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Phenomenology of depression in older compared with younger adults: Meta-analysis

  • J. M. Hegeman (a1), R. M. Kok (a2), R. C. van der Mast (a3) and E. J. Giltay (a3)
Abstract
Background

Late-life depression may differ from early-life depression in its phenomenology.

Aims

To investigate the effect of age on the phenomenology of major depression.

Method

A systematic search was conducted in PubMed, Embase and PsycINFO for all studies examining the relation between age and phenomenology of major depression according to RDC, DSM and ICD criteria. Studies were included only if the age groups were compared at the single-item level using the 17-, 21- or 24-item versions of the Hamilton Rating Scale for Depression; a meta-analysis was done for each item of the 17-item scale.

Results

Eleven papers met the inclusion criteria. Older depressed adults, compared with younger depressed adults, demonstrated more agitation, hypochondriasis and general as well as gastrointestinal somatic symptoms, but less guilt and loss of sexual interest.

Conclusions

The phenomenology of late-life depression differs only in part from that of early-life depression. Major depression in older people may have a more somatic presentation, whereas feelings of guilt and loss of sexual function may be more prevalent in younger people.

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Corresponding author
Dr Annette Hegeman, Department of Psychiatry, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. Email: j.m.hegeman@lumc.nl
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Declaration of interest

None.

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References
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Phenomenology of depression in older compared with younger adults: Meta-analysis

  • J. M. Hegeman (a1), R. M. Kok (a2), R. C. van der Mast (a3) and E. J. Giltay (a3)
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Authors' reply

Annette Hegeman, psychiatrist
25 May 2012

We thank Dr. Mahendran for his valuable remarks. As highlighted by Dr. Mahendran, depression in late-life is often accompanied by medical comorbidity.1 Due to the lack of information on medical comorbidity in thestudies included in our meta-analysis, we could not evaluate to what extent the differences found could be explained by an overlap in somatic symptoms of depression and medical comorbidity. Of the 11 included studies, only 4 reported on medical comorbidity. As the study sample of Koenig et al. consisted of a medical inpatient population, medical comorbidity was present in both the younger and older depressed persons.2 Moreover, age-related differences in the phenomenology of depression persisted after adjustment was made for medical comorbidity. In the studies of Brodaty et al., Gournellis et al. and Tan et al., the levels ofsomatic comorbidity were indeed higher in older compared to younger depressed persons.3,4,5 We did acknowledge that age-related somatic comorbidity may have caused some overlap with somatic symptoms of depression, explaining part of the age-related differences in the phenomenology of major depression. On the other hand, somatic comorbidity may also have an impact on the phenomenology of late-life depression, apart from the overlap of symptoms. Unfortunately, in our meta-analysis itwas impossible to unravel potential mediating effects.

As noted in the introduction section, we agree with Dr. Mahendran that socio-cultural and psychological factors related to ageing may influence the clinical presentation of depression in late life. In this meta-analysis, however, we aimed to investigate whether age-related differences in the phenomenology of depression exist at all. The question as to which of the biological, psychological or socio-cultural factors maycause age-related differences, and how they might modify the phenomenologyof depression in late life, needs further examination.

An important issue raised by Dr. Mahendran concerns the distinction between clinimetrics and psychometrics. Of course clinicians cannot rely on existing psychometric rating scales alone when making clinical decisions. However, this distinction does not affect the overall results of our meta-analysis. Age-related differences in the clinical manifestation of major depression were investigated to start with. Going one step further, phenomenological differences corresponding to differences in prognosis, treatment and determinants, need to be investigated in future research, all of them important for clinical reasoning. Furthermore, this may not be so much an issue of clinimetrics as opposed to psychometrics, but a consequence of the inadequacy of the categorical DSM-IV classification system, leading to extensive comorbidityand diagnostic heterogeneity which impedes the search for determinants.6 As depression is a highly heterogeneous disorder, we focused on major depression to enable the search for age-related differences. Moreover, because no commonly used clinimetrically-based model exists, we chose to use the most appropriate instrument currently available.

1.Proctor EK, Morrow-Howell NL, Dore P et al. Comorbid medical conditions among depressed elderly patients discharged home after acute psychiatric care. Am J Geriatr Psychiatry 2003; 11: 329-38.

2.Koenig HG, Cohen HJ, Blazer DG, et al. Profile of depressive symptoms in younger and older medical inpatients with major depression. J Am Geriatr Soc 1993; 41: 1169-76.

3.Tan LL, Ng LL, Tan S, et al. Depression in Singapore: failure to demonstrate an age effect on clinical features. Int J Geriatr Psychiatry 2001; 16: 1054-60.

4.Gournellis R, Oulis P, Rizos E, et al. Clinical correlates of age of onset in psychotic depression. Arch Gerontol Geriat. 2011; 52: 95-8.

5.Brodaty H, Luscombe G, Parker G, et al. Increased rate of psychosis and psychomotor change in depression with age. Psychol Med 1997;27: 1205-13.

6.van Praag HM. Kraepelin, biological psychiatry, and beyond. Eur Arch Psychiatr Clin Neurosci 2008; 258 (S2): 29-32.

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Conflict of interest: None declared

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Clinimetrics and Psychometrics: never the twain shall meet?

Rathi Mahendran, Senior Consultant Psychiatrist
09 May 2012

Meta-analysis is upheld as a higher order analysis but it is not without fault as is evident in the conundrums raised by Hegeman JM et al'sarticle. (1) While the methodology was rigorously applied, even the final list of eleven studies included in the meta-analysis were not entirely comparable particularly in the area of medical co-morbidity, a point highlighted by the authors. Our own clinical experience and findings and one possibly shared by other psychiatrists has been that the elderly do have significant medical co-morbidity that impact clinical presentations. In one study all but one elderly patient had a medical condition and 60% had two medical conditions. (2) The meta-analysis also does not take into account the significant role socio-economic and cultural factors have in depressive symptom development and progression in the elderly. Socio-economic issues play an important part given the changes in occupation, lifestyle and other roles in the elderly. This paper also serves to highlight the recently resurfaced distinction between clinimetrics and psychometrics. (3) The relevance and applicability of psychometrically driven research is sometimes difficult to translate for the psychiatrist in clinical settings. Clinicians cannot rely entirely on rating instruments to arrive at a diagnosis and to draw care- plans for the management. Clinicians will sieve through the history and presentations indetail and make global judgements on information presented, a process thatgoes beyond the uni-dimensional nature of checklists and rating scales. Fava et al alluded to the "sophisticated thinking that underlies clinical decisions" and that is a point that deserves consideration even as we review journal articles on research which is largely psychometrically driven to glean benefit for our clinical practice. References:1. Hegeman JM, Kok RM, van der Mast RC, Giltay EJ. Phenomenology of depression in older compared with younger adults: meta-analysis. BJP 2012;200:275-281.2. Ko SM, Kua EH. Depression of Yopung and Elderly Patient. SMJ 1997;38910):439-441. 3. Fava GA, Rafanelli C, Tomba E. The Clinical Process in Psychiatry: A Clinimetric Approach. J Clin Psychiatry 2012;73(2):177-184.

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Conflict of interest: None declared

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