Tees & North East Yorkshire NHS Trust, Hartlepool General Hospital, Holdforth Road, Hartlepool TS24 9AH
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ABSTRACT |
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Aims To examine outcome in two such groups after 4.5 years and compare results with those reported elsewhere.
Method Fifty-six adults (aged under 65) and 54 elderly people (over 65) with primary depression were assessed 4.5 years after receiving hospital treatment, and factors influencing the outcome were explored.
Results Recovery rates were higher in the adults than in the elderly (42.8% v. 24%), largely due to higher rates of death (33%) and dementia (14.8%) in the latter group, who also suffered more serious health problems (62.9% v. 28.5%). Survival analysis showed no difference in the recovery time between cohorts, with over 90% recovered after 25 weeks. After deducting the natural deaths, melancholic illness proved a poor outcome predictor in the adults.
Conclusions The outlook for elderly depressed patients is poorer than for younger patients because of concurrent physical disease, a higher death rate and the development of dementia.
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INTRODUCTION |
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This study represents an extended follow-up to one reported earlier (Tuma, 1996), to determine changes in outcome between 1 and 4.5 years and to re-examine outcome predictors.
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METHOD |
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At entry there was a total of 110 patients: 56 adults and 54 elderly, with a ratio of women to men of 2:1. Four and a half years later there were 85 survivors, and 70 of these were interviewed by T.A.T. blind to the one-year assessment, using a semi-structured format. For the 15 remaining, details of mental and physical health were obtained from general practitioners, keyworkers or close relatives (often more than one source); they were not interviewed because of refusal (3), severe physical frailty (7) or forgetfulness (5). Relatives were interviewed when additional information was needed. The Minitab package (1993) was used to analyse discrete and continuous data and the Mathsoft (1998) package for logistical regression, survival analysis and Cox proportional hazards model analysis.
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RESULTS |
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The elderly were less likely to recover and much more likely to die (33.3%)
or to develop dementia (14.8%) than the younger adults. The death rates
exceeded those predicted from Office of Population Censuses & Surveys
tables: observed death rates=33.3%; expected=22.7%
(Office of Population Censuses &
Surveys, 1980-1982). However, if the natural deaths were removed
from the two groups, the recovery rate for the elderly was still lower than
that for the adults (36% v. 48%), but not significantly so
(2=1.4; d.f.= 1, P=0.2).
Most striking is the decline in the percentage of elderly patients allocated to the best possible outcome category of lasting recovery. By contrast, the recovery rate shown at one year for the adult group had largely been maintained. The percentages of patients allocated to the residual symptoms and chronic categories fell in both cohorts, but improvement was confined to the younger patients. Of 15 adults in these categories at year one, three were fully recovered at the date of the extended follow-up, and three were now in the relapse and recovery category. None of the elderly had improved in this way. Dementia, when it developed, tended to occur late: at two years the number of cases with dementia had not increased above that seen at one year (two elderly cases only). By 4.5 years, one adult and eight elderly had become demented, the latter being greatly in excess of the figure expected from earlier studies (Bergmann et al, 1971).
Sixteen adults and 19 elderly suffered relapses between the two follow-ups. Of the adults, 10 relapsed with depression, one with obsessional neurosis and the remaining five with two illnesses (albeit not concurrently): three with depression and mania, and two with depression and paranoid psychosis. Of the elderly, 13 relapsed with depression, one with anxiety neurosis, and the remaining five with two illnesses (again not occurring concurrently): two with depression and mania, one with depression and anxiety neurosis, one with depression and paranoid psychosis and one with mania and paranoid psychosis.
Treatments given and the settings
There were no significant differences between the psychiatric treatments
received by the two groups (Table
2). When in-patient treatment was necessary, the elderly did not
stay significantly longer in hospital (adults: mean length of stay=13.3 weeks;
elderly=14.5 weeks). A significant excess of elderly patients was resident in
nursing homes at follow-up, and nine had needed in-patient treatment for
physical illnesses.
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Physical health, causes of death and dementia
(Table 3)
Thirty-four elderly patients had medical problems which required active
medical treatment, as against 16 in the adult group. Of the 34 elderly, nine
needed in-patient medical treatment (three for cardiovascular disease, two for
respiratory diseases, two for mini-strokes, one for a fractured left femoral
neck and one for a duodenal ulcer). Their mean length of stay in hospital was
14.6 weeks. One adult needed eight weeks' in-patient treatment for Crohn's
disease (partial colectomy and ileostomy). When dementia developed it started
on average 34.7 months after the start of the index illness (see also
Table 2).
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Recovery time and its predicting factors
Survival analysis and the Cox proportional hazards model were applied to
all the 110 patients and zero time was taken as the start of treatment for the
index illness. The survival curve showed no difference in the recovery time
between the adult and the elderly groups, with over 90% having recovered in 25
weeks. The Cox proportional hazards model was applied and the relationship
between recovery time and duration of illness at intake was linearised by
using the log (duration) transformation. The factors listed in
Table 4 are those which
significantly extended the recovery time.
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Factors associated with failure to recover
In judging factors associated with poor recovery from depression, the high
death rate in the elderly (33.3%) was considered to be a confounding factor.
Accordingly, natural deaths were removed from each cohort. The outcome
variables were dichotomised: complete recovery v. non-recovery (all
others). Applying the 2 test, in the adults non-recovery was
associated with melancholic illness (
2=4.86, d.f.=1,
P=0.027), depression of moderate/great severity
(
2=7.5, d.f.=1, P=0.01) and past history of affective
illness (
2=14.1, d.f.=1, P=0.002). In the elderly,
only active medical problems were associated with poor recovery
(
2=5.06, d.f.=1, P=0.02). When multivariate
logistical regression was applied, melancholic illness was found to be a poor
outcome predictor in the adults (odds ratio=3.74, 95% CI=1.12-12.5,
P=0.016), but such analysis could not identify a poor outcome
predictor in the elderly.
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DISCUSSION |
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Comparison with other studies
Death rates were higher than would be expected from the Office of
Population Censuses & Surveys statistics and from those reported by
Brodaty et al (1993)
for their elderly cohort. However, these latter patients were younger (entry
age 60 rather than 65), their follow-up interval rather (16%) shorter, and
their elderly patients recruited from a specialist affective disorder
treatment unit, rather than a psychogeriatric facility which recruits some
patients with poor physical health via geriatric liaison. High death rates
among the elderly with depression have been widely reported
(O'Brien & Ames, 1994),
but this present study, like so many others, sheds no light on the question
why. In this series cardio-vascular and respiratory diseases, either
individually or combined with other system disorders, were important causes of
death. Malignant diseases did not feature as a common cause of death, in
contrast to other findings (O'Brien &
Ames, 1994).
The relatively high incidence of dementia among the elderly will come as little surprise to clinicians, but challenges the view that the major mental disorders of old age represent separate entities with little tendency to overlap - a view frequently expounded by Roth (1955) and based on his seminal studies of outcome. It should be remembered that outcome was measured in those studies at just two years after admission - a longer follow-up might have yielded a result closer to that reported here. The present study was based upon outcome in an admittedly small cohort, but appears to show dementia to be a significant, albeit late, complication arising in the majority of cases in the third year and beyond.
Outcome levels are comparable with those reported by other workers, both for elderly and adult patients, but it must be regarded as disappointing that recovery rates among the elderly (24%) are slightly worse than those reported by Felix Post over a quarter of a century ago (26% at three years; Post, 1972).
Factors predicting outcome
Factors which significantly reduce the chances of recovery - melancholic
illness, chronicity, severity of index illness, and a past history of
affective disorder (especially where previous episodes have been often
repeated) - have all been reported before. That the most reliable statistic,
that of multivariate logistical regression, denies the significance of all
save melancholic illness, both at 1 year and at 4.5 years (in the adult cohort
alone), raises the question of whether the other, more traditionally
recognised, factors should now be discounted; however, the reduction in
numbers in the elderly cohort by death may have reduced the sample size to a
level where factors affecting recovery were obscured. Although the fact that
it was possible to assess only 80% of the cohort fully must be regarded as a
potential weakness in the study, all were traced and the reports from various
sources were consistent.
Overall, the findings remind us that although depressive illness is arguably the most treatable of all psychiatric disorders, irrespective of age of onset, if lasting recovery is the aim, it is also one of the most difficult. The fact that some younger patients, chronically ill at one year, can proceed to partial or full recovery 3.5 years later, reminds us of the need to persevere with active treatments, and always to keep in mind Roth's aphorism: "While there is depression, there is hope" (Roth, 1955).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication June 25, 1998. Revision received October 1, 1999. Accepted for publication October 1, 1999.