Depression: Reynolds CF

Alexopoulos GS, Katz IR, Reynolds CF, Carpenter D, Docherty JP, Anonymous00334. · No affiliation provided · Postgrad Med. · Pubmed #17205639 No free full text.

Abstract: OBJECTIVES: Depression in older patients contributes to personal suffering and family disruption and increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. The majority of clinical trials of antidepressant treatments are conducted in younger patients. For this reason, clinicians often have to extrapolate from studies in populations that do not present the same problems as older patients. For example, older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment. Older patients as a rule need to be on many medications, some of which may contribute to depression and/or interact with antidepressants. Finally, older adults metabolize medications slowly and are more sensitive to side effects than younger patients. Because of these complexities, we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature. METHOD: After reviewing the literature and convening a work group of experts, we prepared a written survey with 64 questions that asked about 857 options. 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For the other options, the experts were asked to write in answers (e.g., average doses) or to check a box to indicate their preferred answer. We sent the survey to 50 national experts on geriatric depression, all of whom completed it. Consensus on each option was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred choice, second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on 89% of the options rated on the 9-point scale. The experts stress the importance of identifying coexisting medical conditions that may be contributing to the depression or complicate treatment. For unipolar nonpsychotic major depression, the preferred strategy is an antidepressant (selective serotonin reuptake inhibitor [SSRI] or venlafaxine XR preferred) plus psychotherapy. For unipolar psychotic major depression, the treatment of choice is an antidepressant (SSRI or venlafaxine XR) plus one of the newer atypical antipsychotics. Electroconvulsive therapy is also first line. For dysthymic disorder or persistent milder depression, the experts recommend combining an antidepressant (SSRIs preferred) and psychotherapy. If the patient has a comorbid medical condition (e.g., hypothyroidism) that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression. Among them, the experts gave the highest ratings for efficacy and tolerability to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also give strong support to including appropriate psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in the treatment program. The majority of experts would continue treatment with antidepressant medication for at least 1 year if a patient has had a single episode of severe unipolar major depression, for 1-3 years for a patient who has had 2 such episodes, and for longer than 3 years if there is a history of 3 or more episodes. CONCLUSIONS: The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas in older individuals. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Nonetheless, the guidelines cannot address the complexities involved in the care of each individual patient and can be most helpful in the hands of experienced clinicians.

Reynolds CF, Clayton PJ. · Geriatric Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. · Acad Med. · Pubmed #19174657 No free full text.

Abstract: In this commentary, the authors reinforce the call to action made in the accompanying reports by Goebert et al and Dunn et al. Depression among medical students and residents is a continuing and worrisome phenomenon; its chronic nature has long-term and compounding effects on trainees. Yet, barriers exist to appropriate care seeking, such as inadequate education about causes, effects, and treatment; unwillingness to take the needed time; limited financial resources to pay for care; and concerns over confidentiality, stigma, or adverse effects on residency application or licensability. Each of these barriers, the authors contend, can be circumvented. Moreover, given the cost of unrecognized or untreated depression among the health care workforce, removal of the barriers reflects both moral and practical necessities. The authors discuss successful prevention and treatment plans at some medical schools and academic health centers (AHCs), as well as initiatives by the American Foundation for Suicide Prevention geared specifically to the nation's medical trainees and physicians. Finally, strong leadership is encouraged in order to remove the barriers to recognizing and treating depression and to change the culture of medicine that contributes to and/or stigmatizes depression among its members.The authors outline the chronic nature of depression and discuss its possibility for long-term impacts on trainees. Given these conditions, the leadership of the nation's schools of medicine and AHCs.

Reynolds CF. · No affiliation provided · Am J Geriatr Psychiatry. · Pubmed #18515686 No free full text.

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Reynolds CF, Cruz M, Teh CF, Rollman BL. · No affiliation provided · J Am Geriatr Soc. · Pubmed #18081675 No free full text.

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Harman JS, Reynolds CF. · No affiliation provided · J Am Geriatr Soc. · Pubmed #10968310 No free full text.

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Rollman BL, Reynolds CF. · No affiliation provided · J Am Geriatr Soc. · Pubmed #10366181 No free full text.

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Reynolds CF, Buysse DJ, Kupfer DJ. · No affiliation provided · JAMA. · Pubmed #10086440 No free full text.

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Lenze EJ, Sheffrin M, Driscoll HC, Mulsant BH, Pollock BG, Dew MA, Lotrich F, Devlin B, Bies R, Reynolds CF. · Washington University School of Medicine, Department of Psychiatry, St Louis, MO, USA. · Dialogues Clin Neurosci. · Pubmed #19170399 No free full text.

Abstract: Incomplete response in the treatment of late-life depression is a large public health challenge: at least 50% of older people fail to respond adequately to first-line antidepressant pharmacotherapy, even under optimal treatment conditions. Treatment-resistant late-life depression (TRLLD) increases risk for early relapse, undermines adherence to treatment for coexisting medical disorders, amplifies disability and cognitive impairment, imposes greater burden on family caregivers, and increases the risk for early mortality, including suicide. Getting to and sustaining remission is the primary goal of treatment, yet there is a paucity of empirical data on how best to manage TRLLD. A pilot study by our group on aripiprazole augmentation in 24 incomplete responders to sequential SSRI and SRNI pharmacotherapy found that 50% remitted over 12 weeks with the addition of aripiprazole, and that remission was sustained in all participants during 6 months of continuation treatment. In addition to controlled assessment, evidence is needed to support personalized treatment by testing the moderating role of clinical (e.g., comorbid anxiety, medical burden, and executive impairment) and genetic (eg, selected polymorphisms in serotonin, norepinephrine, and dopamine genes) variables, while also controlling for variability in drug exposure. Such studies may advance us toward the goal of personalized treatment in late-life depression.

Butters MA, Young JB, Lopez O, Aizenstein HJ, Mulsant BH, Reynolds CF, DeKosky ST, Becker JT. · Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania, USA. · Dialogues Clin Neurosci. · Pubmed #18979948 No free full text.

Abstract: There is a strong association between late-life depression, cognitive impairment, cerebrovascular disease, and poor cognitive outcomes, including progressive dementia, especially Alzheimer's disease. While neuroimaging evidence suggests that cerebrovascular disease plays a prominent role, it seems that depression alone may also confer substantial risk for developing Alzheimer's disease. The relationships between the prominent cerebrovascular changes, other structural abnormalities, specific forms of cognitive dysfunction, and increased risk for developing Alzheimer's disease among those with late-life depression have been difficult to reconcile. The varied findings suggest that there are likely multiple pathways to poor cognitive outcomes. We present a framework outlining multiple, non-mutually exclusive etiologic links between depression, cognitive impairment, and progressive decline, including dementia. Importantly, the model is both testable and falsifiable. Going forward, using models such as this to inform research should accelerate knowledge acquisition on the depression/dementia relationship that may be useful for dementia prevention, monitoring the impact of depression treatment on clinical status and course of illness.

Rajji TK, Mulsant BH, Lotrich FE, Lokker C, Reynolds CF. · Department of Psychiatry, University of Toronto, Geriatric Mental Health Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada. · Drugs Aging. · Pubmed #18808208 No free full text.

Abstract: Late-life depression (LLD) is a common and typically recurrent illness that is often unrecognized and under-treated. It is associated with significant co-morbidities and poor health outcomes. Antidepressants are typically used as a first-line treatment for LLD. We performed a systematic review of the English literature (1996 to August 2007) and present results relevant to the efficacy of antidepressants in acute and maintenance pharmacotherapy of LLD, the predictors of LLD treatment outcomes and pharmacological strategies for non-remission. There is a consensus in the literature that the goal of treatment should be remission. Although antidepressants can be categorized into several classes based on their putative mechanisms of action, there is no consistent evidence that antidepressants from different classes are associated with different rates of remission of LLD. After achieving remission, the evidence supports a beneficial role of maintenance pharmacotherapy in reducing the rate of recurrence of LLD for at least 2 years. There are reports of a number of possible augmentation and switching strategies that can be used when LLD remission is not attained. However, none of these various strategies has been studied rigorously in patients with LLD as yet. Overall, the current literature is adequate for guiding acute and maintenance pharmacotherapy of LLD but further research is urgently needed to guide clinical strategies in non-remission.

Driscoll HC, Karp JF, Dew MA, Reynolds CF. · Advanced Center for Interventions and Services Research for Late-Life Mood Disorders, and the John A. Hartford Center for Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. · Drugs Aging. · Pubmed #17896830 No free full text.

Abstract: In general, the pharmacological treatment of non-psychotic major depressive disorder in old age is only partially successful, with only approximately 50% of older depressed adults improving with initial antidepressant monotherapy. Many factors may predict a more difficult-to-treat depression, including coexisting anxiety, low self-esteem, poor sleep and a high coexisting medical burden. Being aware of these and other predictors of a difficult-to-treat depression gives the clinician more reasonable expectations about a patient's likely treatment course. If an initial antidepressant trial fails, the clinician has two pharmacological options: switch or augment/combine antidepressant therapies. About 50% of patients who do not improve after initial antidepressant therapy will respond to either strategy. Switching has several advantages including fewer adverse effects, improved treatment adherence and reduced expense. However, as a general guideline, if patients are partial responders at 6 weeks, they will likely be full responders by 12 weeks. Thus, changing medication is not indicated in this context. However, if patients are partial responders at 12 weeks, switching to a new agent is advised. If the clinician treats vigorously and if the patient and clinician persevere, up to 90% of older depressed patients will respond to pharmacological treatment. Furthermore, electroconvulsive therapy is a safe and effective non-pharmacological strategy for non-psychotic major depression that fails to respond to pharmacotherapy. Getting well and staying well is the goal; thus, clinicians should treat to remission, not merely to response. Subsequently, maintenance treatment with the same regimen that has been successful in relieving the depression strongly improves the patient's chances of remaining depression free.

Miller MD, Reynolds CF. · Intervention Research Center and the Advanced Center for Interventions and Services Research for Late-Life Mood Disorders, University of Pittsburgh School of Medicine, Department of Psychiatry, Pittsburgh, PA, USA. · Int J Geriatr Psychiatry. · Pubmed #17096459 No free full text.

Abstract: BACKGROUND: The utility of Interpersonal Psychotherapy (IPT) has been documented as a maintenance treatment for late life depression as mono-therapy or in combination with antidepressant medication. Late life depression, however, is frequently co-morbid with declining memory or other cognitive abilities such that the usefulness of one-to-one psychotherapies is called into question for this subgroup. Additionally, concerned caregivers often accompany these patients to request help and their role in the presenting symptoms and in their potential resolution must also be addressed by any successful psychotherapy in this population. OBJECTIVES: To explore ways in which IPT could be modified to better serve the particular presentation and needs of depressed elders with cognitive decline along with their caregivers. METHODS: Various modifications of traditional IPT techniques were experimented with and refined in our collaborative late life research center using regular group supervision and feedback from patients and their caregivers. RESULTS: A key component of these modifications involves the integration of the caregiver into the treatment process in flexible ways that recognize their own role transition that is taking place simultaneously with that of the patient's role transition from a greater to a lesser functional state. Other techniques for resolving role conflicts, particularly those directly involving care issues for the patient, are also delineated. These modifications are collectively referred to as IPT-CI for cognitive impairment. A brief case vignette is presented. CONCLUSION: The modifications outlined in this communication reflect an evolving work-in-progress and serve as a framework for the future development of a manual of guidelines to assist healthcare personnel to optimally treat this population and their caregivers.

Whyte EM, Mulsant BH, Rovner BW, Reynolds CF. · Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, USA. · Int Rev Psychiatry. · Pubmed #17085365 No free full text.

Abstract: Mental health prevention research is an emerging and intriguing field. Preventing mental disorders is attractive as successful prevention, as it could potentially avert both emotional suffering and illness related morbidity and mortality. Several studies have looked at preventing post-stroke depression, a common complication of stroke. In this review article, we will first provide a conceptual overview of mental health prevention research. Then, we will discuss recent research supporting the prevention of depression after stroke and the likely positive effect successful prevention may have on non-psychiatric outcomes.

Shanmugham B, Karp J, Drayer R, Reynolds CF, Alexopoulos G. · Weill-Cornell Institute of Geriatric Psychiatry, 21 Bloomingdale Road, White Plains, NY 10605, USA. · Psychiatr Clin North Am. · Pubmed #16325731 No free full text.

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Areán PA, Reynolds CF. · Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA. · Biol Psychiatry. · Pubmed #16102545 No free full text.

Abstract: Mental illnesses in later life are multidimensional phenomena that occur in interpersonal, psychosocial, and biological contexts. With depression used as an example, the purpose of this article is to review how psychosocial variables contribute to the onset and maintenance of depression in late life, as well as influence treatment outcomes. Particular issues discussed are how these variables can be modified to prevent the onset and relapse of depression, how nonmodifiable risk factors can be addressed to prevent onset and relapse, and how research in this area needs to evolve to improve prevention and treatment.

Lenze EJ, Karp JF, Mulsant BH, Blank S, Shear MK, Houck PR, Reynolds CF. · Intervention Research Center for Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, Pennsylvania, USA. · J Geriatr Psychiatry Neurol. · Pubmed #15911937 No free full text.

Abstract: Understanding and addressing somatic symptoms are complex in older adults, who have more comorbid medical illnesses. This article describes a systematic review of the literature on somatic symptoms in older patients with anxiety disorders. Additionally, the hypothesis was tested that somatic symptoms would respond to selective serotonin reuptake inhibitor treatment in 30 anxious patients aged 60 years and older who participated in a 32-week trial of citalopram. The literature review showed few original data articles about somatic symptoms in older patients with anxiety disorders. These articles suggest that such a relationship is common and that treatment of anxiety, or anxious depression, is associated with a reduction in somatic symptoms. In the analysis, citalopram treatment was associated with a significant decrease in several somatic symptoms from pretreatment baseline. It is concluded that somatic symptoms in older adults with anxiety disorders or anxious depression often improve with successful antidepressant treatment. However, additional treatment and integrated approaches are likely to be necessary for many such individuals.

Young RC, Gyulai L, Mulsant BH, Flint A, Beyer JL, Shulman KI, Reynolds CF. · Payne-Whitney, Westchester, and the Institute for Geriatric Psychiatry, Department of Psychiatry, Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains, New York 10605, USA. · Am J Geriatr Psychiatry. · Pubmed #15249272 No free full text.

Abstract: The authors reviewed the evidence-base for pharmacological treatment of mania and bipolar (BP) depression in late life. Treatment benefits and side effects may be modified by age-associated factors, such as neurocognitive impairments. Lithium and divalproex have most often been studied in elderly patients, and both may be efficacious in acute treatment of mania, but there are no controlled efficacy or effectiveness trials. The role of atypical antipsychotic agents remains to be clarified. Similarly, there are no systematic studies of the treatment of BP depression in elderly patients. The authors make suggestions for management and delineate priorities for research.

Whyte EM, Dew MA, Gildengers A, Lenze EJ, Bharucha A, Mulsant BH, Reynolds CF. · Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. · Drugs Aging. · Pubmed #15182217 No free full text.

Abstract: In the treatment of depression, there is considerable interest in the time course of response and, in particular, the speed with which individuals recover from depressive episodes. Examination of the time course and speed of response is critical for assessing the usefulness of specific treatments. However, while this issue has received attention in mid-life adult populations, it has received little consideration in the context of late-life major depression. The synthesis of empirical reports indicates that, while older adults with depression seem to respond with the same speed as mid-life adults, several factors have consistently been associated with reduced speed of response to antidepressant treatment, including greater severity of depressive symptoms and co-occurring anxiety symptoms. Limited evidence suggests that sleep impairment and genetic factors (e.g. presence of the s allele of the serotonin transporter gene promoter region) may also be associated with reduced speed of response. Some factors have consistently been found to be unrelated to speed of response (demographic characteristics, nonpsychiatric physical illnesses) whereas other factors have only mixed evidence supporting any effect (psychosocial and other clinical factors). While there is little work available to date, some evidence suggests that time course and speed of response affect longer-term outcomes of depression pharmacotherapy; thus, older adults with more rapid versus slower patterns of response may differ in the types of maintenance treatment needed to avert additional depressive episodes. None of potential strategies for accelerating speed of response have been clearly shown to be effective in late-life depression. Future treatment studies for late-life depression should routinely consider not only overall efficacy of a given pharmacotherapy (i.e. total rate of response), but time course and speed of response. To this end, new investigations must be designed to overcome the methodological limitations of prior studies that have examined time course and they should include a range of potential covariates and outcomes of between-patient differences in speed of response. Better understanding of factors related to such differences may suggest new intervention strategies to accelerate response.

Mulsant BH, Whyte E, Lenze EJ, Lotrich F, Karp JF, Pollock BG, Reynolds CF. · Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. · CNS Spectr. · Pubmed #14978461 No free full text.

Abstract: Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.

Lenze EJ, Pollock BG, Shear MK, Mulsant BH, Bharucha A, Reynolds CF. · Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. · CNS Spectr. · Pubmed #14978458 No free full text.

Abstract: Anxiety is common in the elderly and can present as a primary anxiety disorder or as a symptom of another disorder. Generalized anxiety disorder, in particular, is a common syndrome in late life. Anxiety symptoms are also common features of late-life depression and dementia. Treatment of anxiety in elderly persons has typically involved the use of benzodiazepines, which are often effective but problematic because they are associated with increased risk of cognitive impairment, falls, and fractures. Based on their safety and efficacy, antidepressants, particularly serotonergic medications, are considered first-line treatment for most anxiety disorders as well as anxiety symptoms of major depressive disorder. Psychotherapy, particularly cognitive-behavioral therapy, may be effective in these disorders as well; research is underway to adapt this therapy to the needs of elderly persons. Anxiety symptoms in dementia are poorly understood but may respond to atypical antipsychotics, serotonergic antidepressants, or mood stabilizers. Overall, the research in late-life anxiety has not caught up to the literature in late-life depression and, for the most part, treatment recommendations must be extrapolated from studies in young adults.

Reynolds CF. · MHIRC for Late-Life Mood Disorders, University of Pittsburgh School of Medicine, Pittsburg, PA 15213, USA. · Psychopharmacol Bull. · Pubmed #14566207 links to  free full text

Abstract: The elderly population is growing at a rapid rate and currently constitutes more than 12% of the United States' population. Within the next 30 years, the number of elderly persons is expected to more than double, creating a concerning situation regarding provision of healthcare services. Depression is a prevalent and underrecognized disorder in older adults and is associated with both increased healthcare utilization and suicide. Treatment of depression improves quality of life and reduces functional decline and suicidal ideation. Maintenance therapy for depression is commonly overlooked and must be emphasized for management of depression in elderly patients. First-line treatment options include selective serotonin reuptake inhibitors (SSRIs), one of which, paroxetine, has been studied extensively in older adults. The findings of studies that have evaluated the efficacy of paroxetine demonstrate successful treatment of depression and long-term relapse prevention in this population. With the significant personal and societal burden that is associated with major depression in the elderly, appropriate treatment is important and must be incorporated into standard practices by healthcare professionals.

Charney DS, Reynolds CF, Lewis L, Lebowitz BD, Sunderland T, Alexopoulos GS, Blazer DG, Katz IR, Meyers BS, Arean PA, Borson S, Brown C, Bruce ML, Callahan CM, Charlson ME, Conwell Y, Cuthbert BN, Devanand DP, Gibson MJ, Gottlieb GL, Krishnan KR, Laden SK, Lyketsos CG, Mulsant BH, Niederehe G, Olin JT, Oslin DW, Pearson J, Persky T, Pollock BG, Raetzman S, Reynolds M, Salzman C, Schulz R, Schwenk TL, Scolnick E, Unutzer J, Weissman MM, Young RC, Anonymous00321. · National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA. · Arch Gen Psychiatry. · Pubmed #12860770 No free full text.

Abstract: OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF, Silverman MM. · Employment Law Center and the University of California, Hastings College of Law, San Francisco, USA. · JAMA. · Pubmed #12813122 No free full text.

Abstract: OBJECTIVE: To encourage treatment of depression and prevention of suicide in physicians by calling for a shift in professional attitudes and institutional policies to support physicians seeking help. PARTICIPANTS: An American Foundation for Suicide Prevention planning group invited 15 experts on the subject to evaluate the state of knowledge about physician depression and suicide and barriers to treatment. The group assembled for a workshop held October 6-7, 2002, in Philadelphia, Pa. EVIDENCE: The planning group worked with each participant on a preworkshop literature review in an assigned area. Abstracts of presentations and key publications were distributed to participants before the workshop. After workshop presentations, participants were assigned to 1 of 2 breakout groups: (1) physicians in their role as patients and (2) medical institutions and professional organizations. The groups identified areas that required further research, barriers to treatment, and recommendations for reform. CONSENSUS PROCESS: This consensus statement emerged from a plenary session during which each work group presented its recommendations. The consensus statement was circulated to and approved by all participants. CONCLUSIONS: The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians' seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement. This consensus statement recommends transforming professional attitudes and changing institutional policies to encourage physicians to seek help. As barriers are removed and physicians confront depression and suicidality in their peers, they are more likely to recognize and treat these conditions in patients, including colleagues and medical students.

Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. · Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA. · Drugs Aging. · Pubmed #11929324 No free full text.

Abstract: In almost all industrialised countries, men aged 75 years and older have the highest suicide rate among all age groups. Although in younger age groups suicide attempts are often impulsive and communicative acts, suicide attempts in older people (defined as aged 65 years and older) are often long planned and involve high-lethality methods. These characteristics, in addition to the fact that elderly are more fragile and frequently live alone, more often lead to fatal outcome. In later life, in both sexes, the most common diagnosis in those who attempt or complete suicide is major depression. In contrast to other age groups, comorbidity with substance abuse and personality disorders is less frequent. Physical illness plays an important role in the suicidal behaviour of the elderly: most frequently, depression and illness co-occur; less often, the physical illness or the treating medications are causally related to the depressive symptoms. However, only 2 to 4% of terminally ill elderly commit suicide. In addition to physical illness, complicated or traumatic grief, anxiety, unremitting hopelessness after recovery from a depressive episode and history of previous suicide attempts are risk factors for suicide attempts and completed suicide. During a depressive episode, elderly patients with suicidal ideation have higher levels of anxiety and, during treatment, anxiety decreases the probability of remission and recovery. As well as overt suicide attempts, indirect self-destructive behaviours, which often lead to premature death, are common, especially in residents of nursing homes, where more immediate means to commit suicide are restricted. Although we do not have randomised trials of treatment, studies suggest that antidepressant treatment may decrease suicide risk. Prevention and treatment trials are underway to detect the effectiveness of improved treatment of depression by primary care physicians as a means of reducing the prevalence of depressive symptoms, hopelessness and suicidal ideation.

Lenze EJ, Mulsant BH, Shear MK, Alexopoulos GS, Frank E, Reynolds CF. · Intervention Research Centers in Late-Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. · Depress Anxiety. · Pubmed #11668661 No free full text.

Abstract: Since psychiatric disorders differ throughout the lifespan in phenomenology, course, and treatment, there is need for study of comorbidity of such disorders in geriatric populations. Prior findings of low prevalence of comorbid late-life anxiety disorders in depressed elderly are now disputed by recent studies. Risk factors for comorbid late-life depression and anxiety may be different from those for depression without anxiety. Similar to adults, elderly depressives with comorbid anxiety symptoms present with more severe pathology and have a more difficult course of illness, including decreased or delayed treatment response. In this paper, we review the literature on anxiety and depression comorbidity in late life, and we make recommendations for the assessment and treatment of comorbid late-life anxiety and depression. We also recommend directions for future research in the area of psychiatric comorbidity in late life.