1Department of Sleep Medicine, Wenzhou Seventh People’s Hospital, Wenzhou, People’s Republic of China; 2Department of Geriatric Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China; 3Alzheimer’s Disease and Related Disorders Center, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
Correspondence: Wei Li
Department of Geriatric Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200030, People’s Republic of China
Tel +86 021 64387250
Email [email protected]
Purpose: To investigate the prevalence, influencing factors, and cognitive characteristics of depressive symptoms in elderly patients with chronic schizophrenia.
Patients and Methods: A total of 241 elderly patients with chronic schizophrenia and 156 healthy controls were enrolled in this study. The Geriatric Depression Scale (GDS) was used to assess depressive symptoms; the Positive and Negative Syndrome Scale was used to assess psychotic symptoms; and both the Mini-Mental State Examination and Montreal Cognitive Assessment were used to assess overall cognitive function, while the Activity of Daily Living Scale was used to assess daily living ability.
Results: The prevalence of depressive symptoms was 48.5% (117/241) in elderly patients with chronic schizophrenia, which was substantially higher than that of normal controls (17.3%, 27/156). Using a stepwise binary logistic regression analysis, we found that high education (p=0.006, odds ratio [OR]=1.122, 95% confidence interval [CI]:1.034– 1.218) and hypertension (p=0.019, OR=0.519, 95% CI: 0.300– 0.898) were influencing factors for the comorbidity of depressive symptoms. Compared with individuals without depressive symptoms, individuals with depressive symptoms usually display worse overall cognitive function and more severe impairment of activities of daily living, but fewer psychotic symptoms. Interestingly, the GDS score was negatively correlated with the course of the disease (r=− 0.157, p=0.016), suggesting that patients who had recently been admitted to the hospital were more likely to develop depression.
Conclusion: Elderly patients with chronic schizophrenia are often associated with higher levels of depression. Therefore, their overall cognitive function is worse, and their activities of daily living are more seriously impaired. Therefore, these patients should be provided with appropriate psychological comfort, especially those who have recently been admitted to the hospital.
Keywords: elderly, chronic schizophrenia, depressive symptoms, hypertension, education
Introduction
Clinical and subclinical depression are common complications of schizophrenia,1 which affects 44–75% of the elderly.2 Elderly patients with both schizophrenia and depressive symptoms tend to experience increased physical illness, increased functional impairment, and poorer medication management, causing a reduction in life expectancy by 10–25 years.3 In addition to difficulties in treatment, depressive symptoms can affect cognitive function, activities of daily living, and quality of life in elderly patients with schizophrenia.4 Moreover, depressive symptoms are also associated with impaired functional remission and suicide in patients with schizophrenia, independent of psychotic remission.5 Therefore, it is essential that depressive symptoms are identified and managed properly to improve clinical outcomes in elderly patients with schizophrenia.
Accumulated evidence suggests that people with schizophrenia are more likely to suffer from depression than the general population;6 however, data often varies widely. For example, one community study found that 47.5% of older patients with schizophrenia had experienced a depressive episode,7 while another cross-sectional study found that 78.1% of older patients with schizophrenia had either syndromal (47.5%) or subsyndromal (30.6%) depressive symptoms.8 We speculate that the primary reason for the differing results in the above studies may be differences in survey tools and methods. In addition, because the negative symptoms and depressive symptoms of schizophrenia are very similar and often overlap, it is also quite difficult to distinguish them effectively.9
There are several reasons to explain the association between chronic schizophrenia and depressive symptoms. First, depressive symptoms are associated with both insight and negative evaluations of schizophrenia, suggesting that the way a person thinks about the illness may influence the occurrence of depressive responses.10 Second, patients with chronic schizophrenia often develop secondary depressive symptoms within the first year after discontinuing medication.11 Third, inflammatory stimuli can decrease connectivity in reward-relevant neural circuitry and decrease neural activity in the ventral striatum, which ultimately leads to depression;12 however, this mechanism has not yet been widely recognized.
Recently, researchers have focused on identifying biomarkers, such as illness severity13 and marital status, that might be associated with depressive symptoms in patients with schizophrenia.14 Similarly, other general demographic data such as sex, education, hypertension, and diabetes mellitus, may also play a role in the incidence of depressive symptoms in schizophrenia patients.15–17 In China, elderly patients with chronic schizophrenia tend to experience lengthy hospitalizations, and the closed environment often aggravates depression in patients. However, previous studies only focused on elderly individuals with schizophrenia in the community, while ignoring the long-term hospitalized population.1,7 We hypothesize that older patients with schizophrenia who are hospitalized for an extended time period tend to have more severe depressive symptoms and more impaired social functioning.
To test the research hypothesis for the current study, we described clinical characteristics of long-term hospitalized elderly patients with schizophrenia based on four dimensions: depressive symptoms, psychotic symptoms, cognitive symptoms, and daily living ability. Concomitantly, we also explored risk factors that may affect depressive symptoms, such as sex, age, education, smoking, drinking, and lipid metabolism.
Materials and Methods
Participants
This cross-sectional study was conducted from January 1, 2020 to January 1, 2021, and a total of 241 elderly chronic patients (men/women=133/108, average age: 66.38±5.601) with schizophrenia were recruited from the Shanghai Mental Health Center. All participants were required to meet the following requirements: 1) aged 65 years and above; 2) hospitalized long-term (at least one year); 3) diagnosed with schizophrenia according to the International Classification of Diseases 10 diagnostic standards; 4) not diagnosed with any severe medical conditions, such as infections or cancer; and 5) willing to participate in the project. Exclusion criteria were: 1) aged < 65 years; 2) suffering from other mental illnesses or cognition-related disorders, such as Alzheimer’s disease (dementia was diagnosed according to Clinical Dementia Rating (CDR) and cognitive scores), bipolar disorder, or depression; and 3) refusing to cooperate; 4) having data defects in their patient history. All eligible participants’ information, such as general demographic information (age, sex, education, BMI), daily life habit information (such as smoking and drinking), disease-related information (diabetes, hypertension, and hyperlipidemia), and currently prescribed medicines (typical antipsychotics or atypical antipsychotics, antidepressants, and benzodiazepines), were collected using standardized questionnaires. Additional information, such as blood lipids, high-density lipoprotein, low-density lipoprotein, albumin, and fasting glucose was gathered from medical records and collateral resources. Simultaneously, we also recruited 156 control patients who had: 1) no subjective memory complaints; 2) a global CDR score of 0, rated by the clinician; and 3) objective cognitive score in the normal range. General demographic data for the control patients are shown in Schedule 1.
The Research Ethical Committee of the Affiliated Mental Health Center of the Shanghai Jiaotong University School of Medicine approved the study protocol. Written informed consent was obtained from all participants prior to the study. All research procedures were carried out according to the principles of the Declaration of Helsinki.
Neuropsychological Assessment
Depressive Symptoms
The Geriatric Depression Scale (GDS)18 was used to evaluate depressive symptoms in all elderly patients with schizophrenia. The GDS consists of 30 items, assessing a wide range of areas, from emotion (eg apathy, sadness, and crying) to cognition (eg guilt, helplessness, and worthlessness).19 Its scores range from 0 to 30, with a score of 0 to 10 indicating no depression, and a score greater than 11 indicating possible depression.20,21 Previous studies have shown that GDS can effectively assess depressive symptoms in patients with schizophrenia.22–24 In our current study, we used a score of 11 or above as the basis for classifying elderly patients with schizophrenia with depressive symptoms.
Cognitive Function
The Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment Test (MoCA) are the most commonly used assessment tools in the field of geriatric cognition.25,26 The scores of both tests range from 0 to 30, with lower scores representing cognitive impairment. In general, the sensitivity of MoCA is higher than that of MMSE, but MMSE helps to classify the severity of dementia.27,28 Previous studies have suggested that the MMSE and MoCA may be used successfully in elderly patients with schizophrenia.29,30
Psychobehavioral Symptoms
The Positive and Negative Syndrome Scale (PANSS) is considered an operable, drug-sensitive tool that provides a balanced representation of positive and negative symptoms and measures relationships between symptoms as well as with global psychopathology.31 The scale consists of 30 items…
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