|Year : 2015 | Volume
| Issue : 2 | Page : 96-101
Short-term course and outcome of late-life depression
Shrikant Srivastava1, Ambrish Kumar2, Hitesh Khurana1, Sarvada Chand Tiwari1, Shamsi Akbar1
1 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Psychiatry, Pandit BD Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
|Date of Web Publication||18-Jan-2016|
Department of Geriatric Mental Health, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Despite a plethora of prevalence studies, research on the course and outcome of late-life depression (LLD) have received little attention in India. Thus, the present study was undertaken to explore the course and outcome of LLD.
Materials and Methods: A retrospective case note review of outpatient clinic was undertaken. Only those patients having completed the baseline Mini-Mental State Examination (MMSE) and Hamilton Rating Scale for Depression (HAMD) on the first visit were included in the study. Other relevant information was collected from the case notes.
Results: Forty-eight patients fulfilled the selection criteria. The mean age of the sample was 67.3 years, with male preponderance (72%). There was no significant difference in demographic variables between genders, urban/rural domicile, and early/late onset depression (EOD/LOD). The EOD and LOD cases (cut-off age 60 years for the groups) were similar except that the former had more severe illness and longer duration of untreated illness at the baseline. Sixty-five percent patients (n = 31) attended at least one follow-up visit. The mean intervals of the first, second, and third follow-up visits were 3.7 ± 5.1 weeks, 5.1 ± 4.5 weeks, and 8.4 ± 5.7 weeks, and >50% improvement on HAMD was noted in 19%, 21% and 21% patients respectively. However, those who responded at earlier times either dropped out or showed recrudescence of symptoms. While those who responded at later times maintained the benefit.
Conclusions: This is the first study to look at short-term outcome of LLD in India. The response rates were low and patients showed a fluctuating degree of improvement.
Keywords: Early onset depression (EOD), elderly, India, late life depression (LLD), late onset depression (LOD), outcome
|How to cite this article:|
Srivastava S, Kumar A, Khurana H, Tiwari SC, Akbar S. Short-term course and outcome of late-life depression. J Geriatr Ment Health 2015;2:96-101
|How to cite this URL:|
Srivastava S, Kumar A, Khurana H, Tiwari SC, Akbar S. Short-term course and outcome of late-life depression. J Geriatr Ment Health [serial online] 2015 [cited 2019 Nov 19];2:96-101. Available from: http://www.jgmh.org/text.asp?2015/2/2/96/174275
| Introduction|| |
Any depressive syndrome persisting or occurring at the age of 60-65 years is generally considered late life depression (LLD).  Major depressive episodes are seen in 2-3% of elderly, whereas depressive symptoms and minor depressive episodes are present in 12-15% of the elderly population,  which in most cases remain undiagnosed and untreated.  The importance of early recognition and adequate treatment lies in the fact that LLD has been associated with the increase in all causes mortality and disability. 
LLD has been traditionally divided in early- and late-onset categories, depending on the age of onset of the first episode. Early onset depression (EOD) is when the first episode of depression has been before the age of 60 years, and subsequent episodes may be precipitated after 60 years age, whereas late onset depression (LOD) is when the first ever episode of the illness occurs after the age of 60 years. This division is not based on differences in the etiology,  phenomenology,  and the course and outcome of depression. ,, In a case controlled magnetic resonance imaging (MRI) study of LLD and healthy controls, the presence of cerebral microbleeds was an independent risk factor, which also correlated well with the severity of the symptoms.  In 71 patients with EOD and 60 age-matched LOD controls, it was noticed that EOD is prominently characterized by low spirits and ideas of worthlessness.  Fiske et al. in a narrative review concluded that LOD is more likely to have cognitive and somatic symptoms. Complex genetic vulnerabilities and cognitive predisposition along with age associated neurobiological changes makes LOD a unique entity in itself.  In a 4 year follow-up study of 65 patients with EOD and 70 patients with LOD, it was noticed that patients with EOD group had more depressive symptoms, suicidal ideations, and residual depressive symptoms, and slower loss of right hippocampal volume on magnetic resonance neuroimaging than the LOD counterparts. On the contrary, the LOD group had more cognitive and neurological symptoms in absence of dementia.  However, this distinction between EOD and LOD has not gained unanimous support. 
Episodes of depression occurring at a late age are usually long (mean duration 18 weeks) and only 35% patients recover during the first year.  Factors associated with poor prognosis in LLD include high severity of symptoms at onset, past history and/or family history of depression, and functional impairment. Medical comorbidity and psychosocial stressors, often of multiple nature, also relate to poor prognosis, as does poor physical health. 
Studies on LLD in India have mainly focused on prevalence rates in the community - both in urban  and rural  or in specific population  or on psychosocial aspects. , The reported prevalence rates are between 6%  and 52%.  This wide variation is related to sampling technique and the instruments used to measure the presence of depression. More recent epidemiological surveys have reported the prevalence rates between 20% to 25%.  In the only other longitudinal study on LLD published till date from India, at 12 months follow-up,  recovery rates were 28%, and having a shorter duration of illness (DoI) and living in joint family were factors related to recovery.
Thus, the literature on the longitudinal course and prognosis of LLD is sparse, especially data on Indian patients. Hence, the present chart review presents an overview of the data collected in a clinical setting. The aim was to study the course and outcome of LLD in those presenting to a tertiary care clinic.
| Materials and methods|| |
Our study was based on a patient chart review. The study was conducted at the Department of Geriatric Mental Health, King George's Medical University, Lucknow, India.
The patients attending the Geriatric Mental Health outpatient clinic undergo a routine diagnostic workup. The diagnosis based on ICD-10 (Blue Book), recorded in the notes, is made by the consultant of the outpatient clinic. Only those patients having baseline evaluation on mini-mental state examination (MMSE) and Hamilton Rating Scale for Depression (HAMD) were included in the study. All evaluations on MMSE and HAMD were done by a trained social worker (AK) or a psychologist (SA).
Following information was extracted from the case notes:
- Duration of Illness (DoI): This is the period from the time of onset of first episode to the time of presentation in the clinic.
- Duration of untreated illness (DUI): Related to the current episode, and is the period from the onset of the index episode to the time of presentation to the clinic
- Past number of episodes - both mania and depression.
- Response to medication(s) was defined as decrease in HAMD score by 50% or more from the baseline.
- Remission was defined as HAMD score <8.
- Severity of depression as rated on HAMD.
- Geographical distance from the hospital. To see if it affected the illness variables, the geographical distance between the hospital and the patient's village/town was calculated from the Google Maps as the distance travelled by road.
Successful treatment of an episode was considered if the remission was maintained for at least 3 months. The cut-off age for delineating EOD and LOD was 60 years at the time of first presentation to the clinic.
Descriptive statistics such as frequencies and percentages were calculated using MS Excel 2007, and inferential statistics such as independent sample "t" test (two tailed), and Spearman correlational analysis were carried out on SPSS.
| Results|| |
The sample of 48 depressed patients was divided into two groups - early onset (EOD) and late onset (LOD) groups [Table 1]. There were no statistically significant differences between genders or domicile (urban/rural) in any of the illness parameters studied, except that the females, as compared to males, had significantly lower scores on MMSE (18.77 ± 5.7, 26.1 ± 3.8, t = 5.062, df = 43, P < .001). Two of the patients had a prior manic episode, while the rest were of recurrent depression. The severity of illness on HAMD was significantly more in EOD group, and the DUI was also longer in the EOD group, but not statistically significant (t = 1.887, df = 23.03, P = .072). There was a positive correlation between the distance from hospital and HAMD scores (rho = 0.508, P < 0.01).
The follow-up groups
Seventeen patients (35.4%) attended only on the first visit group (FV). This group did not differ from repeat visit group (RV) (those who attended for at least 1 follow-up appointment) group on age (68 vs 66 years), DoI (102 months for each), DUI (21 months for each), domicile (urban 10 vs 13)/rural 7 vs 18), distance from the hospital (55 km vs 58 km) or gender (males 11 vs 23, females 6 vs 8), respectively. Only number of previous episodes were less in FV group as compared to the RV group (means of 0.71 and 2.17, t = -2.012, P = .051). The RV group (N = 31) was studied further for progress during treatment.
The follow-up appointments were given ranging from 1 to 4 weeks, depending on the severity of the illness, medication(s) prescribed, and patient factors such as distance to the hospital and availability of the caregiver. For some patients, owing to personal reasons, the longer inter-visit interval was advised. For the patients who attended later than the advised follow-up period, it was assumed that they had continued the prescribed medication(s), unless it was stated otherwise in the case notes. Thus, the mean intervals of the first, second, and third follow-up visits for all the patients were 3.7 ± 5.1 weeks, 5.1 ± 4.5 weeks, and 8.4 ± 5.7 weeks, respectively. A total of 95 visits for these 31 patients were recorded.
The diagnosis was revised to mild cognitive impairment on the third visit in one patient, and he was excluded from the analysis. Another patient switched to mania within two weeks of therapy with sertraline (100 mg) and quetiapine (50 mg). In 2 patients, no antidepressants were prescribed, and baseline investigations showed the serum B12 levels were in the lower side of the normal range. Both patients improved substantially in two weeks with parenteral vitamin B12 supplementation.
Medications and progress
All patients were prescribed standard antidepressant medication on the first visit [Table 2]. The doses were gradually increased, if required, till a desired response was obtained, or if side effects appeared.
The mean HAMD scores reduced through the follow-up periods [Figure 1]. The response and remission rates at 1 st , 2 nd and 3 rd visits were 6%, 0 and 7%, and 13%, 21% and 14%, respectively. A total of nine patients showed at least 50% in the HAMD scores some point in time [Table 3]. At all the 3 follow-up point, five patients did not achieve response or remission, and thus were considered treatment resistant.
| Discussion|| |
This is a case note review study, hence it has limitations of incomplete reporting and recording of information and lack of standardized diagnostic tools. The sample selected was limited by completed evaluations on the first visit in the case notes. Given the nature of work of making formal assessments in an outpatient clinic of government hospital, where the assessor and patients both are limited on time, some assessments may have been missed. Added to that, some older adults are not able to understand the instructions for completing MMSE for reasons of poor eyesight or hearing, or both. Also, as this is a description of pattern of follow-up, we have kept the statistical analysis to minimum.
There were no differences in illness characteristics between the male and female patients. The male preponderance in the sample is probably, as reported in other Indian studies, due to the fact that males being bread earners of the family are generally given more attention as compared to their female counterparts. Also the moderate correlation between baseline HAMD scores and distance from the hospital (rho = 0.508, P < 0.01) indicated that those living further away, seek treatment when the illness becomes more severe, which is possible given the financial constraints in the Indian setup.
The EOD group had longer duration of illness and higher number of episodes, compared to the LOD group. This was owing to earlier onset of the illness in the fifth decade of life. In the former group, six patients had onset of illness before age of 60 years, but they sought treatment after a long period of time when their ages were above 60 years. This confusing finding is due to the arbitrariness of defining a fixed cut-off age between EOD and LOD, which in the literature is described between 55  and 65 years. 
There was a continuous decline in the HAM-D scores with time. Overall 29% showed response or remission at any point during the follow-up phase. Those who achieved response or remission on the first follow-up visit either failed to attend the subsequent appointments or had recrudescence of symptoms. We have termed increase of symptoms as recrudescence, rather than relapse, as the latter has been defined as worsening of symptoms only after two consecutive follow-up visits. This fluctuating course of LLD has also been described by Beekman et al.  It is quite likely that at later age due to many other cerebral anatomical changes and physical morbidities, the remission achieved is not stable.
For the dropouts, there are various possible explanations. As the availability of medication is not very well regulated, those who responded well may be procuring medications without consultation On the other hand, it is also possible that these patients, having received no benefit from the prescribed medicines, were seeking treatment elsewhere.
Major depression in older persons over longer periods exhibits a chronic remitting course in most studies.  In a 6-year follow-up of community dwelling older adults  among those with clinically significant depressive symptoms, 23% remitted, 44% had an unfavorable outcome but fluctuating course, and 33% didn't show any improvement in their symptoms; among those with subthreshold symptoms, 25% experienced a chronic course. Overall, 35% of the subjects of major depression and 52% of the dysthymia experienced a chronic course. In another study, only 31% recovered and remained well, 28% suffered at least one relapse, 23% of the subjects recovered partially, and 17% remained depressed throughout the follow-up.  Murphy  found that among elderly depressed patients including those with medical comorbidity and followed for 1 year, 35% had good outcome, 48% had either fluctuating course or remained continuously ill, 3% developed dementia, and 14% died.
Treatment studies on LLD also indicate poor response rates. Netherlands Study on Depression in Older Persons (NESDO) reported that despite guidelines-based treatment, LLD runs a chronic course and physical morbidity may add to the complexity of outcome.  A meta-analysis showed only moderate effect size of psychotherapeutic and pharmacological interventions, both treatment modalities being equally effective. 
| Conclusion|| |
To conclude the findings of this study suggest that LLD is generally marked with overall poor outcome. The improvement in symptoms seen at early stage may not be sustained, for which clinician needs to be watchful. There is also a need for trained manpower in rural areas so that patients can seek professional consultation earlier in the course of the illness, as well as continue having treatment for adequate periods under proper supervision.
The authors are thankful to Prof SK Mattoo, Department of Psychiatry, Post-Graduate Institute of Medical Education and Research, Chandigarh, for his constructive commentary on this paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]