Phenomenology Of Depression In Dementia

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Understanding the unique aspects of depression in dementia can assist clinicians and researchers in the detection and treatment of this syndrome.

Lazarus, Newton, Cohler, Lesser, and Schweon (1987) were one of the earlier research groups to examine the phenomenology of depression in dementia. In their investigation of 44 persons with dementia, 18 participants were diagnosed as depressed via the Hamilton Rating Scale. Interrater reliability was .68 for this study. The authors reported that those items associated with inner states of despair were far more common than were vegetative symptoms. Thus, mood, anxiety, and hopelessness were noted to be particular aspects of depression in those with dementia. Much of the data following the Lazarus group's study has supported their initial findings.

Katz (1998) and Verhey and Visser (2000) have specified that mood disorders appear to be more prominent in those with preclinical and those with mild dementia. Verhey and Visser examined a group of 116 nonde-mented patients, of which 25 became demented after two years. Thirteen of the 25 individuals who became demented were depressed at baseline. Their depression was characterized by more minor depression symptoms, specifically mood disturbances, guilt, and suicidal thoughts. These authors advocated a term emotional vulnerability syndrome and urged clinicians to broaden the diagnostic criteria to allow for minor depression.

Chemerinski, Petracca, Sabe, Kremer, and Starkstein (2001) evaluated how well mood as rated by both caregiver and dementia patient accounted for depressive syndromes in 253 persons with AD, 47 persons with depression but no dementia, and 20 healthy controls. Depressed mood as rated by both caregivers and patients was a powerful predictor of a host of other depressive symptoms including apathy, anxiety, insomnia, loss of interest, agitation, and psychomotor retardation. These data further supported the importance of assessing mood in persons with dementia.

Patterson et al. (1990) investigated minor depression in 34 persons with AD and 21 spousal controls. Six (18%) of the patients had evidence of minor depression using the Cornell Scale versus two (10%) of the controls based on interviews. Sadness, lack of pleasure, and anxiety were the most common symptoms among those with depression and dementia, whereas vegetative signs were the least common in that group.

Apathy and social withdrawal have been the second area of focus in the phenomenology of depression studies. Starkstein (2000) reported on the prevalence of apathy in 301 individuals with probable AD, 106 with depression but no dementia, and 25 controls. Approximately one-quarter of those with depression and dementia had apathy symptoms compared to

14% of those with dementia only and 0% in the control group. Forsell, Jorm, Fratiglioni, Grut, and Winbald (1993) used a population-based sample to examine how depression phenomenology changed over time. Investigating 213 persons with possible dementia, 11% met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association [APA], 1987) for major depressive disorder. A principal components analysis was carried out on nine categories of depressive symptoms. Mood disturbance was found to be the most prominent symptom in those with mild dementia and depression, whereas apathy was the most prominent symptom in those with moderate to severe dementia.

Mast (2002) performed a methodologically advanced analysis of the phenomenology of depression in dementia with the goal of identifying unique patterns of symptoms endorsement associated with cognitive impairment. A series of multiple indicators multiple causes (MIMIC) models were estimated from data for 580 geriatric rehabilitation patients with varying levels of cognitive impairment. The MIMIC model methodology combines confirmatory factor analysis with time response concepts and, in the current context, allows for examination of the impact of cognitive impairment at two distinct levels of analysis: the impact of cognitive impairment on global depression severity (i.e., second-order latent factor) and on the probability of endorsing specific symptom clusters (i.e., first-order latent factors; technical descriptions of the MIMIC model methodology can be found in Muthen, 1989; geriatric assessment applications of the MIMIC model can be found in Mast & Lichtenberg, 2000; Mast, MacNeill, & Lichtenberg, 2002). The results from these analyses indicted that greater cognitive impairment was associated with more severe depressive symptoms and was uniquely associated with symptoms of social withdrawal and apathy, even after controlling for the global depression severity effect.

Clinical Implications

• Depressive symptoms in persons with dementia are most likely to consist of mood and/or symptoms of apathy/withdrawal.

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