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LETTER TO THE EDITOR |
Department of Internal Medicine and Geriatrics Poliambulanza Hospital Brescia Geriatric Research Group Brescia, Italy
* University Unit Geriatric Department Ullevaal University Hospital Oslo, Norway
Address correspondence to Renzo Rozzini, MD, Department of Internal Medicine and Geriatrics Poliambulanza Hospital, via Bissolati 57, Brescia, Italy 25124. E-mail: renzo.rozzini{at}iol.it
To the Editor:
Whether depression is a significant independent predictor of mortality in geriatric patients is still a matter of debate. Studies, including one from our research group, have shown that depressive symptoms negatively affect survival in elderly people, but the prognostic effect of different diagnostic categories for depression is still unclear (1–5).
In this perspective, the article by McCusker and colleagues on depression and mortality in hospitalized medical patients is particularly interesting (6). In our geriatric ward, we have collected data on older patients that support the findings presented by McCusker and colleagues and that raise some interesting points of discussion on the relationship between medical conditions, depressive status (minor and major depression), and mortality.
Between January 1, 2002, and January 31, 2003, 1558 patients (aged 65 years and older) were consecutively admitted to our ward. We report data from 1234 patients (female = 67.4%, mean age = 78.8 ± 7.4 years), since 324 patients could not reliably report depressive symptoms due to poor cognition.
Our ward is modeled on the United States' Acute Care of the Elderly units (7,8), and 79% of our patients are admitted after coming to the emergency room. At admission, all the patients receive a comprehensive geriatric assessment, including information on demographics, education, place of residence prior to admission and after discharge, living conditions, household composition, existence and extent of a caregiver network, cognitive and affective status, physical health, and functional abilities. Diagnostic criteria for depression were used according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The severity of depressive symptoms are defined by the Geriatric Depression Scale (15-item version). A 6-month postdischarge vital status was ascertained in all patients.
Patients with major depression totaled 164 (13.3%) and those affected by minor depression were 506 (41.0%).
Table 1 shows the characteristics of patients according to their mood status, classified as no depression, major depression, and minor depression.
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Interestingly, somatic health, as assessed by the APACHE II (Acute Physiology and Chronic Health Evaluation) score and serum albumin, was less impaired in patients with major depression than in those without depression.
Patients with minor depression had higher impairment in mental and functional status (premorbid, on admission, and on discharge) than patients without depression. Furthermore, they also had higher impairment in mental status, functional status (premorbid, on admission, and on discharge), and in somatic health status (as detected by the Charlson Comorbidity Index, and APACHE II score) than patients with major depression.
Among the three groups considered, 6-month mortality was higher in patients without depressive symptoms (13.1%) and in those with minor depression (17.4%), than in those with major depression (7.3%). Thus, confirming the findings of McCusker and colleagues, older patients admitted in our ward with a diagnosis of major depression have a higher burden of negative psychic, functional, and social conditions and a lower 6-month mortality than patients without depression (6). Moreover, the highest burden of disadvantaged somatic conditions was found in patients with minor depression. These data suggest that major depression is a comorbidity, while minor depression is a reactive mood adaptation to functional and/or biological derangements.
The crucial question is if whether older persons hospitalized for somatic diseases with associated depressive symptoms (i.e., minor depression) derive benefits from drug treatment, as demonstrated for patients affected by major depression, or whether depressive burden is a marker of frailty, revealing the lack of psychic competence toward a distressful event, which is likely to be insensitive to antidepressant drug treatment (9–11).
References
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