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Age and Gender in the Phenomenology of Depression
Age and Gender in the Phenomenology of Depression Henry Brodaty, M.B., B.S., M.D., FRACP, FRANZCP, Breda Cullen, B.A., M.Sc. Claire Thompson, B.A. (Hons.), MAPS Philip Mitchell, M.B., B.S., M.D., FRCPsych, FRANZCP Gordon Parker, M.D., Ph.D., D.Sc., FRANZCP, Kay Wilhelm, M.B., B.S., M.D., FRANZCP Marie-Paule Austin, M.D., FRANZCP, MBBS Gin Malhi, M.B., Ch.B., B.Sc., MRCPsych, FRANZCP
Objective: Authors investigated the effects of current age, age at onset, and gender on the phenomenology of depression. Methods: A mixed-age sample of 810 Mood Disorders Unit attendees with a diagnosis of unipolar major depressive episode at or near its nadir were interviewed by clinician-rated and self-report instruments assessing symptoms and severity of depression. Results: Differences were found in depressive phenomenology according to current age but not age at onset, confirming previous findings. Age differences on several variables were found in women only. Subjective ratings of depression severity decreased with age, whereas objective, clinician-rated severity increased. Conclusions: The pattern and severity of depression change with increasing age. Longitudinal prospective studies would further elucidate this age– gender relationship. Clinicians should be aware of the decreased likelihood of older patients’ reporting of depressive symptoms themselves. (Am J Geriatr Psychiatry 2005; 13:589–596)
S
ome findings of the relationship between age and phenomenology of depression have indicated that withdrawal, apathy, lack of interest, lack of drive, suicidality, and guilt are overrepresented in elderly patients;1–4 others have found no such differences.5–7 We noted that elderly patients had more severe depression on clinician-rated, but not self-report, instruments, and were more likely to manifest delusions, hallucinations, agitation, hypochondriasis, marked guilt, and decreased appetite.8,9
The age at onset of first depressive episode may be relevant. Researchers have separated elderly patients with depression into those with early-onset (EO), that is, first onset of depression typically before 60 years, from those with late-onset (LO) illness, that is, first onset of depression in late life, typically 60 years or older. LO patients may have higher rates of apathy,10 delusions,11 and hypochondriasis;3,12 however, these findings have been refuted by others.7,8,13,14 These differences may be explained by different age cut-off
Received November 9, 2003; revised June 18, July 29, 2004; accepted August 2, 2004. From the Academic Dept. for Old-Age Psychiatry (HB,BC,CT), the Mood Disorders Unit, Black Dog Institute, Prince of Wales Hospital, Sydney, Australia (HB,PM,GP,KW,MPA,GM), and the School of Psychiatry, University of New South Wales, Sydney, Australia (HB,PM,GP,KW,MPA,GM). Send correspondence and reprint requests to Prof. Henry Brodaty, Academic Dept. for Old-Age Psychiatry, Euroa Centre, Prince of Wales Hospital, Randwick, NSW 2031, AUSTRALIA. e-mail: [email protected] 䉷 2005 American Association for Geriatric Psychiatry
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Depression, Age, and Gender points used to separate younger from older (and EO from LO) patients, and by differing types of depression.3,7–10,12 The lack of investigation of cut-off points later than 65 years reflects small sample sizes, a limitation addressed here. The accumulation of agerelated pathology, especially cerebrovascular, should be more apparent in older age;15 differences in phenomenology may only manifest themselves in patients age 70 or beyond. The influence of current age and age at onset on depression phenomenology may be influenced by gender. Lifetime prevalence of depression in women is about twice that in men;16,17 possible differences in phenomenology between depressed men and women are less clear18–22 and appear to diminish with age, because of a number of factors, including a mellowing effect of age, leading to lower neuroticism scores, less comorbid anxiety, and increased psychological well-being in women and higher rates of depression in men with age.23–25 Older depressed women with depression may have more mood-related depressive symptoms26 and more appetite disturbance22 than older men, who may, in turn, have more motivational symptoms,26 be more agitated22 and more severely depressed, have more neurovegetative symptoms, and be at greater risk for late-onset depression27 than older women. The aims of the present study were fourfold: 1) to corroborate previous findings on current-age and ageat-onset differences in depression phenomenology by use of a much larger sample; 2) to corroborate agerelated differences between self-report and clinicianrated severity of depression; 3) to explore a cut-off point older than 60 years for current age and age at onset for variability in phenomenology; and 4) to investigate the relationship between gender and current age and age at onset on depression phenomenology. We hypothesized that: 1) older patients would report more symptoms overall, and more neurovegetative melancholic symptoms than younger patients; 2) there would be an increasing discrepancy between selfreport and clinician-rated severity with age; 3) age at onset of depression in older-aged patients would not differentiate phenomenology; 4) differences in phenomenology would remain unchanged by using an older age cut-off point; and 5) the influence of current age and age at onset of depression would be influenced by gender differences.
590
METHODS Participants The sample comprised 1,199 consecutive inpatient and outpatient referrals to the Mood Disorders Unit (MDU) at Prince of Wales Hospital, Sydney. The MDU is a general hospital tertiary-referral unit, whose referrals come equally from general practitioners and psychiatrists.28 We have reported on 717 of these patients, of whom 527 had unipolar major depression.9,10,13 The present article combines those samples with eligible subjects from 482 additional patients assessed at the MDU. Diagnoses were made using clinical and DSM-III-R29 or DSM-IV30 criteria using structured interviews and diagnostic algorithms. In order to improve the homogeneity of the sample, we focused only on those patients who were deemed to be at or near the nadir of a unipolar major depressive episode (at least up to the point of assessment) and whose depression was not secondary to physical illness or substance abuse. Patients were further classified according to hierarchical, mutually exclusive DSM categories of psychotic, melancholic, and non-melancholic depression. Participants gave informed consent. Rating Instruments Patients completed the General Health Questionnaire, 30-item version (GHQ–30)31 and either the Zung Depression Scale1 or Beck Depression Inventory (BDI),32 depending on the cohort in which they were enrolled. Patients were rated by a clinician on the Hamilton Rating Scale for Depression (Ham-D– 17 or Ham-D–21,33 which yields a Total score as well as Psychiatric (HAMPSY) and Somatic (HAMSOM) subscores.34 Other clinician-rated scales used were the Global Assessment of Functioning (GAF),29 the Newcastle Endogenous Depression Inventory,35 and the CORE inventory (CORE I or CORE II) for signs of melancholic depression,36 which comprises three factorially independent subscales: Agitation, Retardation, and Non-Interactiveness. A clinician completed a structured interview for depression. On the basis of our previous research,9,10,13 we selected certain symptoms, assessed with the clinician structured interview, the CORE, and the Ham-D–17, to be examined separately. Sociodemographic data collected
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Brodaty et al. included age, gender, years of education, marital status, and occupational status as rated on the 7-point Daniel Prestige Scale.37 Family and medical history, personality type, and life stressors were assessed but are not reported here. Data Analysis Variables were checked for skewness and were transformed as appropriate. Comparisons between groups were made using two-sample t-tests for normally-distributed continuous data and MannWhitney U tests (denoted by Uz) for skewed continuous data that could not be transformed successfully. Between-groups comparisons of categorical data were made using chi-square tests (v2), with Yates’ continuity correction (CCv2) for 2 ⳯ 2 tables. Analyses of covariance (ANCOVAs) were used to compare groups on continuous variables by age at onset, covarying for current age. Multiple analyses of variance (MANOVAs) were computed with current age and age-at-onset by decade as the between-subjects factors, in order to investigate whether 60 was a suitable cut-off point for dichotomized analyses. Interactions were tested by univariate ANOVA for continuous variables and log-linear model testing for categorical variables. Alpha was set at 0.05, except where multiple comparisons necessitated the use of Bonferroni correction. All analyses were computed using the Statistical Package for the Social Sciences, Version 11.38
RESULTS Participants The sample of 1,199 patients was reduced to 810 after excluding 61 patients with bipolar disorder, 45 who did not fulfill criteria for current major depressive episode, 22 with a non-depression primary diagnosis, 8 with depression secondary to substance abuse, 4 with depression secondary to physical illness, and 249 who were not at or near the nadir of the episode. The remaining 810 participants, of whom 539 (66.5%) were women, had a mean age of 44.8 years (standard deviation [SD]: 16.3; range: 14–88), with 182 (22.5%) age ⱖ60 years and 71 (8.8%) ⱖ70 years. Of the 182 over age 60, there were 39 men and 72 women in their sixties; 14 men and 47 women in
Am J Geriatr Psychiatry 13:7, July 2005
their seventies, and 4 men and 6 women in their eighties. Two hundred seventy-four (33.8%) had never been married, and 150 (18.8%) were classified as having high occupational status (Daniel Prestige Scale categories 1–3).37 Participants had completed a mean of 11.8 years of education (SD: 3.5; range: 0–25). Hierarchical diagnoses were the following: psychotic depression, 94 (11.6%); melancholic depression, 290 (35.8%), and non-melancholic depression, 426 cases (52.6%). The majority (588; 74.1%) had experienced at least one previous depressive episode, and most (679; 83.8%) had consulted a psychiatrist previously.
Comparisons by Current Age Participants younger than age 60 (N⳱628) were compared with those ⱖage 60 (N⳱182). There was no significant difference in the gender ratio between the two groups, but those age 60-and-over were more likely to have been married (CCv2[1]⳱14.05; p ⬍0.001), had lower occupational status (CCv2[1]⳱3.75; p⳱ 0.047) and completed fewer years of education (Uz ⳱ –11.45; p ⬍0.001). Psychotic and melancholic depression were overrepresented in those ⱖage 60 years (⬍age 60: 6.5% psychotic, 31.1% melancholic; ⱖage 60: 29.1% psychotic, 52.2% melancholic; v2[2]⳱131.02; p ⬍0.001; Table 1). There were significant differences between the two groups on almost every clinical variable assessed (Table 1). Patients age 60 years and over had significantly higher scores on the clinician-rated Ham-D–17, HAMPSY, Newcastle, CORE Total, and CORE subscores, and significantly lower scores on the selfreport GHQ–30 and Zung. There was a significant increase with age (by decade) in the discrepancy between clinician- and self-reported ratings of depression severity when Ham-D–17 was plotted against the self-completed depression score (F[7]⳱ 10.713; p ⬍0.001. BDI and Zung z scores were used to allow combination of successive cohorts; Figure 1). With regard to specific symptoms, older patients were more likely to exhibit delusions, motor agitation, severe guilt, and hypochondriasis, and less likely to report hypersomnia. To address the possibility that differences in the CORE scores were due to the overrepresentation of psychotic depression, analyses were repeated for non-psychotic patients only, yielding similar results. Within the ⱖ60 age-
591
592 628 41 (6.5) 195 (31.1) 392 (62.4) 628 26 (4.1) 628 54 (8.6) 628 399 (63.5) 237 (37.7) 626 171 (27.3) 605 159 (26.3) 242 217 (89.7) 146 (60.3) 71 (29.3) 242 23 (9.5) 21 (8.7) 2 (0.8)
N (%)
349 357 165 621 242c 242c 446 544 446 446 446 446
N
ⱖ60 Years
182 53 (29.1) 95 (52.2) 34 (18.7) 182 13 (7.1) 182 55 (30.2) 182 124 (68.1) 76 (41.8) 182 21 (11.5) 152 70 (46.1) 40 39 (97.5) 12 (30.0) 27 (67.5) 40 14 (35.0) 13 (32.5) 1 (2.5)
N (%)
ⱖ60 Years
21.2 (8.4) 53.4 (9.5) 25.9 (11.4) 22.2 (8.0) 9.8 (3.3) 15.2 (5.0) 45.8 (14.4) 5.8 (2.6) 11.8 (7.0) 4.6 (3.1) 2.7 (2.5) 6.1 (4.1)
Mean (SD) 123 123 27 179 40 40 122 176 122 122 122 122
N 0.009 0.0021 0.041 ⬍0.001 ⬍0.001 0.004 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
ⳮ2.62 ⳮ3.07 a* 2.06[190] b ⳮ5.07 a* ⳮ3.77[280] b,d* ⳮ2.88[280] b,d ⳮ4.97 a* ⳮ11.31 a* ⳮ9.36 a* ⳮ8.38 a* ⳮ7.97 a* ⳮ9.70 a*
N (%) 111 30 (27.0) 59 (53.2) 22 (19.8) 111 8 (7.2) 111 30 (27.0) 111 74 (66.7) 47 (42.3) 111 14 (12.6) 94 37 (39.4) 27 26 (96.3) 11 (40.7) 15 (55.6) 27 9 (33.3) 8 (29.6) 1 (3.7)
p ⬍0.001
0.114 ⬍0.001
0.291 0.342 ⬍0.001 ⬍0.001
0.144 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 0.369
2.16[1]e 54.80[1]e* 1.11[1]e 0.80[1]e 18.52[1]e* 21.58[1]e* 1.67[1]e 11.62[1]e* 20.40[1]e* 17.40[1]e* 16.20[1]e* 0.02[1]e
60–69 Years
22.1 (8.2) 54.4 (9.9) 26.1 (12.4) 22.5 (7.7) 9.0 (2.8) 14.8 (5.3) 45.7 (14.7) 5.4 (2.7) 10.6 (6.4) 4.2 (3.0) 2.4 (2.1) 5.7 (4.1)
N 81 78 17 108 27 27 76 105 76 76 76 76
60–69 Years Mean (SD)
131.02[2]f*
Statistic[df]
a
p
Statistic[df]
ⱖ70 Years
71 23 (32.4) 36 (50.7) 12 (16.9) 71 5 (7.0) 71 25 (35.2) 71 50 (70.4) 29 (40.8) 71 7 (9.9) 58 33 (56.9) 13 13 (100.0) 1 (7.7) 12 (92.3) 13 5 (38.5) 5 (38.5) 0 (0.0)
N (%)
ⱖ70 Years
19.7 (8.7) 51.7 (8.5) 25.7 (10.1) 21.9 (8.4) 11.3 (3.7) 15.9 (4.5) 45.9 (13.9) 6.4 (2.3) 13.7 (7.6) 5.3 (3.2) 3.3 (2.9) 6.7 (4.0)
Mean (SD) 42 45 10 71 13 13 46 71 46 46 46 46
N
0.00[1]a 0.04[1]a 0.00[1]a
0.00[1]a 3.13[1]a 3.86[1]a
3.76[1]a
0.14[1]a 0.00[1]a 0.11[1]a
1.02[1]a
0.00[1]a
0.68[2]f
Statistic[df]
ⳮ1.74 1.54[121]b 0.08[25]b 0.49[177]b ⳮ2.18[38]b,d ⳮ0.67[38]b ⳮ0.07[120]b ⳮ2.44a ⳮ2.39[120]b ⳮ2.06[120]b ⳮ2.25[120]b,d ⳮ1.36[120]b a
Statistic[df]
1.000 0.722 1.000
1.000 0.063 0.030
0.045
0.628 0.878 0.641
0.251
1.000
0.713
p
0.082 0.126 0.939 0.628 0.036 0.508 0.947 0.015 0.019 0.041 0.026 0.178
p
Note: SD: standard deviation; GHQ–30: General Health Questionnaire (30-item); Zung: Zung Depression Scale; BDI: Beck Depression Inventory; Ham-D–17: Hamilton Rating Scale for Depression (17-item); HAMPSY: Ham-D Psychiatric subscale; HAMSOM: Ham-D Somatic subscale; GAF: Global Assessment of Functioning; Newcastle: Newcastle Endogenous Depression Inventory. Participants completed either the Zung or the BDI. Ns vary because of the combination, for the purpose of analysis, of different clinical databases using slightly different interview schedules over time, and because of missing data. a Mann-Whitney Uz, if data were unable to be transformed successfully for significant skew. b two-sample t-test. c Early databases did not have individual Ham-D items available. d After successful square-root transformation for significant positive skew. e CCv2 f 2 v g From clinician-structured interview. h from CORE. i from Ham-D. * p ⱕ0.0025 (Bonferroni correction).
Hierarchical diagnosis Psychotic Melancholic Non-melancholic Hallucinationsg Present Delusionsg Present Appetite decreaseg Any Marked Hypersomniag Present Motor Agitationh Present Guilti Any Mild/moderate Severe Hypochondriasisi Any Mild/moderate Severe
Symptom
⬍60 Years
23.1 (8.1) 56.0 (8.8) 30.7 (11.0) 19.1 (6.5) 8.0 (2.4) 12.8 (4.4) 52.3 (12.5) 2.9 (2.6) 5.4 (5.8) 2.2 (3.0) 1.2 (1.5) 2.2 (2.9)
GHQ–30 Zung BDI Ham-D–17 HAMPSY HAMSOM GAF Newcastle CORE Total CORE Retardation CORE Agitation CORE Non-Interactiveness
Current Age
Mean (SD)
Variable
⬍60 Years
Comparisons by Current Age
Current Age
TABLE 1.
Depression, Age, and Gender
Am J Geriatr Psychiatry 13:7, July 2005
Brodaty et al. group, the possibility that the results were due to greater use of antipsychotic medication in older patients with melancholic depression was discounted by a post-hoc analysis. Of patients with non-psychotic melancholic depression, antipsychotic medication was used by 5.1% of those under age 60 and 7.7% of those age 60 and over. We also compared those age 60 to 69 and those age 70 and over, in order to explore whether 60 was too low a cut-off point in the analysis of age difference (Table 1). The absence of significant differences between these age-groups indicates that the over-60 subjects were relatively homogeneous in their symptomatology. Comparisons by Age at Onset Participants currently over age 60 were dichotomized by whether the first onset of their depression was before age 60 (EO; N⳱92) or at age 60 or later (LO; N⳱86; age-at-onset unknown for 4 participants). Because LO patients were significantly older than their EO counterparts (LO mean age: 70.5; SD: 6.8; EO mean age: 66.1; SD: 4.9; Uz ⳱ –4.48; p ⬍0.001), current age was used as a covariate in the analyses of continuous variables. EO and LO patients did not differ with regard to gender, marital status, occupation, FIGURE 1.
Disparity of Self-Rated Versus Clinician-Rated Depression Scores by Decade of Age
0.8 0.6
Disparity Score
0.4 0.2 0.0 –0.2 –0.4
or hierarchical depression diagnosis. There were no significant differences on any variable assessed, except that hypochondriasis was more common in LO patients (Table 2). We compared those with age-at-onset 60–69 and those with age-at-onset ⱖ70 in order to investigate the degree of homogeneity among the LO patients. There were no significant differences on any of the variables (Table 2). Gender Differences There were no gender differences between any pair of comparison groups with regard to the distribution of psychotic, melancholic, and non-melancholic depression types. A direct comparison of men and women, covarying for current age, showed no differences. A series of 2 ⳯ 2 ANOVAs revealed no significant interactions of age (under-60 versus ⱖ60) and gender for GHQ–30, Zung, BDI, Ham-D, HAMPSY, HAMSOM, GAF, Newcastle, CORE Total, Retardation, Agitation, or Non-Interactiveness. For categorical variables (hierarchical diagnosis, hallucinations, delusions, appetite decrease, hypersomnia, motor agitation, guilt, hypochondriasis), the age ⳯ gender interaction was tested by fitting a fully-saturated loglinear model and then examining whether there was a significant reduction in chi-square when the age ⳯ gender ⳯ outcome interaction term was removed from the model. There was no significant reduction in the chi-square value when the interaction was removed for any of these variables. Differing patterns emerged when the current age analyses were repeated for men and women separately. The lower Zung scores found in the ⱖ60 (versus ⬍60) subjects were more likely in women (Uz ⳱ –2.619; p⳱0.009, and Uz ⳱ –1.652; p⳱0.099 for women and men, respectively), as were the increased frequencies of motor agitation (CCv2[1]⳱17.1; p ⬍0.001, and CCv2[1]⳱3.57; p⳱0.044 for women and men, respectively) and severe guilt (CCv2[1]⳱15.5; p ⬍0.001, and CCv2[1]⳱3.9; p⳱0.035 for women and men, respectively).
–0.6
First Episode Versus Recurrence –0.8 teens
20s
30s
40s
50s
Age by Decade
Am J Geriatr Psychiatry 13:7, July 2005
60s
70s
80s
Men were more likely than women to be presenting with their first episode of depression (v2[1]⳱14.88; p ⬍0.001). A comparison of phenomenology in pa-
593
594 92 22 (23.9) 51 (55.4) 19 (20.7) 92 10 (10.9) 92 21 (22.8) 92 59 (64.1) 33 (35.9) 92 11 (12.0) 83 37 (44.6) 16 15 (93.8) 8 (50.0) 7 (43.8) 16 1 (6.3) 1 (6.3) 0 (0.0)
N (%)
71 67 11 89 16 16 55 90 55 55 55 55
N
ⱖ60 Years
86 31 (36.0) 41 (47.7) 14 (16.3) 86 3 (3.5) 86 34 (39.5) 86 65 (75.6) 43 (50.0) 86 9 (10.5) 65 30 (46.2) 23 23 (100.0) 4 (17.4) 19 (82.6) 23 13 (56.5) 12 (52.2) 1 (4.3)
N (%)
ⱖ60 Years
22.1 (8.1) 54.2 (9.7) 26.2 (12.4) 23.2 (8.2) 10.7 (3.6) 15.9 (5.6) 44.0 (13.7) 6.2 (2.2) 13.2 (7.5) 5.1 (3.2) 3.1 (2.9) 6.6 (4.2)
Mean (SD) 49 53 15 86 23 23 66 82 66 66 66 66
N
p 0.205
0.083 0.023
0.105 0.069 0.815 0.869
0.410 0.041 0.017 0.0018 0.005 1.000
3.17[2]d
2.57[1]c 5.06[1]c 2.24[1]c 3.07[1]c 0.01[1]c 0.00[1]c 0.03[1]c 3.30[1]c 4.78[1]c 8.29[1]c* 7.01[1]c 0.00[1]c
0.188 0.236 0.961 0.192 0.030 0.483 0.248 0.038 0.040 0.153 0.165 0.292
p
Statistic[df]
1.70[2] 1.46[2]a 0.04[2]a 1.67[2]a 3.85[2]a,b 0.74[2]a 1.41[2]a 3.35[2]a 3.31[2]a 1.91[2]a 1.83[2]a,b 1.24[2]a
a
Statistic[df]
53 21 (39.6) 24 (45.3) 8 (15.1) 53 2 (3.8) 53 21 (39.6) 53 38 (71.7) 27 (50.9) 53 5 (9.4) 42 16 (38.1) 17 17 (100.0) 4 (23.5) 13 (76.5) 17 10 (58.8) 9 (52.9) 1 (5.9)
N (%)
60–69 Years
23.0 (7.6) 55.9 (9.9) 26.0 (13.8) 23.8 (8.0) 10.3 (3.3) 15.5 (6.4) 43.3 (14.5) 6.2 (2.4) 12.8 (7.2) 5.1 (3.5) 2.7 (2.1) 6.8 (4.4)
Mean (SD) 31 33 10 53 17 17 44 49 44 44 44 44
N
33 10 (30.3) 17 (51.5) 6 (18.2) 33 1 (3.0) 33 13 (39.4) 33 27 (81.8) 16 (48.5) 33 4 (12.1) 23 14 (60.9) 6 6 (100.0) 0 (0.0) 6 (100.0) 6 3 (50.0) 3 (50.0) 0 (0.0)
N (%)
ⱖ70 Years
20.6 (8.8) 51.5 (8.8) 26.6 (10.5) 22.4 (8.6) 12.0 (4.7) 17.0 (2.4) 45.3 (12.4) 6.3 (2.0) 13.9 (8.1) 5.0 (2.6) 4.0 (3.9) 6.3 (3.8)
Mean (SD)
60–69 Years
18 20 5 33 6 6 22 33 22 22 22 22
N
0.00[1]c 0.00[1]c 0.00[1]c
— 0.46[1]c 0.46[1]c
2.25[1]c
0.65[1]c 0.00[1]c 0.00[1]c
0.00[1]c
0.00[1]c
0.78[2]d
Statistic[df]
0.69[2] 1.36[2]a 0.03[2]a 0.72[2]a 0.39[2]a,b 0.22[2]a 0.67[2]a 0.70[2]a 1.74[2]a 0.36[2]a 1.60[2]a,b 0.76[2]a
a
Statistic[df]
ⱖ70 Years
1.000 1.000 1.000
— 0.539 0.539
0.118
0.317 1.000 0.728
1.000
1.000
0.679
p
0.507 0.266 0.971 0.489 0.684 0.805 0.518 0.499 0.183 0.698 0.209 0.471
p
Note: The total number of subjects ⱖ60 years old is less than N shown in Table 1 because age-at-onset data were missing for four subjects. Participants completed either the Zung or the BDI. Ns vary because of the combination, for the purpose of analysis, of different clinical databases, using slightly different interview schedules over time and because of missing data. GHQ–30: General Health Questionnaire (30-item); Zung: Zung Depression Scale; BDI: Beck Depression Inventory; Ham-D–17: Hamilton Rating Scale for Depression (17-item); HAMPSY: Ham-D Psychiatric subscale; HAMSOM: Ham-D Somatic subscale; GAF: Global Assessment of Functioning; Newcastle: Newcastle Endogenous Depression Inventory. a ANCOVA (covarying for current age) F value. b After successful square-root transformation for significant positive skew. c CC v2 d 2 v e From clinician structured interview. f from CORE. g from Ham-D. *p ⱕ0.0025 (Bonferroni-corrected).
Hierarchical diagnosis Psychotic Melancholic Non-melancholic Hallucinationse Present Delusionse Present Appetite decreasee Any Marked Hypersomniae Present Motor agitationf Present Guiltg Any Mild/moderate Severe Hypochondriasisg Any Mild/moderate Severe
Symptom
⬍60 Years
20.5 (8.7) 53.3 (9.1) 24.9 (10.8) 21.5 (7.8) 8.5 (2.2) 14.0 (4.2) 48.1 (15.0) 5.4 (2.8) 10.0 (5.9) 4.0 (2.9) 2.2 (1.7) 5.4 (4.0)
GHQ–30 Zung BDI Ham-D–17 HAMPSY HAMSOM GAF Newcastle CORE Total CORE Retardation CORE Agitation CORE Non-Interactiveness
Age at Onset
Mean (SD)
Variable
⬍60 Years
Comparisons by Age at Onset in Patients ⱖ60 Years Old
Age at Onset
TABLE 2.
Depression, Age, and Gender
Am J Geriatr Psychiatry 13:7, July 2005
Brodaty et al. tients experiencing their first or a subsequent episode of depression found no significant differences.
DISCUSSION Our first aim was to replicate previous findings regarding the relationships between current age and age at onset and depression. In this mixed-age sample of DSM-defined unipolar major-depression patients referred to an MDU, certain diagnoses (melancholia, psychosis) and clinical features (psychomotor agitation, retardation and non-interactiveness, hypochondriasis, and severe guilt) were more common in older patients; hypersomnia was less common. Clinicianrated severity of depression increased with age. These effects appeared to be related to age and not to depressive recurrence. As hypothesized, age at onset of depression had little appreciable influence on these findings, with one exception: hypochondriasis occurred more frequently in LO patients. We confirmed the distinction between severity for subjectively-rated and clinician-rated measures. Subjective depression scale scores were lower in older patients; objective scale scores were higher. This disparity increased markedly with age, possibly reflecting differences in scale items or the propensity for older people to be more accepting of depressive symptoms as normal. The implications for clinicians are important: waiting for spontaneous complaints of depression is likely to result in missed cases. The new findings concern the differing effects of age for each gender and an exploration of phenomenology in the older age-groups. The results confirm our previous findings on phenomenology by current age and age at onset. Our findings extend the previous reports in that we could not demonstrate any difference between the young-old (age 60–69) and the older-old (age 70 years or more). The findings on the differing effects for each gender
of age on phenomenology of depression are intriguing. The older the women, the more likely they were to experience motor agitation, severe guilt, psychomotor changes, and more severe psychological symptoms of depression. The men did not show such a pronounced age-related pattern. Furthermore, this gender effect was apparent only when examined in conjunction with age. Although elderly men and women are not significantly different from each other when viewed cross-sectionally, their lifetime trajectories of depressive phenomenology may differ, diverging by age 60. This may reflect a combination of different factors, such as the increased acceptance of depression in older women, or a differential referral bias for men and women. The small sample size of men in the decades after 70 reduced the power of analyses of the interaction of age and gender. As in younger-age samples, women had more severe depression.39 Although diagnostic subtypes of unipolar depression were similar for men and women regardless of age, older women showed more agitation and severe guilt than did younger women. Severity of psychomotor disturbance increased in older age among the elderly women but not the men. In conclusion, melancholic and psychotic depression appear more common with older age in patients with recurrent unipolar depression referred to a mood disorders unit. Phenomenological differences with older age: more hypochondriasis, guilt, and decreased appetite, were confirmed. Older people tend to underreport the severity of their symptoms. Age at onset has little influence on phenomenology. Effects of older age on phenomenology of depression appear more pronounced in women. We are grateful to Annette Koschera and Dusan Hadzi-Pavlovic for their statistical advice, and to Kay Parker for access to the databases. This project was funded by NHMRC Program Grant #222708 and Eli Lilly, Australia.
References 1. Zung W: A self-rated depression scale. Arch Gen Psychiatry 1965; 12:63–70 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition. Washington, DC, American Psychiatric Association, 1968 3. Brown R, Sweeney J, Loutsch E, et al: Involutional melancholia revisited. Am J Psychiatry 1984; 141:24–28
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4. Ruegg R, Zisook S, Swedlow N: Depression in the aged, an overview. Psychiatr Clin North Am 1988; 11:83–89 5. Gurland B: The comparative frequency of depression in various adult age-groups. J Gerontol 1976; 31:283–292 6. Blazer D, Bachar J, Hughes D: Major depression with melancholia: a comparison of middle-aged and elderly adults. J Am Geriatr Soc 1987; 35:927–932
595
Depression, Age, and Gender 7. Musetti L, Perugi G, Soriani A, et al: Depression before and after age 65. Br J Psychiatry 1989; 155:330–336 8. Brodaty H, Peters K, Boyce P, et al: Age and depression. J Affect Disord 1991; 23:137–149 9. Brodaty H, Luscombe G, Parker G, et al: Increased rate of psychosis and psychomotor change in depression with age. Psychol Med 1997; 27:1205–1213 10. Krishnan K, Hays J, Tupler L, et al: Clinical and phenomenological comparisons of late-onset and early-onset depression. Am J Psychiatry 1995; 152:785–788 11. Alexopoulos G, Young R, Meyers B, et al: Late-onset depression. Psychiatr Clin North Am 1988; 11:101–115 12. Brodaty H, Luscombe G, Parker G, et al: Early- and late-onset depression in old age: different aetiologies, same phenomenology. J Affect Disord 2001; 66:225–236 13. Conwell Y, Nelson J, Kim K, et al: Depression in late life: age at onset as marker of a subtype. J Affect Disord 1989; 17:189–195 14. Carroll B: Psychopathology and neurobiology of manic-depressive disorders, in Psychopathology and the Brain. Edited by Carroll B, Barrett J. New York, Raven, 1991, pp 265–285 15. Brodaty H: Melancholia and the ageing brain, in Melancholia: A Disorder of Mood, Movements, and Thought. Edited by Parker G, Hadzi-Pavlovic D. New York, Cambridge University Press, 1996, pp 237–251 16. Weissman M, Klerman G: The chronic depressive in the community: unrecognized and poorly treated. Compr Psychiatry 1977; 18:523–532 17. Nolen-Hoeksema S: Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987; 101:259–282 18. Frank E, Carpenter L, Kupfer D: Sex differences in recurrent depression: are there any that are significant? Am J Psychiatry 1988; 145:41–45 19. Perugi G, Musetti L, Simonini E, et al: Gender-mediated clinical features of depressive illness: the importance of temperamental differences. Br J Psychiatry 1990; 157:835–841 20. Silverstein B: Gender differences in the prevalence of somatic versus pure depression: a replication. Am J Psychiatry 2002; 159:1051–1052 21. Carter J: Gender differences in the presentation of depressed outpatients: a comparison of descriptive variables. J Affect Disord 2000; 61:59–67 22. Koekler M, Heun R: Gender differences of depressive symptoms in depressed and nondepressed elderly persons. Int J Geriatr Psychiatry 2002; 17:65–72
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23. Korten A, Henderson S: The Australian National Survey of Mental Health and Well-Being: common psychological symptoms and disablement. Br J Psychiatry 2000; 177:325–330 24. Andrews G, Henderson S, Hall W: Prevalence, comorbidity, disability, and service utilisation: overview of the Australian National Mental Health Survey. Br J Psychiatry 2001; 178:145–153 25. Bebbington P: The influence of age and sex on the prevalence of depressive conditions: Report from the National Survey of Psychiatric Morbidity. Psychol Med 1998; 28:9–19 26. Forsell Y, Jorm A, Wingblad B: Association of age, sex, cognitive dysfunctions, and disability with major depressive symptoms in an elderly sample. Am J Psychiatry 1994; 151:1600–1604 27. Lavretsky H: Relationship of age, age at onset, and sex to depression in older adults. Am J Geriatr Psychiatry 1998; 6:248– 256 28. Brodaty H, Harris L, Wilhelm K, et al: Lessons from a mood-disorders unit. Aust N Z J Psychiatry 1993; 27:254–263 29. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987 30. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994 31. Goldberg D: The detection of psychiatric illness by questionnaire. London, UK, Oxford University Press, 1972 32. Beck A, Ward C, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561–571 33. Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56–62 34. Troisi A, Pasini A, Gori G, et al: Clinical predictors of somatic and psychological symptoms of depression in Alzheimer’s disease. Int J Geriatr Psychiatry 1996; 11:23–27 35. Carney M, Roth M, Garside R: The diagnosis of depressive symptoms and the prediction of ECT response. Br J Psychiatry 1965; 111:659–674 36. Parker G, Hadzi-Pavlovic D: Melancholia: A Disorder of Movement and Mood. New York, Cambridge University Press, 1996 37. Daniel A: Power, Privilege, and Prestige: Occupations in Australia. Melbourne, Australia, Longman Cheshire, 1983 38. SPSS 11: Statistical Package for the Social Sciences (SPSS). Chicago, IL, SPSS Inc., 2001 39. Chen L-S, Eaton W, Gallo J, et al: Understanding the heterogeneity of depression through the triad of symptoms, course, and risk factors: a longitudinal, population-based study. J Affect Disord 2000; 59:1–11
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Objective: Authors investigated the effects of current age, age at onset, and gender on the phenomenology of depression. Methods: A mixed-age sample of 810 Mood Disorders Unit attendees with a diagnosis of unipolar major depressive episode at or near its nadir were interviewed by clinician-rated and self-report instruments assessing symptoms and severity of depression. Results: Differences were found in depressive phenomenology according to current age but not age at onset, confirming previous findings. Age differences on several variables were found in women only. Subjective ratings of depression severity decreased with age, whereas objective, clinician-rated severity increased. Conclusions: The pattern and severity of depression change with increasing age. Longitudinal prospective studies would further elucidate this age– gender relationship. Clinicians should be aware of the decreased likelihood of older patients’ reporting of depressive symptoms themselves. (Am J Geriatr Psychiatry 2005; 13:589–596)
S
ome findings of the relationship between age and phenomenology of depression have indicated that withdrawal, apathy, lack of interest, lack of drive, suicidality, and guilt are overrepresented in elderly patients;1–4 others have found no such differences.5–7 We noted that elderly patients had more severe depression on clinician-rated, but not self-report, instruments, and were more likely to manifest delusions, hallucinations, agitation, hypochondriasis, marked guilt, and decreased appetite.8,9
The age at onset of first depressive episode may be relevant. Researchers have separated elderly patients with depression into those with early-onset (EO), that is, first onset of depression typically before 60 years, from those with late-onset (LO) illness, that is, first onset of depression in late life, typically 60 years or older. LO patients may have higher rates of apathy,10 delusions,11 and hypochondriasis;3,12 however, these findings have been refuted by others.7,8,13,14 These differences may be explained by different age cut-off
Received November 9, 2003; revised June 18, July 29, 2004; accepted August 2, 2004. From the Academic Dept. for Old-Age Psychiatry (HB,BC,CT), the Mood Disorders Unit, Black Dog Institute, Prince of Wales Hospital, Sydney, Australia (HB,PM,GP,KW,MPA,GM), and the School of Psychiatry, University of New South Wales, Sydney, Australia (HB,PM,GP,KW,MPA,GM). Send correspondence and reprint requests to Prof. Henry Brodaty, Academic Dept. for Old-Age Psychiatry, Euroa Centre, Prince of Wales Hospital, Randwick, NSW 2031, AUSTRALIA. e-mail: [email protected] 䉷 2005 American Association for Geriatric Psychiatry
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Depression, Age, and Gender points used to separate younger from older (and EO from LO) patients, and by differing types of depression.3,7–10,12 The lack of investigation of cut-off points later than 65 years reflects small sample sizes, a limitation addressed here. The accumulation of agerelated pathology, especially cerebrovascular, should be more apparent in older age;15 differences in phenomenology may only manifest themselves in patients age 70 or beyond. The influence of current age and age at onset on depression phenomenology may be influenced by gender. Lifetime prevalence of depression in women is about twice that in men;16,17 possible differences in phenomenology between depressed men and women are less clear18–22 and appear to diminish with age, because of a number of factors, including a mellowing effect of age, leading to lower neuroticism scores, less comorbid anxiety, and increased psychological well-being in women and higher rates of depression in men with age.23–25 Older depressed women with depression may have more mood-related depressive symptoms26 and more appetite disturbance22 than older men, who may, in turn, have more motivational symptoms,26 be more agitated22 and more severely depressed, have more neurovegetative symptoms, and be at greater risk for late-onset depression27 than older women. The aims of the present study were fourfold: 1) to corroborate previous findings on current-age and ageat-onset differences in depression phenomenology by use of a much larger sample; 2) to corroborate agerelated differences between self-report and clinicianrated severity of depression; 3) to explore a cut-off point older than 60 years for current age and age at onset for variability in phenomenology; and 4) to investigate the relationship between gender and current age and age at onset on depression phenomenology. We hypothesized that: 1) older patients would report more symptoms overall, and more neurovegetative melancholic symptoms than younger patients; 2) there would be an increasing discrepancy between selfreport and clinician-rated severity with age; 3) age at onset of depression in older-aged patients would not differentiate phenomenology; 4) differences in phenomenology would remain unchanged by using an older age cut-off point; and 5) the influence of current age and age at onset of depression would be influenced by gender differences.
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METHODS Participants The sample comprised 1,199 consecutive inpatient and outpatient referrals to the Mood Disorders Unit (MDU) at Prince of Wales Hospital, Sydney. The MDU is a general hospital tertiary-referral unit, whose referrals come equally from general practitioners and psychiatrists.28 We have reported on 717 of these patients, of whom 527 had unipolar major depression.9,10,13 The present article combines those samples with eligible subjects from 482 additional patients assessed at the MDU. Diagnoses were made using clinical and DSM-III-R29 or DSM-IV30 criteria using structured interviews and diagnostic algorithms. In order to improve the homogeneity of the sample, we focused only on those patients who were deemed to be at or near the nadir of a unipolar major depressive episode (at least up to the point of assessment) and whose depression was not secondary to physical illness or substance abuse. Patients were further classified according to hierarchical, mutually exclusive DSM categories of psychotic, melancholic, and non-melancholic depression. Participants gave informed consent. Rating Instruments Patients completed the General Health Questionnaire, 30-item version (GHQ–30)31 and either the Zung Depression Scale1 or Beck Depression Inventory (BDI),32 depending on the cohort in which they were enrolled. Patients were rated by a clinician on the Hamilton Rating Scale for Depression (Ham-D– 17 or Ham-D–21,33 which yields a Total score as well as Psychiatric (HAMPSY) and Somatic (HAMSOM) subscores.34 Other clinician-rated scales used were the Global Assessment of Functioning (GAF),29 the Newcastle Endogenous Depression Inventory,35 and the CORE inventory (CORE I or CORE II) for signs of melancholic depression,36 which comprises three factorially independent subscales: Agitation, Retardation, and Non-Interactiveness. A clinician completed a structured interview for depression. On the basis of our previous research,9,10,13 we selected certain symptoms, assessed with the clinician structured interview, the CORE, and the Ham-D–17, to be examined separately. Sociodemographic data collected
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Brodaty et al. included age, gender, years of education, marital status, and occupational status as rated on the 7-point Daniel Prestige Scale.37 Family and medical history, personality type, and life stressors were assessed but are not reported here. Data Analysis Variables were checked for skewness and were transformed as appropriate. Comparisons between groups were made using two-sample t-tests for normally-distributed continuous data and MannWhitney U tests (denoted by Uz) for skewed continuous data that could not be transformed successfully. Between-groups comparisons of categorical data were made using chi-square tests (v2), with Yates’ continuity correction (CCv2) for 2 ⳯ 2 tables. Analyses of covariance (ANCOVAs) were used to compare groups on continuous variables by age at onset, covarying for current age. Multiple analyses of variance (MANOVAs) were computed with current age and age-at-onset by decade as the between-subjects factors, in order to investigate whether 60 was a suitable cut-off point for dichotomized analyses. Interactions were tested by univariate ANOVA for continuous variables and log-linear model testing for categorical variables. Alpha was set at 0.05, except where multiple comparisons necessitated the use of Bonferroni correction. All analyses were computed using the Statistical Package for the Social Sciences, Version 11.38
RESULTS Participants The sample of 1,199 patients was reduced to 810 after excluding 61 patients with bipolar disorder, 45 who did not fulfill criteria for current major depressive episode, 22 with a non-depression primary diagnosis, 8 with depression secondary to substance abuse, 4 with depression secondary to physical illness, and 249 who were not at or near the nadir of the episode. The remaining 810 participants, of whom 539 (66.5%) were women, had a mean age of 44.8 years (standard deviation [SD]: 16.3; range: 14–88), with 182 (22.5%) age ⱖ60 years and 71 (8.8%) ⱖ70 years. Of the 182 over age 60, there were 39 men and 72 women in their sixties; 14 men and 47 women in
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their seventies, and 4 men and 6 women in their eighties. Two hundred seventy-four (33.8%) had never been married, and 150 (18.8%) were classified as having high occupational status (Daniel Prestige Scale categories 1–3).37 Participants had completed a mean of 11.8 years of education (SD: 3.5; range: 0–25). Hierarchical diagnoses were the following: psychotic depression, 94 (11.6%); melancholic depression, 290 (35.8%), and non-melancholic depression, 426 cases (52.6%). The majority (588; 74.1%) had experienced at least one previous depressive episode, and most (679; 83.8%) had consulted a psychiatrist previously.
Comparisons by Current Age Participants younger than age 60 (N⳱628) were compared with those ⱖage 60 (N⳱182). There was no significant difference in the gender ratio between the two groups, but those age 60-and-over were more likely to have been married (CCv2[1]⳱14.05; p ⬍0.001), had lower occupational status (CCv2[1]⳱3.75; p⳱ 0.047) and completed fewer years of education (Uz ⳱ –11.45; p ⬍0.001). Psychotic and melancholic depression were overrepresented in those ⱖage 60 years (⬍age 60: 6.5% psychotic, 31.1% melancholic; ⱖage 60: 29.1% psychotic, 52.2% melancholic; v2[2]⳱131.02; p ⬍0.001; Table 1). There were significant differences between the two groups on almost every clinical variable assessed (Table 1). Patients age 60 years and over had significantly higher scores on the clinician-rated Ham-D–17, HAMPSY, Newcastle, CORE Total, and CORE subscores, and significantly lower scores on the selfreport GHQ–30 and Zung. There was a significant increase with age (by decade) in the discrepancy between clinician- and self-reported ratings of depression severity when Ham-D–17 was plotted against the self-completed depression score (F[7]⳱ 10.713; p ⬍0.001. BDI and Zung z scores were used to allow combination of successive cohorts; Figure 1). With regard to specific symptoms, older patients were more likely to exhibit delusions, motor agitation, severe guilt, and hypochondriasis, and less likely to report hypersomnia. To address the possibility that differences in the CORE scores were due to the overrepresentation of psychotic depression, analyses were repeated for non-psychotic patients only, yielding similar results. Within the ⱖ60 age-
591
592 628 41 (6.5) 195 (31.1) 392 (62.4) 628 26 (4.1) 628 54 (8.6) 628 399 (63.5) 237 (37.7) 626 171 (27.3) 605 159 (26.3) 242 217 (89.7) 146 (60.3) 71 (29.3) 242 23 (9.5) 21 (8.7) 2 (0.8)
N (%)
349 357 165 621 242c 242c 446 544 446 446 446 446
N
ⱖ60 Years
182 53 (29.1) 95 (52.2) 34 (18.7) 182 13 (7.1) 182 55 (30.2) 182 124 (68.1) 76 (41.8) 182 21 (11.5) 152 70 (46.1) 40 39 (97.5) 12 (30.0) 27 (67.5) 40 14 (35.0) 13 (32.5) 1 (2.5)
N (%)
ⱖ60 Years
21.2 (8.4) 53.4 (9.5) 25.9 (11.4) 22.2 (8.0) 9.8 (3.3) 15.2 (5.0) 45.8 (14.4) 5.8 (2.6) 11.8 (7.0) 4.6 (3.1) 2.7 (2.5) 6.1 (4.1)
Mean (SD) 123 123 27 179 40 40 122 176 122 122 122 122
N 0.009 0.0021 0.041 ⬍0.001 ⬍0.001 0.004 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001
ⳮ2.62 ⳮ3.07 a* 2.06[190] b ⳮ5.07 a* ⳮ3.77[280] b,d* ⳮ2.88[280] b,d ⳮ4.97 a* ⳮ11.31 a* ⳮ9.36 a* ⳮ8.38 a* ⳮ7.97 a* ⳮ9.70 a*
N (%) 111 30 (27.0) 59 (53.2) 22 (19.8) 111 8 (7.2) 111 30 (27.0) 111 74 (66.7) 47 (42.3) 111 14 (12.6) 94 37 (39.4) 27 26 (96.3) 11 (40.7) 15 (55.6) 27 9 (33.3) 8 (29.6) 1 (3.7)
p ⬍0.001
0.114 ⬍0.001
0.291 0.342 ⬍0.001 ⬍0.001
0.144 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 0.369
2.16[1]e 54.80[1]e* 1.11[1]e 0.80[1]e 18.52[1]e* 21.58[1]e* 1.67[1]e 11.62[1]e* 20.40[1]e* 17.40[1]e* 16.20[1]e* 0.02[1]e
60–69 Years
22.1 (8.2) 54.4 (9.9) 26.1 (12.4) 22.5 (7.7) 9.0 (2.8) 14.8 (5.3) 45.7 (14.7) 5.4 (2.7) 10.6 (6.4) 4.2 (3.0) 2.4 (2.1) 5.7 (4.1)
N 81 78 17 108 27 27 76 105 76 76 76 76
60–69 Years Mean (SD)
131.02[2]f*
Statistic[df]
a
p
Statistic[df]
ⱖ70 Years
71 23 (32.4) 36 (50.7) 12 (16.9) 71 5 (7.0) 71 25 (35.2) 71 50 (70.4) 29 (40.8) 71 7 (9.9) 58 33 (56.9) 13 13 (100.0) 1 (7.7) 12 (92.3) 13 5 (38.5) 5 (38.5) 0 (0.0)
N (%)
ⱖ70 Years
19.7 (8.7) 51.7 (8.5) 25.7 (10.1) 21.9 (8.4) 11.3 (3.7) 15.9 (4.5) 45.9 (13.9) 6.4 (2.3) 13.7 (7.6) 5.3 (3.2) 3.3 (2.9) 6.7 (4.0)
Mean (SD) 42 45 10 71 13 13 46 71 46 46 46 46
N
0.00[1]a 0.04[1]a 0.00[1]a
0.00[1]a 3.13[1]a 3.86[1]a
3.76[1]a
0.14[1]a 0.00[1]a 0.11[1]a
1.02[1]a
0.00[1]a
0.68[2]f
Statistic[df]
ⳮ1.74 1.54[121]b 0.08[25]b 0.49[177]b ⳮ2.18[38]b,d ⳮ0.67[38]b ⳮ0.07[120]b ⳮ2.44a ⳮ2.39[120]b ⳮ2.06[120]b ⳮ2.25[120]b,d ⳮ1.36[120]b a
Statistic[df]
1.000 0.722 1.000
1.000 0.063 0.030
0.045
0.628 0.878 0.641
0.251
1.000
0.713
p
0.082 0.126 0.939 0.628 0.036 0.508 0.947 0.015 0.019 0.041 0.026 0.178
p
Note: SD: standard deviation; GHQ–30: General Health Questionnaire (30-item); Zung: Zung Depression Scale; BDI: Beck Depression Inventory; Ham-D–17: Hamilton Rating Scale for Depression (17-item); HAMPSY: Ham-D Psychiatric subscale; HAMSOM: Ham-D Somatic subscale; GAF: Global Assessment of Functioning; Newcastle: Newcastle Endogenous Depression Inventory. Participants completed either the Zung or the BDI. Ns vary because of the combination, for the purpose of analysis, of different clinical databases using slightly different interview schedules over time, and because of missing data. a Mann-Whitney Uz, if data were unable to be transformed successfully for significant skew. b two-sample t-test. c Early databases did not have individual Ham-D items available. d After successful square-root transformation for significant positive skew. e CCv2 f 2 v g From clinician-structured interview. h from CORE. i from Ham-D. * p ⱕ0.0025 (Bonferroni correction).
Hierarchical diagnosis Psychotic Melancholic Non-melancholic Hallucinationsg Present Delusionsg Present Appetite decreaseg Any Marked Hypersomniag Present Motor Agitationh Present Guilti Any Mild/moderate Severe Hypochondriasisi Any Mild/moderate Severe
Symptom
⬍60 Years
23.1 (8.1) 56.0 (8.8) 30.7 (11.0) 19.1 (6.5) 8.0 (2.4) 12.8 (4.4) 52.3 (12.5) 2.9 (2.6) 5.4 (5.8) 2.2 (3.0) 1.2 (1.5) 2.2 (2.9)
GHQ–30 Zung BDI Ham-D–17 HAMPSY HAMSOM GAF Newcastle CORE Total CORE Retardation CORE Agitation CORE Non-Interactiveness
Current Age
Mean (SD)
Variable
⬍60 Years
Comparisons by Current Age
Current Age
TABLE 1.
Depression, Age, and Gender
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Brodaty et al. group, the possibility that the results were due to greater use of antipsychotic medication in older patients with melancholic depression was discounted by a post-hoc analysis. Of patients with non-psychotic melancholic depression, antipsychotic medication was used by 5.1% of those under age 60 and 7.7% of those age 60 and over. We also compared those age 60 to 69 and those age 70 and over, in order to explore whether 60 was too low a cut-off point in the analysis of age difference (Table 1). The absence of significant differences between these age-groups indicates that the over-60 subjects were relatively homogeneous in their symptomatology. Comparisons by Age at Onset Participants currently over age 60 were dichotomized by whether the first onset of their depression was before age 60 (EO; N⳱92) or at age 60 or later (LO; N⳱86; age-at-onset unknown for 4 participants). Because LO patients were significantly older than their EO counterparts (LO mean age: 70.5; SD: 6.8; EO mean age: 66.1; SD: 4.9; Uz ⳱ –4.48; p ⬍0.001), current age was used as a covariate in the analyses of continuous variables. EO and LO patients did not differ with regard to gender, marital status, occupation, FIGURE 1.
Disparity of Self-Rated Versus Clinician-Rated Depression Scores by Decade of Age
0.8 0.6
Disparity Score
0.4 0.2 0.0 –0.2 –0.4
or hierarchical depression diagnosis. There were no significant differences on any variable assessed, except that hypochondriasis was more common in LO patients (Table 2). We compared those with age-at-onset 60–69 and those with age-at-onset ⱖ70 in order to investigate the degree of homogeneity among the LO patients. There were no significant differences on any of the variables (Table 2). Gender Differences There were no gender differences between any pair of comparison groups with regard to the distribution of psychotic, melancholic, and non-melancholic depression types. A direct comparison of men and women, covarying for current age, showed no differences. A series of 2 ⳯ 2 ANOVAs revealed no significant interactions of age (under-60 versus ⱖ60) and gender for GHQ–30, Zung, BDI, Ham-D, HAMPSY, HAMSOM, GAF, Newcastle, CORE Total, Retardation, Agitation, or Non-Interactiveness. For categorical variables (hierarchical diagnosis, hallucinations, delusions, appetite decrease, hypersomnia, motor agitation, guilt, hypochondriasis), the age ⳯ gender interaction was tested by fitting a fully-saturated loglinear model and then examining whether there was a significant reduction in chi-square when the age ⳯ gender ⳯ outcome interaction term was removed from the model. There was no significant reduction in the chi-square value when the interaction was removed for any of these variables. Differing patterns emerged when the current age analyses were repeated for men and women separately. The lower Zung scores found in the ⱖ60 (versus ⬍60) subjects were more likely in women (Uz ⳱ –2.619; p⳱0.009, and Uz ⳱ –1.652; p⳱0.099 for women and men, respectively), as were the increased frequencies of motor agitation (CCv2[1]⳱17.1; p ⬍0.001, and CCv2[1]⳱3.57; p⳱0.044 for women and men, respectively) and severe guilt (CCv2[1]⳱15.5; p ⬍0.001, and CCv2[1]⳱3.9; p⳱0.035 for women and men, respectively).
–0.6
First Episode Versus Recurrence –0.8 teens
20s
30s
40s
50s
Age by Decade
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60s
70s
80s
Men were more likely than women to be presenting with their first episode of depression (v2[1]⳱14.88; p ⬍0.001). A comparison of phenomenology in pa-
593
594 92 22 (23.9) 51 (55.4) 19 (20.7) 92 10 (10.9) 92 21 (22.8) 92 59 (64.1) 33 (35.9) 92 11 (12.0) 83 37 (44.6) 16 15 (93.8) 8 (50.0) 7 (43.8) 16 1 (6.3) 1 (6.3) 0 (0.0)
N (%)
71 67 11 89 16 16 55 90 55 55 55 55
N
ⱖ60 Years
86 31 (36.0) 41 (47.7) 14 (16.3) 86 3 (3.5) 86 34 (39.5) 86 65 (75.6) 43 (50.0) 86 9 (10.5) 65 30 (46.2) 23 23 (100.0) 4 (17.4) 19 (82.6) 23 13 (56.5) 12 (52.2) 1 (4.3)
N (%)
ⱖ60 Years
22.1 (8.1) 54.2 (9.7) 26.2 (12.4) 23.2 (8.2) 10.7 (3.6) 15.9 (5.6) 44.0 (13.7) 6.2 (2.2) 13.2 (7.5) 5.1 (3.2) 3.1 (2.9) 6.6 (4.2)
Mean (SD) 49 53 15 86 23 23 66 82 66 66 66 66
N
p 0.205
0.083 0.023
0.105 0.069 0.815 0.869
0.410 0.041 0.017 0.0018 0.005 1.000
3.17[2]d
2.57[1]c 5.06[1]c 2.24[1]c 3.07[1]c 0.01[1]c 0.00[1]c 0.03[1]c 3.30[1]c 4.78[1]c 8.29[1]c* 7.01[1]c 0.00[1]c
0.188 0.236 0.961 0.192 0.030 0.483 0.248 0.038 0.040 0.153 0.165 0.292
p
Statistic[df]
1.70[2] 1.46[2]a 0.04[2]a 1.67[2]a 3.85[2]a,b 0.74[2]a 1.41[2]a 3.35[2]a 3.31[2]a 1.91[2]a 1.83[2]a,b 1.24[2]a
a
Statistic[df]
53 21 (39.6) 24 (45.3) 8 (15.1) 53 2 (3.8) 53 21 (39.6) 53 38 (71.7) 27 (50.9) 53 5 (9.4) 42 16 (38.1) 17 17 (100.0) 4 (23.5) 13 (76.5) 17 10 (58.8) 9 (52.9) 1 (5.9)
N (%)
60–69 Years
23.0 (7.6) 55.9 (9.9) 26.0 (13.8) 23.8 (8.0) 10.3 (3.3) 15.5 (6.4) 43.3 (14.5) 6.2 (2.4) 12.8 (7.2) 5.1 (3.5) 2.7 (2.1) 6.8 (4.4)
Mean (SD) 31 33 10 53 17 17 44 49 44 44 44 44
N
33 10 (30.3) 17 (51.5) 6 (18.2) 33 1 (3.0) 33 13 (39.4) 33 27 (81.8) 16 (48.5) 33 4 (12.1) 23 14 (60.9) 6 6 (100.0) 0 (0.0) 6 (100.0) 6 3 (50.0) 3 (50.0) 0 (0.0)
N (%)
ⱖ70 Years
20.6 (8.8) 51.5 (8.8) 26.6 (10.5) 22.4 (8.6) 12.0 (4.7) 17.0 (2.4) 45.3 (12.4) 6.3 (2.0) 13.9 (8.1) 5.0 (2.6) 4.0 (3.9) 6.3 (3.8)
Mean (SD)
60–69 Years
18 20 5 33 6 6 22 33 22 22 22 22
N
0.00[1]c 0.00[1]c 0.00[1]c
— 0.46[1]c 0.46[1]c
2.25[1]c
0.65[1]c 0.00[1]c 0.00[1]c
0.00[1]c
0.00[1]c
0.78[2]d
Statistic[df]
0.69[2] 1.36[2]a 0.03[2]a 0.72[2]a 0.39[2]a,b 0.22[2]a 0.67[2]a 0.70[2]a 1.74[2]a 0.36[2]a 1.60[2]a,b 0.76[2]a
a
Statistic[df]
ⱖ70 Years
1.000 1.000 1.000
— 0.539 0.539
0.118
0.317 1.000 0.728
1.000
1.000
0.679
p
0.507 0.266 0.971 0.489 0.684 0.805 0.518 0.499 0.183 0.698 0.209 0.471
p
Note: The total number of subjects ⱖ60 years old is less than N shown in Table 1 because age-at-onset data were missing for four subjects. Participants completed either the Zung or the BDI. Ns vary because of the combination, for the purpose of analysis, of different clinical databases, using slightly different interview schedules over time and because of missing data. GHQ–30: General Health Questionnaire (30-item); Zung: Zung Depression Scale; BDI: Beck Depression Inventory; Ham-D–17: Hamilton Rating Scale for Depression (17-item); HAMPSY: Ham-D Psychiatric subscale; HAMSOM: Ham-D Somatic subscale; GAF: Global Assessment of Functioning; Newcastle: Newcastle Endogenous Depression Inventory. a ANCOVA (covarying for current age) F value. b After successful square-root transformation for significant positive skew. c CC v2 d 2 v e From clinician structured interview. f from CORE. g from Ham-D. *p ⱕ0.0025 (Bonferroni-corrected).
Hierarchical diagnosis Psychotic Melancholic Non-melancholic Hallucinationse Present Delusionse Present Appetite decreasee Any Marked Hypersomniae Present Motor agitationf Present Guiltg Any Mild/moderate Severe Hypochondriasisg Any Mild/moderate Severe
Symptom
⬍60 Years
20.5 (8.7) 53.3 (9.1) 24.9 (10.8) 21.5 (7.8) 8.5 (2.2) 14.0 (4.2) 48.1 (15.0) 5.4 (2.8) 10.0 (5.9) 4.0 (2.9) 2.2 (1.7) 5.4 (4.0)
GHQ–30 Zung BDI Ham-D–17 HAMPSY HAMSOM GAF Newcastle CORE Total CORE Retardation CORE Agitation CORE Non-Interactiveness
Age at Onset
Mean (SD)
Variable
⬍60 Years
Comparisons by Age at Onset in Patients ⱖ60 Years Old
Age at Onset
TABLE 2.
Depression, Age, and Gender
Am J Geriatr Psychiatry 13:7, July 2005
Brodaty et al. tients experiencing their first or a subsequent episode of depression found no significant differences.
DISCUSSION Our first aim was to replicate previous findings regarding the relationships between current age and age at onset and depression. In this mixed-age sample of DSM-defined unipolar major-depression patients referred to an MDU, certain diagnoses (melancholia, psychosis) and clinical features (psychomotor agitation, retardation and non-interactiveness, hypochondriasis, and severe guilt) were more common in older patients; hypersomnia was less common. Clinicianrated severity of depression increased with age. These effects appeared to be related to age and not to depressive recurrence. As hypothesized, age at onset of depression had little appreciable influence on these findings, with one exception: hypochondriasis occurred more frequently in LO patients. We confirmed the distinction between severity for subjectively-rated and clinician-rated measures. Subjective depression scale scores were lower in older patients; objective scale scores were higher. This disparity increased markedly with age, possibly reflecting differences in scale items or the propensity for older people to be more accepting of depressive symptoms as normal. The implications for clinicians are important: waiting for spontaneous complaints of depression is likely to result in missed cases. The new findings concern the differing effects of age for each gender and an exploration of phenomenology in the older age-groups. The results confirm our previous findings on phenomenology by current age and age at onset. Our findings extend the previous reports in that we could not demonstrate any difference between the young-old (age 60–69) and the older-old (age 70 years or more). The findings on the differing effects for each gender
of age on phenomenology of depression are intriguing. The older the women, the more likely they were to experience motor agitation, severe guilt, psychomotor changes, and more severe psychological symptoms of depression. The men did not show such a pronounced age-related pattern. Furthermore, this gender effect was apparent only when examined in conjunction with age. Although elderly men and women are not significantly different from each other when viewed cross-sectionally, their lifetime trajectories of depressive phenomenology may differ, diverging by age 60. This may reflect a combination of different factors, such as the increased acceptance of depression in older women, or a differential referral bias for men and women. The small sample size of men in the decades after 70 reduced the power of analyses of the interaction of age and gender. As in younger-age samples, women had more severe depression.39 Although diagnostic subtypes of unipolar depression were similar for men and women regardless of age, older women showed more agitation and severe guilt than did younger women. Severity of psychomotor disturbance increased in older age among the elderly women but not the men. In conclusion, melancholic and psychotic depression appear more common with older age in patients with recurrent unipolar depression referred to a mood disorders unit. Phenomenological differences with older age: more hypochondriasis, guilt, and decreased appetite, were confirmed. Older people tend to underreport the severity of their symptoms. Age at onset has little influence on phenomenology. Effects of older age on phenomenology of depression appear more pronounced in women. We are grateful to Annette Koschera and Dusan Hadzi-Pavlovic for their statistical advice, and to Kay Parker for access to the databases. This project was funded by NHMRC Program Grant #222708 and Eli Lilly, Australia.
References 1. Zung W: A self-rated depression scale. Arch Gen Psychiatry 1965; 12:63–70 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition. Washington, DC, American Psychiatric Association, 1968 3. Brown R, Sweeney J, Loutsch E, et al: Involutional melancholia revisited. Am J Psychiatry 1984; 141:24–28
Am J Geriatr Psychiatry 13:7, July 2005
4. Ruegg R, Zisook S, Swedlow N: Depression in the aged, an overview. Psychiatr Clin North Am 1988; 11:83–89 5. Gurland B: The comparative frequency of depression in various adult age-groups. J Gerontol 1976; 31:283–292 6. Blazer D, Bachar J, Hughes D: Major depression with melancholia: a comparison of middle-aged and elderly adults. J Am Geriatr Soc 1987; 35:927–932
595
Depression, Age, and Gender 7. Musetti L, Perugi G, Soriani A, et al: Depression before and after age 65. Br J Psychiatry 1989; 155:330–336 8. Brodaty H, Peters K, Boyce P, et al: Age and depression. J Affect Disord 1991; 23:137–149 9. Brodaty H, Luscombe G, Parker G, et al: Increased rate of psychosis and psychomotor change in depression with age. Psychol Med 1997; 27:1205–1213 10. Krishnan K, Hays J, Tupler L, et al: Clinical and phenomenological comparisons of late-onset and early-onset depression. Am J Psychiatry 1995; 152:785–788 11. Alexopoulos G, Young R, Meyers B, et al: Late-onset depression. Psychiatr Clin North Am 1988; 11:101–115 12. Brodaty H, Luscombe G, Parker G, et al: Early- and late-onset depression in old age: different aetiologies, same phenomenology. J Affect Disord 2001; 66:225–236 13. Conwell Y, Nelson J, Kim K, et al: Depression in late life: age at onset as marker of a subtype. J Affect Disord 1989; 17:189–195 14. Carroll B: Psychopathology and neurobiology of manic-depressive disorders, in Psychopathology and the Brain. Edited by Carroll B, Barrett J. New York, Raven, 1991, pp 265–285 15. Brodaty H: Melancholia and the ageing brain, in Melancholia: A Disorder of Mood, Movements, and Thought. Edited by Parker G, Hadzi-Pavlovic D. New York, Cambridge University Press, 1996, pp 237–251 16. Weissman M, Klerman G: The chronic depressive in the community: unrecognized and poorly treated. Compr Psychiatry 1977; 18:523–532 17. Nolen-Hoeksema S: Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987; 101:259–282 18. Frank E, Carpenter L, Kupfer D: Sex differences in recurrent depression: are there any that are significant? Am J Psychiatry 1988; 145:41–45 19. Perugi G, Musetti L, Simonini E, et al: Gender-mediated clinical features of depressive illness: the importance of temperamental differences. Br J Psychiatry 1990; 157:835–841 20. Silverstein B: Gender differences in the prevalence of somatic versus pure depression: a replication. Am J Psychiatry 2002; 159:1051–1052 21. Carter J: Gender differences in the presentation of depressed outpatients: a comparison of descriptive variables. J Affect Disord 2000; 61:59–67 22. Koekler M, Heun R: Gender differences of depressive symptoms in depressed and nondepressed elderly persons. Int J Geriatr Psychiatry 2002; 17:65–72
596
23. Korten A, Henderson S: The Australian National Survey of Mental Health and Well-Being: common psychological symptoms and disablement. Br J Psychiatry 2000; 177:325–330 24. Andrews G, Henderson S, Hall W: Prevalence, comorbidity, disability, and service utilisation: overview of the Australian National Mental Health Survey. Br J Psychiatry 2001; 178:145–153 25. Bebbington P: The influence of age and sex on the prevalence of depressive conditions: Report from the National Survey of Psychiatric Morbidity. Psychol Med 1998; 28:9–19 26. Forsell Y, Jorm A, Wingblad B: Association of age, sex, cognitive dysfunctions, and disability with major depressive symptoms in an elderly sample. Am J Psychiatry 1994; 151:1600–1604 27. Lavretsky H: Relationship of age, age at onset, and sex to depression in older adults. Am J Geriatr Psychiatry 1998; 6:248– 256 28. Brodaty H, Harris L, Wilhelm K, et al: Lessons from a mood-disorders unit. Aust N Z J Psychiatry 1993; 27:254–263 29. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987 30. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994 31. Goldberg D: The detection of psychiatric illness by questionnaire. London, UK, Oxford University Press, 1972 32. Beck A, Ward C, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561–571 33. Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56–62 34. Troisi A, Pasini A, Gori G, et al: Clinical predictors of somatic and psychological symptoms of depression in Alzheimer’s disease. Int J Geriatr Psychiatry 1996; 11:23–27 35. Carney M, Roth M, Garside R: The diagnosis of depressive symptoms and the prediction of ECT response. Br J Psychiatry 1965; 111:659–674 36. Parker G, Hadzi-Pavlovic D: Melancholia: A Disorder of Movement and Mood. New York, Cambridge University Press, 1996 37. Daniel A: Power, Privilege, and Prestige: Occupations in Australia. Melbourne, Australia, Longman Cheshire, 1983 38. SPSS 11: Statistical Package for the Social Sciences (SPSS). Chicago, IL, SPSS Inc., 2001 39. Chen L-S, Eaton W, Gallo J, et al: Understanding the heterogeneity of depression through the triad of symptoms, course, and risk factors: a longitudinal, population-based study. J Affect Disord 2000; 59:1–11
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