Commentary

BackgroundThere may be differences in gender and marital status in the impact of grandchild care on the depression of the Chinese older adults. This research explores the effect of grandchild care on the depression of Chinese older adults of different genders and marital status, and explores the mediating role of intergenerational support from children between grandchild care and depression.MethodsThis research uses the data of 3540 Chinese older adults from the China Health and Retirement Longitudinal Study (CHARLS) in 2018. The OLS model is used to analyze the effect of grandchild care on the depression of the older adults. and the older adults are classified according to gender and marital status, and the differences in the effect of grandchild care on the depression of the elderly of different genders and marital status is explored. Finally, the bootstrap method is used to test the mediating effect of intergenerational support from children.ResultsThe research finds that grandchild care has a significant impact on the depression of the older adults in China, and providing grandchild care can significantly reduce the depression of the older adults. The effect of grandchild care on the depression of the older adults is different between different genders and marital status. After categorizing the older adults by gender, the grandchild care only has a significant impact on the depression of female older adults; after classified by marital status, grandchild care only has a significant impact on the depression of the older adults who don’t have a spouse. The mediating effect analysis shows that both children’s emotional support and children’s economic support have a mediating effect between grandchild care and depression of the older adults.ConclusionThe depression of the Chinese older adults is affected by grandchild care, and this effect is more prominent in female older adults and the older adults who don’t have a spouse. The society should support and encourage capable older adults to participate in grandchild care, and children should also provide more intergenerational support to the older adults who provide grandchild care, so as to further play the role of grandchild care in relieving depression of the older adults.

ELECTROCONVULSIVE THERAPY (ECT) IS ONE OF THE most controversial treatments in all of medicine. There are a number of reasons for this. The discovery in the 1930s that inducing a series of generalized seizures, initially with chemicals, later with electric current, could cause the recovery of patients with severe and previously untreatable mental disorders produced a wave of enthusiasm that eventually led to a period of indiscriminate use and misuse in the middle decades of the 20th century. This period of abuse created, perhaps deservedly at that time, a bad reputation for an effective treatment modality. That reputation was enhanced by the immediate adverse effects of bitten tongues and even fractured bones and teeth caused by the induction of generalized seizures, and the painful effects of electroshocks administered without anesthesia when they did not successfully induce a seizure with loss of consciousness. The 1975 movie One Flew Over the Cuckoo’s Nest contributed to an erroneous view of ECT as a punitive, painful, and assaultive procedure used by authorities to control inconvenient creativity. That view has been associated with attempts to regulate, or even eliminate, the use of ECT through legislation in a number of jurisdictions, and public fears and distrust about the use of ECT have persisted. The best response to such concerns on the part of physicians is to be aware of the facts about current use of ECT, including its efficacy and possible adverse effects, so they can respond to questions from patients, families, and the public. The indications, possible adverse effects, and current recommendations for treatment procedures have been summarized in a task force report just published by the American Psychiatric Association Committee on Electroconvulsive Therapy. An effective and safe treatment for severe major depression, ECT has had response rates reported in the range of 80% to 90% as a first-line treatment, and in the range of 50% to 60% for patients who have not responded to 1 or more trials of treatment with antidepressant drugs. Electroconvulsive therapy may also be seriously considered as treatment for patients with acute mania, and for patients with schizophrenia who have not responded to adequate trials of antipsychotic medications. As currently practiced, ECT involves the use of informed consent, ultra-brief general anesthesia and muscle relaxants (thus attenuating motor seizure activity) with appropriate airway management, and use of ECT devices to provide adequate ictal responses. Most patients in the United States receive 3 treatments per week, and a course of ECT for major depression generally consists of 6 to 12 treatments, with the course ended or tapered as soon as maximum response has been reached. This usually occurs more quickly than the 4 to 6 weeks required for an adequate trial of an antidepressant drug. There continues to be some controversy about the use of right unilateral or bilateral electrode placement, with right unilateral ECT causing less cognitive adverse effects, but bilateral ECT often viewed as being more effective. A recent randomized controlled trial showed that right unilateral ECT at high dosage was as effective as bilateral ECT in many patients and caused less impairment on several measures of anterograde and retrograde memory. The issue of cognitive adverse effects from ECT is central to its reputation for harm and requires careful consideration to separate facts from myths. Studies of this issue have been reviewed and summarized by the American Psychiatric Association Committee on Electroconvulsive Therapy. Patients experience a variable but usually brief period of disorientation (postictal confusion) immediately after seizure induction. Electroconvulsive therapy also typically results in retrograde amnesia, greatest immediately after the course of treatment and for events that occurred temporally close to the treatment. The extent of the retrograde amnesia usually decreases substantially with time, but many patients have persistent loss of memory for some events that occurred in the interval starting several months before and extending to several weeks after their ECT course. Anterograde amnesia, characterized by rapid forgetting of learned information, also may occur during and immediately following ECT but resolves within a few weeks. Importantly, there is no objective evidence that ECT has any long-term effect on the capacity to learn and retain new information. Assessment of cognitive effects from ECT is complicated by the cognitive impairments associated with the mental disorders being treated. For example, patients with severe depression may have substantial impairments in cognitive function, and patients with schizophrenia or other psychotic

Depression Among Older Adults: A 20-Year Update on Five Common Myths and Misconceptions

Older adults with depression often present with signs and symptoms indicative of functional or cognitive impairment. These somatic symptoms make evaluating and treating depression in older adults more complex. Late life depression (LLD), depression in adults over the age of 65, is more frequently associated with cognitive changes. Cognitive impairment in LLD may be a result of the depressive disorder or an underlying dementing condition. Memory complaints are also common in older adults with depression. There is a wide range of cognitive impairment in LLD including decreased central processing speed, executive dysfunction, and impaired short-term memory. The etiology of cognitive impairment in LLD may include cerebrovascular disease, a significant risk factor for LLD, which likely interrupts key pathways between frontal white matter and subcortical structures important in mood regulation. Because depressive symptoms often coexist with dementia, it is important to determine the temporal relationship between depressive symptoms and cognitive change. If depressive symptoms pre-date the cognitive impairment and cognitive symptoms are mild and temporary, LLD is the likely etiology of the cognitive impairment. If cognitive changes appear prior to depressive symptoms and persist after LLD is successfully treated, an underlying dementia is more likely. Clinicians should be exclude common conditions such as thyroid disease which can contribute to depressive symptoms and cognitive impairment prior to treating LLD. Both antidepressants and psychotherapy can be effective in treating LLD. Subsequent evaluations following treatment should also reassess cognition.

Electroconvulsive therapy (ECT) is a well-established treatment for mood disorders in younger adults and has been consistently shown to be safe and effective in unipolar depression in older adults. However, data on this treatment in older adults with bipolar disorder are limited. In this retrospective study, we report outcomes from all cases of older adults with bipolar depression who received ECT from a large academic institution over a 7-year period. We retrospectively identified all patients 65 years and older with bipolar depression who were treated with ECT over a 7-year period. Patients receiving ECT for an episode of bipolar depression were included in the study based on chart review and availability of documented outcome measures. Primary outcomes were changes in Montreal Cognitive Assessment and Clinical Global Impressions scores. We identified 34 patients meeting inclusion criteria. Collectively, patients had statistically significant improvement in Montreal Cognitive Assessment scores and reductions in Clinical Global Impressions severity scores after treatment. Pre- and posttreatment Montgomery-Asberg Depression Rating Scale scores were also available for a subset of 20 patients and demonstrated a similarly significant reduction in severity with treatment. There were no serious adverse effects of treatment, and no patients discontinued treatment. Electroconvulsive therapy was well tolerated and effective in treating bipolar depression in older adults. Importantly, these findings challenge commonly held worries about cognitive decline in older adults receiving ECT. It should be a regular consideration for management of this challenging illness in a population that may otherwise not respond to pharmacotherapy.

ObjectivesThe use of electroconvulsive therapy (ECT) varies across countries. The aim of this study was to describe and explore the use of ECT in Sweden in 2013.MethodsThe Swedish mandatory patient register of the National Board of Health and Welfare includes information on diagnoses and treatments, including ECT. All 56 hospitals that provide ECT in Sweden also report to the nonmandatory national quality register for ECT, which contains information on patient and treatment characteristics. In this study, we combined data from both registers. In addition, all hospitals responded to a survey concerning equipment and organization of ECT.ResultsWe identified 3972 unique patients who received ECT in Sweden in 2013. This translates into 41 ECT-treated individuals per 100,000 inhabitants. Of these patients, 85% opted to participate in the quality register. The median age was 55 years (range, 15–94 years), and 63% were women. The indication was depression in 78% of the treatment series. Of 4 711 hospitalized patients with severe depression, 38% received ECT. The median number of treatments per index series was 7. Unilateral treatment was used in 86% of the series.ConclusionsIn Sweden, ECT is used at a relatively high rate as compared with other western countries, and the rate was unchanged from the last survey in 1975. However, there is room for improvement in the specificity of use and availability of ECT for disorders where ECT is considered a first-line treatment.

The effects of electroconvulsive therapy are usually estimated from changes in depression scales from studies with relatively small patient samples. Larger patient samples can be achieved from epidemiological registers, which provide information on other social and clinical predictors, results and risks. To examine whether depression severity predicts the use of electroconvulsive therapy, risk of re-hospitalization, suicidal behaviour and mortality following electroconvulsive therapy in patients with major depression. A cohort of 92,895 patients diagnosed with single or recurrent depression between 2005 and 2016 in the Danish National Patient Registry was followed for electroconvulsive therapy and adverse outcomes. Associations between electroconvulsive therapy and outcomes were analysed using Cox regression. A total of 5004 (5.4%) patients were treated with electroconvulsive therapy. Depression severity was the strongest predictor of electroconvulsive therapy. Electroconvulsive therapy was used more frequently above age 70, in those better educated or married, whereas comorbid alcohol abuse or history of prior stroke at study entry were associated with lower rates. Electroconvulsive therapy was associated with lower mortality. The adjusted hazard ratio for the association between electroconvulsive therapy and suicide in patients with mild depression was 6.99 (3.30-14.43), whereas it was 1.10 (0.55-2.20) in those with severe depression and psychotic symptoms. A similar pattern was seen for emergency contacts and attempted suicide. Electroconvulsive therapy was associated with lower all-cause mortality and the relative risk for re-hospitalization and attempted and committed suicide was lowest in patients with the most severe depression. Electroconvulsive therapy is an important treatment, with significant public health benefits, for patients with severe depression.

The Committee for Treatment Guidelines of Mood Disorders, Japanese Society of Mood Disorders, published a Japanese guideline for the treatment of late-life depression in 2020. Based on that guideline, the present guideline was developed and revised to incorporate the suggestions of global experts and the latest published evidence. In the diagnosis of late-life depression, it is important to carefully differentiate it from bipolar disorders, depressive states caused by physical and organic brain disease, drug effects, and dementia, and to determine the comorbidity between late-life depression and dementia. It is necessary to fully understand the clinical characteristics and psychosocial background of late-life depression, evaluate the patient's condition, and provide basic interventions based on these factors. Problem-solving therapy, reminiscence therapy/life review therapy, and behavioral activation therapy, and other forms of psychotherapy can reduce depressive symptoms. In terms of pharmacotherapy, newer antidepressants or non-tricyclic antidepressants are recommended for late-life depression, and it is recommended that the efficacy of least the minimal effective dosage should first be determined. Switching antidepressants and aripiprazole augmentation can be used to treatment-resistant therapy. Electroconvulsive therapy and repetitive transcranial magnetic stimulation have demonstrated usefulness for late-life depression. Exercise therapy, high-intensity light therapy, and diet therapy also show some effectiveness and are useful for late-life depression. Continuation therapy should be maintained for at least 1year after remission.

Several studies have found a strong relationship between physical activity and mental depression in older adults. Despite this, the social isolation, limited physical activity, and decreased social interactions caused by the 2020 COVID-19 pandemic control measures of "home isolation and reduction unnecessary travel" had a significant mental impact on older adults. the goal of this study was to look into the complex effects of physical activity participation on mental health in older adults during COVID-19 prevention and control and the relationship between physical activity and mental depression in older adults through the mediating effect of self-efficacy and the moderating effect of social support. The Physical Activity Rating Scale (PARS-3), the Center for Streaming Depression Scale (CES-D), the Self-Efficacy Scale (GSES), and the Social Support Rating Scale (SSRS) were used to assess 974 older adults in five urban areas of Chengdu, China. The SPSS was used to analyze the collected data using mathematical statistics, linear regression analysis, and the AMOS to construct the research model. The study's findings revealed that self-efficacy mediated the relationship between physical activity and mental depression in older adults (β = -0.101, 95%CI (-0.149, -0.058)), and social support moderated the relationship between physical activity and mental depression in older adults (t = -9.144, p < 0.01). Physical activity reduces psychological depressive symptoms in older adults and modulates psychological depression in older adults via the mediation efficacy of self-efficacy and the moderating effect of social support.

Optimizing Outcomes of Treatment-Resistant Depression (TRD) in Older Adults (OPTIMUM): Measures of Psychological Well-Being

Depression is often associated with decreased cognitive performance among older adults. The current study focused on the association of neuropsychological functioning and personality traits in depressed and non-depressed older adults. Data from 75 depressed and 103 non-depressed adults over the age of 60 were analyzed. All participants underwent standardized clinical assessment for depression prior to participation and completed the NEO-PI-R and a series of neuropsychological assessments. A series of multiple linear regressions were conducted to examine the relationships between personality and neuropsychological performance among depressed and non-depressed older adults. Results indicated that higher Openness to Experience was related to better performance on Parts A and B of the Trail Making Test among depressed older adults, and to better Digit Span Backward performance among all participants. Higher levels of neuroticism were related to poorer performance on Digit Span Backward, but only among depressed older adults. Depressed participants performed more poorly on the Symbol Digit Modalities Test and the Controlled Oral Word Association Test. Personality characteristics, particularly Openness to Experience, modified the relationship between depression and neuropsychological functioning among older adults. Results indicate that interventions aimed at increasing one's Openness to Experience could potentially attenuate some of the neuropsychological impairments that are associated with depression.

Physical activity and depression in older adults: the knowns and unknowns

Medication nonadherence in depressed and anxious older adults is prevalent and associated with non-response to antidepressant pharmacotherapy. Evidence-based options to improve medication adherence are limited in this population. To review the state of the literature on the types and efficacy of psychosocial interventions for improving antidepressant pharmacotherapy adherence in depressed and anxious older adults. We conducted a scoping review according to PRISMA-ScR guidelines. PubMed/Medline and article references starting in 1980 up to 28 February 2023 were reviewed. Of the 710 records screened, 4 psychosocial interventions were included in the review. All studies included depressed older adults, and none included anxious older adults. Samples included racial and ethnic minorities and were primarily women. The psychosocial interventions consisted mainly of psychoeducation with usual care as the control comparison. Measures of antidepressant adherence included self-reported adherence or pill counting. Three of the four randomized controlled trials improved medication adherence rates and reduced depression symptom burden. Effective interventions exist for improving antidepressant medication adherence in depressed older adults. Improved adherence can reduce depression symptom burden. The lack of interventions for anxious older adults highlights the need to develop and deliver interventions for anxious older adults prescribed antidepressant pharmacotherapy.

Electroconvulsive therapy in depressed older adults with unrepaired abdominal aortic aneurysm: Safety first!

Byline: B. Gangadhar In the recently introduced Mental Health Care bill, electroconvulsive therapy (ECT) practice figures with a caution. The bill allows the use of ECT only under anesthesia (modification). In other words, if the bill is passed and implemented, the unmodified (direct) ECT cannot be practiced. Concerns have been raised by some well-meaning psychiatrist colleagues. The cost of ECT would increase, thus taxing the poor patients. Anesthesiologists to provide modification are fewer. In emergency ECT situations, depending on anesthesiologists would pose challenges in that crucial eleventh hour. The position in the bill and the arguments for or against the unmodified ECT are examples of the issues to be faced by psychiatrists in the days to come. How are we prepared? In its first move, the Indian Psychiatric Society produced the position paper on unmodified ECT. [sup][1] It did endorse the benefits of modification in ECT and also conceded that such a procedure should be the contemporary standard. At the same time, the group recorded the concerns of denying ECT on the grounds of unavailability of resources to support modification. The position of the society is to allow use of unmodified ECT only in exceptional circumstances. Unmodified ECT has been a matter of concern and debate since many years. As early as in 1980, Lancet published several views for and against following a report of use of unmodified ECT in Broadmoor (UK). Arguing for unmodified ECT, Crammer [sup][2] also stated that some patients actually preferred ECT without injections (unmodified). Another supporter of this procedure stated that withholding ECT when modification is not possible amounts to unethical practice. Situations of failing to get a vein for intravenous injections (repeated injections in previous ECT sessions can result in such a difficulty) is one such circumstance when unmodified ECT may be the option. [sup][3] On the other hand, nearly 40 other psychiatrists wrote against unmodified ECT, terming it as anachronistic and indefensible. [sup][4] They also opined that unavailability of anesthesiologist does not condone use of unmodified ECT. It may be noted that some psychiatry textbooks from the West have altogether dropped information on unmodified ECT in their recent editions. There is no doubt that modified ECT should remain the current standard of ECT practice. In reality, however, unmodified ECT is in vogue in many parts of the world, [sup][5] China, [sup][6] Pakistan, [sup][7] and India. [sup][8] Together, this would account for the largest ECT population in the world. In our country itself, a recent survey indicated that over 50% of ECTs are unmodified. [sup][9] Clearly, the bill would affect the majority in this regard. This majority would, therefore, not get the benefits of ECT as unmodified ECT would be disallowed. Even if supported by the position adopted by the Indian Psychiatric Society, most, barring the exceptional ones, would be denied ECT. Psychiatrists may also be tempted to adopt different definitions of this exceptional indication. For example, a social reason was an urgent indication for ECT. [sup][10] It is true that earlier users of unmodified ECT had recognized adverse events such as fractures and even rupture of bladder, [sup][11] apart from others, that discouraged them from using unmodified ECT. In this context, Indian reports have reassured, though not convincingly, that unmodified ECT is not as unsafe as has been projected. [sup][12],[13] Benzodiazepine as a muscle relaxant has been suggested as an alternative to modification. [sup][14],[15] It is arguable, however, as an anticonvulsant this drug may interfere with seizure induction. Suggestions have also been advanced if psychiatrists can be trained in ECT-related anesthesia procedures. [sup][16] This issue surely deserves consideration for debate and consensus. In this background, we need to be also alert to the concerns of patients and their kin. …