Depression across the Lifespan

Depression is the most common mental disorder, not only for adults, but for children and teenagers as well. The DSM-IV classifies depression as a mood disorder. It states that an individual has suffered a “major depressive episode” if certain symptoms persist for at least two weeks, including a loss of enjoyment in previously pleasurable activities, a sad or irritable mood, a significant change in weight or appetite, problems sleeping or concentrating, and feelings of worthlessness. These symptoms of depression fall into four categories: mood, cognitive, behavioral, and physical. Depression affects how individuals feel, think, behave, and how their bodies work. People with depression may experience symptoms in any or all of the categories, depending on personal characteristics and the severity of the depression. Although depression is usually first noticed during the teen or early adult years, a person can have an episode of depression at any age. Major depressive disorder (MDD) is estimated to be 2% in children and 6% in adolescents and up to 25% of adults age >60 experience MDD, dysthymic disorder, or “minor” depression. Although diagnosis and treatment of major depressive disorder is similar among all patients, its symptoms and course may be atypical in children, adolescents, and older adults. Awareness of these varying clinical manifestations can facilitate early recognition and treatment. Although diagnosis and treatment of depression is similar regardless of a patient’s age, younger and older patients may not exhibit typical depressive symptoms.

Children usually display anxiety, irritability, temper tantrums, and somatic complaints before verbally expressing depressive feelings. Children and adolescents may be more likely to have symptoms like unexplained aches and pains and social withdrawal. Depression in children may co-occur with anxiety, disruptive behavior disorders or attention deficit disorder. Psychotic depression in children manifests more often as auditory hallucinations than delusions.

Younger vs middle-age adults Researchers found that the presentation of depressive symptoms in young adult patients (age 18 to 35) differed from those of middle-age (age 36 to 50) patients.Younger patients were more likely to be irritable, complain of weight gain and hyper somnia, and have a negative view of life and the future. They also were more likely to report previous suicide attempts and endorse symptoms consistent with generalized anxiety disorder, social phobia, panic disorder, and drug abuse. Middle-age patients had more depressive episodes, deceased libido, and middle insomnia, and more frequently reported gastrointestinal symptoms such as diarrhea or constipation. ypical MDD mood symptoms often are absent in older patients.

Frequently, somatic complaints, motor restlessness, or psycho motor retardation are seen; these symptoms may be attributable to a concurrent medical illness. This in turn may worsen the physical illness, leading to social isolation and considerable medical morbidity. Pain plays an important role in depression, particularly in older adults. Chronic pain affects up to 65% of older adults who live in the community and up to 80% of those who are institutionalized.The most common causes of pain in these patients are osteoarthritis, osteoporosis, fibromyalgia, degenerative disk disease, lumbar spinal stenosis, and scoliosis. In addition, neuropathic pain, such as post-herpetic neuralgia and peripheral neuropathy and injuries resulting from falls often cause long-lasting pain.

The presence of pain tends to negatively affect recognizing and treating depression. Regardless of their age, when a patient presents with pain or depression, investi-gate and consider treating both conditions. Memory decline is likely to be depressed older adults’ chief complaint, and when objectively tested these patients often show cognitive impairment.Whether depressive symptoms in this age group are a reaction to early cognitive deficits or are an early symptom of neurodegeneration remains controversial.Some case-control studies have found a link between a history of depression and Alzheimer’s disease (AD). In general, older patients whose first episode of depression occurs in late life have a higher relative risk of developing some form of dementia; research suggests that 50% of late-life MDD patients will develop dementia within 5 years.

Researchers have considered the pos-sibility that mild cognitive impairment average of 4.3 years.Thirty-six patients with MCI (60%) progressed to AD. Presence of depression at the time of MCI diagnosis did not pre-dict conversion to AD but persistence of depression for 2 to 3 years and the pres-ence of melancholic features were associ-ated with higher risk for AD.

Course and prognosis MDD has been characterized as a self-limited disease, with an average duration of 6 to 9 months. However, newer prospective studies suggest that a substantial number of patients recover more slowly or do not ever fully re-cover.Several factors, such as genetic/bio-logic vulnerability and psychosocial factors, influence the courses, prognosis, and risk of relapse/recurrence of MDD in all age groups. The typical duration of a major depressive episode for clinically referred children and adolescents is 8 to 13 months. Approximately 90% of these patients’ major depressive episodes remit by 2 years, but up to 10% persist.Within 5 years of MDD onset, up to 70% of children and adolescents will experience a recurrence,a rate comparable to adults. Anxiety disorders, panic disorders, pho-bias, substance abuse, conduct and oppo-sitional disorders, and attention-deficit/ hyperactivity disorder occur 2 to 6 times more frequently in children and adoles-cents with MDD.Children with MDD who have significant psychiatric and psy-chosocial comorbidity experience poorer outcomes. of older patients fail to respond adequately to first-line antide-pressant pharmacotherapy.Treatment-resistant MDD in older patients increases due to nonadherence to treatment for comor-bid medical disorders, disability and cognitive impairment, burden on caregivers, risk for early mortality, including suicide.

Regardless of a patient’s age, MDD treatment should begin with education. All patients should be involved in their treatment. Patients need to become familiar with their triggers and stressors, improve their coping skills, and adopt a healthy lifestyle, which includes a nutri-tious diet, frequent exercise, and adequate sleep. As maintenance treatment we rec-ommend that patients participate in fre-quent socialization and activities.

In addition to lifestyle modification, other treatment options for depression include pharmacotherapy, interpersonal psychotherapy, cognitive-behavioral ther-apy (CBT), and electroconvulsive therapy (ECT). All these modalities are effective for acute and maintenance treatment and should be considered when determining the best approach for each patient. The effectiveness of antidepressants in general is comparable among and within classes.

The benefits of exercise for all patients cannot be underestimated. minutes of daily exercise is part of recommended lifestyle changes. Exercise needs to be taken as seriously as medica-tion compliance. For mild de-pression, supportive therapy seems to be as effective as CBT and medications.A randomized controlled trial of 439 de-pressed adolescents found that CBT plus fluoxetine conferred quicker benefit, but in the long run may not be any more ef-ficacious than pharmacotherapy alone.Researchers also found that CBT plus fluoxetine was no more effective than pharmacotherapy alone for adolescents with moderate to severe depression. Compared with younger pa-tients, geriatric patients typically require lower antidepressant dosages to achieve a specific blood level, but the blood levels at which antidepressants are most effec-tive appear to be similar.Older patients also may be more likely to relapse and less likely to achieve full response to antide-pressants than younger patients.

In older adults, amitriptyline, imipramine, and doxepin are not preferred because these agents may cause orthostatic hypoten-sion and urinary retention.A depressed older adult who experiences weight loss might benefit from an antidepressant that improves appetite, such as mirtazapine.Some research suggests that maintenance antidepressant therapy in older patients experiencing a first-time episode of MDD should continue for up to 2 years. A meta-analysis of 12 studies of CBT in depressed adults age ≥?60 with chronic pain found that CBT was effective at improving self-reported pain but had no significant effect on depressive symptoms, physical function, or medication use.ECT often is prescribed for depressed older adults be-cause its safety and efficacy for these pa-tients has been well documented.Other neuromodulation therapies include vagus nerve, repetitive transcranial magnetic stimulation, and deep brain stimulation, but none of these treatments have been ex-tensively evaluated in older patients.

References

American Psychiatric Association. (2000). . Revised 4 edition. Washington, DC: American Psychiatric Association. Depression across the life span.
(2012). Retrieved September 20, 2012 from http://www.dbsalliance.org/site/PageServer?pagename=education_depression_lifespan Feldman, R. (2011). Development Across the Life Span. 6th edition. Upper Saddle River: Prentice Hall. Meyer, S. E., Chrousos, G. P., Gold, P. W. (2001). Major depression and the stress system: A life span perspective. Development and Psychopathology, 13, 565-580. Retrieved September 15, 2012 from [->0]

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