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CEREBROVASCULAR RISK FACTORS AND DEPRESSION IN OLDER PRIMARY CARE PATIENTS
Abstracts risk factors or lesions do not develop depression. However, executive dysfunction, a syndrome that often accompanies “vascular depression,” appears to influence the course of geriatric depression. The author has observed that executive dysfunction is associated with chronicity as well as early relapse and recurrence of geriatric depression. This finding suggests that executive dysfunction is an essential part of the pathophysiology of depression and may be one of the central mechanisms by which vascular lesions produce depression. Functional imaging studies using activation techniques may clarify the pathophysiology of depressive syndromes associated with depression occurring in the context of vascular brain damage.
CEREBROVASCULAR RISK FACTORS AND DEPRESSION IN OLDER PRIMARY CARE PATIENTS. Jeffrey M. Lyness, M.D.
S
everal systemic conditions are known to be risk factors for cerebrovascular disease, including coronary artery disease, diabetes mellitus, hypertension, cigarette smoking, atrial fibrillation, and left ventricular hypertrophy. A significant association of these cerebrovascular risk factors (CVRFs) with depression would provide supportive evidence for the cerebrovascular model of depression. Our group had found previously that these CVRFs were not significantly associated with depressive severity in older psychiatric inpatients with major depression, nor for the most part was their prevalence elevated in these depressive patients compared with nondepressed community control subjects. The author has examined the relationship of CVRFs to depressive symptoms and syndromes in a broad group of older patients recruited from primary care settings. Cross-sectionally, CVRFs were not significantly associated with depressive diagnoses or symptoms in this group. In preliminary analyses, cumulative CVRF severity at intake to the study significantly and independently predicted depressive symptom severity at one year follow-up but did not predict depressive disorder diagnosis. These findings provide only limited support for the notion that the cerebrovascular model of depression might apply to the majority of older patients seen in primary care settings. However, there are limitations to the risk factor approach to testing an etiological model, especially over a relatively short follow-up time period. Future risk factor approaches must examine these issues over longer time frames in a variety of community- and treatment setting-based patient groups.
GLOBAL MEDICAL BURDEN AND LATE-LIFE MAJOR DEPRESSION: IMPLICATIONS FOR THE CEREBROVASCULAR MODEL. Anand Kumar, M.D.
D
epression in late life is consistently associated with medical comorbidity. This association has been demonstrated in inpatient, ambulatory, and long-term care set-
Am J Geriatr Psychiatry Supplement, Fall 1999
tings. A broad spectrum of medical disorders, including malignancies, cardiovascular, musculoskeletal, and metabolic disorders, are associated with mood disorders in late life. While vascular mechanisms may predominate in depression following acute vascular events such as stroke or myocardial infarction, the pathways leading to depression in more stable clinical populations remain unclear. Data from our laboratory suggest that high-intensity lesion volume, determined using MRI, correlates more significantly with overall medical comorbidity than with cerebrovascular risk factors. Atrophy and lesions appear to represent complementary, relatively independent pathways to latelife major depression (MDD). In this presentation, the authors discuss new data demonstrating that the total medical burden plays an important role in the pathophysiology of MDD in elderly patients. In primary care and other general clinical populations, where several vascular and nonvascular disorders coexist, a complex set of pathways may be responsible for mood disturbances. It may be premature to denote “purely vascular” mechanisms in mixed clinical settings where most cases of mood disorders are currently managed.
THE PROGNOSTIC IMPACT OF DEPRESSION IN PATIENTS WITH MYOCARDIAL INFARCTION: EVIDENCE FOR AND AGAINST THE VASCULAR HYPOTHESIS. Nancy Frasure-Smith, Ph.D.
T
his presentation will include data examining the symptom patterns and long-term prognostic consequences of depression assessed during hospitalization for an acute myocardial infarction (n⳱896). Although all patients had established coronary artery disease, those patients with evidence of greater risk of vascular problems (previous treatment for hypertension and/or diabetes; n⳱390) were significantly more likely to have elevated scores on the Beck Depression Inventory (BDIⱖ10; P⳱0.0028) during hospitalization. However, they were less likely to endorse the item reflecting guilt. Depressed patients with greater risk of vascular problems were more likely to remain depressed at 12 months than other depressed patients (P⳱0.001). Over 12 months depressed patients were at significantly higher risk of cardiac mortality than nondepressed patients (odds ratio⳱3.4; 95% CI⳱1.7 - 6.6; P⳱0.0003). This risk was independent of whether or not patients had evidence of vascular risk. There was, however, an interaction of depression, age, and vascular risk showing that while there was always an increase in mortality risk associated with depression, the mortality risk for those age ⱖ 65 was particularly marked for those with a history of treatment of hypertension or diabetes (odds ratio⳱11.1; 95% CI⳱2.4 - 52.0; P⳱0.0002). While post-MI patients with previous history of hypertension or diabetes
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CEREBROVASCULAR RISK FACTORS AND DEPRESSION IN OLDER PRIMARY CARE PATIENTS. Jeffrey M. Lyness, M.D.
S
everal systemic conditions are known to be risk factors for cerebrovascular disease, including coronary artery disease, diabetes mellitus, hypertension, cigarette smoking, atrial fibrillation, and left ventricular hypertrophy. A significant association of these cerebrovascular risk factors (CVRFs) with depression would provide supportive evidence for the cerebrovascular model of depression. Our group had found previously that these CVRFs were not significantly associated with depressive severity in older psychiatric inpatients with major depression, nor for the most part was their prevalence elevated in these depressive patients compared with nondepressed community control subjects. The author has examined the relationship of CVRFs to depressive symptoms and syndromes in a broad group of older patients recruited from primary care settings. Cross-sectionally, CVRFs were not significantly associated with depressive diagnoses or symptoms in this group. In preliminary analyses, cumulative CVRF severity at intake to the study significantly and independently predicted depressive symptom severity at one year follow-up but did not predict depressive disorder diagnosis. These findings provide only limited support for the notion that the cerebrovascular model of depression might apply to the majority of older patients seen in primary care settings. However, there are limitations to the risk factor approach to testing an etiological model, especially over a relatively short follow-up time period. Future risk factor approaches must examine these issues over longer time frames in a variety of community- and treatment setting-based patient groups.
GLOBAL MEDICAL BURDEN AND LATE-LIFE MAJOR DEPRESSION: IMPLICATIONS FOR THE CEREBROVASCULAR MODEL. Anand Kumar, M.D.
D
epression in late life is consistently associated with medical comorbidity. This association has been demonstrated in inpatient, ambulatory, and long-term care set-
Am J Geriatr Psychiatry Supplement, Fall 1999
tings. A broad spectrum of medical disorders, including malignancies, cardiovascular, musculoskeletal, and metabolic disorders, are associated with mood disorders in late life. While vascular mechanisms may predominate in depression following acute vascular events such as stroke or myocardial infarction, the pathways leading to depression in more stable clinical populations remain unclear. Data from our laboratory suggest that high-intensity lesion volume, determined using MRI, correlates more significantly with overall medical comorbidity than with cerebrovascular risk factors. Atrophy and lesions appear to represent complementary, relatively independent pathways to latelife major depression (MDD). In this presentation, the authors discuss new data demonstrating that the total medical burden plays an important role in the pathophysiology of MDD in elderly patients. In primary care and other general clinical populations, where several vascular and nonvascular disorders coexist, a complex set of pathways may be responsible for mood disturbances. It may be premature to denote “purely vascular” mechanisms in mixed clinical settings where most cases of mood disorders are currently managed.
THE PROGNOSTIC IMPACT OF DEPRESSION IN PATIENTS WITH MYOCARDIAL INFARCTION: EVIDENCE FOR AND AGAINST THE VASCULAR HYPOTHESIS. Nancy Frasure-Smith, Ph.D.
T
his presentation will include data examining the symptom patterns and long-term prognostic consequences of depression assessed during hospitalization for an acute myocardial infarction (n⳱896). Although all patients had established coronary artery disease, those patients with evidence of greater risk of vascular problems (previous treatment for hypertension and/or diabetes; n⳱390) were significantly more likely to have elevated scores on the Beck Depression Inventory (BDIⱖ10; P⳱0.0028) during hospitalization. However, they were less likely to endorse the item reflecting guilt. Depressed patients with greater risk of vascular problems were more likely to remain depressed at 12 months than other depressed patients (P⳱0.001). Over 12 months depressed patients were at significantly higher risk of cardiac mortality than nondepressed patients (odds ratio⳱3.4; 95% CI⳱1.7 - 6.6; P⳱0.0003). This risk was independent of whether or not patients had evidence of vascular risk. There was, however, an interaction of depression, age, and vascular risk showing that while there was always an increase in mortality risk associated with depression, the mortality risk for those age ⱖ 65 was particularly marked for those with a history of treatment of hypertension or diabetes (odds ratio⳱11.1; 95% CI⳱2.4 - 52.0; P⳱0.0002). While post-MI patients with previous history of hypertension or diabetes
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