Psychosomatics
Journal Home Search Current Issue Past Issues Subscribe All APPI Journals Help Contact Us
 
Psychosomatics 47:296-303, August 2006
doi: 10.1176/appi.psy.47.4.296
© 2006 Academy of Psychosomatic Medicine
Quicksearch
Advanced Search
Or Search All APPI Journals
This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via Google Scholar
Google Scholar
* Articles by Koenig, H. G.
* Articles by Johnson, J. L.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Koenig, H. G.
* Articles by Johnson, J. L.
Related Collections
* Depression
* Syndromes Secondary to General Medical Disorders

Comparison of Major and Minor Depression in Older Medical Inpatients With Chronic Heart and Pulmonary Disease

Harold G. Koenig, M.D., Joan Vandermeer, R.N., M.S.N., C.S., Angie Chambers, R.N., Lesley Burr-Crutchfield, R.N., and Jeffrey L. Johnson, M.S.

Received March 12, 2005; revised June 28, 2005; accepted August 9, 2005. From the Duke Univ. Medical Center and the GRECC VA Medical Center, Durham, NC. Please send correspondence and reprint requests to Dr. Koenig, Box 3400, Duke Univ. Medical Center, Durham, NC 27710. e-mail: koenig{at}geri.duke.edu


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 Conclusions
 REFERENCES
 
Depressed medical inpatients with congestive heart failure (CHF) and/or chronic pulmonary disease (CPD) were examined to determine characteristics distinguishing major depression (N=413) from minor depression (N=587). Consecutively admitted patients age 50 or over were screened for depressive disorder with the Structured Clinical Interview for Depression (SCID–IV). CHF/CPD patients with major depression differed from those with minor depression not only on number and severity of depressive symptoms but also on race/ethnicity, comorbid psychiatric illnesses, dyspnea, life stressors, social support, and previous antidepressant therapy. CHF/CPD patients with major and minor depression have distinct psychosocial and physical characteristics that distinguish one from another.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 Conclusions
 REFERENCES
 
Approximately 2.4 million Americans have congestive heart failure (CHF),1 and another 14-to-20 million have chronic pulmonary disease (CPD).2CHF is the most common reason for hospitalization in older adults and is the most frequent discharge diagnosis submitted for Medicare reimbursement.3,4 Patients have difficulty coping with the functional disability and distressing physical symptoms caused by these conditions. Rates of depression range from 30% to 60% in patients with CHF5,6 and 16% to 76% in those with CPD.7,8 Depression, in turn, predicts greater use of health services,9,10 worse health outcomes,11 and greater mortality.12,13

Major Versus Minor Depression
Understanding the characteristics of medically ill patients with major depression and minor depression diagnosed during acute hospitalization is important because major depression is a recognized mental illness and because minor depression is much more common in such settings, may be confused with it, and has different clinical outcomes. Differences in clinical outcome between major and minor depression are poorly understood, although the time-course of minor depression appears to be limited, with the majority of patients experiencing relief within 3 months after discharge. Patients with major depression, on the other hand, experience persistent symptoms and disability many months after hospitalization, with nearly 50% showing little improvement after nearly a year.

Little attention, however, has been paid to the different types of depressive disorder found in hospitalized CHF/CPD patients or how major and minor depression can be differentiated from one another. General studies of older medical inpatients with minor depression indicate that they differ from those with major depression in having fewer negative life stressors, less severe physical disability, better perceived health, less severe medical illness, and more social support.14 Information on differences between major and minor depression in patients with CHF/CPD, in particular, however, is limited. In a small sample of CHF inpatients (39 with major depression and 23 with minor depression), those with minor depression appeared to have lower rates of past psychiatric disorder (especially depression), less physical disability, less severe medical illness, higher income, and greater social support, as compared with those with major depression, although specific statistical comparisons between these two groups were not made.15

The best data come from Freedland and colleagues’ study16 of 682 CHF inpatients (135 with major depression, 111 with minor depression, and 436 without depression). Although, again, no direct statistical comparisons were made specifically between major and minor depression, the data suggest that patients with major depression were more likely to be female, younger, were more likely to have a history of depression, severe physical disability, advanced New York Heart Association (NYHA) class, and were more likely to have comorbid CPD than those with minor depression.

There are even fewer data on patients with CPD, although at least one study has reported greater physical disability and poorer quality of life in patients with minor depression.17 No studies, to our knowledge, have yet directly compared CHF or CPD patients with major versus minor depression.

Here, we examined a large sample of CHF/CPD patients systematically diagnosed with DSM–IV depressive disorders during an acute medical hospitalization. The overall purpose of this study was to examine the correlates and course of CHF/CPD patients with major and minor depression; non-depressed patients were not included. This report from the baseline evaluation explores cross-sectional differences between patients with major and minor depression in terms of vulnerability, psychosocial stressors, coping resources, and treatments for depression.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 Conclusions
 REFERENCES
 
To obtain a mixture of subjects from academic and community settings, between November 1999 and December 2003 we assessed consecutive patients admitted to Duke University Medical Center (DUMC, with over 1,000 beds) and three nearby community hospitals (ranging in size from 102 to 369 beds). Inclusion criteria were being age 50 or older, having an active medical diagnosis of CHF or CPD (or both), having major or minor depression, attaining a score of 22 or higher on the 30-item Mini-Mental State Exam (MMSE),18 being English-speaking and able to communicate by telephone, and residing within 35 miles of the admitting hospital. The admitting physician made the diagnosis of CHF and/or CPD, which had to be documented in the patient’s medical record.

After obtaining written informed consent from patients and verbal consent from their physicians, research-trained psychiatric nurses systematically assessed patients for major depression or minor depression by use of the Structured Clinical Interview for DSM–IV (SCID–I/NP; Version 2.0).19 These diagnoses require that depressive symptoms cause significant social or occupational dysfunction, as DSM–IV specifies. Depressive symptoms were counted toward the diagnosis regardless of presumed etiology ("inclusive" approach). Although this approach may overdiagnose depression, it: 1) is consistent with DSM–IV (which claims to be largely descriptive and nonetiologic); 2) results in depression diagnoses that are more reliable and consistent across examiners; and 3) identifies depressive disorders that persist over time and cause significant impairment of functioning that would otherwise be missed by the "etiologic" approach.14

Research nurses were re-trained every 6 months to ensure that the method of data collection was consistent. IRBs at each of the participating hospitals approved the study.

Measures
Instruments to assess patients are described in four groups, each thought to have a unique influence on factors differentiating major from minor depression: vulnerability, psychosocial, coping resources, and treatment for depression. Research nurses administered all the measures.

Vulnerability
Information was gathered on age, gender, ethnicity, and living situation, factors known to influence depression in CHF/CPD patients.6,7,13,20–22 We measured depression severity with the 17-item, clinician-rated Hamilton Rating Scale for Depression (Ham-D).23 Research nurses, experienced in psychiatric diagnosis, assessed patients for the presence of other major Axis I disorders with a DSM–IV checklist containing the key criteria for these disorders. Cognitive impairment was determined by the brief MMSE,24 a measure that assesses the first 14 items of the full 30-item MMSE.

We inquired about previous history of depression as part of the SCID. Previous psychiatric history (besides depression) and family psychiatric history was obtained with the Duke Depression Evaluation Schedule (DDES).25 Patients were asked whether they had ever experienced a mental or nervous condition that required some form of treatment, ever taken "nerve" medication for any reason, or ever had a problem with alcohol or drug abuse. Family psychiatric history was also assessed by DDES, which determined whether any first-degree relative (parents, siblings, children, grandchildren) ever had a mental or nervous condition, ever saw a psychiatrist or was admitted to a psychiatric hospital, ever took nerve medicine for 3 months or more, ever made a suicide attempt or committed suicide, or ever had a problem with drugs or alcohol.

Physical and psychosocial stressors
The Cumulative Illness Rating Scale (CIRS) is a 12-item, clinician-rated scale that assesses severity of impairment for 12 major organ systems, each rated on a 0-to-4 scale of severity.26 Next, the admitting diagnosis and other active comorbid medical illnesses were identified from the medical record and classified into 31 categories of illness on the basis of the ICD-9. The Charlson Comorbidity Index (CCI) was used to assign "weights" to each active medical diagnosis in order to determine a total comorbidity score for each.27 Third, physical functioning, as reported by the patient, was measured with the Duke Activity Status Index (DASI), a 12-item questionnaire assessing activities of daily living (ADLs) and designed specifically for those with chronic conditions such as CHF or CPD.28

In addition to global measures of physical health, two disease-specific measures were administered. Guyatt and colleagues have shown that impairment of functioning in patients with chronic heart failure is virtually identical to that seen in patients with chronic lung disease.29 Guyatt’s Chronic Heart Failure/Chronic Respiratory Disease Questionnaire measures three domains of functioning (dyspnea, fatigue, and emotional functioning). We used only the dyspnea subscale, which examines how much shortness of breath the patient experienced in the previous 2 weeks while performing five important activities. Each item is rated by the patient on a 1-to-7 scale, ranging from "not at all short of breath" to "extremely short of breath," and produces an index ranging from 5 to 35. Patients with CHF were also placed into NYHA30 Classes I through IV on the basis of physical functioning assessed with the Specific Activity Scale, a measure of ADLs that uses metabolic-equivalent tasks as anchor-points.31

Stressful life events (SLE) unrelated to health that occurred during the previous 12 months were also examined.32 Systematic research has identified 12 common negative life events in later life that are unrelated to the respondent’s health. For each negative event, patients are asked if it was expected, important, or had a negative effect (total SLE score ranges from 0 to 72).

Coping resources
We determined education level by the highest grade completed. Total yearly income was dichotomized at the poverty level for a two-person elderly family (≤$15,000: 0; >$15,000: 1). The 11-item version of the Duke Social Support Index (DSSI) measures two components of social support: social network and subjective support.33 These coping resources were chosen because of their known relationship to depression in other populations.

Depression treatments
Current and past treatments for depression were examined in two ways. First, subjects were asked whether they were currently taking any medication for depression or had ever taken it in the past; psychotherapy was assessed in a similar manner. Second, subjects’ medical records were reviewed to determine whether any antidepressant medication or psychotherapy was documented either for the present admission or during previous admissions. A history of having received electroconvulsive therapy (ECT) at any time in the past was likewise determined. Also, we examined intensity of antidepressant use with a modified version of a single-item scale used to rate intensity of treatment in drug studies.34 This scale includes the type of antidepressant, dose, and duration of treatment, and covers a wider range of old and new antidepressants.

Statistical Analyses
CHF/CPD patients with major depression and minor depression were compared in bivariate analyses using chi-square and Student t-tests (Table 1). Logistic regression was then used to identify characteristics of depressed CHF/CPD patients with major depression that uniquely differentiated them from patients with minor depression. Groups of variables were entered into the model in a stepwise fashion, retaining those with a p value <0.05. They were entered on the basis of a theoretical model of depression as developing in a vulnerable person faced with psychosocial stressors, who then mobilizes coping resources to ward off depression, and, if unable, then seeks depression treatment to relieve his or her symptoms. Thus, vulnerability factors were entered first, then psychosocial stressors, coping factors, and depression treatments in consecutive order. Results are presented as odds ratios (OR) and 95% confidence intervals (CI). Because of the multiple comparisons, level of statistical significance was set at p=0.01 and trend level at 0.01>p<0.05.


View this table:
[in this window]
[in a new window]
 

TABLE 1. Comparison of Major and Minor Depression (Bivariate)




  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 Conclusions
 REFERENCES
 
A total of 1,000 CHF/CPD patients with either major (N=413) or minor depression (N=587) were identified between October 1999 and December 2003. Thirty-two fulfilled criteria for dysthymia (5.6% with major depression and 1.5% with minor depression); removing these patients did not affect the results, so they were included. Half were from DUMC (N=505), and the other half were from the three smaller community hospitals (N=495). CHF alone was present in 17%, CHF and CPD in 30%, and CPD alone in 53% (60% with COPD). Among CHF patients, 91% had NYHA Class III or IV disorder. Among CPD patients on whom pulmonary function tests were available (N=219), average FEV – 1/FVC was 64.1% (range: 22.6% to 100.0%).

Major Versus Minor Depression
With regard to vulnerability, bivariate analyses showed that patients with major depression differed from those with minor depression in being younger and white (Table 1). Patients with major depression also had more comorbid psychiatric illness, previous history of depression, and family history of depression. Degree of stress was also greater in patients with major depression, as indicated by poorer physical functioning (ADLs), more shortness of breath, and more negative life stressors. Among coping resources, education and income did not differ, but social support was significantly lower in those with major versus minor depression. There were also differences in depression treatments; those with major depression were more likely to be currently receiving antidepressant medication and at greater intensity, and more likely to have received antidepressant drugs in the past. They were also more likely to be receiving psychotherapy currently, more likely to have received it in the past, and more likely to have a history of ECT.

Multivariate analyses (Table 2) revealed that patients with major depression tended to be white; whites were 48% more likely to have major depression than minor depression (OR: 1.48; 95% CI: 1.06–2.06; trend at p=0.02). Cognitive functioning was worse in patients with major depression; for every 1-point increase on the brief MMSE (range: 0–18), the likelihood of having major depression decreased by 14% (OR: 0.86; 95% CI: 0.76–0.96; p=0.006). Most significantly, however, was the finding that patients with major depression were more likely to have comorbid psychiatric illnesses in addition to their depression; the presence of comorbid illness more than doubled the likelihood of having major depression (OR: 2.04; 95% CI: 1.53–2.71; p<0.0001). Common comorbid psychiatric illnesses in patients with major depression included anxiety disorder (41.2%), delirium (18.9%), and substance abuse (5.3%).


View this table:
[in this window]
[in a new window]
 

TABLE 2. Logistic-Regression Model Comparing Major and Minor Depression



With regard to physical stressors, patients with major depression tended to have worse physical functioning and more medical symptoms. For every 1-point increase on the DASI (which measures ability to perform ADLs on a scale from 12 to 36), there was a 5% reduction in the likelihood of major, as compared with minor depression (OR: 0.95; 95% CI: 0.91–0.99; trend at p=0.03). Patients with major depression also had more shortness of breath, such that for every 1-point increase on the CHQ (Chronic Heart Failure Questionnaire)/CRQ (Chronic Respiratory Questionnaire) scale, which ranges from 5 to 35, there was a 5% increase in likelihood of major depression (OR: 1.05; 95% CI: 1.02–1.05; p<0.001).

Those with major depression also had more negative life stressors unrelated to physical health (OR: 1.04; 95% CI: 1.02–1.05; p<0.0001) and worse social support (OR: 0.90; 95% CI: 0.87–0.94; p<0.0001). For every 1-point increase on the Duke Social Support Index (range: 11–33), the likelihood of major depression decreased by 10%. Finally, patients with major depression were more likely to have received antidepressant medications sometime in the past (OR: 1.67; 95% CI: 1.23–2.27; p=0.001), but were not more likely than patients with minor depression to be currently receiving antidepressants or psychotherapy (either likelihood or intensity), when previous antidepressant use was controlled.

Differences between major and minor depression were somewhat greater in those over age 65 than those ages 50 to 65 in terms of cognitive functioning (OR: 0.81 in older versus OR: 0.92 in younger patients), shortness of breath (OR: 1.08 versus 1.01), and previous history of antidepressant treatment (OR: 1.75 versus 1.58), but age effects were otherwise minimal.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
Conclusions
 REFERENCES
 
To our knowledge, this is the first study to compare CHF/CPD patients with major and minor depression in order to identify the unique characteristics of each type of depressive disorder that justifies their separation into distinct diagnostic categories. Controversy abounds in the literature on whether minor depression is a legitimate, distinct clinical entity that requires specific treatment.35 There are those who argue that minor depression exists on a continuum with major depression,36 although there is less information on differences between major and minor depression in primary-care settings on which to base such discussions.37

Besides depression severity, we found that patients with major depression differed from those with minor depression in that they were more likely to be white, had worse cognitive functioning, more comorbid psychiatric illnesses, more psychosocial stressors, fewer coping resources (less social support), and were more likely to have a history of treatment with antidepressant drugs. First, non-whites tended to have major depression less often than whites. Since more than 98% of non-whites in our sample were African American, this finding is consistent with reports by others studying CHF/CPD patients who have found less severe depression among black patients.6,21,23 In a study of 60 hospitalized patients over age 70 with CHF, Freedland and colleagues23 also found that rates of major depression in hospitalized elderly CHF patients differed by race/ethnicity: 24% of whites had major depression, versus 0% of non-whites. African Americans may have other resources to help them cope with the distress of having CHF/CPD (larger extended families, stronger religious beliefs, greater resilience as a result of years of coping with deprivation).38,39 Alternatively, African Americans may be less likely to admit to having depressive symptoms or may not express depressive symptoms in the same way that whites do.40,41

Second, those with major depression had worse cognitive functioning and more comorbid psychiatric illnesses. Differences in cognitive functioning were particularly notable among those over age 65 and are not surprising, given the known effect of severe depression on cognitive functioning, especially in elderly patients42 and in those compromised by medical disorders that affect blood oxygenation.43 Likewise, in a previous study of CHF inpatients, we found that comorbid psychiatric disorders were 10 times more common among depressed than nondepressed patients.16 Understandably, patients burdened not only with severe medical illness but also with psychiatric conditions such as anxiety disorders or substance abuse (as found in this study), might be at higher risk for severe depression.

Third, patients with major depression tended to have greater impairment of physical functioning and, especially, more severe shortness of breath than those with minor depression. Other studies have reported worse physical health and poorer functioning in more severely depressed CHF/CPD patients,7,16,21,44 although few have examined differences in shortness of breath between depressed and non-depressed patients,7 and the present study may be the first to examine such differences between major and minor depression. Dyspnea, like severe pain, is not only uncomfortable but also frightening to patients as they battle feelings of suffocation and fear of death. It is not surprising that the severity of depression and hopelessness increase as shortness of breath worsens.

Fourth, CHF/CPD patients with major depression had experienced more negative life events within the previous year and had fewer coping resources than those with minor depression. Since these were older patients, many were dealing with the loss of loved ones, financial pressures, or need for relocation, adding to the stress of physical illness. Patients with major depression also had less social support to help buffer against these stressors. Both our group and other researchers have found level of social support or degree of social functioning correlates inversely with severity of depression in general-medical inpatients,15,45 and CHF/CPD patients in particular.16,22,46 It is not surprising that support from family and friends is particularly important as patients grapple with the stress of disabling symptoms and frequent hospitalizations.

Finally, patients with major depression, versus those with minor, were more likely to have received antidepressant medications sometime in the past (42.2% versus 24.5%) and tended to be receiving such treatment currently (44.3% versus 28.8%), although current treatment did not distinguish patients with major from minor depression after past treatment was controlled for. Such differences in treatment rate in cross-sectional studies probably reflect depression severity, since physicians recognize patients with severe depression more readily. Of concern, however, is the fact that nearly 40% of patients with major depression had never received antidepressant therapy at any time in their lives, and over half (56%) were not receiving it currently. Others report similar findings in CHF inpatients,13 and Rumsfeld and colleagues22 found that fewer than 16% of CHF outpatients scoring above the usual cutoff on a depressive symptoms scale were taking antidepressants.

Study Limitations
The cross-sectional associations presented here prevent any conclusions regarding temporal order of effects. Furthermore, the multiple statistical comparisons made here increase the possibility of Type I error, even though we reduced our significance level to p=0.01. The use of the inclusive approach to make depression diagnoses may also have overdiagnosed depression here (although, as noted earlier, we feel that the benefits of this approach outweigh the limitations). Finally, patients were not recruited on the basis of first onset of CHF/CPD, and we did not collect information on time since initial diagnosis. Despite these limitations, the study involved a relatively large number of patients who were systematically identified, diagnosed, and assessed using standardized measures of depression, physical health, and other baseline characteristics. We chose to analyze outcomes for the combined sample of CHF and CPD patients, rather than examine them separately, because a significant proportion (30%) had both CHF and CPD, and because of the similarities between CHF-only and CPD-only patients on many characteristics, including depression severity (Ham-D 15.0 versus 15.3, respectively), MDD (38% versus 43%), and shortness of breath (CHQ–CRQ 31.0 versus 29.9), as others have also reported.47


  Conclusions

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 Conclusions
REFERENCES
 
CHF/CPD patients with major depression differ from those with minor depression not only on depression severity but also in terms of the their vulnerability to depression, severity of psychosocial stressors, coping resources, and treatment factors. These data provide further support for the existence of minor depression as a distinct clinical entity separate from major depression in medically ill patients, as others have suggested.48 Hospitalized patients with CHF/CPD at particularly higher risk for major depression are white, have cognitive impairment and other comorbid psychiatric illnesses, have worse physical functioning, more severe shortness of breath, and other concurrent life stressors unrelated to physical health. Also, they are likely to have less social support and a history of previous antidepressant use. Patients with minor depression should be carefully monitored for the emergence or worsening of depression, and psychiatric consultation should be sought if patients do not appear to be improving (in this study, fewer than 10% of patients had improved).


  ACKNOWLEDGMENTS

 
Funding was provided by NIMH Grant R01-MH57662 (Dr. Koenig).

None of the authors has a conflict of interest with regard to occupation, financial, or other matters relevant to the subject matter contained in this manuscript.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 Conclusions
 REFERENCES
 

  1. Ni H: Prevalence of self-reported heart failure among U.S. adults: results from the 1999 National Health Interview Survey. Am Heart J 2003; 146:121–128[CrossRef][Medline]
  2. Tiep BL: Disease management of COPD with pulmonary rehabilitation. Chest 1997; 112:1630–1656[Medline]
  3. Graves EJ, National Center for Health Statistics:1989 Summary: National Hospital Discharge Survey: Advanced Data From Vital and Health Statistics. Hyattsville, MD, U.S. Public Health Service;1991:1–2 DHHS Pub. 91-1250, PHS Pub. No. 199
  4. Graves EJ: Detailed diagnosis and procedures: National Hospital Discharge Survey, 1990. Vital Health Statistics 1992, 13, No. 113:1-224, DHHS Pub. 92-1774
  5. MacMahon KM, Lip GY: Psychological factors in heart failure: a review of the literature. Arch Intern Med 2002; 162:509–516[Abstract/Free Full Text]
  6. Vaccarino V, Kasal SV, Abramson J, et al: Depressive symptoms and risk for functional decline and death in patients with heart failure. J Am Coll Cardiol 2001; 38:199–205[Abstract/Free Full Text]
  7. Felker B, Katon W, Hedrick SC, et al: The association between depressive symptoms and health status in patients with chronic pulmonary disease. Gen Hosp Psychiatry 2001; 23:56–61[CrossRef][Medline]
  8. Agle DP, Baum GL, Chester EH, et al: Multidisciplinary treatment of chronic pulmonary insufficiency: psychologic aspects of rehabilitation. Psychosom Med 1973; 35:41–49[Abstract/Free Full Text]
  9. Spertus JA, Tooley J, Jones P, et al: Expanding the outcomes in clinical trials of heart failure: the quality-of-life and economic components of EPHESUS (EPlerenone's neuroHormonal Efficacy and SUrvival Study). Am Heart J 2002; 143:636–642[CrossRef][Medline]
  10. Sullivan M, Simon G, Spertus J, et al: Depression-related costs in heart failure care. Arch Intern Med 2002; 162:1860–1866[Abstract/Free Full Text]
  11. O'Connor CM, Joynt KE: Depression: are we ignoring an important comorbidity in heart failure? J Am Coll Cardiol 2004; 43:1550–1552[Free Full Text]
  12. Rozzini R, Sabatini T, Frisoni GB, et al: Depression and major outcomes in older patients with heart failure. Arch Intern Med 2002; 162:362–364[Free Full Text]
  13. Jiang W, Alexander J, Christopher E, et al: Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med 2001; 161:1849–1856[Abstract/Free Full Text]
  14. Koenig HG, George LK, Meador KG: Differences in psychosocial and health correlates of major and minor depression in medically ill older adults. J Am Geriatr Soc 1997; 45:1487–1495[Medline]
  15. Koenig HG: Depression in elderly patients with congestive heart failure. Gen Hosp Psychiatry 1998; 20:29–43[CrossRef][Medline]
  16. Freedland KE, Rich MW, Skala JA, et al: Prevalence of depression in hospitalized patients with congestive heart failure. Psychosom Med 2003; 65:119–128[Abstract/Free Full Text]
  17. Yohannes AM, Baldwin RC, Connolly MJ: Prevalence of subthreshold depression in elderly patients with chronic obstructive pulmonary disease. Int J Geriatr Psychiatry 2003; 18:412–416[CrossRef][Medline]
  18. Folstein M, Folstein S, McHugh P: "Mini-Mental State:" a practical method for grading cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198[CrossRef][Medline]
  19. First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders-Non-Patient Edition (SCID-I/NP, Version 2.0), New York, Biometrics Research Department, New York State Psychiatric Institute, 1996
  20. Gottlieb SS, Khatta M, Friedmann E, et al: The influence of age, gender, and race on the prevalence of depression in heart failure patients. J Am Coll Cardiol 2004; 43:1542–1549[Abstract/Free Full Text]
  21. Rumsfeld JS, Havranek E, Masoudi FA, et al: Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol 2003; 42:1811–1817[Abstract/Free Full Text]
  22. Freedland KE, Carney RM, Rich MW, et al: Depression in elderly patients with congestive heart failure. J Geriatr Psychiatry 1991; 24:59–71
  23. Hamilton M: Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967; 6:278–296[Medline]
  24. Koenig HG: An abbreviated Mini-Mental State Exam for medically ill elders. J Am Geriatr Soc 1996; 44:215–216[Medline]
  25. Center for the Study of Depression in Later Life: Duke Depression Evaluation Schedule. Durham, NC, Dept. of Psychiatry, Duke University Medical Center, 1994
  26. Linn B, Linn M, Gurel L: Cumulative Illness Rating Scale. J Am Geriatr Soc 1968; 16:622–626[Medline]
  27. Charlson ME, Pompei P, Ales KL, et al: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases 1987; 40:373–383[CrossRef][Medline]
  28. Hlatky MA, Boineau RE, Higginbotham MB, et al: A brief self-administered questionnaire to determine functional capacity (The Duke Activity Status Index). Am J Cardiol 1989; 64:651–654[CrossRef][Medline]
  29. Guyatt GH, Nogradi S, Halcrow S, et al: Development and testing of a new measure of health status for clinical trials in heart failure. J Gen Intern Med 1989; 42:101–107
  30. Criteria Committee of the New York Heart Association: Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, 9th Edition. Boston, MA, Little, Brown & Co, 1994, pp 243-256
  31. Goldman L, Hashimoto B, Cook F, et al: Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation 1981; 64:1227–1234[Abstract/Free Full Text]
  32. Blazer DG, Hughes DC, George LK: The epidemiology of depression in an elderly community population. Gerontologist 1987; 27:281–287[Medline]
  33. Koenig HG, Westlund RE, George LK, et al: Abbreviating the Duke Social Support Index for use in chronically ill older adults. Psychosomatics 1993; 34:61–69[Abstract/Free Full Text]
  34. Prudic J, Haskett RF, Mulsant B, et al: Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry 1996; 153:985–992[Abstract/Free Full Text]
  35. Cuijpers P, de Graaf R, van Dorsselaer S: Minor depression: risk profiles, functional disability, healthcare use, and risk of developing major depression. J Affect Disord 2004; 79:71–79[CrossRef][Medline]
  36. Rapaport MH, Judd LL, Schettler PJ, et al: A descriptive analysis of minor depression. Am J Psychiatry 2002; 159:637–643[Abstract/Free Full Text]
  37. Oxman TE, Sengupta A: Treatment of minor depression. Am J Geriatr Psychiatry 2002; 10:256–264[Abstract/Free Full Text]
  38. Patel SS, Shah VS, Peterson RA, et al: Psychosocial variables, quality of life, and religious beliefs in ESRD patients treated with hemodialysis. Am J Kidney Dis 2002; 40:1013–1022[CrossRef][Medline]
  39. McRae MB, Carey PM, Anderson-Scott R: Black churches as therapeutic systems: a group-process perspective. Health Educ Behav 1998; 25:778–789[Abstract]
  40. Harralson TL, White TM, Regenberg AC, et al: Similarities and differences in depression among black and white nursing home residents. Am J Geriatr Psychiatry 2002; 10:175–184[Abstract/Free Full Text]
  41. Neighbors HW, Jackson JS, Campbell L, et al: The influence of racial factors on psychiatric diagnosis: a review and suggestions for research. Community Ment Health J 1989; 25:301–311[CrossRef][Medline]
  42. van Exel E, Westendorp RG, Stek ML, et al: Patients with late-onset depression have poor cognitive functioning in old age. J Am Geriatr Soc 2001; 49:231–233[Medline]
  43. Raskin A, Gershon S, Crook TH, et al: The effects of hyperbaric and normobaric oxygen on cognitive impairment in the elderly. Arch Gen Psychiatry 1978; 35:50–56[Abstract]
  44. Kim H, Kunik ME, Molinari VA, et al: Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics 2000; 41:465–471[Abstract/Free Full Text]
  45. Koenig HG, Meador KG, Shelp F, et al: Depressive disorders in hospitalized medically ill patients: a comparison of young and elderly men. J Am Geriatr Soc 1991; 39:881–890[Medline]
  46. Kurtz M, Kurtz J, Stommel M, et al: Predictors of depressive symptomatology of geriatric patients with lung cancer: a longitudinal analysis. Psycho-Oncology 2002; 11:12–22[CrossRef][Medline]
  47. Jaeschke R, Singer J, Guyatt GH: Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 1989; 10:407–415[CrossRef][Medline]
  48. Williams JW Jr, Stellato CP, Cornell J, et al: The 13- and 20-item Hopkins Symptom Checklist Depression Scale: psychometric properties in primary-care patients with minor depression or dysthymia. Int J Psychiatry Med 2004; 34:37–50[CrossRef][Medline]




This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via Google Scholar
Google Scholar
* Articles by Koenig, H. G.
* Articles by Johnson, J. L.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Koenig, H. G.
* Articles by Johnson, J. L.
Related Collections
* Depression
* Syndromes Secondary to General Medical Disorders

Get information about faster international access.

Privacy Policy

Copyright © 2006 Academy of Psychosomatic Medicine. All rights reserved.

Home | Search | Current Issue | Past Issues | Subscribe | All APPI Journals | Help | Contact Us

American Psychiatric Publishing, Inc. Academy of Psychosomatic Medicine
1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901 * 800-368-5777 * appi at psych.org