Symptomatology of Late-Life Minor Depression Among Primary Care Patients E. OXMAN, M.D. JAMES E. BARRElT, M.D. JANE BARRElT. M.Sc. PAUL GERBER. M.D.
THOMAS
Patients offour general internists andfour family physicians were interviewed hy two psychiatrists to identify those suffering from depressive disorders. Nineteen elderly (60 years ofage and older) patients and 22 younger (hetween 18 and 59 years of age) patients met Research Diagnostic Criteria (RDC)jor minor depressi!'e disorder. and 73 elderly and 79 younger patients had no psychiatric disorder. In general. the elderly depressed medical outpatients and the younger depressed medical outpatients had similar symptomatology. as did the elderly and noneldaly medical outpatients without psychiatric disorders.
ommon clinical problems are known to present differently in the elderly than they do in younger patients. Some clinicians report that the symptoms and signs of late-life depression are symptomatically unique. For example. it has been reported that depressed mood, I guilt.! and suicidal ideation J are less common in elderly depressive patients, while somatic complaints.J,4 feelings of uselessness. sleep disturbance,J·~ memory complaints. ~ and lethargy are more common. h Researchers have also found higher frequencies of delusions in depressed inpatients whose first episode of depression occurred after the age of 60. 7 In contrast, other investigators have reported
C
Received October 2. 1988; revised April 10. 1989; accepted May 5. 1989. From DanmoUlh Medical School and (he Danmouth Hitchcock Medical Center. Hanover. New Hampshire. Address reprint requests to Dr. Oxman. DepanmentofPsychiatry. Danmouth Medical School. Hanover. NH 03756. Copyright © 1990 The Academy of Psychosomatic Medicine.
174
that medically healthy elderly depressive patients are no different from their younger counterparts. x Recently. Blazer et a\.9 found lillIe difference in symptomatology of elderly and middle-aged inpatients with major depression with melancholia. The majority of these studies focused on elderly persons identified as psychiatric patients. There is less information on possible symptomatic differences in patients who remain outside the specialty sector. such as community residents or primary care patients. Such information is important because the most likely source of care for older individuals with psychiatric problems is their primary care provider within the context of a visit for medical illness or complaints. llu I For the past several years our research group has conducted a study of depression in rural primary care outpatients. IH' We were interested in the rates and characteristics of depression in physicians' practices, and. as part of this research, we obtained symptom self-report data on outpatients with and without a depressive disorder established by clinical interview. These data PSYCHOSOMATICS
Oxman et al.
allow us to compare depressive symptomatology in older and younger primary care outpatients with depressive disorders. They complement Blazer et at.·s study of depressive symptoms in older and younger depressed inpatients. Because of the increased likelihood of illness and disability with age. it is possible that symptoms related to medical illness in the elderly. e.g.• disturbed sleep or decreased energy, may be more common and make it harder to accurately diagnose depression. Our data also allow us to compare differences in potentially false-positive depressive symptoms in older and younger primary care patients without depressive disorders. In this paper we examined two questions: Do elderly primary care patients with depressive disorders have different presenting depressive symptomatology than younger depressed primary care patients? and Do elderly primary care patients without psychiatric disorders have different presenting depressive symptomatology than younger primary care patients without psychiatric disorders?
proached by their physician to take part in a diagnostic interview administered by one of two study psychiatrists (JEB or TEO). The psychiatrists made their diagnoses using a structured interview and were blinded to the scores on the screening inventory. In most instances this interview, about 20 minutes in length, took place in the clinic immediately following the patient's visit with his or her physician. This structured psychiatric interview was the method used to identify those with a disorder. The screening inventory was not used to make diagnoses; it was an independent measure of symptoms that patients were willing and able to report. By these procedures. 1.245 patients were approached to take the screen. Of the 1,149 patients who completed the screen, 366 were approached for the diagnostic interview, and 333 (91 %) completed the interview. Each interviewer made psychiatric diagnoses. as appropriate, for each patient upon completion of the interview. Further details of the selection process, study procedures, and characteristics of the sample have been reported elsewhere. 12
METHOD AND PROCEDURES Psychiatric Assessment and Diagnosis Subjects Subjects were male and female patients aged 18 and over of four general internists in a fee-forservice practice in Hanover, New Hampshire, and of four family physicians in a nearby family practice in Lebanon, New Hampshire. The practices serve a heterogeneous. predominantly rural community that includes faculty and staff of Dartmouth College, a white-collar population consisting of those working in retail businesses. a rural population of individuals engaged in farming. dairying, and lumbering. and a sizable retirement population. During a 16-month period patients of the participating physicians were asked to complete a screening inventory, a 49-item, self-report scale, immediately prior to seeing their physician. The inventory included a 20-item depression screen scale with a range of possible scores of 0 to 60. All patients scoring above 9, and a 10% random sample of patients below 9, were apVOLUME 31 • NUMBER 2 • SPRING 1990
The structured clinical interview was based on a shortened version of the Schedule for Affective Disorders and Schizophrenia (SADS).'4 Psychiatric diagnoses were made using selected diagnostic categories of the Research Diagnostic Criteria (RDC), I~ a system whose categories relate very closely to the psychiatric nomenclature in DSM-I/l. '6 At weekly meetings. each patient who had received any diagnosis was discussed by the two psychiatrists to arrive at a consensus diagnosis. Finally. since most of the patients with diagnoses were entered into a longitudinal study and were interviewed again subsequently. this initial diagnosis was modified. if appropriate. based on any additional information obtained. The use of information from at least two points in time permitted a more accurate diagnosis, particularly for the presence of a character disorder. 17 The prevalence of all RDC depressive disorders in this sample was 10%. For the present 175
Late-Life Minor Depression
report, we selected for study patients who met ROC criteria for minor depressive disorder diagnoses. episodic minor depressive disorder. and chronic intermittent minor depressive disorder, because. by ROC definition. both episodic minor depressive disorder and chronic intermittent minor depressive disorder require at least two depressive symptoms from the same list of 16 depressive symptoms. Episodic minor depressive disorder is similar to DSM-I/l adjustment disorder with depressed mood but without the requirement of an obvious stressor. Chronic intermittent minor depressive disorder requires similar symptoms lasting at least two years; it is similar to DSM-I/l dysthymic disorder. In this sample of elderly patients. 52.6% had episodic minor depressive disorder, and 47.4% had chronic intermittent minor depressive disorder; in the younger patients. 59.1 % had the episodic variety and 40.9% had the chronic type. Major depressive disorder was not included for separate analysis because it involved only two patients under 60 years of age and two patients over 60. The interview also identified patients with no active psychiatric disorder. This group included patients with no psychiatric symptomatology and patients whose symptoms were of insufficient number or severity at the time of the TABLE I.
interview to meet criteria for any ROC disorder. By ROC definition. no patient in the "no psychiatric disorder" group had significant psychiatric impairment present, defined as having symptoms that interfere with work. family, or social functioning; having been given medication because of the symptoms; and having sought or been referred for help. Depressive Symptomatology The screening inventory consisted of 45 selfreport items from the Hopkins Symptom Check List (HSCL-90)18 and four items from the Center for Epidemiologic Studies Depression Scale (CES-D).19 Each item was rated on a 4-point scale indicating the degree to which it had been experienced by the patient during the past week, with oindicating not at all; I. a little; 2. quite a bit; and 3. extremely. From the 49 items, we selected 20 items that corresponded to the 16 depressive symptoms that make up the ROC definitional list of symptoms for episodic and chronic intermittent minor depressive disorders. For separate analysis we also selected four additional depressive items that were not part of the ROC definitionallist of depressive symptoms. We scored the depression symptom items as
Demographic characteristics and self-ratings or physical health or medical outpatients with minor depressive disorder and no psychiatric disorder Depressive Disorder Nonelderly (18 to 59)
Elderly
Characteristic
(n=22)
(60+) (n=191
No Psychiatric Disorder Nonelderly (18 to 59)
Elderly
(n=79)
(n=73)
(60+)
Mean age (yrs)
43.5
7 \.6
45.0
7 \.2
Sex (% patients) male female
36.4 63.6
10.5 89.5
57.0 43.0
35.1 64.9
Marital status (% patients) married widowed separated or divorced never married
54.6 0.0 22.7 22.7
57.9 42.1 0.0 0.0
87.3
55.6 33.3 2.8 8.33
Self-rating of physical health (% patients) superior good fair poor
0.0 45.4 45.4 9.1
0.0 26.3 68.4 5.3
10.3 62.8 25.6
176
1.3
5.1 6.3
1.3
5.6 55.6 37.5 1.4
PS YCHOSOMATICS
Oxman et al.
either absent or present. Patients over 60 with a depressive disorder were compared with patients 18 to 59 years old for the presence or absence of each symptom. A second similar comparison was carried out for those patients above and below 60 with no psychiatric disorder. Because one-quarter of the comparisons had smallest expected values less than five. chi square or confidence intervals could not be used appropriately. For uniformity. Fisher's Exact Test. two tailed. was used to perform statistical tests for significance in the resulting 2 x 2 tables.
ing too much. blaming myself, feeling slowed down and low in energy. and feeling that everything is an effort. Suicidal thoughts were the least frequently reported criterion symptom by patients in both age groups (5.3% of elderly patients and 22.7% of younger patients). Of the four additional depressive symptoms. nearly all the elderly and younger patients reported feeling blue. and over two-thirds of both age groups reported they got no fun out of life and all pleasure and joy had gone from life. TABLE 2. Depressive symptoms of elderly and nonelderly primary care outpatients who meet criteria for RDC" minor depressive disorder
RESULTS Demographic characteristics of the patients with minor depressive disorder and of the patients with no psychiatric disorder are presented in Table I. As expected. there were more widows and more women among the older patients. In addition. there were proportionally more women than men in the depressive group. a finding that has been repeated in many studies. 20 Table I also presents the patient's own rating of his or her physical health. broken down by age and diagnostic group. A trend was found for older patients to report worse physical health than younger patients among both the depressive patients and those with no psychiatric disorder. But independent of age. 63.4% of all depressive patients perceived their physical health as fair or poor. compared with 32.7% of patients with no psychiatric disorder. a significant difference 2 (X =12.8. df= I. p
THOMAS
Patients offour general internists andfour family physicians were interviewed hy two psychiatrists to identify those suffering from depressive disorders. Nineteen elderly (60 years ofage and older) patients and 22 younger (hetween 18 and 59 years of age) patients met Research Diagnostic Criteria (RDC)jor minor depressi!'e disorder. and 73 elderly and 79 younger patients had no psychiatric disorder. In general. the elderly depressed medical outpatients and the younger depressed medical outpatients had similar symptomatology. as did the elderly and noneldaly medical outpatients without psychiatric disorders.
ommon clinical problems are known to present differently in the elderly than they do in younger patients. Some clinicians report that the symptoms and signs of late-life depression are symptomatically unique. For example. it has been reported that depressed mood, I guilt.! and suicidal ideation J are less common in elderly depressive patients, while somatic complaints.J,4 feelings of uselessness. sleep disturbance,J·~ memory complaints. ~ and lethargy are more common. h Researchers have also found higher frequencies of delusions in depressed inpatients whose first episode of depression occurred after the age of 60. 7 In contrast, other investigators have reported
C
Received October 2. 1988; revised April 10. 1989; accepted May 5. 1989. From DanmoUlh Medical School and (he Danmouth Hitchcock Medical Center. Hanover. New Hampshire. Address reprint requests to Dr. Oxman. DepanmentofPsychiatry. Danmouth Medical School. Hanover. NH 03756. Copyright © 1990 The Academy of Psychosomatic Medicine.
174
that medically healthy elderly depressive patients are no different from their younger counterparts. x Recently. Blazer et a\.9 found lillIe difference in symptomatology of elderly and middle-aged inpatients with major depression with melancholia. The majority of these studies focused on elderly persons identified as psychiatric patients. There is less information on possible symptomatic differences in patients who remain outside the specialty sector. such as community residents or primary care patients. Such information is important because the most likely source of care for older individuals with psychiatric problems is their primary care provider within the context of a visit for medical illness or complaints. llu I For the past several years our research group has conducted a study of depression in rural primary care outpatients. IH' We were interested in the rates and characteristics of depression in physicians' practices, and. as part of this research, we obtained symptom self-report data on outpatients with and without a depressive disorder established by clinical interview. These data PSYCHOSOMATICS
Oxman et al.
allow us to compare depressive symptomatology in older and younger primary care outpatients with depressive disorders. They complement Blazer et at.·s study of depressive symptoms in older and younger depressed inpatients. Because of the increased likelihood of illness and disability with age. it is possible that symptoms related to medical illness in the elderly. e.g.• disturbed sleep or decreased energy, may be more common and make it harder to accurately diagnose depression. Our data also allow us to compare differences in potentially false-positive depressive symptoms in older and younger primary care patients without depressive disorders. In this paper we examined two questions: Do elderly primary care patients with depressive disorders have different presenting depressive symptomatology than younger depressed primary care patients? and Do elderly primary care patients without psychiatric disorders have different presenting depressive symptomatology than younger primary care patients without psychiatric disorders?
proached by their physician to take part in a diagnostic interview administered by one of two study psychiatrists (JEB or TEO). The psychiatrists made their diagnoses using a structured interview and were blinded to the scores on the screening inventory. In most instances this interview, about 20 minutes in length, took place in the clinic immediately following the patient's visit with his or her physician. This structured psychiatric interview was the method used to identify those with a disorder. The screening inventory was not used to make diagnoses; it was an independent measure of symptoms that patients were willing and able to report. By these procedures. 1.245 patients were approached to take the screen. Of the 1,149 patients who completed the screen, 366 were approached for the diagnostic interview, and 333 (91 %) completed the interview. Each interviewer made psychiatric diagnoses. as appropriate, for each patient upon completion of the interview. Further details of the selection process, study procedures, and characteristics of the sample have been reported elsewhere. 12
METHOD AND PROCEDURES Psychiatric Assessment and Diagnosis Subjects Subjects were male and female patients aged 18 and over of four general internists in a fee-forservice practice in Hanover, New Hampshire, and of four family physicians in a nearby family practice in Lebanon, New Hampshire. The practices serve a heterogeneous. predominantly rural community that includes faculty and staff of Dartmouth College, a white-collar population consisting of those working in retail businesses. a rural population of individuals engaged in farming. dairying, and lumbering. and a sizable retirement population. During a 16-month period patients of the participating physicians were asked to complete a screening inventory, a 49-item, self-report scale, immediately prior to seeing their physician. The inventory included a 20-item depression screen scale with a range of possible scores of 0 to 60. All patients scoring above 9, and a 10% random sample of patients below 9, were apVOLUME 31 • NUMBER 2 • SPRING 1990
The structured clinical interview was based on a shortened version of the Schedule for Affective Disorders and Schizophrenia (SADS).'4 Psychiatric diagnoses were made using selected diagnostic categories of the Research Diagnostic Criteria (RDC), I~ a system whose categories relate very closely to the psychiatric nomenclature in DSM-I/l. '6 At weekly meetings. each patient who had received any diagnosis was discussed by the two psychiatrists to arrive at a consensus diagnosis. Finally. since most of the patients with diagnoses were entered into a longitudinal study and were interviewed again subsequently. this initial diagnosis was modified. if appropriate. based on any additional information obtained. The use of information from at least two points in time permitted a more accurate diagnosis, particularly for the presence of a character disorder. 17 The prevalence of all RDC depressive disorders in this sample was 10%. For the present 175
Late-Life Minor Depression
report, we selected for study patients who met ROC criteria for minor depressive disorder diagnoses. episodic minor depressive disorder. and chronic intermittent minor depressive disorder, because. by ROC definition. both episodic minor depressive disorder and chronic intermittent minor depressive disorder require at least two depressive symptoms from the same list of 16 depressive symptoms. Episodic minor depressive disorder is similar to DSM-I/l adjustment disorder with depressed mood but without the requirement of an obvious stressor. Chronic intermittent minor depressive disorder requires similar symptoms lasting at least two years; it is similar to DSM-I/l dysthymic disorder. In this sample of elderly patients. 52.6% had episodic minor depressive disorder, and 47.4% had chronic intermittent minor depressive disorder; in the younger patients. 59.1 % had the episodic variety and 40.9% had the chronic type. Major depressive disorder was not included for separate analysis because it involved only two patients under 60 years of age and two patients over 60. The interview also identified patients with no active psychiatric disorder. This group included patients with no psychiatric symptomatology and patients whose symptoms were of insufficient number or severity at the time of the TABLE I.
interview to meet criteria for any ROC disorder. By ROC definition. no patient in the "no psychiatric disorder" group had significant psychiatric impairment present, defined as having symptoms that interfere with work. family, or social functioning; having been given medication because of the symptoms; and having sought or been referred for help. Depressive Symptomatology The screening inventory consisted of 45 selfreport items from the Hopkins Symptom Check List (HSCL-90)18 and four items from the Center for Epidemiologic Studies Depression Scale (CES-D).19 Each item was rated on a 4-point scale indicating the degree to which it had been experienced by the patient during the past week, with oindicating not at all; I. a little; 2. quite a bit; and 3. extremely. From the 49 items, we selected 20 items that corresponded to the 16 depressive symptoms that make up the ROC definitional list of symptoms for episodic and chronic intermittent minor depressive disorders. For separate analysis we also selected four additional depressive items that were not part of the ROC definitionallist of depressive symptoms. We scored the depression symptom items as
Demographic characteristics and self-ratings or physical health or medical outpatients with minor depressive disorder and no psychiatric disorder Depressive Disorder Nonelderly (18 to 59)
Elderly
Characteristic
(n=22)
(60+) (n=191
No Psychiatric Disorder Nonelderly (18 to 59)
Elderly
(n=79)
(n=73)
(60+)
Mean age (yrs)
43.5
7 \.6
45.0
7 \.2
Sex (% patients) male female
36.4 63.6
10.5 89.5
57.0 43.0
35.1 64.9
Marital status (% patients) married widowed separated or divorced never married
54.6 0.0 22.7 22.7
57.9 42.1 0.0 0.0
87.3
55.6 33.3 2.8 8.33
Self-rating of physical health (% patients) superior good fair poor
0.0 45.4 45.4 9.1
0.0 26.3 68.4 5.3
10.3 62.8 25.6
176
1.3
5.1 6.3
1.3
5.6 55.6 37.5 1.4
PS YCHOSOMATICS
Oxman et al.
either absent or present. Patients over 60 with a depressive disorder were compared with patients 18 to 59 years old for the presence or absence of each symptom. A second similar comparison was carried out for those patients above and below 60 with no psychiatric disorder. Because one-quarter of the comparisons had smallest expected values less than five. chi square or confidence intervals could not be used appropriately. For uniformity. Fisher's Exact Test. two tailed. was used to perform statistical tests for significance in the resulting 2 x 2 tables.
ing too much. blaming myself, feeling slowed down and low in energy. and feeling that everything is an effort. Suicidal thoughts were the least frequently reported criterion symptom by patients in both age groups (5.3% of elderly patients and 22.7% of younger patients). Of the four additional depressive symptoms. nearly all the elderly and younger patients reported feeling blue. and over two-thirds of both age groups reported they got no fun out of life and all pleasure and joy had gone from life. TABLE 2. Depressive symptoms of elderly and nonelderly primary care outpatients who meet criteria for RDC" minor depressive disorder
RESULTS Demographic characteristics of the patients with minor depressive disorder and of the patients with no psychiatric disorder are presented in Table I. As expected. there were more widows and more women among the older patients. In addition. there were proportionally more women than men in the depressive group. a finding that has been repeated in many studies. 20 Table I also presents the patient's own rating of his or her physical health. broken down by age and diagnostic group. A trend was found for older patients to report worse physical health than younger patients among both the depressive patients and those with no psychiatric disorder. But independent of age. 63.4% of all depressive patients perceived their physical health as fair or poor. compared with 32.7% of patients with no psychiatric disorder. a significant difference 2 (X =12.8. df= I. p
