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Rapid Responses: Rapid Responses published:
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Role of treatment in major depression
- Prasad S Kulkarni (3 February 2009)
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Depression, aging, cerebral blood flow and blood viscosity.
- Les O. Simpson (23 February 2009)
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Food for thought in the treatment of old age depression in primary care
- Alex E Jewkes (2 March 2009)
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Who is older, 55 or 65?
- Dr Qaiser Javed (14 March 2009)
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Prasad S Kulkarni, Addl Medical Director Serum Institute of India Ltd, Pune-411028, India
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The study by Licht-Strunk (1) is impressive. 63% of patients with major depressive disorder did not receive any treatment at the end of 3 years follow up. Does this point to a need for specialist care for this condition? It would have been great if the authors could verify the self reported data on treatment prescribed / referrals with the medical records. Secondly, out of 126 patients who did not receive any treatment at the begining of the study, 83 (66%) had recovered at 3 years, without any intervention. (This is an underestimate since only only 160 patients out of 204 were available at 3 years) What to make of this? More than two thirds of elderly patients with major depressive disorders recover on their own? Reference: 1. E Licht-Strunk, H W J Van Marwijk, T Hoekstra, J W R Twisk, M De Haan, and A T F Beekman. Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up. BMJ 2009; 338: a3079 Competing interests: None declared |
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Les O. Simpson, retired experimental pathologist Dunedin, New Zealand 9077
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How is it possible that in 2008, a group studying depression in the elderly make no reference to information published since the 1980s which reports that depressive illness is accompanied by reduced regional cerebral blood flow ? Nor do they appear to be aware that because of age- related increases in blood viscosity and reduced red cell deformability, aging is also associated with reduced regional cerebral blood flow. Because the blood flow changes in depression are reproduced during the aging process, it is hardly surprising that depression is a problem in the elderly. Given that this information has been around for some time, a fundamental question relating to the paper by Licht-Strunk et al would ask, "Is it possible to consider the outcome of a disorder without consideration of its pathophysiology ?" Consider the relevance of the available information. Sackheim et al (1) reviewed the reports relating to regional cerebral blood flow in mood disorders which had been published by 1990. They seemed unimpressed by many of the reports but recognised that inadequate rates of cerebral blood flow could reduce the rate of glucose metabolism and have an adverse effect on tissue function. They noted that, "The cause of the regional cerebral blood flow deficits is unknown." Since 1990 there has been a number of neuroimaging studies which confirmed the reduction in regional cerebral blood flow in subjects with major depression, but without any discussion of the factor or factors responsible for the reduced blood flow. Bench et al (2) reported a study in which patients had been scanned during and after an episode of depression. They stated, "Thus, recovery from depression is associated with increases in regional cerebral blood flow in the same areas in which focal decreases in regional cerebral blood flow are described in the depressed state, in comparison with normal subjects." Others have reported similar findings. Because of a general lack of information about blood rheology changes in depressive illness, a report of the beneficial effects of exercise for those suffering from depression (3) has interesting implications, as an Australian group had reported beneficial effects of exercise in postnatal depression. Since the publication of a paper titled, "Changes in blood rheology produced by exercise," (4) Ernst and others have shown that exercise reduces blood viscosity and increases red cell deformability. Therefore, because exercise was beneficial for patients with depressive illness, could this imply that the reduced regional cerebral blood flow was the consequence of changed blood rheology ? In writing about the changes in blood rheology which occur during the aging process, Ajmani and Rifkind (5) made the following points. a. Plasma viscosity is increased because of increased levels of fibrinogen. b. The poor filterability of blood from the elderly indicated reduced red cell deformability. c. The adverse effects on blood flow may be manifested as tissue dysfunction particularly in the brain and muscles. Therefore it is not surprising that a Swedish study (6) published in 1989 concluded that, "...the mean cerebral blood flow decreased progressively with age." An English study published two years later (7) noted that, "Decreases in regional cerebral blood flow suggest a regionally specific loss of cerebral function with age." While many factors may induce changes in blood rheology which may lead to an episode of depression in young people, similar stresses in the elderly would amplify the age-related changes and possibly prolong an episode of depression. Licht-Strunk et al noted that, "The effects of depression are well documented on daily functioning, wellbeing, the onset and prognosis of chronic physical illnesses such as cardiovascular disorders,diabetes, mortality and utilisation of health services." As there is a large literature which documents changes in blood rheology in chronic disorders, including cardiovascular disorders and diabetes (8) it is possible that impaired blood flow is the primary problem,in the conditions noted above. What this implies is that the elderly should be advised about the importance of their diet and encouraged to reduce their intake of saturated fats and to increase their intake of oily fish or to take at least 6 grams daily of fish oil as a supplement. Furthermore, it would be of interest to learn of the effects of 6 grams of fish oil daily on the cerebral blood flow and symptoms of depression. References. 1. Sackheim HA, Prohovnik I, Moeller JR, et al. Regional cerebral blood flow in mood disorders. Arch Gen Psychiatry 1990; 47: 60-70. 2. Bench CJ, Frackowiak RS, Dolan RJ. Changes in regional cerebral blood flow on recovery from depression. Psychol Med 1995; 25: 247-61. 3. Babyak M, Blumenthal TA, Herman S, et al. Exercise benefit for major depression: maintenance of therapeutic benefits for 10 months. Psychosom Med 2000; 62: 633-8. 4. Ernst E. Changes in blood rheology produced by exercise. JAMA 1985; 253: 2962-3. 5. Ajmani RS, Rifkind JM. Hemorheological changes during human aging. Gerontology 1998; 44: 111-20. 6. Hagstadius S, Risberg J. Regional cerebral blood flow characteristics and variations with age in resting normal subjects. Brain Cogn 1989; 10: 29-43. 7. Martin AJ, Friston KJ, Colebatch JG,et al. Decrease in regional cerebral blood flow with normal aging. Cereb Blood Flow Metab 1991;11: 684-9. 8. Simpson LO. Blood viscosity factors - the missing dimension in modern medicine. Mumford Institute, New Jersey, 2008. Competing interests: None declared |
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Alex E Jewkes, Foundation Year 2 Doctor Manchester Royal Infirmary
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I wholeheartedly applaud Lich-Stunk et al for their extensive longitudinal study into geriatric depression in a primary care setting (1). Their article certainly provides much area for discussion. Of particular note was the finding of no association between treatment for depression and recovery. In spite of possible confounders mentioned in the study, primary care physicians should certainly take note. Antidepressant prescibing in the elderly can be particularly hazardous- the increased risk of GI bleeding in SSRI prescription is but one caution that rapidly springs to mind. The above study made no mention of non-pharmacological interventions in primary care. Given they form a key part of NICE guidelines for the treatment of depression of all severities, it would have been interesting to note their prevalence. Indeed, perhaps the routine follow-up and physician contact afforded by Lich-Stunk and colleagues aided patients in their recovery? Given the risks of medication, and the questions raised by this study on their benefits in all elderly patients, physicians should certainly consider other forms of management. Reference 1- E Licht-Strunk, H W J Van Marwijk, T Hoekstra, J W R Twisk, M De Haan, and A T F Beekman Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up BMJ 2009; 338: a3079 Competing interests: None declared |
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Dr Qaiser Javed, Core trainee level 1(Psychiatry) Clatterbridge Hospital,CH63 4JY
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Without any doubt, this study is very impressive & I appreciate Lich-Stunk et al for their detailed longitudinal cohort study in primary care setting. What I strongly believe that in order to get good number of patients they have included patients aged 55 in the group of older people or probably they have not done the power calculation prior to that study otherwise they would have got the results with significant difference statistically in table 2 (Univariable & multivariable Cox survival analyses for potential predictors of no recovery from major depressive disorder, measured at baseline with follow up for three years). Ideally they should have included patients aged 65 or more in order to consider older patients in this study or preferably aged 75 or more to get clear picture of possible outcome of depression in older patients in primary care. Reference 1. E Licht-Strunk, H W J Van Marwijk, T Hoekstra, J W R Twisk, M De Haan, and A T F Beekman. Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up. BMJ 2009; 338: a3079 Competing interests: None declared |
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