Treatment-resistant depression in late life

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.     

The cerebrovascular model of depression in late life

Depression in older people, especially depression with an older age of onset, may be a manifestation of acquired brain disease. The cerebrovascular model of depression, often referred to as "vascular depression," hypothesizes that otherwise clinically occult small vessel brain disease contributes to the pathogeneses of some late-life depressive conditions. This paper reviews several lines of evidence supporting the cerebrovascular model and addresses the limitations of the existing literature. Several directions for future research are noted, including empirical testing of the notion that cerebrovascular disease might underlie the pathogeneses of depression with prominent executive dysfunction or other cognitive impairments. At this time, there are no specific therapeutic options for patients with suspected vascular depression beyond standard approaches to depression treatments, although education about the possibly greater risks of chronicity should be included in treatment planning. Therapy of cerebrovascular risk factors and stroke-risk reduction are important as consistent with general practice guidelines, although it is not known whether this will reduce the incidence or improve the outcome of late-life depression.     

Homosexuality, ethics and identity synthesis.

Implicit metaphysical assumptions concerning the nature of sexual orientation are reflected in the language used to frame ethical debates concerning "reorientation" therapies. An alternative metaphysical construal is presented concerning sexual orientation and sexual identity development and synthesis. This alternative construal allows for humility concerning what we know and do not know about sexual orientation, underscores the client's self-determination and autonomy, and demonstrates regard for personal and religious valuative frameworks. Rather than focusing on therapies aimed specifically at sexual reorientation, clinicians would do well to provide clients with informed consent and to facilitate identity development and synthesis in keeping with their clients' requests for professional services.     

Attachment to God,depression and loss in late life: a longitudinal study

ABSTRACT

Prior research shows that being anxiously and avoidantly attached to God is associated with psychologically problematic outcomes including depressive feelings. However, a clear understanding of how these insecure attachments to God are associated with depressive feelings is still missing. Therefore, a longitudinal study among 329 nursing home residents aged 65–99 was set up to investigate the prospective relation between anxious and avoidant attachment to God and the experience of depressive feelings, as well as whether this relation is moderated by a loss experience. That is, the loss of close relatives can be particularly stressful in late life, challenging existing attachment relationships and placing older adults at risk for depression. Results confirm that insecure attachments to God are distinctly related to depressive feelings, but that this relation is not moderated by a loss experience. Our results also show that depressive feelings predicts attachment to God, instead of the other way around.     

Female identity development and self-reflection in late adolescence

The primary aim of this study was to assess whether the capacity for self-reflection in late adolescent females is related to their level of identity development. It was hypothesized that females characterized by advanced identity status (either identity achievement or moratorium) would exhibit a greater capacity for self-reflection than those characterized by less advanced identity status (foreclosure or diffusion). Of 85 subjects who met the criteria for this study (female college students in the New York City area), 32 fit purely into one of four identity statuses; among this latter group, a t test revealed a significantly higher degree of self-reflection for the advanced identity status subjects. Implications for the psychology of identity are discussed.     

The implications of religious identity for teaching ethics

Some debate exists about the degree to which one should merge one’s identities, particularly those with important normative content, with one’s teaching practices. This issue becomes particularly important for those with a religious identity who purposefully merge their identity with classroom practices. This article examines the qualitative answers of 328 Christian professors to a question addressing how they merge their Christian theological tradition with their ethical teaching in the classroom. We find that the answers demonstrate the identity merging takes place in multiple ways. For these professors, teaching consists of multiple sub-practices (e.g. discussion, lecturing, grading, etc.) that need to be guided by certain virtues and theological perspectives and justifications in order to develop the requisite goods. Indeed, both good teaching and their conception of the good cannot be separated from their identity.     

The evolution of paternal identity in late adulthood

The experience of fatherhood in late adulthood has received little attention in the psychoanalytic literature. After a presentation of the literature on fatherhood and a consideration of the developmental tasks of late adulthood in which the experience of fatherhood is embedded, the dynamically charged, developmentally conflicted nature of the relationships between late-life fathers and their children is explored. A basic premise is that the changing nature of these relationships inevitably confronts the elderly patriarch with considerable intra-psychic turmoil, reflection, and conflict that must be engaged and mastered if these most significant relationships are to be maintained and sustained for both generations. Clinical examples illustrate the theoretical points presented.     

Life satisfaction and identity structure in late middle-aged men and women

A total of 32 retirement-age subjects (17 men and 15 women) provided information about their lives by rating each of their identities in terms of a list of self-generated features. They also rank-ordered their currently enacted identities in terms of time spent in each and completed a life-satisfaction questionnaire. The Identities X Features matrices were analyzed by algorithms that generated a hierarchical model of identity structure for each subject based on feature ratings. The hierarchical levels of identities were combined with time-spent rankings to obtain an index of personal style, a measure that reflected the unique organization of identities for each subject. Personal style indices were then correlated with life-satisfaction scores. Results confirmed the prediction that life satisfaction in this age group is a function of the amount of time spent in identities that give expression to multiple aspects of the self.     

Visualized prosocial behavior and emotion in late life

Correlational research suggests that among older adults prosociality relates to positive emotions; yet causality remains unclear. We conducted an experiment to investigate whether visualizing a prosocial action would experience enhanced positive and lower negative emotion, and whether this would be particularly true for those with certain altruistic personality traits. Participants aged sixty and above were primed with a prosocial (helping a needy stranger), social (going out with friends), or neutral (walking down the street) induction. Results indicated that positive affect was highest among those who visualized a prosocial interaction, and that this effect was strongest among those higher in social responsibility. In contrast, less altruistically oriented participants reported higher negative affect in the prosocial condition. Thus, while prosociality promoted positive affect particularly among the socially responsible, it led to increased negative affect among those lower in altruistic orientation. Results suggest that individual differences influence older adults’ responses to exposure to prosocial involvement.     

Welfare participation and social support in late life

The purpose of this study was to examine the relationships among participation in welfare programs, gender, and change in social support in adults aged 65 and older. It was hypothesized that older men receiving public assistance would encounter more social network problems than older women on welfare. The findings reveal that during the 7-year study older men in receipt of welfare benefits, compared with older women on welfare, received less social support from others, were more dissatisfied with the assistance they got, and encountered more negative interaction from informal social network members (i.e., family and friends). The results suggest that those who administer welfare programs, as well as public policymakers, should consider developing interventions that address the wider psychosocial problems associated with receiving public assistance.     

Congruence of personality and life events in depression

Consistent with the personality-event congruence hypothesis, highly sociotropic depressed patients (n = 19) reported more recent negative interpersonal events than negative autonomy events and more negative interpersonal events than did highly autonomous depressed patients (n = 22), for whom the hypothesis was not supported. There was no evidence of such congruence among nondepressed schizophrenic patients (n = 44). In a second study, there was significant personality-event congruence in dysphoric students (n = 26) but not in nondysphoric students (n = 56). Both the high-sociotropy and high-autonomy dysphoric groups separately yielded nonsignificant trends consistent with congruence. These findings add to the growing support for the importance of the sociotropy construct in depression and weaker support for the autonomy construct or its measurement, and they suggest that the congruence effect does not generalize to all psychopathologies.     

Quality of life and depression in haemodialysis patients

Chronic kidney disease is associated with a high prevalence of depression, which increases inversely with the glomerular filtration rate. This paper aims to evaluate the factors associated with a low quality of life and depression in patients on haemodialysis. Two hundred patients undergoing haemodialysis answered the Medical Outcomes Study 36 – Item Short – Form Health Survey (SF-36) and Beck Depression Inventory (BDI). Clinical and laboratory variables were analysed and correlated with these two tools. The prevalence of depression was 29%. Anaemia and hypoalbuminemia were independent risk factors for depression. All SF-36 domains showed worse results in patients with depression, and the pain domain presented the highest correlation. Our findings provide evidence that patients on haemodialysis have a low quality of life and a high prevalence of depression. A greater number of comorbidities, an excessive number of medications, diabetes mellitus, anaemia and hypoalbuminemia were associated with a reduced quality of life.     

Social and demographic correlates of loneliness in late life

Although loneliness is often viewed as a serious problem of old age, few studies have addressed either its measurement or prevalence among older populations. The present study analyzed survey data from newspaper questionnaires circulated in three North American cities (N = 2,026) in order to examine the prevalence of loneliness across the life-span and some of its correlates in late life. Loneliness decreased across the adult life-span, with respondents age 65 and older the least lonely; elders were also more satisfied with their social relationships. Neither gender nor living alone was related to loneliness for older people. The data also partially confirm the desolation hypothesis, suggesting that desolation, or the loss of an intimate attachment, rather than isolation per se is a major correlate of loneliness in late life. Further, recency of loss was strongly related to increased loneliness. Directions for future research and intervention are discussed.     

Cultural identity, explanatory style, and depression in Navajo adolescents

This study investigated the interrelationships among cultural identity, explanatory style, and depression in Navajo adolescents. A total of 332 (197 female, 135 male) Navajo adolescents completed 7 self-report measures. These data were used to create, via structural equation modeling, a series of factor models and full structural models. Analyses indicated that current factor structures for explanatory style and depression are adequate for use with Navajo adolescents. Increased control and predictability and limited duration of stressful encounters were both predictive of decreased symptoms of depression. Higher levels of Navajo cultural identity had a modest effect in terms of reducing depression. Other factors, such as perceived discrimination and urban/reservation domicile, are important to study to provide an increased understanding of depression among Navajo adolescents.     

Goal-directedness and personal identity as correlates of life outcomes

Although much research has been conducted on goal setting, researchers have not examined goal-directedness or propensity to set goals as a stable human characteristic in adults. In this study, a survey was developed and distributed to 104 adult participants to assess their goal-directedness, personal identity, and various life outcomes. A theoretical model was developed and tested using structural equation modeling that proposed that both goal-directedness and personal identity should positivcly influence important life outcomes. Analysis showed that goal-directedness and personal identity are positively related to personal well-being, salary, and marital satisfaction. Further, personal identity was positively related to job satisfaction but, contrary to related research, goal-directedness did not predict job satisfaction.     

Ego identity status, identification, and decision-making style in late adolescents

Measures of identification with same-sex parent and decision-making style were administered to 30 male and 30 female late adolescents who had been classified by Marcia's (1964) criteria as either identity achieved, foreclosed, moratorium, or diffused. As predicted, male and female foreclosed subjects were more impulsive than were those in the other statuses, and male moratorium subjects were more reflective than others. However, female moratoriums were impulsive, and male and female diffused were reflective, findings which contradict theoretical expectation. Similarly, data on identification were mixed; female achieved subjects scored (as predicted) with higher identification than female moratorium or diffused subjects, while diffused males were highly identified with their fathers. One reason offered for the conflicting results is that identity formation is, as some have suggested, a different process for women than it is for men. Therefore, study of both genders with the same measures and hypotheses is not recommended.