C h o o s i n g Trea t m e n t f o r D e p re s s i o n a n d E v a l u a t i n g Response Patricia A. Arean,
PhD*,
Grace Niu,
PhD
KEYWORDS Late life depression Psychotherapy Targeted treatment Mood disorders Geriatrics KEY POINTS Late life depression (LLD) has devastating social, clinical, and economic consequences. On average, pharmacologic and behavioral interventions are effective for LLD, but many patients have suboptimal response. The choice of treatment of LLD should be informed by patient preferences and suspected underlying causes of the presenting symptoms. Patients with LLD and comorbid executive dysfunction exhibit a brittle response to serotonin-specific reuptake inhibitor medication, but respond very well to targeted behavioral treatment (ie, problem-solving therapy). Future research should continue to investigate subtypes of LLD and develop efficient assessment and treatment tools to target them.
INTRODUCTION Late Life Depression Defined
Late life depression (LLD) is one of the most common psychiatric problems among older adults,1,2 and, overall, it is very similar in presentation to major depression in younger populations. The clinical characteristics of this illness include the following: Depressed mood nearly every day for at least 2 weeks, OR Difficulty fully enjoying pleasant activities (anhedonia) nearly every day for at least 2 weeks.
Funding Sources: National Institute of Mental Health, National Institute of Diabetes and Diseases of the Kidney, and National Institute on Aging (P.A. Arean). National Institute of Mental Health (G. Niu). Funding: National Institute of Health K24 2MH074717; T32 MH01826. Conflict of Interest: None to report. Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA * Corresponding author. E-mail address: [email protected] Clin Geriatr Med - (2014) -–http://dx.doi.org/10.1016/j.cger.2014.04.005 geriatric.theclinics.com 0749-0690/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2
Arean & Niu
To meet criteria for LLD, patients must have at least 1 of the 2 symptoms above and 3 to 4 of the symptoms listed below:
Marked difficulty with sleep, either too little or too much Poor appetite, either too little or too much Trouble concentrating or making decisions Low energy Thoughts of guilt or worthlessness Feeling keyed up and tense or moving more slowly than usual Thoughts of death or suicide.
Contrary to popular wisdom, LLD is less common than major depression in younger cohorts, despite the increased exposure of older persons to adverse life events.2 LLD is associated with several negative consequences, however, making it a very important public health problem to address. LLD has been implicated in the following:
Increased health care costs3 Increased morbidity and mortality4 Greater risk for hospitalization5 Greater risk of death, compared with nondepressed older adults6 High risk for suicide, as older adults are more likely to complete a suicide than any other age group7 More disability leading to greater perceived burden on family members and loved ones (Table 1).8,9
Effects and Effectiveness of Treatment
Effective treatment of LLD results in very positive outcomes. Treatment of depression leads to improved functioning and quality of life10–12 and reduces all-health care costs13–15 and all-cause mortality.6 Although several existing treatments for LLD can have a positive impact on its sequelae, recent field trials have demonstrated that existing interventions may not be as effective in the general population as they are in clinical trials. For example, in the Improving Mood: Access to Collaborative Treatment (IMPACT) trial, less than 50% of older people accessing depression treatment had clinically significant improvement despite having increased access to depression treatment.16,17 Given the significant costs and disability associated with LLD, the treatments must be offered that the physician knows have maximum benefit and the fewest side effects to the general population. The authors suggest that the poorer-than-expected benefits in field trials are largely due to selecting treatments without a full understanding of the determinants involved in their outcomes. This treatment includes heterogeneity in LLD itself that requires suitably tailored treatment choices.
Table 1 Costs of depression and benefits of treatment Costs
Benefits
Increased health care costs
Decreased all-cause health care costs
Greater rate of hospitalization
Greater productivity
Disability
Reduced all-cause mortality
Increased risk of suicide
Improved quality of life
Caregiver disability Caregiver depression risk
Treating Late Life Depression
Research is just beginning to explore how to target treatment of depression based on treatment moderators. Moderators are pretreatment patient characteristics that influence how patients respond to different types of treatments. Thus far, research suggests that clinicians could maximize the potential for good treatment outcome by considering several easily identified clinical characteristics (see Selecting Treatment, below). Furthermore, improvements can be maximized through careful monitoring of treatment outcome and proactive corrective action when treatments fail to be effective (see Data-Driven Decision-Making section). Finally, it is also important to be aware of what treatments are evidence-based and what the limitations are to the evidence base (discussed in next section). EVIDENCE-BASED TREATMENTS REVIEWED
Several effective treatments for LLD exist and include behavioral interventions (eg, psychotherapy), medications, and electroconvulsive therapy (ECT).17–22 The treatments are only slightly modified for older adults, with modifications addressing illness and disease burden, physical disability, and cognitive impairments.23 Recent studies have demonstrated that treating late life mood disorders can offset the impact of the disorder. Older adults who responded to depression treatment lived longer,24 resulting in lower all-cause health costs25 5 years after positive treatment response, compared with older adults who did not respond to treatment. Treatments that are considered to be evidence-based, first-line interventions are most antidepressant medications, specifically serotonin-specific reuptake inhibitor (SSRI) antidepressants (see Mulsant review in this issue), cognitive behavioral therapy (CBT26–28), problem-solving therapy (PST29–36), and interpersonal therapy (IPT37). ECT is generally reserved for patients who fail to respond to antidepressant medication and psychotherapy.38,39 Recent meta-analyses of treatment impact on LLD have revealed interesting insights. One study found that antidepressant medication and psychotherapy had very similar positive effects on LLD.40 Another found that among psychotherapies, IPT seemed to have a slightly larger effect size compared with CBT and PST, but patients given PST are less likely to drop out of treatment.41 Although all interventions have been found to be effective in primary care medicine, only PST has been used successfully in patients with mild dementia,42,43 and as telephone-/Internet-based treatment of LLD.34–36 Despite clinical wisdom that the combination of psychotherapy and medication is the best option, particularly for more moderate depression, there are very few studies demonstrating the added benefit of combined treatments, and the outcomes vary between studies.44 Results from studies that have compared antidepressant medications with psychotherapy and from studies of combined treatments for late-life depression have been mixed. Antidepressants seem to be better than IPT for chronic, recurrent, late-life depression, but CBT appears to be as effective as antidepressants.45,46 Adults with LLD are reluctant to take medications47,48 and may be prone to drug side effects. Both psychotherapy and pharmacotherapy can be offered as long as there are no contraindications and patient preferences should be considered (Table 2). ALTERNATIVE THERAPEUTIC APPROACHES
In addition to evidence-based treatments, there are also less formal behavioral interventions for LLD, including physical exercise, psychoeducation, and other supportive interventions. Although the effects of these interventions vary by the level of depression severity in the sample, presence of comorbid conditions, and the type of control group used, they seem to have beneficial effects on older adults with less severe depression.49
3
4
Arean & Niu
Table 2 Evidence-based treatments and indications Intervention
Treatment
Indications
CBT
12 sessions. Individual and group
LLD; primary care medicine
PST
4–8 sessions. Individual and group
LLD; LLD1ED; primary care medicine; disabled patients; telephone therapy
IPT
12–16 sessions. Individual
LLD; primary care medicine
SSRIs
Citalopram; escitalopram; fluoxetene; paroxetene; sertraline
LLD; primary care medicine, not indicated for LLD1ED
Serotonin–norepinephrine reuptake inhibitors
Venlafaxine, duloxetine, and milnacipran
LLD; primary care medicine
Antipsychotic augmentation
Aripiprazole; quetiapine
LLD
Mirtazapine
Oral tablets
LLD; primary care medicine
Vortioxetine
Oral tablets
LLD; LLD1ED; primary care medicine
ECT
Recurrent treatments
LLD; LLD1psychosis
Psychoeducation and Bibliotherapy
Providing adults with information about depression, related problems, and ways to overcome the constituent symptoms is effective in helping to manage LLD. Intervention formats include lectures, group discussions, and reading materials (bibliotherapy). One study evaluating a self-management program for adults with age-related macular degeneration found that providing 12 hours of health education and problem-solving skills to a group of older adults over the course of 6 weeks led to the improvement in mood and function and increased confidence in coping abilities and aided in the prevention of depression.50 The advantages of bibliotherapy are that it is self-paced, more convenient, less costly and does not have the stigma associated with seeing a mental health professional. Bibliotherapy has also been found to be an effective treatment of depression in older adults.51,52 Physical Exercise
Because physical activity has been suggested to improve core mood symptoms, exercising has been tested as a means of improving depressive symptoms.53 Certain forms of exercise, such as Tai Chi, have been found to reduce all categories of depressive symptoms, including somatic, psychological, and interpersonal relations, and improve overall well-being.54,55 Aerobic exercise also reduces depressive symptoms for adults with low to high symptomatology and leads to longer remission rates over time.56 In some groups of older adults, exercise has been found to be superior to social intervention in the extent of response in symptoms over a period of 10 weeks.57 Supportive Interventions
Supportive interventions include a variety of acts that focus on understanding and supporting an individual’s striving toward coping with distress and are less structured and often led by paraprofessionals.49 There is increasing evidence to suggest that personalized care planning by adequately trained care staff might be an effective intervention for detecting and reducing depression in residential care for older people.58,59 Furthermore, the delivery of secondary preventative interventions to non-mental
Treating Late Life Depression
health professionals has been linked with improving the quality of care to and reducing clinically significant depression in residential settings.60 SELECTING TREATMENT
There are several correlates of response to depression treatment among older adults. Some correlates have clinical utility in selecting treatment, whereas others are important to be aware of, but as of yet cannot inform treatment selection. Discussed here are the correlates that can inform treatment selection and that are easy to measure in a pretreatment clinical interview. Table 3 lists other predictors of outcome. Age
A recent meta-analysis indicated that although antidepressants are effective treatment for older adults, age seems to impact these effects. The older the patient, the less likely there is to be a positive response to treatment. Specifically, studies that have set the bar at a lower age of 65 tend not to find significant differences between medications and placebo.61 This effect has not been found for psychotherapy62 or ECT.63 Executive Dysfunction
Although not listed in the ICD-10 (International Classification of Diseases) or DSM-V (Diagnostic and Statistical Manual), the most prominent subcategory of LLD with Table 3 Correlates of treatment outcome Predictive Value for Treatment Selection
Predictive of Treatment Response in General
Age
Greater age 5 poorer response to Alzheimer’s Disease; behavioral treatment indicated
Late vs early onset
Data are mixed; research finds late onset differs from early,106 but studies find no association for onset and outcomes107
ED
Executive dysfunction 5 poor response to AD; PST indicated
Personality Dx
Data show poor response to all depression treatment107,108
SES
Low SES 5 poor response to all depression treatment; inclusion of case management indicated
Anxiety
Data are mixed; some indication that posttraumatic stress disorder will reduce effect of all treatment109; little evidence that Generalized Anxiety Disorder influences outcome110 Medications have protective effect to prevent depression,111 but inconclusive as an intervention for LLD Caution using antidepressant medications, no clear evidence that any treatment is effective112 Inconclusive, insufficient data available113
Post stroke
Heart disease
Memory impairment
5
6
Arean & Niu
predictive value is Late Life Depression with Executive Dysfunction (LLD1ED).64 LLD1ED is associated with white matter changes on magnetic resonance images (MRIs) of the brain and poor performance on measures of executive functions, cognitive control in particular.65–68 It is estimated that 50% of older adults with major depression have LLD1ED.69 LLD1ED has been characterized as major depression (symptoms described above), with these additional clinical characteristics: Apathy rather than anhedonia; patients with apathy have difficulty initiating pleasant activities, but once they do, they are able to experience pleasure from them Psychomotor slowing Lack of insight into their depression Poor cognitive control as evidenced by simple cognitive tests (eg, Stroop ColorWord Interference Task) (Table 4). CASE VIGNETTE 1: EXAMPLE OF LLD
WITH
EXECUTIVE DYSFUNCTION (CASE COMPOSITE)
Mrs Y is a 70-year-old Caucasian woman who was referred by her primary care provider for decreased mood and difficulty adhering to her heart medications. Before the doctor’s referral, Mrs Y was an active member of her community, but had over the last 6 months dropped all of her activities. A physical examination ruled out any medical reasons for her symptoms. Clinical examination found that Mrs Y had major depression, characterized by sad mood, low energy, sleeping too much, poor appetite (eating too little), feelings of worthlessness, and thoughts of being better off dead. This was her first episode of depression; the only major life event she reported was her 2 adult children returning home to live with her after having lost their jobs. In addition to these symptoms of major depression, Mrs Y also exhibited symptoms of apathy; she had little interest in pursuing pleasant activities, but when her children forced her to go to church or socialize, she reported short-term enjoyment from the activity. She also reported feeling like she was walking through mud during her usual activities and had trouble deciding how to get started on must-do tasks. A brief evaluation of executive dysfunction (eg, Stroop Color-Word Task) revealed a score of 22, indicating mild executive dysfunction.
Several studies have repeatedly found that patients with LLD and ED have a poor and unstable response to SSRI antidepressants, ecitalopram in particular.70–75 However, behavioral interventions that address executive impairment, namely problemsolving treatment, have significantly positive effects on mood and functioning in older adults with LLD and ED.12,43 Assessment of ED is not complex and therefore is an easily identified pretreatment variable that any clinician can measure. The Stroop Color-Word Interference Test is a Table 4 LLD and LLDDED Late Life Depression
LLD with ED
Depression mood 2 wk
Depressed mood 2 wk, may lack insight
Anhedonia
Apathy
Trouble sleeping, too little or too much
Trouble sleeping, often too much
Poor appetite (too little or too much)
Poor appetite (too little or too much)
Trouble concentrating/easily distracted
Easily distracted, difficulty making decisions
Low energy
Low energy, trouble getting started
Feelings of guilt or worthlessness
Feelings of guilt or worthlessness
Keyed up or tense/moving more slowly
Moving more slowly
Thoughts of death or suicide
Thoughts of death or suicide Poor cognitive control (Stroop
PhD*,
Grace Niu,
PhD
KEYWORDS Late life depression Psychotherapy Targeted treatment Mood disorders Geriatrics KEY POINTS Late life depression (LLD) has devastating social, clinical, and economic consequences. On average, pharmacologic and behavioral interventions are effective for LLD, but many patients have suboptimal response. The choice of treatment of LLD should be informed by patient preferences and suspected underlying causes of the presenting symptoms. Patients with LLD and comorbid executive dysfunction exhibit a brittle response to serotonin-specific reuptake inhibitor medication, but respond very well to targeted behavioral treatment (ie, problem-solving therapy). Future research should continue to investigate subtypes of LLD and develop efficient assessment and treatment tools to target them.
INTRODUCTION Late Life Depression Defined
Late life depression (LLD) is one of the most common psychiatric problems among older adults,1,2 and, overall, it is very similar in presentation to major depression in younger populations. The clinical characteristics of this illness include the following: Depressed mood nearly every day for at least 2 weeks, OR Difficulty fully enjoying pleasant activities (anhedonia) nearly every day for at least 2 weeks.
Funding Sources: National Institute of Mental Health, National Institute of Diabetes and Diseases of the Kidney, and National Institute on Aging (P.A. Arean). National Institute of Mental Health (G. Niu). Funding: National Institute of Health K24 2MH074717; T32 MH01826. Conflict of Interest: None to report. Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA * Corresponding author. E-mail address: [email protected] Clin Geriatr Med - (2014) -–http://dx.doi.org/10.1016/j.cger.2014.04.005 geriatric.theclinics.com 0749-0690/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2
Arean & Niu
To meet criteria for LLD, patients must have at least 1 of the 2 symptoms above and 3 to 4 of the symptoms listed below:
Marked difficulty with sleep, either too little or too much Poor appetite, either too little or too much Trouble concentrating or making decisions Low energy Thoughts of guilt or worthlessness Feeling keyed up and tense or moving more slowly than usual Thoughts of death or suicide.
Contrary to popular wisdom, LLD is less common than major depression in younger cohorts, despite the increased exposure of older persons to adverse life events.2 LLD is associated with several negative consequences, however, making it a very important public health problem to address. LLD has been implicated in the following:
Increased health care costs3 Increased morbidity and mortality4 Greater risk for hospitalization5 Greater risk of death, compared with nondepressed older adults6 High risk for suicide, as older adults are more likely to complete a suicide than any other age group7 More disability leading to greater perceived burden on family members and loved ones (Table 1).8,9
Effects and Effectiveness of Treatment
Effective treatment of LLD results in very positive outcomes. Treatment of depression leads to improved functioning and quality of life10–12 and reduces all-health care costs13–15 and all-cause mortality.6 Although several existing treatments for LLD can have a positive impact on its sequelae, recent field trials have demonstrated that existing interventions may not be as effective in the general population as they are in clinical trials. For example, in the Improving Mood: Access to Collaborative Treatment (IMPACT) trial, less than 50% of older people accessing depression treatment had clinically significant improvement despite having increased access to depression treatment.16,17 Given the significant costs and disability associated with LLD, the treatments must be offered that the physician knows have maximum benefit and the fewest side effects to the general population. The authors suggest that the poorer-than-expected benefits in field trials are largely due to selecting treatments without a full understanding of the determinants involved in their outcomes. This treatment includes heterogeneity in LLD itself that requires suitably tailored treatment choices.
Table 1 Costs of depression and benefits of treatment Costs
Benefits
Increased health care costs
Decreased all-cause health care costs
Greater rate of hospitalization
Greater productivity
Disability
Reduced all-cause mortality
Increased risk of suicide
Improved quality of life
Caregiver disability Caregiver depression risk
Treating Late Life Depression
Research is just beginning to explore how to target treatment of depression based on treatment moderators. Moderators are pretreatment patient characteristics that influence how patients respond to different types of treatments. Thus far, research suggests that clinicians could maximize the potential for good treatment outcome by considering several easily identified clinical characteristics (see Selecting Treatment, below). Furthermore, improvements can be maximized through careful monitoring of treatment outcome and proactive corrective action when treatments fail to be effective (see Data-Driven Decision-Making section). Finally, it is also important to be aware of what treatments are evidence-based and what the limitations are to the evidence base (discussed in next section). EVIDENCE-BASED TREATMENTS REVIEWED
Several effective treatments for LLD exist and include behavioral interventions (eg, psychotherapy), medications, and electroconvulsive therapy (ECT).17–22 The treatments are only slightly modified for older adults, with modifications addressing illness and disease burden, physical disability, and cognitive impairments.23 Recent studies have demonstrated that treating late life mood disorders can offset the impact of the disorder. Older adults who responded to depression treatment lived longer,24 resulting in lower all-cause health costs25 5 years after positive treatment response, compared with older adults who did not respond to treatment. Treatments that are considered to be evidence-based, first-line interventions are most antidepressant medications, specifically serotonin-specific reuptake inhibitor (SSRI) antidepressants (see Mulsant review in this issue), cognitive behavioral therapy (CBT26–28), problem-solving therapy (PST29–36), and interpersonal therapy (IPT37). ECT is generally reserved for patients who fail to respond to antidepressant medication and psychotherapy.38,39 Recent meta-analyses of treatment impact on LLD have revealed interesting insights. One study found that antidepressant medication and psychotherapy had very similar positive effects on LLD.40 Another found that among psychotherapies, IPT seemed to have a slightly larger effect size compared with CBT and PST, but patients given PST are less likely to drop out of treatment.41 Although all interventions have been found to be effective in primary care medicine, only PST has been used successfully in patients with mild dementia,42,43 and as telephone-/Internet-based treatment of LLD.34–36 Despite clinical wisdom that the combination of psychotherapy and medication is the best option, particularly for more moderate depression, there are very few studies demonstrating the added benefit of combined treatments, and the outcomes vary between studies.44 Results from studies that have compared antidepressant medications with psychotherapy and from studies of combined treatments for late-life depression have been mixed. Antidepressants seem to be better than IPT for chronic, recurrent, late-life depression, but CBT appears to be as effective as antidepressants.45,46 Adults with LLD are reluctant to take medications47,48 and may be prone to drug side effects. Both psychotherapy and pharmacotherapy can be offered as long as there are no contraindications and patient preferences should be considered (Table 2). ALTERNATIVE THERAPEUTIC APPROACHES
In addition to evidence-based treatments, there are also less formal behavioral interventions for LLD, including physical exercise, psychoeducation, and other supportive interventions. Although the effects of these interventions vary by the level of depression severity in the sample, presence of comorbid conditions, and the type of control group used, they seem to have beneficial effects on older adults with less severe depression.49
3
4
Arean & Niu
Table 2 Evidence-based treatments and indications Intervention
Treatment
Indications
CBT
12 sessions. Individual and group
LLD; primary care medicine
PST
4–8 sessions. Individual and group
LLD; LLD1ED; primary care medicine; disabled patients; telephone therapy
IPT
12–16 sessions. Individual
LLD; primary care medicine
SSRIs
Citalopram; escitalopram; fluoxetene; paroxetene; sertraline
LLD; primary care medicine, not indicated for LLD1ED
Serotonin–norepinephrine reuptake inhibitors
Venlafaxine, duloxetine, and milnacipran
LLD; primary care medicine
Antipsychotic augmentation
Aripiprazole; quetiapine
LLD
Mirtazapine
Oral tablets
LLD; primary care medicine
Vortioxetine
Oral tablets
LLD; LLD1ED; primary care medicine
ECT
Recurrent treatments
LLD; LLD1psychosis
Psychoeducation and Bibliotherapy
Providing adults with information about depression, related problems, and ways to overcome the constituent symptoms is effective in helping to manage LLD. Intervention formats include lectures, group discussions, and reading materials (bibliotherapy). One study evaluating a self-management program for adults with age-related macular degeneration found that providing 12 hours of health education and problem-solving skills to a group of older adults over the course of 6 weeks led to the improvement in mood and function and increased confidence in coping abilities and aided in the prevention of depression.50 The advantages of bibliotherapy are that it is self-paced, more convenient, less costly and does not have the stigma associated with seeing a mental health professional. Bibliotherapy has also been found to be an effective treatment of depression in older adults.51,52 Physical Exercise
Because physical activity has been suggested to improve core mood symptoms, exercising has been tested as a means of improving depressive symptoms.53 Certain forms of exercise, such as Tai Chi, have been found to reduce all categories of depressive symptoms, including somatic, psychological, and interpersonal relations, and improve overall well-being.54,55 Aerobic exercise also reduces depressive symptoms for adults with low to high symptomatology and leads to longer remission rates over time.56 In some groups of older adults, exercise has been found to be superior to social intervention in the extent of response in symptoms over a period of 10 weeks.57 Supportive Interventions
Supportive interventions include a variety of acts that focus on understanding and supporting an individual’s striving toward coping with distress and are less structured and often led by paraprofessionals.49 There is increasing evidence to suggest that personalized care planning by adequately trained care staff might be an effective intervention for detecting and reducing depression in residential care for older people.58,59 Furthermore, the delivery of secondary preventative interventions to non-mental
Treating Late Life Depression
health professionals has been linked with improving the quality of care to and reducing clinically significant depression in residential settings.60 SELECTING TREATMENT
There are several correlates of response to depression treatment among older adults. Some correlates have clinical utility in selecting treatment, whereas others are important to be aware of, but as of yet cannot inform treatment selection. Discussed here are the correlates that can inform treatment selection and that are easy to measure in a pretreatment clinical interview. Table 3 lists other predictors of outcome. Age
A recent meta-analysis indicated that although antidepressants are effective treatment for older adults, age seems to impact these effects. The older the patient, the less likely there is to be a positive response to treatment. Specifically, studies that have set the bar at a lower age of 65 tend not to find significant differences between medications and placebo.61 This effect has not been found for psychotherapy62 or ECT.63 Executive Dysfunction
Although not listed in the ICD-10 (International Classification of Diseases) or DSM-V (Diagnostic and Statistical Manual), the most prominent subcategory of LLD with Table 3 Correlates of treatment outcome Predictive Value for Treatment Selection
Predictive of Treatment Response in General
Age
Greater age 5 poorer response to Alzheimer’s Disease; behavioral treatment indicated
Late vs early onset
Data are mixed; research finds late onset differs from early,106 but studies find no association for onset and outcomes107
ED
Executive dysfunction 5 poor response to AD; PST indicated
Personality Dx
Data show poor response to all depression treatment107,108
SES
Low SES 5 poor response to all depression treatment; inclusion of case management indicated
Anxiety
Data are mixed; some indication that posttraumatic stress disorder will reduce effect of all treatment109; little evidence that Generalized Anxiety Disorder influences outcome110 Medications have protective effect to prevent depression,111 but inconclusive as an intervention for LLD Caution using antidepressant medications, no clear evidence that any treatment is effective112 Inconclusive, insufficient data available113
Post stroke
Heart disease
Memory impairment
5
6
Arean & Niu
predictive value is Late Life Depression with Executive Dysfunction (LLD1ED).64 LLD1ED is associated with white matter changes on magnetic resonance images (MRIs) of the brain and poor performance on measures of executive functions, cognitive control in particular.65–68 It is estimated that 50% of older adults with major depression have LLD1ED.69 LLD1ED has been characterized as major depression (symptoms described above), with these additional clinical characteristics: Apathy rather than anhedonia; patients with apathy have difficulty initiating pleasant activities, but once they do, they are able to experience pleasure from them Psychomotor slowing Lack of insight into their depression Poor cognitive control as evidenced by simple cognitive tests (eg, Stroop ColorWord Interference Task) (Table 4). CASE VIGNETTE 1: EXAMPLE OF LLD
WITH
EXECUTIVE DYSFUNCTION (CASE COMPOSITE)
Mrs Y is a 70-year-old Caucasian woman who was referred by her primary care provider for decreased mood and difficulty adhering to her heart medications. Before the doctor’s referral, Mrs Y was an active member of her community, but had over the last 6 months dropped all of her activities. A physical examination ruled out any medical reasons for her symptoms. Clinical examination found that Mrs Y had major depression, characterized by sad mood, low energy, sleeping too much, poor appetite (eating too little), feelings of worthlessness, and thoughts of being better off dead. This was her first episode of depression; the only major life event she reported was her 2 adult children returning home to live with her after having lost their jobs. In addition to these symptoms of major depression, Mrs Y also exhibited symptoms of apathy; she had little interest in pursuing pleasant activities, but when her children forced her to go to church or socialize, she reported short-term enjoyment from the activity. She also reported feeling like she was walking through mud during her usual activities and had trouble deciding how to get started on must-do tasks. A brief evaluation of executive dysfunction (eg, Stroop Color-Word Task) revealed a score of 22, indicating mild executive dysfunction.
Several studies have repeatedly found that patients with LLD and ED have a poor and unstable response to SSRI antidepressants, ecitalopram in particular.70–75 However, behavioral interventions that address executive impairment, namely problemsolving treatment, have significantly positive effects on mood and functioning in older adults with LLD and ED.12,43 Assessment of ED is not complex and therefore is an easily identified pretreatment variable that any clinician can measure. The Stroop Color-Word Interference Test is a Table 4 LLD and LLDDED Late Life Depression
LLD with ED
Depression mood 2 wk
Depressed mood 2 wk, may lack insight
Anhedonia
Apathy
Trouble sleeping, too little or too much
Trouble sleeping, often too much
Poor appetite (too little or too much)
Poor appetite (too little or too much)
Trouble concentrating/easily distracted
Easily distracted, difficulty making decisions
Low energy
Low energy, trouble getting started
Feelings of guilt or worthlessness
Feelings of guilt or worthlessness
Keyed up or tense/moving more slowly
Moving more slowly
Thoughts of death or suicide
Thoughts of death or suicide Poor cognitive control (Stroop
