RESUMO
OBJECTIVE: The purpose of this study was to determine treatment outcome in elderly patients with consecutively treated episodes of recurrent unipolar major depression. METHOD: Subjects were 32 "young" elderly patients with recurrent unipolar depression (mean age = 66.8 years, SD = 5.1) and with two consecutively treated episodes of major depression. Both index and subsequent episodes of major depression were treated in open trial with combined nortriptyline and interpersonal psychotherapy. Rates of remission in index and subsequent episodes were compared by using nonparametric statistics and survival analysis with proportional hazards modeling. RESULTS: Of 30 patients who completed treatment of the subsequent episode, 27 (90%) achieved stable remission of symptoms in both consecutively treated episodes, whereas three patients (10%) did not. Twenty-two (81%) of 27 patients who responded to treatment had a shorter time to remission in treatment of the subsequent episode than in the index episode. Survival analysis with proportional hazards modeling detected a significant difference in time to remission of the index and subsequent episodes (32 paired observations). CONCLUSIONS: In this research study group, recurrent episodes of unipolar major depression in the young elderly were successfully treated to remission in over 80% of patients by using combined pharmacotherapy and psychotherapy similar to that employed in treatment of the index episode. Remission rate and time to remission in consecutively treated episodes were comparable to those in a group of midlife patients with recurrent depression reported by Kupfer et al. in 1989. Thus, recurrent depressive disorder appears to be as treatable in the young elderly as it is in midlife patients.
Assuntos
Transtorno Depressivo/terapia , Fatores Etários , Idoso , Terapia Combinada , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nortriptilina/uso terapêutico , Modelos de Riscos Proporcionais , Psicoterapia , Recidiva , Análise de Sobrevida , Resultado do TratamentoRESUMO
The relation between hopelessness and suicide attempts in the elderly was examined by studying the course of hopelessness in depressed patients. Sixty-three elderly patients with recurrent major depression were treated with nortriptyline and interpersonal psychotherapy and underwent serial ratings of hopelessness and depression during the acute and continuation phases of treatment. Patients who had made a suicide attempt in the past had significantly higher hopelessness scores than nonattempters during both phases of treatment. They were also more likely to drop out of treatment. A high degree of hopelessness persisting after remission of depression in elderly patients appears to be associated with a history of suicidal behavior. It may also increase the likelihood of premature discontinuation of treatment and lead to future suicide attempts or suicide.
Assuntos
Transtorno Depressivo/psicologia , Nortriptilina/uso terapêutico , Escalas de Graduação Psiquiátrica , Psicoterapia , Tentativa de Suicídio/estatística & dados numéricos , Fatores Etários , Idoso , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/terapia , Feminino , Seguimentos , Avaliação Geriátrica , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Recidiva , Suicídio/estatística & dados numéricos , Tentativa de Suicídio/psicologiaRESUMO
Among 547 elderly inpatients grouped by DSM-III-R axis I diagnoses, the diagnostic rate of comorbid personality disorder varied four-fold, from 6% in patients with an organic mental disorder to 24% in those with major depression. The previously reported low prevalence of comorbid personality disorder in geriatric patients may be due to its lower rate of diagnosis among patients with organic mental disorders.
Assuntos
Transtornos Mentais/epidemiologia , Transtornos da Personalidade/epidemiologia , Idoso , Comorbidade , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/epidemiologia , Feminino , Avaliação Geriátrica , Hospitalização , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Neurocognitivos/diagnóstico , Transtornos Neurocognitivos/epidemiologia , Transtornos da Personalidade/diagnóstico , PrevalênciaRESUMO
OBJECTIVE: The authors examined the rate of response to the combination of nortriptyline and interpersonal psychotherapy for acute and continuation treatment of elderly patients with recurrent major depression. METHOD: The subjects were 73 elderly patients, 61 of whom completed treatment. Nortriptyline steady-state blood levels were maintained at 80-120 ng/ml, and interpersonal psychotherapy was administered weekly for 9.1 weeks (medium) of acute therapy and was decreased from biweekly to triweekly during 16 weeks of continuation therapy. During acute treatment nonresponding patients also received brief adjunctive pharmacotherapy with lithium or perphenazine. RESULTS: Of the 61 subjects given adequate trials of nortriptyline and interpersonal psychotherapy, 48 (78.7%) achieved full remission (Hamilton depression rating of 10 or lower over 16 weeks of continuation therapy), 10 patients (16.4%) did not respond (Hamilton rating never below 15), and three achieved only partial remission (Hamilton rating of 11-14). Early versus late onset was not associated with a difference in response rate. During the placebo-controlled, double-blind transition to maintenance therapy, 19 (76.0%) of the 25 patients randomly assigned to placebo maintenance conditions showed continued recovery and six relapsed. None of the 24 patients assigned to nortriptyline conditions relapsed. CONCLUSIONS: Use of nortriptyline plus interpersonal psychotherapy for 9.1 weeks (median) of acute and 16 weeks of continuation therapy appears to be associated with good response and relatively low attrition but about a 25% chance of relapse during double-blind discontinuation of nortriptyline. These data require confirmation in a controlled clinical trial of acute and continuation therapy.
Assuntos
Transtorno Depressivo/terapia , Nortriptilina/uso terapêutico , Psicoterapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Terapia Combinada , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/psicologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento , Placebos , Escalas de Graduação Psiquiátrica , RecidivaRESUMO
OBJECTIVE: The authors conducted a prospective study of the clinical utility of the four DSM-III-R subtypes of primary degenerative dementia of the Alzheimer type (with delirium, with delusions, with depression, or uncomplicated) and acute psychiatric hospitalization for treatment of these subtypes. METHOD: The subjects were 120 consecutive inpatients with Alzheimer's disease, most of whom had behavioral abnormalities. Each subject received detailed physical, neurological, psychiatric, and mental status examinations. The presence or absence of specific behavioral problems was also documented. Patients were treated with medication, psychotherapy, and behavioral techniques. RESULTS: While all patients could be assigned to one of the four DSM-III-R behavioral subtypes, the uncomplicated subtype did not accurately reflect the burden of behavioral symptoms in the patients who did not have delirium, delusions, or depression. Each behavioral subtype responded in a characteristic way to inpatient treatment, as reflected by changes in scores on four psychometric scales used to assess cognitive impairment, psychiatric symptoms severity, and level of functioning at admission and at discharge, as well as by changes in residential setting following hospitalization. Half of all patients admitted from their homes and two-thirds of those with depression were able to go home following discharge. CONCLUSIONS: Behavioral syndromes in Alzheimer's disease should not be overlooked, because they have both clinical and prognostic significance. Short-term psychiatric hospitalization is effective and efficient for achieving the goal of returning patients to their homes and for safely implementing specific treatments in this frail population, and it may reduce the need for institutionalization.
Assuntos
Doença de Alzheimer/diagnóstico , Hospitalização , Transtornos Mentais/diagnóstico , Idoso , Doença de Alzheimer/classificação , Doença de Alzheimer/terapia , Antipsicóticos/uso terapêutico , Terapia Comportamental , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/terapia , Delírio/diagnóstico , Delírio/terapia , Delusões/diagnóstico , Delusões/terapia , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/terapia , Feminino , Idoso Fragilizado/psicologia , Humanos , Institucionalização , Masculino , Transtornos Mentais/terapia , Prognóstico , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Psicoterapia , Índice de Gravidade de DoençaRESUMO
Reliable quantitative ratings of chronic medical illness burden have proved to be difficult in geropsychiatric practice and research. Thus, the purpose of the study was to demonstrate the feasibility and reliability of a modified version of the Cumulative Illness Rating Scale (CIRS; Linn et al., 1968) in providing quantitative ratings of chronic illness burden. The modified CIRS was operationalized with a manual of guidelines geared toward the geriatric patient and for clarity was designated the CIRS(G). A total of 141 elderly outpatient subjects (two medical clinic groups of 20 each, 45 recurrent depressed subjects, 21 spousally bereaved subjects, and 35 healthy controls) received comprehensive physical examinations, reviews of symptoms, and laboratory testing. These data were then used by nurse practitioners, physician's assistants, and geriatric psychiatrists to compute CIRS(G) ratings of chronic illness burden. As hypothesized, analysis of variance demonstrated significant differences among groups with respect to total medical illness burden, which was highest among medical clinic patients and lowest in control subjects. Good interrater reliability (i.e., intraclass correlations of 0.78 and 0.88 in a subsample of 10 outpatients and a separate group of 10 inpatients, respectively) was achieved for CIRS(G) total scores. Among medical clinic patients, a significant correlation was found, as expected, between CIRS(G) chronic illness burden and capability as quantified by the Older Americans Activities of Daily Living Scale; and between CIRS(G) scores and physicians' global estimates of medical burden. Finally, with repeated measures of illness burden approximately 1 year from symptom baseline, significant rises were detected, as expected. The current data suggest that the CIRS(G) can be successfully applied in medically and psychiatrically impaired elderly subjects, with good interrater reliability and face validity (credibility).
Assuntos
Doença Crônica/psicologia , Transtorno Depressivo/diagnóstico , Inventário de Personalidade/estatística & dados numéricos , Papel do Doente , Atividades Cotidianas/psicologia , Idoso , Transtorno Depressivo/psicologia , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , PsicometriaRESUMO
We found increased age (p = 0.001) and history or evidence of stroke (p = 0.016) to be significant independent multivariate predictors of the presence and severity of leukoencephalopathy on magnetic resonance imaging brain scans in a mixed population of 35 elderly psychiatric patients and 25 neurologically healthy elderly volunteers. These results suggest that subcortical ischemia, as well as age-related changes that may not be vascular in origin, contribute to the emergence of periventricular and other deep white matter hyperintensities that are commonly seen on the magnetic resonance imaging brain scans of older adults.