Serum cortisol level and depression severity in a sample of Brazilian elders

Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (Capes)Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (Fapesp)Capes FoundationMinistry of Education of Brazil, BrasiliaFapesp AgencyCapes Agency"National Counsel of Technological and Scientific Development" (CNPq - Researcher Level 1C)Univ Sao Paulo, Med Sch FMUSP, Old Age Res Grp Proter, Inst Psychiat, Sao Paulo, SP, BrazilUniv Sao Paulo, Med Sch FMUSP, Old Age Res Grp Proter, Dept Psychiat, Sao Paulo, SP, BrazilUniv Melbourne, Dept Psychiat, Austin Hlth, Heidelberg, Vic, AustraliaFed Univ Sao Paulo Unifesp, Dept Prevent Med, Sao Paulo, SP, BrazilFed Univ Sao Paulo Unifesp, Dept Prevent Med, Sao Paulo, SP, BrazilFAPESP: 04/09586-9FAPESP: 2014/05467-7FAPESP: 2014/05467-7CAPES: BEX 0893/14-5Ministry of Education of Brazil, Brasilia: DF 70040-20Web of Scienc

Prevention of depression and anxiety in community-dwelling older adults: the role of physical activity

Background: With the growth of the elderly population in Brazil and the increasing impact of depression and anxiety, the importance of preventing these disorders has been highlighted. Studies have shown an inverse relationship between rates of depression/anxiety and physical activity, pointing out its role as a possible protective factor. Objectives: To conduct a randomized study with elderly adults in the community, who present with subsyndromal depression and anxiety, that will evaluate the effectiveness of physical activity with a collaborative stepped-care strategy; and to compare the effectiveness of physical activity in preventing subsyndromal depression and anxiety, with regard to the usual care group. Methods: The article contains the methodological description of an arm of a large study entitled “Prevention and Treatment of Depression in Elderly”, in which 2,566 Brazilian older adults were screened to identify clinically significant depressive and anxiety symptoms. Those with clinically significant depressive or anxiety symptoms, not meeting criteria for depressive or anxiety disorder, will be invited to participate in a randomized clinical trial with 2 intervention groups: a step-by-step preventive care programme using physical activity, and usual care. The effectiveness of physical activity in the prevention of depressive and anxiety disorders will be evaluated. Discussion: New health policies could be implemented, aiming to reduce the number of elderly people with depression and anxiety in primary care. In addition, training may be implemented for family health teams so that screening tools could be used to make an early identification of individuals with (or at risk of developing) mental disorders

Mental health in medical students during COVID-19 quarantine: a comprehensive analysis across year-classes

OBJECTIVES: The COVID-19 pandemic brought abrupt changes when quarantine measures were implemented. Most medical students had distance learning as their main content delivery mode, but in clerkship (fifth and sixth years), in-person activities were maintained under new protocols. These different modes may have affected student mental health. This study examines mental burden and empathy in medical students during the beginning of the COVID-19 pandemic according to the year of attendance. METHODS: All students attending first to the sixth year in the same medical school were invited to participate. The Hospital Anxiety and Depression Scale (HADS), the Self-Reporting Questionnaire (SRQ-20), the Interpersonal Reactivity Index (IRI), and the Mindful Attention Awareness Scale (MAAS) were provided. RESULTS: HADS scores for Anxiety and Depression (n=347) were 9.8±4.3 and 7.1±3.6, respectively; the SRQ-20 (n=373) score was 8.1±4.5; all scores were negatively correlated with the year of attendance. IRI (n=373) scores were: 2.6±0.5 (Empathic Concern), 2.7±0.7 (Perspective Taking), 2.5±0.9 (Fantasy), and 1.7±0.7 (Personal Distress). Fantasy was negatively correlated with the year of attendance. MAAS scores were positively correlated with the year of attendance. Worse mental health scores were found for first-year students across all scales. CONCLUSIONS: We found high levels of mental burden in medical students in the early period of the COVID-19 pandemic, especially in first-year students, who may have fewer resources to deal with stress. Moreover, as they entered college a short time before the pandemic, they were unable to experience academic life fully or create important new social support networks to deal with adversities

Translating advances in the molecular basis of schizophrenia into novel cognitive treatment strategies

The presence and severity of cognitive symptoms, including working memory, executive dysfunction and attentional impairment, contributes materially to functional impairment in schizophrenia. Cognitive symptoms have proven resistant to both first- and second-generation antipsychotic drugs. Efforts to develop a consensus set of cognitive domains that are both disrupted in schizophrenia and are amenable to cross-species validation (e.g. the NIMH CNTRICS and RDoC initiatives) are an important step towards standardisation of outcome measures that can used in preclinical testing of new drugs. While causative genetic mutations have not been identified, new technologies have identified novel genes as well as hitherto candidate genes previously implicated in the pathophysiology of schizophrenia and/or mechanisms of antipsychotic efficacy. This review comprises a selective summary of these developments, particularly phenotypic data arising from preclinical genetic models for cognitive dysfunction in schizophrenia, with the aim of indicating potential new directions for pro-cognitive therapeutics

Predictors of treatment outcome in depression in later life: a systematic review and meta-analysis

Background: Predictor analyses of late-life depression can be used to identify variables associated with outcomes of treatments, and hence ways of tailoring specific treatments to patients. The aim of this review was to systematically identify, review and meta-analyse predictors of outcomes of any type of treatment for late-life depression. Methods: Pubmed, Embase, CINAHL, Web of Science and PsycINFO were searched for studies published up to December 2016. Primary and secondary studies reported treatment predictors from randomised controlled trials of any treatment for patients with major depressive disorder aged over 60 were included. Treatment outcomes included response, remission and change in depression score. Results: Sixty-seven studies met the inclusion criteria. Of 65 identified statistically significant predictors, only 7 were reported in at least 3 studies. Of these, 5 were included in meta-analyses, and only 3 were statistically significant. Most studies were rated as being of moderate to strong quality and satisfied key quality criteria for predictor analyses. Limitations: The searches were limited to randomised controlled trials and most of the included studies were secondary analyses. Conclusions: Baseline depression severity, co-morbid anxiety, executive dysfunction, current episode duration, early improvement, physical illnesses and age were reported as statistically significant predictors of treatment outcomes. Only the first three were significant in meta-analyses. Subgroup analyses showed differences in predictor effect between biological and psychosocial treatment. However, high heterogeneity and small study numbers suggest a cautious interpretation of results. These predictors were associated with various mechanisms including brain pathophysiology, perceived social support and proposed distinct types of depressive disorder. Further investigation of the clinical utility of these predictors is suggested

Clinical characteristics and structural changes in magnetic resonance imaging: importance for the outcome of late life depression

A relação entre as alterações estruturais cerebrais e a resposta ao tratamento da depressão em idosos continua a ser uma área intrigante de pesquisa. Neste estudo, foram investigadas diferenças quanto ao volume total e regionalizado de substância cinzenta e branca em exames de ressonância magnética (RM) de idosos com depressão (de acordo com os critérios do DSMIV-TR) e de controles. Além disso, para melhor compreender a fisiopatologia da depressão no idoso, o volume total das hiperintensidades em substância branca foi quantificado e comparado entre os grupos. A amostra foi composta por 30 idosos com depressão e 22 controles. Os idosos com depressão foram divididos em grupos de acordo com o uso prévio de antidepressivos, a resposta ao tratamento farmacológico, assim como de acordo com a idade de início da depressão. As imagens de RM foram processadas utilizando o programa Statistical Parametric Mapping e a morfometria baseada em voxel (DARTEL). A quantificação do volume total das hiperintensidades em substância branca foi realizada através de uma variação do método automático conhecido como Expectation Maximization Segmentation (EMS). Na análise do cérebro inteiro, encontramos uma redução volumétrica significativa no giro reto e no córtex orbitofrontal bilateralmente em pacientes em comparação com os controles.Além disso, os pacientes que não estavam em uso de antidepressivos no momento da aquisição da RM apresentaram uma redução volumétrica ainda maior no giro reto e no córtex orbitofrontal bilateralmente. Pacientes com uso prévio de antidepressivos mostraram uma redução volumétrica no giro reto e córtex orbitofrontal bilateralmente em comparação com os controles e pacientes sem uso prévio de antidepressivos apresentaram uma redução ainda maior no giro reto e no córtex orbitofrontal bilateralmente em comparação com os controles. De acordo com seu estado de remissão após o uso de um algoritmo de tratamento farmacológico da depressão em idosos, os pacientes foram classificados nos grupos remissão e não remissão. O grupo remissão apresentou uma redução volumétrica no giro reto e no córtex orbitofrontal bilateralmente e no pólo temporal médio direito, em comparação com o grupo controle. O grupo não remissão mostrou uma redução volumétrica ainda maior no giro reto e no córtex orbitofrontal bilateralmente em comparação com o grupo controle. Para investigar fatores preditores de remissão, foi utilizada uma regressão logística. A pontuação inicial do Mini Exame do Estado Mental e o volume corrigido (para o volume total de substância branca) inicial do córtex orbitofrontal superior lateral esquerdo classificaram os pacientes de acordo com a resposta ao tratamento farmacológico. As mesmas análises estatísticas foram realizadas em relação ao volume de substância branca. Pacientes sem uso prévio de antidepressivos mostraram uma redução volumétrica no giro frontal superior direito em comparação com os controles. Além disso, o grupo com depressão de início tardio apresentou um aumento volumétrico no lóbulo posterior esquerdo do cerebelo em comparação com o grupo controle. Em relação ao volume total das hiperintensidades de substância branca, a amostra final processada com o EMS foi constituída por 22 pacientes e 19 controles. As mesmas comparações entre grupos descritas anteriormente foram realizadas e não foi encontrada diferença estatisticamente significante entre os grupos. Foi realizada uma nova regressão logística para investigar fatores preditores de remissão nessa amostra menor, incluindo o volume total de hiperintensidades de substância branca e não foi encontrado resultado estatisticamente significante. Em conclusão, os idosos com depressão apresentam redução volumétrica no giro reto e no córtex orbitofrontal bilateralmente e isso pode ser uma característica da depressão em idosos e um potencial biomarcador dessa condição. O uso de antidepressivos pode proteger contra a redução volumétrica de substância cinzenta e branca e parece ter um efeito neurotrófico nesses pacientes. Além disso, déficit cognitivo e redução de substância cinzenta no córtex orbitofrontal superior lateral esquerdo no início do estudo podem ser preditores de pior resposta ao tratamento farmacológico da depressão no idoso. Estudos longitudinais, com amostras maiores e com pacientes com depressão mais grave poderão contribuir para uma melhor compreensão da fisiopatologia da depressão em idososThe association between structural brain changes and treatment response in patients with late-life depression (LLD) remains an intriguing area of research. This magnetic resonance imaging (MRI) study investigated the baseline gray and white matter volume of elderly with and without major depression (according to the DSM-IV-TR criteria). Moreover, to better understand the pathophysiology of LLD, white matter hyperintensities total volume was quantified and compared among groups. The sample consisted of 30 elderly patients with depression and 22 elderly healthy controls. Depressed patients were classified according to their previous use of antidepressants, to their response to pharmacological treatment, and to their age of depression onset. Brain MRI scans were processed using statistical parametric mapping and voxel-based morphometry (DARTEL). White matter hyperintensities total volume was conducted with a variation of an automatic method known as Expectation Maximization Segmentation (EMS). In the whole-brain analysis, we found a significant volumetric reduction in the gyrus rectus and in the orbitofrontal cortex (OFC) bilaterally in patients in comparison with controls. Additionally, patients who were not taking antidepressants at the time of the MRI had an even greater volumetric decrease in the gyrus rectus and in the orbitofrontal cortex bilaterally. Besides, we classified patients according to their previous antidepressant use (with or without) and compared them with controls. Patients with previous antidepressant use had a volumetric reduction in the gyrus rectus and in the OFC bilaterally in comparison with controls and patients without previous antidepressant use had an even greater reduction in the gyrus rectus and in the OFC bilaterally in comparison with controls. According to their remission status after the use of a pharmacologic algorithm treatment, patients were classified in remitted or not remitted. In comparison with controls, remitted patients showed a volumetric reduction in a cluster that included the gyrus rectus and in the OFC bilaterally and in another cluster that included the right middle temporal pole. Non-remitted patients showed an even greater volumetric reduction in the gyrus rectus and in the OFC bilaterally compared with controls. A logistic regression was used to investigate baseline predictive factors of remission. Baseline Mini Mental State Examination scores and the left superior lateral OFC standardized (to the total gray matter volume) volume classified patients with respect to their remission status. Regarding white matter volume, the same statistical analyses were conducted. Patients without previous antidepressant use showed a volumetric reduction in the right superior frontal gyrus in comparison with controls. In addition, late onset depression group had a volumetric increase in the left posterior cerebellum lobe in comparison with controls. In relation to the white matter hyperintensities total volume, 22 patients and 19 controls were processed with EMS. The same comparisons among groups were conducted and no statistical significant difference was found. A logistic regression was conducted to investigate baseline predictive factors of remission in this smaller sample, including the white matter hyperintensities total volume and no statistically significant result was found. In conclusion elderly with depression have volumetric reduction in the gyrus rectus and in the OFC bilaterally and this may be characteristic of late life depression and a potential biomarker of this condition. Antidepressant use seems to protect against gray matter reduction and to have a neurotrophic effect. In addition, cognitive deficits and regional gray matter abnormalities at baseline seem to be predictors of worse response to antidepressant treatment. Further longitudinal studies with larger sample size and more severe depression intensity may contribute to a better understanding of the pathophysiology of depression in the elderl

Treatment of Depression in Older Adults

Depression is the most frequent mental disorder in older people, often causing emotional distress and reduced quality of life. Despite its clinical significance, depression remains underdiagnosed and inadequately treated in older patients. Regarding prognosis, data suggest that almost 70% of patients, treated long enough and with appropriate doses, recover from an index episode of depression. Antidepressants are efficient for treating depressed outpatients with several comorbid physical diseases as well as hospitalized patients, with selective serotonin reuptake inhibitors being the antidepressants of choice for older patients. Available data can guide pharmacological treatment in both the acute and maintenance stages, but further research is required to guide clinical strategies when remission is not achieved. Approaches for the management of resistance to treatment are summarized, including optimization strategies, drug changes, algorithms, and combined and augmentation pharmacological treatments. Finally, additional therapeutic choices such as electroconvulsive therapy, transcranial magnetic stimulation, and integrated psychotherapy are presented