Persistent Depressive Disorder E-Book

J. Kim Penberthy

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Serie: Advances in Psychotherapy – Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 255

Veröffentlichungsjahr: 2019

Beschreibung

This compact guide is packed with the latest knowledge on the assessment and treatment of persistent depressive disorders (PDDs) – the new DSM-5 diagnosis that amalgamates the categories dysthymic disorder (DD), chronic major depression (MDD), and DD with major depressive episode (MDE). Written by a leading expert, the book guides us through the complexities of assessing PDDs and the models for understanding how these difficult to identify and potentially life-threatening disorders develop and are maintained over long periods. It then outlines those therapies that have the strongest evidence base. The author goes on to explore in detail the cognitive behavioral analysis system of psychotherapy (CBASP), a treatment specifically developed for PDDs. This compelling integrated approach incorporates components of learning, developmental, interpersonal, and cognitive theory with aspects of interpersonal mindfulness. We are led expertly through the therapeutic process using clinical vignettes and practical tips, with particular attention paid to identifying the assessment and therapy methods most valuable in CBASP. Printable tools in the appendices can be used in daily practice. This book is of interest to clinical psychologists, psychotherapists, psychiatrists, counsellors, and students.

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 43

Persistent Depressive Disorders

J. Kim Penberthy

University of Virginia, Charlottesville, VA

About the Author

J. Kim Penberthy, PhD, ABPP, is the Chester F. Carlson Professor of Psychiatry & Neurobehavioral Sciences at the University of Virginia School of Medicine in Charlottesville, VA. She has spent her career treating patients with depressive disorders, training other professionals regarding effective treatments, and conducting research in the effective diagnosis and treatment of depression and related disorders. Dr. Penberthy is internationally known for her research regarding effective treatment for persistent depression and related disorders using the cognitive behavioral analysis system of psychotherapy (CBASP) and has developed applications for comorbidities and group administration.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Saybrook University, Oakland, CA

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, ABPP, Adjunct Professor, Faculty of Education, Western University, London, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://us.hogrefe.com/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2019933086

Library and Archives Canada Cataloguing in Publication

Title: Persistent depressive disorders / J. Kim Penberthy, University of Virginia, Charlottesville, VA.

Names: Penberthy, J. Kim, author.

Series: Advances in psychotherapy--evidence-based practice ; v. 43.

Description: Series statement: Advances in psychotherapy--evidence-based practice ; volume 43 |

Includes bibliographical references.

Identifiers: Canadiana (print) 20190060794 | Canadiana (ebook) 20190060808 | ISBN 9780889375055

(softcover) | ISBN 9781616765057 (PDF) | ISBN 9781613345054 (EPUB)

Subjects: LCSH: Depression, Mental—Treatment—Handbooks, manuals, etc. | LCSH: Depression, Mental—

Diagnosis—Handbooks, manuals, etc. | LCSH: Depression, Mental—Etiology—Handbooks, manuals, etc.

| LCGFT: Handbooks and manuals.

Classification: LCC RC537 P46 2019 | DDC 616.85/27—dc23

© 2019 by Hogrefe Publishing

http://www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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Format: EPUB

ISBN 978-0-88937-505-5 (print) • ISBN 978-1-61676-505-7 (PDF) • ISBN 978-1-61334-505-4 (EPUB)

http://doi.org/10.1027/00505-000

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Contents

1 Description of Persistent Depressive Disorders

1.1 Terminology

1.2 Definition

1.3 Epidemiology

1.3.1 Gender and Sex Differences

1.3.2 Age

1.3.3 Ethnicity and Cultural and Socioeconomic Differences

1.4 Course and Prognosis

1.4.1 Dysthymic Disorder: Course

1.4.2 Major Depressive Disorder: Course

1.4.3 Onset Age

1.4.4 Impact of Treatment on Clinical Course

1.5 Differential Diagnosis

1.6 Comorbidities

1.7 Diagnostic Procedures and Documentation

1.7.1 Diagnostic Interviews

1.7.2 Clinician Rating Scales

1.7.3 Self-Report Scales

1.7.4 Scales Assessing Constructs Related to PDD

2 Theories and Models of Persistent Depressive Disorders

2.1 Biological Models

2.1.1 Genetics

2.1.2 Monoamine Hypothesis

2.1.3 Serotonin

2.1.4 Dopamine

2.1.5 Brain-Derived Neurotrophic Factor

2.1.6 Neuroendocrine Models

2.1.7 Glutamate

2.1.8 Brain Structure

2.2 Psychological Models

2.2.1 Interpersonal Models

2.2.2 Learning and Behavioral Models

2.2.3 Cognitive and Integrative Models

2.2.4 Mindfulness-Based Models

3 Diagnosis and Treatment Indications

3.1 Motivation or Readiness to Change

3.2 Longitudinal Life Course

3.3 Symptom Severity and Suicide Risk

3.4 Onset Age

3.5 Trauma History

3.6 Co-Occurring Disorders or Medical Comorbidities

4 Treatment

4.1 Methods of Treatment

4.1.1 Interpersonal Psychotherapy

4.1.2 Cognitive Behavior Therapy

4.1.3 Cognitive Behavioral Analysis System of Psychotherapy

4.1.4 Mindfulness-Based Cognitive Therapy

4.1.5 Pharmacotherapy

4.2 Variations and Combinations of Methods

4.3 Problems in Carrying Out Treatments

4.4 Multicultural Issues

5 Further Reading

Interpersonal Psychotherapy

Cognitive Behavior Therapy

Cognitive Behavioral Analysis System of Psychotherapy

Mindfulness-Based Cognitive Therapy

6 References

7 Appendix: Tools and Resources

CBASP Significant Other History: Guide for Elicitation

CBASP Case Formulation Sample Worksheet of Patient Allison D.

Presenting or Key Problems of Living

Clinical Course Profile With Timeline for Onset, Remission, and Relapse

Significant Other History (SOH)

Transference Hypothesis

Impact Message Inventory

CBASP Case Formulation Worksheet

Presenting or Key Problems of Living

Clinical Course Profile

Significant Other History

Transference Hypothesis

Impact Message Inventory

Treatment Plan

Summary

CBASP Situational Analysis Format for the Coping Survey Questionnaire

Elicitation Phase Prompts for Situational Analysis in CBASP

Remediation Phase Prompts for Situational Analysis in CBASP

Internet Resources

National Institute of Mental Health Website on Depression

American Psychological Association

Interpersonal Psychotherapy Institute

Beck Institute for Cognitive Behavior Therapy

Academy of Cognitive Therapy

Cognitive Behavioral Analysis System of Psychotherapy

CBASP Network

International CBASP Society

Your Guide to Mindfulness-Based Cognitive Therapy

|1|1Description of Persistent Depressive Disorders

1.1 Terminology

The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; APA, 2013) lists eight distinct depressive disorders, with the common feature of all being the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that negatively impact functioning. What differs among these depressive disorders is chronicity, timing of symptoms, and presumed etiology. This book will focus on the DSM-5 category of persistent depressive disorder (PDD), which is an amalgamation of the categories from the DSM, fourth edition (DSM-IV; APA, 1994), of dysthymic disorder (DD), chronic major depressive disorder (MDD), and DD with a major depressive episode (MDE) also referred to as double depression

PDD and DD are both coded as 300.4 in the DSM-5. In the International Classification of Diseases, 10th edition, PDD is coded as F34.1 and Dysthymic Disorder is coded as 6A72 in the ICD-11 (ICD-10, WHO, 1992; ICD-11, WHO, 2018). The DSM-5 code for MDE is 296.XX with extensions to distinguish recurrence and severity (unspecified 296.X0, mild 296.X1, moderate 296.X2, severe with psychotic features 296.X4 or without psychotic features 296.X3, full 296.X6 or partial remission 296.X5) and identifiers that specify with anxious distress, mixed features, melancholic features, atypical features, mood-congruent psychotic features, mood-incongruent psychotic features, peripartum onset, catatonia (for which there are the additional DSM-5 code 293.89 and ICD-10 code F06.1), and seasonal pattern (used with recurrent episodes only). The ICD-10 code for MDE, single episode, is F32.X and recurrent MDE is coded as F33.X, with severity extensions (mild F3X.0, moderate F3X.1, severe F3X.2, with psychotic features F3X.3, unspecified F3X.9, and partial F3X.4 or full remission F3X.5). Other specifiers include early onset (onset prior to age 21 years) or late onset (onset at age 21 years or older). The ICD-11 code for single episode depressive disorder is 6A70 and recurrent depressive disorder is coded as 6A71 (WHO, 2018). The ICD-11 also has a diagnostic code for mixed depressive and anxiety disorder where neither sets of symptoms, considered separately would justify a depression or anxiety diagnosis, but symptoms are present and impair functioning (WHO, 2018).

|2|1.2 Definition

Researchers have found few meaningful differences between DD and chronic MDD (Keller et al., 1995; Klein & Santiago, 2003), and thus these were merged into PDD in DSM-5. This new category of depressive disorders gives more weight to duration than to severity of symptoms. DSM-5 defines PDD using the same set of symptoms as that used for DD, with the assumption that most patients who meet the full criteria for chronic MDD also meet the criteria for DD. However, because of differences in symptomatic criteria, especially regarding duration of symptoms, some patients with chronic MDD will not meet the DSM-5 criteria for PDD. The diagnosis of PDD in DSM-5 includes both chronic MDD and DD as defined by the DSM-IV (APA, 1994), and provides specifiers that define the combination between these two conditions. Thus, the diagnosis of PDD is indicated if any of the following are present:

PDD as pure DD with no MDE during a 2-year period;

Double depression: PDD with intermittent MDEs, where the criteria for one or more MDEs have been met during a 2-year period of DD, but the symptoms did not reach the diagnostic threshold of MDE for at least 8 weeks;

PDD and chronic MDD (MDE criteria have been met for > 2 years) both diagnosed;

Chronic MDD only where the MDD has been present for > 2 years.

Figure 1 provides a visual representation of these course profiles.

PDD is characterized by depressed mood that occurs for most of the day, for more days than not, for a duration of at least 2 years in an adult, or at least 1 year in a child or adolescent. Children or adolescents may experience irritability instead of depressed mood. During periods of depressed mood or irritability, at least two of six additional symptoms listed in Box 1 must be present to diagnosis PDD, and any symptom-free intervals must last no longer than 2 months to maintain the diagnosis of PDD. Additionally, there must never have been a manic, mixed, or hypomanic episode in the first 2 years, and criteria must never have been met for cyclothymic disorder. To meet the diagnostic criteria for PDD, the symptoms must not be due to the direct physiological effects of the use or abuse of a substance (e.g., alcohol, illicit drugs, or medications), a general medical condition (such as cancer or a stroke), or be better explained by the patient meeting criteria for schizoaffective disorder, schizophrenia, delusional disorder, or other psychotic disorder. The symptoms must also cause significant distress or impairment in social, occupational, educational, and/or other important areas of functioning.

The 2-year minimum duration has been debated, and researchers examining characteristics of DD in adults occasionally use symptom duration of 1 year or longer (Brown, Craig, & Harris, 2008). For clinical and prognostic purposes, the duration of depressive symptoms is important both below and above the 2-year mark regardless of criteria met. MDD may precede PDD, and MDEs may occur during PDD. Patients who meet MDD criteria for 2 years should be given a diagnosis of PDD as well as MDD.

The diagnostic criteria for an MDE are listed in Box 2. To have a diagnosis of MDE, the patient must endorse having five or more of the nine symptoms within the same 2-week period, with at least one of the symptoms being depressed mood or loss of interest or pleasure. The other caveats for diagnosis of MDE are the same as those for PDD. The diagnosis of MDD is made if criteria for MDE are continually met for at least 2 years, and there is a lifetime absence of mania and hypomania.

|5|If all of the symptoms of MDE are present during a PDD, an additional diagnosis of MDE should be made – this is sometimes referred to as double depression. An additional important change in DSM-5 is that bereavement is not excluded from the MDE diagnostic criteria, as it was in DSM-IV, meaning that it is possible for patients with mild to moderate symptoms of depression to be diagnosed with MDE within the first 2 months following a loved one’s death.

Some researchers have proposed that the relabeling of chronic MDD and DD into the diagnosis of PDD risks the creation of another broad and heterogeneous diagnosis and have hypothesized that DD is best defined as a type of depression experienced within MDD (Rhebergen & Graham, 2014). Others have provided evidence supporting the idea that persistent or chronic depression is a specific diagnostic subtype within the larger group of affective disorders (Rubio, Markowitz, & Alegria, 2011). McCullough et al. (1990) emphasized the distinction between early-onset (depression before the age of 21 years) and late-onset (depression at or after the age of 21) patients as proposed by Akiskal et al. (Akiskal, King, Rosenthal, Robinson, & Scott-Strauss, 1981). This distinction is substantiated by evidence that the majority of patients with DD (72%) have an early onset and that these patients have an earlier onset of MDE with a longer index of the initial MDE, which suggests a more severe condition (Klein et al., 1999).

1.3 Epidemiology

Data regarding prevalence of PDD can be confusing due to changes in the DSM-5 criteria and the fact that some epidemiological surveys document and record MDEs, and others use chronic MDD, and still others use DD or PDD as their criteria. Double depression is not always specified in studies evaluating rates of depression. Thus, current rates of depression may vary from past reports, and care should be used in interpreting data.

The WHO (WHO, 2017) categorizes depression as DD, MDE, or MDD in their epidemiological research, and as such may be an overestimate of PDD as described in the DSM-5. The WHO (2017) estimates that as of 2015, there were 322 million people worldwide diagnosed with DD, MDE, or MDD, which is an 18% increase since 2005. The WHO ranks depression as the leading cause of ill health and disability worldwide, and estimates global rates of depression at 4.4%, with depression being more common among females (5.1%) than males (3.6%). Prevalence varies by WHO region, from a low of 2.6% among adult males in the Western Pacific Region and 5.9% among adult females in the African Region. Prevalence rates also vary by age, peaking in older adulthood (about 7.5% among women aged 55–74 years, and about 5.5% among men in the same age group).

About 20% of adult patients who have an MDE suffer from chronic MDD (Angst, Gamma, Rossler, Ajdacic, & Klein, 2009), which is defined as meeting criteria for MDE continually for at least 2 years. The 12-month prevalence and lifetime prevalence for chronic MDD has been estimated to be 5.3% and 13.2%, respectively (Hasin, Goodwin, Stinson, & Grant, 2005). A review of |6|prior studies up to the year 2000 found a 12-month prevalence rate of 4.1% and an average lifetime prevalence rate of 6.7% for MDD (Waraich, Goldner, Somers, & Hsu, 2004). The DSM-5 cites data from the Kessler et al. (2003) study, which gives a 12-month prevalence rate of 7% for MDD in the US.

Multiple studies have explored the prevalence of DD in the US using the DSM-IV criteria. The National Comorbidity Survey–Replication reported a 12-month DD prevalence of 1.5% (Kessler et al., 2003). The DSM-5 cites 12-month prevalence rates of 0.5% for PDD based on data from Blanco et al. (2010). In a 2004 analysis of the literature, investigators determined a lifetime prevalence of 3.6% for DD in US communities (Waraich et al., 2004).

In a recent study of the prevalence of DSM-5–specified MDD and related disorders, researchers determined a lifetime prevalence of 15.2% for PDD with persistent MDD, 3.3% for PDD with pure DD, and 28.3% for any report of MDE or MDD (Vandeleur et al., 2017). These same researchers reported that patients with PDD and MDD were the most severely impaired, followed by those with recurrent MDE, single episode MDE, and PDD. They further suggest that this research casts doubt on the pertinence of grouping MDD and DD within the new category of PDD. These data may explain higher reported prevalence rates of MDD when both MDE and MDD are combined in one group. A summary of lifetime prevalence rates from Vandeleur et al. (2017) is shown in Table 1.

Fewer studies of the incidence of PDD and MDD are available. Waraich, Goldner, Somers, and Hsu (2004) conducted a review including incidence rates of mood disorders and found only four studies exploring annual incidence rates of MDD. Those authors provided an overall best estimate incidence rate of 2.9 per 100 with a 95% confidence interval (95% CI) of 1.3 to 4.8. These |7|results are fairly old and quite variable and thus should be interpreted with caution. Angst et al. (2009) prospectively studied a group of people in Zurich and found a 5.7% cumulative incidence rate for what they termed “long-term depression” which was a combination of DD, MDD, and double depression diagnoses.

1.3.1 Gender and Sex Differences

Epidemiological studies have shown that the lifetime prevalence of both DD and MDD in women is almost twice that in men (Blanco et al., 2010). This ratio has been documented in different countries and across ethnic groups. A comprehensive review of almost all general population studies conducted to date in the US, Puerto Rico, Canada, France, Iceland, Taiwan, Korea, Germany, and Hong Kong, reported that women predominate over men in lifetime prevalence rates of major depression (Piccinelli & Gomez Homen, 1997). This difference has been documented in clinical and community samples and across racial groups. Depression may be more persistent in women, and female sex is a significant predictor of relapse (Kuehner, 1999). Sex differences relating to depression vary with age, with male and female children showing similar incidence rates. Sex differences in prevalence rates first appear around the age of 10 years and persist until midlife, after which they disappear (Noble, 2005). Therefore, women have the greatest risk for developing depressive disorders during their childbearing years. Before puberty and after menopause in women, the two sexes appear to be affected about equally (Noble, 2005).

Several biological processes are thought to be involved in the predisposition of women to depression, including genetically determined vulnerability, hormonal fluctuations related to various aspects of reproductive function, and sensitivity to such hormonal fluctuations in brain systems that mediate depressive states. Psychosocial events such as role-stress, victimization, sex-specific socialization, internalization coping style, and disadvantaged social status may all contribute to the increased vulnerability of women to depression. Depression in women may develop during different phases of the reproductive cycle, and infertility, miscarriage, oral contraceptives, and hormone replacement treatment have been associated with depression in women (Noble, 2005).

In a systematic review and meta-analysis, Lucassen, Stasiak, Samra, Frampton, and Merry (2017) reported robust evidence that rates of depressive disorders are elevated in sexual minority youths in comparison with heterosexual young people. Their research demonstrated that sexual minority youths have approximately 2 times the odds of a depressive disorder compared with their heterosexual peers. They further state that female sexual minority youths appear to be at particular risk. In a review of PDD in transgender versus cisgender patients, in both adults and adolescents, Budge, Adelson, and Howard (2013) found MDE rates of 51.4% for transgender women and 48.3% for transgender men – rates that far surpass those for the general population. Additional research supports this finding, with lifetime prevalence rates of MDD or DD for transgender patients, ranging from 48% to 62% (Nemoto, Bodeker, & Iwamoto, 2011; Nuttbrock et al., 2010). Even after sexual reassignment procedures to alleviate gender dysphoria, depressive disorders often |8|persist in this population (Dhejne et al., 2011). Sadly, there are also high rates of attempted suicide, with 32% of both transgender men and women ever having attempted suicide (Clements-Nolle, Marx, Guzman, & Katz, 2001).

Theories regarding why rates of PDD are so high among sexual minorities include minority stress theory, which posits that patients who have minority identities may experience stress and related depressive symptoms due to experiences of discrimination and aggression (Budge et al., 2013; Nuttbrock et al., 2014). Nuttbrock et al. (2014) found a significant association between gender abuse and MDE in transgender females. Budge et al. (2013) found that avoidant coping served as a mediator between transition status and depressive symptoms in a group of transgender patients, where transition status was negatively related to avoidant coping. The further along patients were in their identity process, the less avoidant coping they used. Those who used more avoidant coping strategies reported more depression and anxiety. Budge et al. (2013) hypothesized that those patients who are in the beginning stages of their transition process may use more avoidant coping, and thus are at increased risk for depressive disorders.

1.3.2 Age

MDD may first appear at any age, but the likelihood of onset generally increases with puberty, with the incidence peaking in the 20s. Point prevalence estimates of MDD are low in childhood at about 1% to 3%, but by adolescence, the rates are comparable to those found in adulthood (Kessler et al., 2005). Patients with adolescent-onset MDD experience more negative outcomes relative to nondepressed adolescents or those with adult-onset MDD (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993). The Oregon Adolescent Depression Project (Lewinsohn, et al., 1993) was a prospective, epidemiological study of adolescents assessed through age 30. These researchers found that the natural course of adolescent-onset MDD is marked by impairment in a range of important psychosocial domains, including relationship quality, school and work functioning, finances, physical health, psychiatric comorbidity, and suicidality.

Although the negative implications of adolescent-onset MDD for functioning are well-documented, a small body of literature suggests that it is MDD recurrence, rather than early onset, that accounts for this impairment. Hammen, Brennan, Keenan-Miller, and Herr (2008) compared adolescents with MDD onset prior to age 15 who did and did not experience recurrence, on a number of psychosocial outcomes at age 20, and found that the recurrent group had more severe and pervasive impairment in relationship, school and work, financial, and physical health domains.

DD usually has an early and insidious onset in childhood, adolescence, or young adulthood (mean age 15 years) and has a chronic course. DD is termed early-onset if the onset of diagnostic symptoms is prior to age 21. Late-onset DD is rarer and is designated if the onset of diagnostic symptoms is during or after age 21. Research examining the lifetime prevalence rates of depression in US adolescents found an overall rate of 11.7% for MDD or DD, with a 15.9% rate for female and 7.7% rate for male adolescents (Merikangas et al., 2010). Early-onset depressives have higher rates of depressive personality traits and |9|disorders than late-onset depressives and have higher rates of comorbid personality disorders (Klein et al., 1999).

MDE and MDD appear less frequently among older adults than at earlier ages (Hasin, Goodwin, Stinson, & Grant, 2005). A recent study found prevalence rates of MDD and DD in adults over 65 to be 3.1% and 0.5%, respectively (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010). This is similar to other reported rates ranging from 1% 5% in most large-scale epidemiological investigations, with the majority of studies reporting prevalence rates in the lower end of that range. There may be clear reasons for the low rates of depressive disorders in older adults, including the fact that depressed individuals die earlier. Another theory is that older adults possess psychological and social factors and capacities that appear to buffer against depression in the context of stressful events and biological risks (Hendrie et al., 2006).

In contrast to young adults with DD, older adults present with late age of onset, without MDD and other psychiatric disorders, and with a low rate of family history of mood disorders. They often have stressors such as loss of social support, bereavement, and cerebrovascular or neurodegenerative pathology. A minority of older DD adults report chronic depression dating from youth, with psychiatric comorbidity similar to young adults with DD. In older versus younger adults, DD and subsyndromal depression increase disability and lead to poorer medical outcomes (Byers et al., 2010).

Rates of depression have been reported to be higher in older women than in older men, in part due to women living longer than men. There are few differences in depression prevalence in the older population by race or ethnicity, although depressive symptoms are more common among Hispanic older women than non-Hispanic whites (Swenson, Baxter, Shetterly, Scarbro, & Hamman, 2000). Rates of MDD among older adults are substantially higher in particular subsets of the older adult population, including medical outpatients (5–10%), medical inpatients (10–12%), and residents of long-term care facilities (14–42%) (Djernes, 2006).

1.3.3 Ethnicity and Cultural and Socioeconomic Differences

The WHO World Mental Health (WMH) Survey Initiative assessed a set of DSM-IV disorders in countries from every continent (Kessler & Bromet, 2013). The 12-month prevalence estimate of DSM-IV MDE in 18 countries ranged from 2.2% (Japan) to 10.4% (Brazil). The midpoint across all countries was 5%, and the weighted average 12-month prevalence was 5.5% for the 10 highest income and 5.9% for the eight low-middle income countries. The National Health and Nutrition Examination Survey III (NHANES III; Riolo, Nguyen, Greden, & King, 2005