Over Living in the Community

The authors would like to acknowledge the contribution of Drs. V. K. Sharma, P. Saunders, C. Sullivan, С McWilliam, L. M. Voruganti, and S. V. Manohar, who undertook the follow-up interviewing, and Dr. N. Wood, Miss M. Heary, Mrs. J. Silcock, Miss C. Hensey, Mrs. J. Wood, and Mrs. R. Searle, who undertook the interviewing of the initial sample. Our thanks are also due to Mr. M. Kayodi for his work on the computer and to Mrs. B. Ackerley for her skill in organizing the interviewing. This research was supported by grants from the Wellcome Trust and the Mersey Regional Health Authority, United Kingdom.
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The University Department of Psychiatry, The Royal Liverpool Hospital, Liverpool, L69 3BX, England

The prevalence of depression in the original random sample of 1,070 com­munity subjects was 11.3% overall (8.3% for depressive neurosis, 3.0% for de­pressive psychosis). Of the total sample, 2.7% reached case levels (diagnostic confidence level 3 and above) on both depression and anxiety clusters, or 24.0% of the depressive cases as a whole, or 70.7% of the anxious cases as a whole. Table 1 shows the percentage prevalence for subjects having coexistent levels of depression and anxiety after other diagnoses, e.g., organic states, schizophrenia,
hypochondriasis, obsessional and phobic states, had been excluded. Of the whole sample, 3.8% reached case level for anxiety and 32.2% reached subcase level; 11.7% of the total sample reached a subcase level of depression and of the 8.3% with depressive neurosis, 4.9% and 1.8% reached subcase and case levels of anx­iety, whereas, of the 3.0% with depressive psychosis, 1.9% and 0.9%, respectively, reached subcase and case levels of anxiety. Thus, although the association of depressive levels with anxiety levels was common, 83.5% of cases of depression were associated with some levels of anxiety; those with coexistent case levels of both depression and anxiety seem to represent only a small proportion of elderly subjects. The outcome of the subjects in the study at this stage in the analysis is expressed crudely as dead, well (no confidence level on any diagnostic cluster), and psy-chiatrically ill (reached case level 3 and above on a diagnostic cluster). The first 80 subjects followed up after 3 years are reported. Ten of these 80 subjects with depressive case levels refused interview. The death rate of the subjects as a whole over the three years was 18%, or 6% per year, but was higher for the depressive sample at 27.1% or 9% per year. In order to compare outcome on these three indices the sample was split in a number of ways. The sample was separated into those depressive cases that had no anxiety confidence levels (14) and those depressive cases that had some anxiety levels (56) (Table 2). Although there is a tendency for a higher proportion of those subjects with depressive case levels and anxiety levels to be well at the end of three years, the differences do not reach statistical significance. The subjects were divided into those depressive cases with no AGECAT anxiety levels taken together with those scoring level 1 (19), against those scoring AGECAT anxiety levels 2 to 5 (51). Those depressive (more…)

This study uses the GMS-AGECAT package in order to assess the prevalence and outcome of anxious depression in elderly persons living in the community. The Geriatric Mental State (GMS) is a semistructured standardized clinical in­terview for assessing the mental state of elderly persons and for facilitating the making of a reliable psychiatric diagnosis. The full interview, which consists of 500 symptom items, was developed in response to the needs of our epidemio­logical studies in New York and London (2,5). Symptom profiles can be derived from this interview that show changes in levels over time, especially in response to treatment. The GMS items have been shown to be reliable between interviewers interviewing the same subject, and a clinical or intuitive diagnosis made by psychiatrists on the basis of the interview reaches good reliability. The full GMS interview was shortened using a series of linear discriminant function analyses to form the community version suitable for screening for mental illness, describing the mental state by symptom profiles and deriving a psychiatric diagnosis on community samples (GMSA) (6).In order to compare psychiatric diagnosis and prevalence levels of different studies, it was important not only to measure reliably the level of symptoms, but also to standardize the selection of a diagnosis and the decision whether the subject represented a case of illness. As a consequence the computerized diag­nostic system AGECAT, which runs to several thousand lines of FORTRAN, was developed (4). This system condenses the 157 symptom components of the mental state into 38 symptom subclusters that are in turn assembled under eight diagnostic clusters according to their importance for determining the certainty of diagnosis for that cluster. Each subject is allotted a level of confidence of disgnosis from 0 to 6 on each diagnostic cluster. Clusters are then compared level for level according to a hierarchy starting with organic disorder, including depression and ending with anxiety. At the end of this process the subject emerges with a main diagnosis, an alternative diagnosis if appropriate, the levels of con­fidence on all eight clusters, levels on 19 symptom components forming a profile of illness, depression and organic scores for quick case identification, and an organic/depression index, which our preliminary follow-up studies indicate has some success in predicting which subcases will become cases in later years (3) Cases of illness are not, of course, to be found in nature; they must therefore be defined for each study. However, psychiatrists generally seem to recognize a certain level or cluster of symptoms as forming a syndrome. When that point is reached we define it as a syndrome case. A subject may reach case level on several syndromes. The AGECAT method has the value that it allows us to examine subjects who reach case confidence levels on both the depression and anxiety clusters. The depression cluster is split into depressive psychosis (roughly equivalent to endogenous depression) and depressive neurosis (roughly equivalent to reactive depression). Syndrome case levels are at confidence level 3 and above. Levels 1 and 2 represent subcases. The AGECAT diagnostic system has been tested for validity against psychiatric diagnosis on a consecutive series of 150 hospital admissions and 396 community subjects, and in a replication sample on a additional 647 community subjects. Kappa values for the agreement between AGECAT and psychiatrists’ diagnosis reached 0.80 and above for organic disorders and 0.76 for depression. The data from our other interviews, the History and Aetiology Schedule for an informant, Social Status Schedule, and the Physical Status Schedule, are not reported here. The subjects described here formed part of a random community sample in Liverpool of 1,070, derived from general practitioners’ lists and interviewed in their own homes using the GMS-AGECAT package. The initial interviews were undertaken by four psychologists and one senior nurse trained in the method, whose ratings were shown to reach satisfactory reliability against those of the project psychiatrists (1). The follow-up study three years later was undertaken by psychiatrists interviewing the whole of the surviving sample using similar methods. Not all the data have been entered into the computer for the 3 year follow-up, and only the first 80 subjects with depression are reported here.

In this study of elderly community residents aged 65 and over, no evidence emerged that levels of anxiety associated with case levels of depressive illness affected outcome when measured crudely in terms of death, being well (having no significant psychiatric symptoms), and being psychiatrically ill three years later. Only a tiny proportion of the subjects appeared to receive antidepressant medication during this time.
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