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Late-life delusional depression
Journal of Affective Elsevier
133
Disorders, 11 (1986) 133-137
JAD 00396
Late-Life Delusional Depression Barnett
S. Meyers *J and Robert Greenberg
2
’ Department of Psychiatry, New York Hospital - Westchester Division, Cornell University Medrcal College, 21 Bloomingdale Road, Whrte Plains, NY 10605, and ’ New York Medical College, and Inputrent Psychiatry DanbuT Hospital, DanbuT, CT (U.S.A.) (Received (Accepted
Department,
7 April, 1986) 30 June, 1986)
Summary A study of 161 consecutively admitted elderly major depressives with a mean age of 71.7 t_ 6.6 revealed that 72 patients (45%) were delusional. Delusional depressives were significantly older than nondelusionals at onset (62.4 t 15.5 + 17.2), but were of comparable age at admission. Utilizing the median age of onset (60) as a cut-off, a sex difference was identified: an association between lateness of onset and delusions was only apparent in women. The presence of a concurrent medical or neurologic disorder or hearing deficit did not increase the association. The importance of investigating samples of elderly patients to identify age effects that only occur in late-life is emphasized.
Key words: Delusional
depression - Elderly - Sex difference
Introduction There has been considerable debate as to whether patients who are depressed and delusional represent a clinical entity distinct from their depressed but nondelusional counterparts. One model holds that delusions are simply another symptom of severe depression and that anyone with a depressive illness could potentially become delusional (Guze et al. 1975; Frances et al. 1981).
This work was completed at The New York Hospital Cornell University Medical Center - Westchester Division. This paper has been presented at the Annual Meeting of the American Psychiatric Association, Dallas, TX, May, 1985. * To whom correspondence should be addressed. 0165-0327/86/$03.50
0 1986 Elsevier Science Publishers
An alternative model postulates that delusions occurring during a depression are distinct from other symptoms and that delusional depression is actually a different clinical entity. Evidence for this model has been reviewed by Nelson and Bowers (1981), and by Glassman and Roose (1981). It includes the identification of differences in such diverse variables as clinical presentation, symptom profile, course of illness, treatment response, family history, and biologic markers. Age of onset bears an uncertain relationship to symptoms of depressive illness, including delusions (Mendewicz 1976; Weisman 1979; Zis et al. 1979; Winokur et al. 1980; Glassman et al. 1981; Brown et al. 1984). We have previously reported a highly signifi-
B.V. (Biomedical
Division)
134 cant association between onset after age 60 and delusionality in 34 elderly unipolar endogenous depressives (Meyers et al. 1984). This finding contrasts with those from studies carried out with mixed aged adult samples in which delusional and nondelusional depressives have been found to be comparable for age of onset and age at index admission (Guze et al. 1975; Charney et al. 1981; Frances et al. 1981; Glassman et al. 1981). We have suggested that an age effect occurring only late in life could be washed out in studies using subjects over a broad range of adult ages (Meyers et al. 1985). The present investigation is an extension of the first in an attempt to elucidate the contribution of age of onset to late-life delusional depression. Method Our initial study reviewed the records of all patients admitted to one of three psychogeriatric units at the Westchester Division of New York Hospital between April 1, 1979 and April 1, 1981. The current study expanded this sample by including patients admitted to the other two psychogeriatric units and extending the time period examined to include all patients admitted between January 1, 1979 and December 31, 1983. Charts meeting DSM-III criteria (American Psychiatric Association 1980) for major depression with or without melancholia, were included for study. Only unipolar patients were considered. Exclusion criteria included medication with mood altering potential, active medical illness to which depression could be secondary, the presence of significant cognitive or hearing impairment, and patients in whom symptoms, delusionality, or age of onset was questionable. Included charts were categorized according to age of onset, sex, age at index and the presence of delusions. Age of onset data was obtained through interviews with the patient and the closest available friend or relative utilizing criteria of the Schedule for Affective Disorders and Schizophrenia - Lifetime Version (Spitzer et al. 1977). A delusion was defined as a false fixed belief that the patient could not reality test, that was not consonant with the patient’s family or social background and that the patient did not believe prior to becoming ill. Mood congruent and
mood incongruent delusions were included. Feelings of guilt, hopelessness, or worthlessness were not considered delusional unless the patient demonstrated an irrational belief as to the justification of these feelings. These criteria are identical to those in the first study except that research Diagnostic Criteria (Spitzer et al. 1978) for endogenous depression were used initially. A sample from the second cohort matched for sex and age of onset with the initial 34 patients was randomly selected. Heterogeneity &i-square analysis was then carried out to establish whether the association between lateness of onset and delusionality was comparable for the two studies. In analyzing data from the entire sample chisquare analysis with Yates’ correction was used for dichotomous data and Student’s t-test for continuous variables. Results Chart review identified 271 geriatric admissions during the 5-year period who met DSM-III criteria for a unipolar major depression. The charts of 110 of these patients had exclusion criteria and were considered separately. Of the remaining 161 patients, 34 were part of the previously reported study and 127 comprised an additional study sample. The 34 patients who met RDC for endogenous depression in the initial study also met DSM-III criteria. Mean ages at index and onset for the first group were comparable to those for the 127 new patients (72.6 + 7.3 vs. 71.4 k 6.5 and 56.1 f 18.5 vs. 56.5 + 17.1). The sample of 34 patients from the second cohort matched for sex and age of onset had a comparable association of lateness of onset and delusionality. The initial set of 34 patients was then combined with the sample of 127 new patients to provide a cohort of 161 for further data analysis. Age and delusions Mean age at index admission of the 161 patients was 71.7 f 6.6 and at onset was 56.4 f 17.3 (Table 1). Seventy-two of these patients (45%) were delusional. No attempt was made to classify the delusions by mood congruence. Delusional themes were somatic in 21, persecutory in 21, of
TABLE
1
AGE DATA OF ELDERLY
MAJOR
DEPRESSIVES
Delusional (n = 72)
Nondelusional (n = 89)
Total (n = 161)
Age at index (mean f SD)
72.6*
70.9+
71.7*
Age onset a (mean f SD)
62.4 + 15.5
6.8
6.4
51.5 f 17.2
a Delusional patients were significantly (t = 4.18, df = 159, P -z 0.001).
6.6
56.4+ 17.3 older at age of onset
guilt or sin in 13, of poverty in two, nihilistic in one, and of jealousy in one. An additional 13 patients had delusions of more than one type. Mean age of onset for delusional patients was 62.4 + 15.5 compared to 51.5 + 17.2 for nondelusionals (t = 4.18, a”= 159, P < 0.001). Age of onset distribution demonstrated an increasing number of patients with first episode as age increased (Fig. 1). An association between delusionality and lateness of onset did not appear until the seventh decade. The median age of onset was 60 for both sexes. Fifty-one of the 87 patients (59%) with onset at or after the median were delusional compared to 21 of the 74 with onset before 60 (28%) (xf = 13.60, P < 0.001). Delusional patients were not significantly older at index than nondelusionals (72.6 + 6.8 vs. 70.9 k 6.4). Age, sex and delusionality Fifty-five of the 124 women (44%) were delusional compared to 17 of the 37 men (46%). Men were younger than women at index admission (69.2 f 6.4 vs. 72.4 + 6.5, t = 2.71, df = 60.5, P < 0.01). Between-sex comparisons for age of onset in the delusional, nondelusional, and combined groups did not reveal significant differences. Age of onset distribution demonstrates that the association between lateness of onset and delusionality was most apparent in women. Utilizing the median onset age of 60 as a cut-off, seven of the 17 men (41%) with their first episode before age 60 were delusional compared to ten of the 20 men (50%) with onset at or after this age (x,’ = 0.04, P n.s.).
1
1 I9
Hatched
Age
of onset
area
lndlcates
by decade delustonal
Fig. 1. Age of onset and delusionality sex.
Patients
by decade
divided
by
This contrasts with the female data in which 14 of the 57 women (25%) with onset before the seventh decade were delusional compared to 41 of the 67 (61%) late-onset women (x,’ = 15.29, P -C0.001). Excluded patients Age of onset could be established in 87% of the 110 excluded patients. Examination of their data failed to demonstrate a correlation between age of onset and delusionality. Eleven of the 33 with first episode before age 60 (33%) were delusional compared to 21 of the 54 (39%) earlier-onset patients. Discussion The occurrence of delusions in major depressive illness beginning in late-life was not investigated in previous studies. Our data demonstrates a strong association between lateness of onset and delusionality. The mean age of onset for delusional depressives was significantly later than for nondelusional patients (62.4 + 15.5 vs. 51.5 + 17.2,
136 P < 0.001). The greater tendency for patients to be delusionally depressed with increasing age of onset began in those with the first episode in the sixth decade. A significant association between delusions and onset after age 59 only occurred in women. Methodologic factors could have contributed to these results. Ideally, we would like to know, by studying a large random sample of elderly unipolar depressives, the percentage of patients at various ages who are delusional. The use of an inpatient psychogeriatric service results in an inherent sampling bias that could influence our results. The investigators were not blind to age of onset or delusionality and this could have influenced judgement. However, charts without sufficiently clear information to allow definite classification were excluded. Retrospective falsification could be more common in delusional patients, especially those with paranoid concerns. Denial of previous illness would lessen the reporting of prior episodes. and increase the association between delusionality and lateness of onset. However, the fact that 68% of the 51 late-onset delusional patients reported having prior episodes compared to 36% of the 36 of the nondelusional group argues against this explanation. The preferential hospitalization of later-onset delusional depressives is a possible source of sampling bias. The onset of an unfamiliar illness with frankly aberrant behavior may lead to earlier hospitalization in an older patient than in a young adult. Such sampling questions can only be answered by comparable studies that include large numbers of outpatients. The correlation between onset at or after the median of 60 and delusions in women but not in men is an interesting though puzzling finding. If this sex difference in association is valid, it provides a clue to the interaction of age- and sexrelated biologic or psychosocial factors in the development of delusions. Data from the 110 excluded patients did not show the correlation between lateness of onset and delusionality found in the rest of the sample. This suggests that the association applies to clear-cut major depression, but not necessarily to depression arising as a consequence of significant medi-
cal or neurologic illness. The meaning of these findings requires further study: biologic, social and psychologic correlates of aging should be sought which may contribute to the occurrence of this syndrome. For example, dopamine+hydroxylase (DBH) activity has been found to be decreased in the serum of delusional unipolar depressives (Meltzer et al. 1976), and decreased activity of this enzyme has been found to occur with increased age (Ogihara et al. 1975). Additional factors such as social isolation and diminished hearing occur in late life, and both may increase the risk of delusionality (Roth 1955; Kay et al. 1961; Cooper et al. 1976). It is of note that the 26 patients with clinically apparent diminished hearing, regardless of other exclusion criteria, or age of onset, did not have an increased frequency of delusions. How the interaction of genetic with age-related biologic and psychosocial factors could produce late-onset delusional depression remains speculative. This study did not distinguish between patients with mood-congruent and mood-incongruent delusions. Recent reports demonstrate that a subgroup of unipolar depressives with mood-incongruent delusions behave like RDC schizoaffectives on measures of family history, treatment outcome and course (Coryell et al. 1984a, b). Schizoaffective illness classically begins in young adulthood. Clarification of whether the mood-incongruent delusional patients included in this study represent a late-onset form of schizoaffective illness requires further investigation. In conclusion, the data from a study limited to hospitalized elderly major depressives demonstrates a late-onset delusional variant of this illness. Previous studies that have not recognized this entity have examined mixed-aged samples of adult patients, a design that could identify a linear correlation between age and delusionality but could fail to recognize a modal relationship occurring in late life. Such an association occurs in disorders such as Parkinson’s disease and the dementias. Our data supports the conceptualization of late-onset delusional depression as a subtype of major depression meriting further study.
137 Acknowledgements This study was partially supported by grant MH-00443 from the National Institutes of Mental Health. The authors wish to thank Marlene Carlson for her valuable assistance in the preparation of this paper. References American Psychiatric Association, DSM-III: Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, The American Psychiatric Association, Washington, DC, 1980. Blazer, D.G., The epidemiology of late life depression. Presented at The Gerontological Society of America Scientific Meetings, San Antonio, 1984. Brown, R.P., Sweeney, J., Leutsch, E., Kocsis, J. and Frances, A., Involutional melancholia revisited, Am. J. Psychiatry, 141 (1984) 24-28. Charney, D.S. and Nelson, J.C., Delusional and nondelusional unipolar depression: further evidence for distinct subtypes, Am. J. Psychiatry, 13 (1981) 328-333. Cooper, A.F., Garside, R.F. and Kay, D.W.K., A comparison of deaf and non-deaf patients with paranoid and affective psychoses, Br. J. Psychiatry, 129 (1976) 532-538. Coryell, W., Pfohl, B. and Zimmerman, M., The clinical and neuroendocrine features of psychotic depression, J. Nerv. Ment. Dis., 172 (1984a) 521-528. Cot-yell, W., Lavori, P., Endicott, J., Keller, M. and VanEerdewegh, M., Outcome in schizoaffective, psychotic, and nonpsychotic depression, Arch. Gen. Psychiatry, 41 (1984b) 787-791. Frances, A., Brown, R.P., Kocsis, J.H. and Mann, J.J., Psychotic depression: a separate entity?, Am. J. Psychiatry, 138 (1981) 831-833. Glassman, A.H. and Roose, S.P., Delusional depression: a distinct clinical entity?, Arch. Gen. Psychiatry, 38 (1981) 424-427. Glassman, A.H., Kantor, S.J. and Shostak, M., Depression, delusions, and drug response, Am. J. Psychiatry, 132 (1975) 716-719. Guze, S.B., Woodruff, R.A. and Clayton, P.J., The significance of psychotic affective disorder, Arch. Gen. Psychiatry, 32 (1975) 1147-1150. Hagnell, O., Lanke, J., Rorsman, B. et al., Are we entering an age of melancholy? Depressive illnesses in a prospective epidemiological study over 25 years: the Lundby study, Sweden, Psychol. Med. (London), 12 (1982) 279-289. Hordem, A., Holt, N.F., Burt, C.G. et al., Amitriptyline in depressive states, Br. J. Psychiatry, 109 (1963) 815-825.
Jolley, D.J. and Arie, T., Psychiatric service for the elderly: how many beds?, Br. J. Psychiatry, 129 (1976) 418-423. Meltzer, H.Y., Cho, H.W., Carroll, B.J. et al., Serum dopamine-Shydroxylase activity in the affective psychoses and schizophrenia, Arch. Gen. Psychiatry, 33 (1976) 585-591. Mendewicz, J., The age factor in depressive illness: some genetic considerations, J. Gerontol., 3 (1976) 300-303. Meyers, B., Kalyam, B. and Mei-Tal, V., Late onset delusional depression: a distinct clinical entity, J. Clin. Psychiatry, 45 (1984) 347-349. Meyers, B.S., Greenberg, R. and Mei-Tal, V., Delusional depression in the elderly. In: C.A. Shamoian (Ed.), Treatment of Affective Disorders in the Elderly, American Psychiatric Press, Washington, DC, 1985. Minter, R.E. and Mandel, M.R., The treatment of psychotic major depressive disorder with drugs and electroconvulsive therapy, J. Nerv. Ment. Dis., 167 (1979) 726-733. Myers, J.K., Weissman, M.M., Tischler, G.L. et al., Six-month prevalence of psychiatric disorders in three communities, Arch. Gen. Psychiatry, 41 (1984) 959-967. Myers, J.M., Sheldon, D. and Robinson, S.S., A study of 138 elderly first admissions, Am. J. Psychiatry, 120 (1963) 244-249. Nelson, C.J. and Bowers, M.B., Delusional unipolar depression - description and drug response, Arch. Gen. Psychiatry, 35 (1978) 1321-1328. Ogihara, T., Nugent, CA., Shen, SW. and Goldfein, S., Serum dopamine-/3-hydroxylae activity in parents and children, J. Lab. Clin. Med., 85 (1975) 566-573. Roth, M., The natural history of mental disorder in old age, J. Ment. Sci., 101 (1955) 281-301. Spar, J.E., Ford, C.V. and Liston, E.H., Hospital treatment of elderly neuropsychiatric patients. II. Statistical profile of the first 122 patients in a new teaching ward, J. .Am. Geriatr. Sot., 28 (1980) 539-543. Spicer, C.C., Hare, E.H. and Slater, E., Neurotic and psychotic forms of depressive illness: evidence from age-incidence in a national sample, Br. J. Psychiatry, 123 (1973) 535-541. Spitzer, R.L. and Endicott, J., Schedule for Affective Disorders and Schizophrenia Lifetime Version (SADS-L), New York State Psychiatric Institute, New York, 1977. Spitzer, R.L., Endicott, J. and Robins, E., Research diagnostic criteria: rationale and reliability, Arch. Gen. Psychiatry, 35 (1978) 773-782. Weisman, N.M., The myth of involutional melancholia, J. Am. Med. Assoc., 242 (1979) 742-144. Winokur, G., Behar, D. and Schlesser, M., Clinical and biological aspects of depression in the elderly. In: J.O. Cole and J.E. Barrett (Eds.), Psychopathology in the Aged, Raven Press, New York, 1980. Zis, A.P. and Goodwin, F.K., Major affective disorder as a recurrent illness, Arch. Gen. Psychiatry, 36 (1979) 835-839.
133
Disorders, 11 (1986) 133-137
JAD 00396
Late-Life Delusional Depression Barnett
S. Meyers *J and Robert Greenberg
2
’ Department of Psychiatry, New York Hospital - Westchester Division, Cornell University Medrcal College, 21 Bloomingdale Road, Whrte Plains, NY 10605, and ’ New York Medical College, and Inputrent Psychiatry DanbuT Hospital, DanbuT, CT (U.S.A.) (Received (Accepted
Department,
7 April, 1986) 30 June, 1986)
Summary A study of 161 consecutively admitted elderly major depressives with a mean age of 71.7 t_ 6.6 revealed that 72 patients (45%) were delusional. Delusional depressives were significantly older than nondelusionals at onset (62.4 t 15.5 + 17.2), but were of comparable age at admission. Utilizing the median age of onset (60) as a cut-off, a sex difference was identified: an association between lateness of onset and delusions was only apparent in women. The presence of a concurrent medical or neurologic disorder or hearing deficit did not increase the association. The importance of investigating samples of elderly patients to identify age effects that only occur in late-life is emphasized.
Key words: Delusional
depression - Elderly - Sex difference
Introduction There has been considerable debate as to whether patients who are depressed and delusional represent a clinical entity distinct from their depressed but nondelusional counterparts. One model holds that delusions are simply another symptom of severe depression and that anyone with a depressive illness could potentially become delusional (Guze et al. 1975; Frances et al. 1981).
This work was completed at The New York Hospital Cornell University Medical Center - Westchester Division. This paper has been presented at the Annual Meeting of the American Psychiatric Association, Dallas, TX, May, 1985. * To whom correspondence should be addressed. 0165-0327/86/$03.50
0 1986 Elsevier Science Publishers
An alternative model postulates that delusions occurring during a depression are distinct from other symptoms and that delusional depression is actually a different clinical entity. Evidence for this model has been reviewed by Nelson and Bowers (1981), and by Glassman and Roose (1981). It includes the identification of differences in such diverse variables as clinical presentation, symptom profile, course of illness, treatment response, family history, and biologic markers. Age of onset bears an uncertain relationship to symptoms of depressive illness, including delusions (Mendewicz 1976; Weisman 1979; Zis et al. 1979; Winokur et al. 1980; Glassman et al. 1981; Brown et al. 1984). We have previously reported a highly signifi-
B.V. (Biomedical
Division)
134 cant association between onset after age 60 and delusionality in 34 elderly unipolar endogenous depressives (Meyers et al. 1984). This finding contrasts with those from studies carried out with mixed aged adult samples in which delusional and nondelusional depressives have been found to be comparable for age of onset and age at index admission (Guze et al. 1975; Charney et al. 1981; Frances et al. 1981; Glassman et al. 1981). We have suggested that an age effect occurring only late in life could be washed out in studies using subjects over a broad range of adult ages (Meyers et al. 1985). The present investigation is an extension of the first in an attempt to elucidate the contribution of age of onset to late-life delusional depression. Method Our initial study reviewed the records of all patients admitted to one of three psychogeriatric units at the Westchester Division of New York Hospital between April 1, 1979 and April 1, 1981. The current study expanded this sample by including patients admitted to the other two psychogeriatric units and extending the time period examined to include all patients admitted between January 1, 1979 and December 31, 1983. Charts meeting DSM-III criteria (American Psychiatric Association 1980) for major depression with or without melancholia, were included for study. Only unipolar patients were considered. Exclusion criteria included medication with mood altering potential, active medical illness to which depression could be secondary, the presence of significant cognitive or hearing impairment, and patients in whom symptoms, delusionality, or age of onset was questionable. Included charts were categorized according to age of onset, sex, age at index and the presence of delusions. Age of onset data was obtained through interviews with the patient and the closest available friend or relative utilizing criteria of the Schedule for Affective Disorders and Schizophrenia - Lifetime Version (Spitzer et al. 1977). A delusion was defined as a false fixed belief that the patient could not reality test, that was not consonant with the patient’s family or social background and that the patient did not believe prior to becoming ill. Mood congruent and
mood incongruent delusions were included. Feelings of guilt, hopelessness, or worthlessness were not considered delusional unless the patient demonstrated an irrational belief as to the justification of these feelings. These criteria are identical to those in the first study except that research Diagnostic Criteria (Spitzer et al. 1978) for endogenous depression were used initially. A sample from the second cohort matched for sex and age of onset with the initial 34 patients was randomly selected. Heterogeneity &i-square analysis was then carried out to establish whether the association between lateness of onset and delusionality was comparable for the two studies. In analyzing data from the entire sample chisquare analysis with Yates’ correction was used for dichotomous data and Student’s t-test for continuous variables. Results Chart review identified 271 geriatric admissions during the 5-year period who met DSM-III criteria for a unipolar major depression. The charts of 110 of these patients had exclusion criteria and were considered separately. Of the remaining 161 patients, 34 were part of the previously reported study and 127 comprised an additional study sample. The 34 patients who met RDC for endogenous depression in the initial study also met DSM-III criteria. Mean ages at index and onset for the first group were comparable to those for the 127 new patients (72.6 + 7.3 vs. 71.4 k 6.5 and 56.1 f 18.5 vs. 56.5 + 17.1). The sample of 34 patients from the second cohort matched for sex and age of onset had a comparable association of lateness of onset and delusionality. The initial set of 34 patients was then combined with the sample of 127 new patients to provide a cohort of 161 for further data analysis. Age and delusions Mean age at index admission of the 161 patients was 71.7 f 6.6 and at onset was 56.4 f 17.3 (Table 1). Seventy-two of these patients (45%) were delusional. No attempt was made to classify the delusions by mood congruence. Delusional themes were somatic in 21, persecutory in 21, of
TABLE
1
AGE DATA OF ELDERLY
MAJOR
DEPRESSIVES
Delusional (n = 72)
Nondelusional (n = 89)
Total (n = 161)
Age at index (mean f SD)
72.6*
70.9+
71.7*
Age onset a (mean f SD)
62.4 + 15.5
6.8
6.4
51.5 f 17.2
a Delusional patients were significantly (t = 4.18, df = 159, P -z 0.001).
6.6
56.4+ 17.3 older at age of onset
guilt or sin in 13, of poverty in two, nihilistic in one, and of jealousy in one. An additional 13 patients had delusions of more than one type. Mean age of onset for delusional patients was 62.4 + 15.5 compared to 51.5 + 17.2 for nondelusionals (t = 4.18, a”= 159, P < 0.001). Age of onset distribution demonstrated an increasing number of patients with first episode as age increased (Fig. 1). An association between delusionality and lateness of onset did not appear until the seventh decade. The median age of onset was 60 for both sexes. Fifty-one of the 87 patients (59%) with onset at or after the median were delusional compared to 21 of the 74 with onset before 60 (28%) (xf = 13.60, P < 0.001). Delusional patients were not significantly older at index than nondelusionals (72.6 + 6.8 vs. 70.9 k 6.4). Age, sex and delusionality Fifty-five of the 124 women (44%) were delusional compared to 17 of the 37 men (46%). Men were younger than women at index admission (69.2 f 6.4 vs. 72.4 + 6.5, t = 2.71, df = 60.5, P < 0.01). Between-sex comparisons for age of onset in the delusional, nondelusional, and combined groups did not reveal significant differences. Age of onset distribution demonstrates that the association between lateness of onset and delusionality was most apparent in women. Utilizing the median onset age of 60 as a cut-off, seven of the 17 men (41%) with their first episode before age 60 were delusional compared to ten of the 20 men (50%) with onset at or after this age (x,’ = 0.04, P n.s.).
1
1 I9
Hatched
Age
of onset
area
lndlcates
by decade delustonal
Fig. 1. Age of onset and delusionality sex.
Patients
by decade
divided
by
This contrasts with the female data in which 14 of the 57 women (25%) with onset before the seventh decade were delusional compared to 41 of the 67 (61%) late-onset women (x,’ = 15.29, P -C0.001). Excluded patients Age of onset could be established in 87% of the 110 excluded patients. Examination of their data failed to demonstrate a correlation between age of onset and delusionality. Eleven of the 33 with first episode before age 60 (33%) were delusional compared to 21 of the 54 (39%) earlier-onset patients. Discussion The occurrence of delusions in major depressive illness beginning in late-life was not investigated in previous studies. Our data demonstrates a strong association between lateness of onset and delusionality. The mean age of onset for delusional depressives was significantly later than for nondelusional patients (62.4 + 15.5 vs. 51.5 + 17.2,
136 P < 0.001). The greater tendency for patients to be delusionally depressed with increasing age of onset began in those with the first episode in the sixth decade. A significant association between delusions and onset after age 59 only occurred in women. Methodologic factors could have contributed to these results. Ideally, we would like to know, by studying a large random sample of elderly unipolar depressives, the percentage of patients at various ages who are delusional. The use of an inpatient psychogeriatric service results in an inherent sampling bias that could influence our results. The investigators were not blind to age of onset or delusionality and this could have influenced judgement. However, charts without sufficiently clear information to allow definite classification were excluded. Retrospective falsification could be more common in delusional patients, especially those with paranoid concerns. Denial of previous illness would lessen the reporting of prior episodes. and increase the association between delusionality and lateness of onset. However, the fact that 68% of the 51 late-onset delusional patients reported having prior episodes compared to 36% of the 36 of the nondelusional group argues against this explanation. The preferential hospitalization of later-onset delusional depressives is a possible source of sampling bias. The onset of an unfamiliar illness with frankly aberrant behavior may lead to earlier hospitalization in an older patient than in a young adult. Such sampling questions can only be answered by comparable studies that include large numbers of outpatients. The correlation between onset at or after the median of 60 and delusions in women but not in men is an interesting though puzzling finding. If this sex difference in association is valid, it provides a clue to the interaction of age- and sexrelated biologic or psychosocial factors in the development of delusions. Data from the 110 excluded patients did not show the correlation between lateness of onset and delusionality found in the rest of the sample. This suggests that the association applies to clear-cut major depression, but not necessarily to depression arising as a consequence of significant medi-
cal or neurologic illness. The meaning of these findings requires further study: biologic, social and psychologic correlates of aging should be sought which may contribute to the occurrence of this syndrome. For example, dopamine+hydroxylase (DBH) activity has been found to be decreased in the serum of delusional unipolar depressives (Meltzer et al. 1976), and decreased activity of this enzyme has been found to occur with increased age (Ogihara et al. 1975). Additional factors such as social isolation and diminished hearing occur in late life, and both may increase the risk of delusionality (Roth 1955; Kay et al. 1961; Cooper et al. 1976). It is of note that the 26 patients with clinically apparent diminished hearing, regardless of other exclusion criteria, or age of onset, did not have an increased frequency of delusions. How the interaction of genetic with age-related biologic and psychosocial factors could produce late-onset delusional depression remains speculative. This study did not distinguish between patients with mood-congruent and mood-incongruent delusions. Recent reports demonstrate that a subgroup of unipolar depressives with mood-incongruent delusions behave like RDC schizoaffectives on measures of family history, treatment outcome and course (Coryell et al. 1984a, b). Schizoaffective illness classically begins in young adulthood. Clarification of whether the mood-incongruent delusional patients included in this study represent a late-onset form of schizoaffective illness requires further investigation. In conclusion, the data from a study limited to hospitalized elderly major depressives demonstrates a late-onset delusional variant of this illness. Previous studies that have not recognized this entity have examined mixed-aged samples of adult patients, a design that could identify a linear correlation between age and delusionality but could fail to recognize a modal relationship occurring in late life. Such an association occurs in disorders such as Parkinson’s disease and the dementias. Our data supports the conceptualization of late-onset delusional depression as a subtype of major depression meriting further study.
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