 71 (36)Depressed 91 (45) 52 (26)Demented 6 (3) 18 (9)Dead 20 (10) 50 (25)Refused to participate 3 (2) 8 (4)Total 199 (100) 199 (100)also higher than that of non-depressed persons, but their highmortality was explained by the high number of physical diseases.Longstanding depression was a predictor for high mortality,independently of the physical diseases present at the onset of thetreatment of depression. The physical diseases that occur duringthe treatment and predict a longstanding course may explain thehigh death rate seen here.These results also underline the need for intensive and adequatetreatment of depression and physical diseases in depressed olderpersons.REFERENCES1. American Psychiatric Association. Diagnostic and Statistical Manual,3rd edn (DSM-III). Washington, DC: APA.2. Kivelä S-L, Pahkala K, Laippala P. Prevalence of depression in anelderly population in Finland. Acta Psychiat Scand 1988; 78: 401–13.3. Kivelä S-L, Pahkala K, Laippala P. A one-year prognosis ofdysthymic disorder and major depression in old age. Int J GeriatPsychiat 1991; 6: 81–7.4. Kivelä S-L, Ko¨ngäs-Saviaro P, Pahkala K et al. Five-year prognosisfor dysthymic disorder in old age. Int J Geriat Psychiat 1993; 8: 939–47.5. Kivelä S-L. Long-term prognosis of major depression in old age: acomparison with prognosis of dysthymic disorder. Int Psychogeriat1995; suppl 7: 69–82.6. 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