The type of treatment of the anxious-depression of the aged patient, on the basis of what is reported above, should consider three main variables: the role of anxiety, the primarity or endogenicity of the depression, and the coexistence of somatic disorders. Anxiety, insomnia, and somatizations justify the onset of a secondary depres­sion and may play a preeminent role in the depressive picture. In this instance, anxiety should be treated with anxiolytic agents, first of all of benzodiazepine type, or with low-dose neuroleptics, or as a second choice with beta-adrenergic blockers or valproic acid amide. The choice of one of these agents could be motivated as follows: the use of benzodiazepines appears to be justified especially by the lack of important organic problems (vascular or metabolic brain disorders). It is known that benzodiazepines (BD2) could cause paradoxical effects, such as psychomotor agitation or confusional states, especially in subjects with a marked metabolic impairment in CNS. In other terms, the more impaired the cerebral functions, the easier the onset of paradoxical effects or side effects (confusional states). At any rate, it is necessary to prefer BDZ without active metabolites and with a short or ultra-short half-life (oxazepam, triazolam) without risks of ac cumulation owing to longer half-lives since the marked reduction of liver met­abolic capacity. The new BDZ, so-called antidepressant benzodiazepines such as alprazolam, adinazolam, zometapine (this latter is still in the stage of phase II study) are rather interesting, since they act on the noradrenergic system and exert an an­tidepressant as well as an anxiolytic action. The limit to the use of these agents is that they can activate, in some cases, the anxious somatizations and, therefore, are contraindicated if the degree of somatization is particularly remarkable. Low-dose neuroleptics, such as trifluo­perazine and thioridazine, have no contraindications; but it must be stressed that they could worsen the depression, if it is not secondary to the anxious phenomena, but is elusive, creeping, and masked in its severity (depressive "iceberg").
Beta-adrenergic blockers are particularly indicated in the course of somati­zations, especially at heart level. The limit to their use is that they are of course hypotensive and, therefore, must be used in low doses and, like neuroleptics, could worsen depression. Concerning the use of valproic acid amide, it is widely used in subjects in which treatment with the above mentioned agents is problematic, and, in any rate, it could be combined with one of them, since valproic acid is a metabolic inhibitor and will tend to raise the blood levels of the combined drugs, with the obvious result that the side effects will also increase. In the course of anxiolytic therapy, it is possible that the patient has no more anxiety or somatizations, but the depressive features not only do not disappear, but could even become more evident and severe. This could suggest hidden endogenous depressive elements, probably worsened by the use of a neuroleptic (more…)

1. Altamura, A. C, Mauri, M. C, and Guercetti, G. (1986): Prog. Neuropsychopharmacol. Biol Psychiatry, 10:67-75. 2. Altamura, A. C, Melorio, Т ., Colombo, G, and Cazzullo, С L. (1984): Clin. Neuropharmacol. 7(Suppl. 1):850-851. 3. Altamura, A. C, Melorio, Т ., Invernizzi, G., and Gomeni, R. (1982): Psychopharmacology, 78: 380-382. 4. Cazzullo, С L., and Altamura, A. C. (1985): Integr. Psychiatry, 3:50S-57S. 5. Grimsson, A., Idanpaan-Heikkila, J., Lunde, P. K., Olafsson, O., and Westerholm, B. (1977): Nord. Med., 92:49-54. 6. Lopez-Ibor, J. J. Jr. (1950): In: La angustia vital. Paz Montalvo, Madrid. 7. Lopez-Ibor, J. J. Jr. (1985): Psychopathology, 18:133-139. 8. Millard, P. H. (1983): Br. Med. J., 287:375-376. 9. Post, F. (1976): In: Depression: Behavioral, Biochemical Diagnostic and Treatment Concepts, edited by D. M. Gallant and G. M. Simpson, pp. 205-231. Spectrum Publications Inc., New York. 10. Weitbrecht, H. J. (1963): Psychiatrie im Grundriss. Springer, Berlin. 11. West, E. D., and Dally, P. J. (1959): Br. Med. J., Ы 491-1494. (more…)

I should like to discuss briefly a particularly important topic concerning the relationship between depression and anxiety in the elderly. It is well known that these experiences could be interpreted as the expression of the same dysthymic spectrum (dimensionalist view) or as manifestation (mutually distinct) with dif­ferent etiopathogenesis, clinical course, and outcome, which could be occasionally coincident in certain periods of life (dualist view). In the aged patient, anxiety almost invariably accompanies the depressive symptoms. This anxiety could be regarded as a response elicited by stress and conflictuality that the subject un­dergoes because of various reasons, such as changes in life-style, etc. In other words, anxiety can be considered as a sort of aspecific "background noise" in the existential experience of the subject. However, in some cases it could acquire a deeper and more specific value; it becomes a "vital anxiety," as described by Lopez-Ibor (6), with a feature of biologically determined endoge-nicity, which could be only apparently related to a conflict situation. It seems to be coincident with the depressive phenomena itself in terms of pathogenetic biological mechanism, differing from the pure depressive picture only in the phenomenology. This should be a "continuum" of phenomena of the same dysthymic spectrum, and the definition of endothymic anxiety or of anxious thymopathy (7), or endoreactive dysthymia (10) or, again, atypical depression (11) (to be differentiated from the dysthymic disorders and from the adaptation disorders of DSM-III), at least for the disorders of adult age, could stress the peculiarity of this kind of anxiety combined with depression, not in terms of pure occasional phenomenological overlapping, but of pathologically and biologically determined coincidence. In my own experience, anxiety and depression cannot be framed "tout court" in dualistic or dimensionalistic definitions. An important factor is the frequent coexistence in the aged patient of the two aspects in the so-called anxious-de­pressive syndrome. Now, I will try to point out the onset and time course of the symptoms anxiety and depression within this syndrome. In many cases, an anxious state is found initially, which is extremely more frequent than in the younger subject, without "crystallizations" of neurotic type (phobic, obsessive pictures, etc.). It can remain as such or turn to a depressive state, whose severity could qualify in etiopatho-genetic terms, namely, the depressive state following an initial period of anxiety (which could be interpreted in the aged subject as a "trigger" experience) will be deeper the more biologically vulnerable the subject, or the more prone to severe depressive episodes. In some cases, depression seems to be more superficial, with anxiety, insomnia, and the presence of somatizations covering the greater part of the clinical picture with a preserved psychomotor activity. This form of depression can be more related to reactive or situational factors than to endog­enous, biologically determined ones. Only in this instance is it appropriate to talk of an "anxious-depressive state." On the contrary, in the depressive forms of late onset, depression could end up with a total replacement of the initial anxious phenomena. In the reactive forms, we observe the prevalence of excit­ability, restlessness, irritability, whereas in the endogenous forms the psychomotor inhibition is prevalent and suicidal tendencies are present, such as the depressive somatic core or biological symptoms (like circadian mood variations, loss of appetite, loss of weight, reduced libido, insomnia) peculiar to major depression in the adult. Therefore, the evolution of the initial anxiety is different, de­pending on the occurrence of dysthymic or adaptation disorders, or of endoge­nous features. In the former instances, anxiety leads to a reactive depressive state, in the latter, it can be viewed as a phenomenon of a biologically determined dysthymic spectrum, substantially overlapping the major depression of adult subjects. Concerning endogenicity or primarity of depression, it is clear that I am referring to the depressive states occurring in advanced age and not depressive states ap­pearing in elderly subjects suffering also in their adult life from a major affective disorder.

Department of Clinical Psychiatry, Laboratory of Clinical Neuropsychopharmacology, University of Milan, 20122 Milan, Italy
Depression and anxiety are phenomena frequently experienced by the elderly. The use of antidepressant, anxiolytic, and hypnotic drugs is an important indication of this, since its frequency is extremely high just past the age of 65 (especially in women), and the suicide rate reaches its peak at about 70 years (5). Very often these phenomena are mixed in the form usually termed anxious-depressive syndrome, in which a psychopathological state is defined in purely phenomenological terms and in which the anxious and depressive components are mixed, with more or less pronounced somatic complaints and insomnia. In late life, this syndrome is characterized by a higher etiopathogenetic het­erogeneity, but also by a more evident complexity in semiological, diagnostic, nosographic, and, accordingly, therapeutic terms. From an etiopathogenetic point of view, in the elderly, depression and anxiety generally arise from a mixture of sociogenetic, psychogenetic, and biological factors difficult to elucidate. Therefore, any attempt to perform a subdivision in nosographic terms of the two major entities, the endogenous depressive forms and the reactive forms, using, for example, the Newcastle Inventory Scale (9), is virtually impossible, since there is a huge imbalance in favor of the reactive type due to the burden of sociogenetic and environmental factors. From the semiological perspective, the symptoms of both the anxious and depressive series are variable, often more or less partially masked, generally anomalous versus those observed in the adult. Thoughts often appear to be focused on the indi­vidual’s objective physical troubles, in the sense of minus or of various functional changes (reduced deambulation, prostatic hypertrophy, aches, etc.), with a very intense affective participation. These peculiar ideoaffective processes could be the single "signs" of a latent depressive situation and the diagnostic difficulties of these forms arise, indeed, from these phenomenological peculiarities. From the therapeutic point of view, functional impairment at cerebral and extracerebral levels, as well as changes in some physiological parameters regulating the kinetic disposition of the various compounds into the body, make the use of psychotropic drugs particularly complex. (more…)