RESUMO
OBJECTIVE: This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. METHOD: Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. RESULTS: A principal-components analysis conducted on intake data (N = 82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. CONCLUSIONS: The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.
Assuntos
Luto , Transtorno Depressivo/diagnóstico , Pesar , Viuvez/psicologia , Fatores Etários , Idoso , Atitude Frente a Morte , Comorbidade , Choro , Depressão/diagnóstico , Depressão/epidemiologia , Depressão/psicologia , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/psicologia , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Inventário de Personalidade , Probabilidade , Escalas de Graduação Psiquiátrica , Autoimagem , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/epidemiologia , Estresse Psicológico/diagnóstico , Estresse Psicológico/epidemiologiaRESUMO
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
Our objective was to assess the effects of nortriptyline on electroencephalographic sleep and subjective sleep quality in spousally bereaved, depressed elders. Ten elderly volunteers with bereavement-related major depression had electroencephalographic sleep studies while depressed, after remission of depressive symptoms while still taking nortriptyline, and after nortriptyline discontinuation. Changes in sleep measures over time were compared both within bereaved subjects and with age- and sex-matched healthy controls. Remission of depressive symptoms while still on nortriptyline was associated with improvements in sleep quality (P < .002), rapid eye movement (REM) percent (P < .02), REM latency (P < .05), REM density (P < .05), and delta sleep ratio (P < .05). After discontinuation of nortriptyline, REM percent, REM latency, and delta ratio reverted to pretreatment levels, while sleep efficiency and sleep quality continued to show improvement coincident with sustained clinical remission. These data suggest that nortriptyline may be clinically useful in treating the sleep disturbance of elders with bereavement-related depression and that a double-blind, placebo-controlled, randomized clinical trial is warranted.
Assuntos
Luto , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/psicologia , Nortriptilina/uso terapêutico , Transtornos do Sono-Vigília/etiologia , Idoso , Transtorno Depressivo/diagnóstico , Eletroencefalografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nortriptilina/administração & dosagem , Sono REM , Resultado do TratamentoRESUMO
This study sought to determine possible causal linkages among stressful life events, social rhythms, and levels of depressive symptomatology for 81 elderly subjects (51 recently widowed, 30 healthy controls). We examined the associations among stressful life events (i.e., bereavement status at baseline or a severely threatening event occurring between baseline and followup), social rhythm stability, and the level of depressive symptoms. Results indicated that while stressful life events were not associated with significant changes in social rhythm stability, social rhythm stability was a significant negative correlate of both baseline and followup levels of depressive symptomatology; that is, lower levels of social rhythm stability at baseline were associated with high levels of depressive symptoms at baseline (rho = -0.33, n = 81, p < 0.001) and at followup (rho = -0.23, n = 81, p < 0.05). Bereavement was also a significant positive correlate of depressive symptomatology both at baseline (rho = 0.79, n = 81), p < 0.0001) and at followup (rho = 0.55, n = 81, p < 0.0001). It is likely that future research will benefit from social rhythm assessment obtained temporally closer to major life events and from the use of structured interviews to ascertain the presence of syndromal major depression at followup as well as the inclusion of subjects with a wider range of functional impairments. Nevertheless, these results represent a first step in disentangling possible causal connections among stressful life events, social rhythms, and depressive symptomatology.
Assuntos
Envelhecimento/psicologia , Transtorno Depressivo/psicologia , Acontecimentos que Mudam a Vida , Comportamento Social , Estresse Psicológico/psicologia , Idoso , Luto , Ritmo Circadiano , Feminino , Humanos , Masculino , Apoio SocialRESUMO
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
The metabolic ratios (MRs) between debrisoquine (DBQ) and 4-hydroxydebrisoquine in urine after a single dose of 10 mg DBQ was determined in 175 unmedicated, healthy subjects older than age 59 (mean of 75 years). Creatinine clearance was determined on the same 8-hour urine collection. Test procedures were well tolerated in all cases. Although age was significantly correlated with creatinine clearance (r = -.38), there was no relationship between age and MR. Analysis by kernel density estimation revealed a bimodal distribution of MRs with an antimode of 11.6. Six subjects (3.4%) were categorically slow DBQ metabolizers (MR greater than 11.6). The proportion of elderly slow metabolizers approaches the lower range determined in a younger population. Our findings, that DBQ oxidative metabolism does not necessarily change with aging, alone, and that (genetic) slow DBQ metabolizers endure into old age, remaining at risk for treatment with many commonly used psychotropics, suggests the need to study the relevance of metabolic phenotyping in elderly psychiatric patients.
Assuntos
Debrisoquina/metabolismo , Psicofarmacologia , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/metabolismo , Debrisoquina/urina , Feminino , Humanos , Hidroxilação , Masculino , Pessoa de Meia-Idade , FenótipoRESUMO
BACKGROUND: The aim of this study was to generate preliminary data on the clinical efficacy of nortriptyline in bereavement-related depression in late life. METHODS: Data are presented on 13 patients (5 men, 8 women), ranging in age from 61 to 78 years (mean = 71.1). Mean time from spousal loss to the beginning of treatment was 11.9 months (range 2-25). Subjects were required to meet Research Diagnostic Criteria for syndromal current major depression and to have a stable Hamilton Rating Scale for Depression (HAM-D) score of greater than or equal to 15. Ten of the 13 volunteers were experiencing their first lifetime episode of major depression. Patients were treated with nortriptyline (mean dose = 49.2 mg/day; mean steady-state level = 68.1 ng/mL). Ratings performed at base-line and weekly during therapy were used to assess symptomatology, intensity of grief, level of functioning, social support, physical impairment, and medication side effects. RESULTS: Pretreatment HAM-D ratings average 22.1 +/- 3.6; posttreatment, 7.2 +/- 2.8, representing a 67.9% decrease. All other rating scales showed significant clinical improvement, except the Texas Revised Inventory of Grief (a measure of grief intensity) (pretreatment, 51.4 +/- 7.3; posttreatment, 46.6 +/- 6.9, only a 9.3% decrease). CONCLUSIONS: These results suggest that nortriptyline is associated with significant symptomatic improvement in all areas of bereavement-related depression except continued intensity of grief after a median treatment interval of 6.4 weeks. This study indicates the need for a controlled clinical trial to determine the placebo response rate, the relapse rate after discontinuation of medication, and the value of combination therapy (using both pharmacotherapy and psychotherapy).
Assuntos
Transtorno Depressivo/tratamento farmacológico , Pesar , Nortriptilina/uso terapêutico , Fatores Etários , Idoso , Morte , Transtorno Depressivo/psicologia , Esquema de Medicação , Feminino , Seguimentos , Humanos , Acontecimentos que Mudam a Vida , Masculino , Casamento/psicologia , Pessoa de Meia-Idade , Nortriptilina/administração & dosagem , Nortriptilina/sangue , Inventário de Personalidade , Projetos Piloto , Escalas de Graduação Psiquiátrica , Índice de Gravidade de DoençaRESUMO
Depressive illness with initial onset after age 60 has different clinical and prognostic features compared to depression beginning at a younger age. We evaluated waking electroencephalograms (EEGs) in 61 elderly depressed patients (32 early onset, 29 late onset) without cognitive impairment and not receiving psychotropic medications. The groups were comparable for age, severity of Hamilton depression score, education, and Folstein Mini-Mental State scores. Conventional visual EEG analysis revealed no significant differences in the mean alpha rhythm, incidence of abnormal records, or types of EEG abnormalities. Computerized spectral EEG analysis was also performed in 48 patients (23 early onset, 25 late onset). There were no significant differences in the pooled parasagittal mean frequency, theta--beta difference, combined delta and theta percentage, or relative power of the frequency bands. Thus, waking EEGs do not differentiate between elderly patients with the initial onset of the depression before or after age 60.
Assuntos
Transtorno Depressivo/fisiopatologia , Eletroencefalografia , Vigília/fisiologia , Fatores Etários , Idoso , Córtex Cerebral/fisiopatologia , Demência/diagnóstico , Demência/fisiopatologia , Demência/psicologia , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/psicologia , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Testes de PersonalidadeRESUMO
The effects of a 2-night rapid eye movement (REM) sleep deprivation (RSD) procedure on electroencephalographic sleep and mood were examined in 15 healthy elderly control subjects, 14 elderly patients with endogenous depression, and 15 patients with primary degenerative dementia. Compared with control subjects, both patient groups maintained a higher amount of REM sleep time and REM activity during RSD. Unexpectedly, depressed patients showed little rebound in visually scored or automated REM sleep measures following RSD, and they showed stability of REM activity temporal distribution from baseline to recovery conditions. This contrasted with the rebound in REM sleep activity seen in control subjects, and the more modest increase in demented patients. The RSD was fairly specific, with some impact on delta sleep during the procedure but not during recovery sleep. Mood ratings were unaffected by RSD. These findings demonstrated a greater plasticity of REM sleep regulation in the healthy elderly control subjects and suggested a higher REM "pressure" with a "ceiling effect" in depressed patients. Patients with dementia appeared to have an impaired capacity to respond to the challenge of RSD.
Assuntos
Doença de Alzheimer/fisiopatologia , Transtorno Depressivo/fisiopatologia , Eletroencefalografia , Privação do Sono , Sono REM/fisiologia , Afeto/fisiologia , Idoso , Envelhecimento/fisiologia , Doença de Alzheimer/diagnóstico , Doença de Alzheimer/psicologia , Ritmo Circadiano , Ritmo Delta , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/psicologia , Feminino , Humanos , Masculino , Escalas de Graduação Psiquiátrica , Sono/fisiologia , Vigília/fisiologiaRESUMO
Nocturnal penile tumescence (NPT) studies were evaluated in 17 men with a clinical diagnosis of organic erectile dysfunction in comparison to age-matched healthy controls (n = 17) and depressed men (n = 17). The dysfunctional group had significantly fewer NPT episodes and reduced maximal penile tip changes when compared to healthy controls and depressed patients. Further, the dysfunctional group had significantly diminished erectile fullness and reduced penile rigidity. Diagnostic performance of polygraphic (night 1) and visual inspection (nights 2 or 3) components of the NPT protocol were examined in these criterion groups. A diagnostic classification based on polygraphic measures successfully discriminated 73.5% of dysfunctional and healthy control subjects, but classified 47% of depressives in the dysfunctional range. Use of visual inspection indices correctly identified 88% of the dysfunctional sample and 94% of normal controls, and reduced the "false-positive" rate in depression to only 18%. Results support the diagnostic utility of NPT studies, particularly when enhanced by visual inspection procedures. Nevertheless, the presence of major depression may confound interpretation of such studies.