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The psychomotor retardation that may be seen in major depression represents an interesting parallel to bradykinesia, a core feature of Parkinson's disease. Psychomotor retardation has been correlated with the severity of depression and is a predictor of response to electroconvulsive therapy (ECT). Psychomotor retardation has typically been assessed by subjective clinical judgement including clinical rating scales. Gross activity levels have also been measured with actigraphy previously. The Parkinson's KinetiGraph (PKG) was developed to assess bradykinesia, dyskinesia and tremor in Parkinson's disease and allows for an objective assessment of motor symptoms over time. It has not been used previously to assess motor symptoms in depression. The aim of the current pilot study was to use the PKG to objectively measure both bradykinesia and immobility in depressed inpatients undergoing ECT before, during and at the end of therapy and review correlations with depressive symptomatology and treatment response. The majority of patients (9/12) had PKG defined bradykinesia at baseline and 7/9 of these improved with ECT. All patients with bradykinesia who remitted clinically demonstrated improvements in bradykinesia scores. PKG defined immobility was present at baseline in 11/12 total patients and improved in the majority of these patients (9/11) post ECT. Correlations between clinically assessed melancholia and PKG measures were significant (r = 0.701, p 0.011 at baseline to rs = 0.655, p 0.021 at end). A strong association between bradykinesia and immobility scores and depression severity was not seen. The PKG is a potentially useful wearable technology to objectively assess motor symptoms in depression.

There is a widespread belief that suicides around the world are under-counted. A substantial proportion of suicides may have been inappropriately registered as accidental or of undetermined cause or intent. There is reason to explore to what extent low suicide rates in some nations could be partly attributable to under-counting. Mortality statistics of most countries are available on-line. Numbers of suicide deaths in Spain, and in England and Wales (E & W), in male and female 5-year age groups, in each year between 2014 and 2018, were documented, along with deaths coded to ICD-10 accident or ‘undetermined death’ categories. Crude mortality rates were calculated using official population figures. Single year suicide, undetermined death, and non-transport accidental death rates of 12 other nations were calculated. Spain’s crude suicide rate per 100,000 remains low (7.89) compared to other nations; its event of undetermined intent (EUI) death rate was 0.09 (contrasting with E & W’s 1.74). Its accidental poisoning rate is much lower than that of E & W. The study showed much higher rates of ill-defined/unknown cause deaths in late life in Spain (both genders) than in E & W, and age-associated increases in accidental drowning rates parallel with increased suicide by drowning. Reportedly low suicide rates in Spain could be partly attributable to increased rates of ‘hidden suicide’ (accidental drowning, male accidental poisoning, and possibly ill-defined/unknown cause deaths, but not EUIs). It would be appropriate (and not just in Spain) to increase numbers of verbal and/or forensic autopsies in questionable ‘undetermined’ cases.

The suicide rates officially reported by most countries are widely believed to be lower than actual rates, attributable partly to inaccuracy of registration of deaths and misclassification of cause of death. In this review paper, we discuss under-counting of deaths and of suicides, referring to findings from international research. We then describe the three main ICD-10 cause of death categories that possibly harbour 'hidden suicides': ill-defined or unknown causes of death, events of undetermined intent (EUI), and accidental deaths. We used the 2017 Australian mortality statistics to illustrate these three categories. The World Health Organization (WHO) data and international research show (1) that mortality data provided to the WHO by a large number of its Member States are of questionable quality and not timely; and (2) substantial variations among countries in rates of suicide, ill-defined or unknown deaths, EUIs, and accidental deaths (notably, poisoning). Accurate reporting of suicides is needed to advance research on suicide prevention and develop more effective suicide prevention programmes. Nations should endeavor to obtain, publish and analyse data regarding annual rates of deaths coded as of ill-defined/unknown cause, EUI, and accidental poisoning and other relevant types of accident.

Objectives:There is a paucity of available research to guide clinical practice in delusional disorder (DD), particularly in late life. This study aimed to evaluate antipsychotic use and treatment outcomes in patients with DD aged 65 years and older. Secondarily, we sought to examine associated clinical features and socio-demographic variables.Design and setting:This descriptive study reviewed all consecutive cases of DD referred to an Australian old age psychiatry service over a 12-year period. Fifty-five patients were assessed in the inpatient and/or community setting, with data verified from a review of all individual medical records.Measurements:Data were collected with respect to antipsychotic use, outcomes, and clinical features. Socio-demographic variables of DD cases were compared to a non-matched comparison group (n=278) and an age and gender matched comparison group with a 1:1 ratio (n=55).Results:The predominant type of DD was persecutory (87%). Non-prominent hallucinations were experienced by 18%, and depressive symptoms occurred in 22%. There was a statistically significant association between having DD and social isolation (χ2= 11.04 (DF=1) ppConclusions:Clinical improvement, including sustained recovery, occurred in more than half of those with late life DD. The majority of those who improved (96%) received atypical antipsychotics.

Suicide data relating to 1979-2014 were obtained from three East Asian jurisdictions (Taiwan, Hong Kong, Japan) and two 'Western' countries (Australia, New Zealand). Rates and age patterns of suicide have changed markedly since 1979. Graphs of these patterns largely remained either upward-sloping, bimodal or flat (uniform) over the 36 years, male commonly differing from female, and East Asian patterns more like each other than those of the Western countries. Japan's male middle-aged suicide rate reached a peak in 1999-2003, which, like increased rates among working age males in Hong Kong and Taiwan, has been attributed largely to consequences of Asian financial crises. Male to female ratios of suicide rates have remained higher in the Western countries, but late life suicide rates have decreased to varying extents in all five jurisdictions. Identifying reasons for differences between jurisdictions in their suicide rates and patterns at particular times, and over time, is likely to point to factors (period, cohort, psychosocial or cultural) that protect against or foster suicidal ideation. This avenue of research may assist in identifying ways of preventing suicide.

Based on psychological autopsy data, the study compared awareness of suicide risk in the deceased among next-of-kin (NOK) and health care professionals (HCPs), and communication between these two groups in the month before death. The NOKs had significantly more knowledge about the decedent's suicide warning signs than the HCPs (90.5% vs. 44.6%). Contact between NOK and HCP was initiated more often by the family than the HCPs (29.4% vs. 5.9%). The study found communication gaps between HCPs and NOK and stresses the need for suicide prevention strategies strengthening communication between these two groups.

Objective The aim of this study was to review animal hoarding cases referred to the Royal Society for the Prevention of Cruelty to Animals (RSPCA) in New South Wales (NSW) to examine mental health factors that influence the development of animal hoarding and to consider strategies for dealing with such cases. Methods Data were gathered by RSPCA inspectors regarding consecutive cases referred to the agency over 2 years. Result Details were provided about animals and 50 identified hoarders (11 male, 39 female; mean age 57 years) on 48 properties. The mean number of animals per case was 53 (range 6–300). Fifteen participants (30%) were known to have had involvement with mental health or social services. Mental health factors appeared to contribute to animal hoarding in well over 50% of cases. Severe and moderate squalor were observed in 52% and 21% of dwellings assessed respectively, many with accumulated rubbish. Conclusions Animal hoarding is largely attributable to psychological and psychiatric problems. It is recommended that clinical services work alongside animal welfare inspectorates, assessing (and, where appropriate, treating) such problems. What is known about the topic? Animal hoarding is believed to be partly attributable to the hoarders having psychiatric or psychological problems, but relevant mental health assessment of hoarders is not usually arranged. Recidivism after removal of animals is nearly 100%. What does this paper add? The study confirms that animal hoarders commonly have mental health issues. However, RSPCA inspectors are not expected to screen for such issues or refer cases to mental health clinicians. What are the implications for practitioners? There is good reason to develop clinical services to help animal hoarders deal with their psychological or psychiatric problems.

Objective To describe the characteristics of animal hoarding in New South Wales, Australia. Design Cross sectional study of consecutive referred cases. Methods Files of animal hoarding cases referred to RSPCA NSW in 2013-15 were examined. Details concerning animal hoarding cases and supportive services, living conditions and factors believed to have contributed to animal accumulation were recorded. Data were analysed. Results Data were available regarding 48 properties where 50 persons (78% female) were found to be hoarding animals. Most were over 50 years of age; 40% lived alone; 15 (30%) had contact with mental health services and/or community social services. Animal hoarders were categorised as 'breeders' (30%), 'overwhelmed caregiver' (24%), 'rescuers' (22%), 'exploiters' (10%) or 'incipient hoarders' (14%); 24% were associated with animal rescue networks. Accumulation of animals was attributed most commonly to unplanned breeding (60% of properties) and collecting strays (38%). Other reasons for accumulation included receiving donations of animals and planned breeding; in 38% of cases there was only one identified reason. The median number of animals was 35 (range, 6-300), with cats hoarded on 75% of properties and dogs on 52%. In 75% of cases, the living conditions of animals were rated as 'very unsanitary' or 'filthy'. Conclusions This study provides reasons for recommending increased regulatory control of companion animal breeding and management, and training and support for veterinarians to help reduce the human and animal suffering caused by animal hoarding. There is widespread agreement that psychiatric and personality problems underlie cases of animal hoarding. Closer links between animal welfare organisations and mental health services are desirable.

Objective To compare the professional and personal impact of patient suicide and sudden death on health care professionals (HCPs) and determine factors associated with these impacts. Method The sample was derived from a sudden death-controlled psychological autopsy study of suicide. HCPs were identified by deceased's next of kin, by other HCPs, from coroners' files and from medical records. The HCPs were interviewed about their last contact with the deceased and the impact of the death on their lives. Results Two hundred eleven HCPs were interviewed following suicide; 92 after sudden death. Suicide deaths were significantly more likely to impact upon the HCP's professional practice [suicide n =79 (37.4%); sudden death n =9 (9.9%); χ 2 =22.06, P n =55 (26.1%); sudden death n =12 (13.0%); χ 2 =5.58, P =.018] than sudden deaths. Using multinomial logistic regression, being female and suicide within a week of the consultation predicted professional and personal impacts; having less than 5 years experience predicted professional impact and receipt of support/counseling predicted personal impact. Conclusion Suicide deaths have a greater impact than sudden deaths upon the life of HCPs. Clinical inexperience influences impacts on professional practice and availability of support impacts on personal life.

Aim The present study aims to analyse predicting factors of suicide among older adults compared to sudden death controls and middle-aged suicides. Methods During the period 2006–2008, at two Australian sites, the psychological autopsy method was utilised to investigate suicides of individuals over the age of 35 by interviewing next-of-kin and healthcare professionals. A case–control study design was applied using sudden death cases as controls. Initial information was gathered from coroner's offices. Potential informants were approached and interviews were conducted using a semi-structured format. Results In total, 261 suicides (73 aged 60+) and 182 sudden deaths (79 aged 60+) were involved. Older adult suicides showed a significantly lower prevalence of psychiatric diagnoses (62%) when compared to middle-aged suicide cases (80%). In both age groups, subjects who died by suicide were significantly more likely to present a psychiatric diagnosis, compared to controls; however, diagnosis did not remain in the final prediction model for older adults. Hopelessness and past suicide attempts remained in the final model for both age groups. In addition, living alone was an important predictor of suicide in older adults. Conclusion Although mood disorders represent an important target for suicide prevention in old age, there should be increased attention for other risk factors including psychosocial, environmental, and general health aspects of late life.

Introduction People who die by suicide have a higher risk of an alcohol-use disorder (AUD) at the time of death. The present study aims to compare 1) suicide cases with and without AUD, and 2) suicide and sudden-death controls with AUD. Methods The psychological autopsy method was utilized to investigate suicide and sudden death in Australia (QLD and NSW). Initial information was gathered from coroners’ offices. Potential informants were approached and semi-structured interviews were conducted. Univariate and multivariate logistic regression were applied. Results People with AUD who died by suicide were significantly more likely to have another substance-use disorder, history of suicide attempt, recent serious arguments with spouse/partner and other family members, been unfaithful to partner/spouse, be victims of a crime, and were less likely to be from a non-English speaking background. They were also younger and had higher levels of aggression compared to non-AUD suicides. AUD suicides were more likely to have mood disorders, previous suicide attempt, expressing hopelessness, higher scores in aggression towards self, romantic relationship breakup, and serious arguments with other family members than AUD sudden deaths. Aggressive behavior, having another substance-use disorder, and history of serious arguments with family members remained significant in the final model comparing suicides with and without AUD. Conclusion Our findings support that aggressive behavior, comorbidity with other psychiatric disorders as predisposing factors, and recent interpersonal conflicts such as breakup and family conflicts can trigger suicide in people with AUD. There is a need for proper diagnosis, risk assessment, and treatment in suicidal people with AUD.

PURPOSE We wanted to determine whether an educational intervention targeting general practitioners reduces the 2-year prevalence of depression and self-harm behavior among their older patients. METHODS Our study was a cluster randomized controlled trial conducted between July 2005 and June 2008. We recruited 373 Australian general practitioners and 21,762 of their patients aged 60 years or older. The intervention consisted of a practice audit with personalized automated audit feedback, printed educational material, and 6 monthly educational newsletters delivered over a period of 2 years. Control physicians completed a practice audit but did not receive individualized feedback. They also received 6 monthly newsletters describing the progress of the study, but they were not offered access to the educational material about screening, diagnosis and management of depression, and suicide behavior in later life. The primary outcome was a composite measure of clinically signifi cant depression (Patient Health Questionnaire score ≥10) or self-harm behavior (suicide thoughts or attempt during the previous 12 months). Information about the outcomes of interest was collected at the baseline assessment and again after 12 and 24 months. We used logistic regression models to estimate the effect of the intervention in a complete case analysis and intention-to-treat analysis by imputed chain equations (primary analysis). RESULTS Older adults treated by general practitioners assigned to the intervention experienced a 10% (95% CI, 3%-17%) reduction in the odds of depression or self-harm behavior during follow-up compared with older adults treated by control physicians. Post hoc analyses showed that the relative effect of the intervention on depression was not signifi cant (OR = 0.93; 95% CI, 0.83- 1.03), but its impact on self-harm behavior over 24 months was (OR = 0.80; 95% CI, 0.68-0.94). The benefi cial effect of the intervention was primarily due to the relative reduction of self-harm behavior among older adults who did not report symptoms at baseline. The intervention had no obvious effect in reducing the 24-month prevalence of depression or self-harm behavior in older adults who had symptoms at baseline. CONCLUSIONS Practice audit and targeted education of general practitioners reduced the 2-year prevalence of depression and self-harm behavior by 10% compared with control physicians. The intervention had no effect on recovery from depression or self-harm behavior, but it prevented the onset of new cases of self-harm behavior during follow-up. Replication of these results is required before we can confi dently recommend the roll-out of such a program into normal clinical practice.

Data concerning 127 persons aged 35 years or above who died by suicide (as determined in consecutive cases by a Sydney coroner) were analyzed. Psychological autopsy (PA) interviews were conducted in 52 cases, and details were compared with the 75 cases where data were available only from coroner's files (CF). Most characteristics of the two groups were similar, although more CF suicide victims were of Asian background and unable to speak English fluently. Consensus diagnoses were reached following detailed discussion about PA and CF cases. Logistic regression showed no significant difference between age-groups in the proportion diagnosed with major depression, which contrasts with the results of an earlier U.S. study.

The aim of this study was to review the use of clozapine in a Sydney area old age psychiatry service. Data were extracted from case files of all people who were treated in a health area's old age psychiatry units with clozapine during a 15-year period. Additional details were obtained from clinicians who provided ongoing care after discharge from the hospital. Note was made of psychiatric diagnoses, length of time taking clozapine, dosage, side effects and outcome. Sixteen patients aged over 65 years commenced or continued taking clozapine while inpatients of the service. Of the 13 patients who had a history of schizophrenia or schizoaffective disorder, four patients (all female) developed neutropenia and therefore clozapine was stopped. In one case, neutropenia was first diagnosed 6 years after commencing the medication. Two women died; the nine other women, and one of the deceased, stopped taking clozapine, usually because of side effects. The mean daily dose at cessation was 236 mg. All five men were still taking clozapine (mean 260 mg daily) when followed at a mean age of 72 years, having taken it for an average of 10 years. This case review adds to evidence of the risk of neutropenia when older people are prescribed clozapine.

Hoarding can be a symptom of multiple neurological and psychiatric disorders, including obsessive-compulsive disorder (OCD). Recent evidence suggests that, in many cases, hoarding can also be a standalone problem that presents independently from other conditions; this has led to the proposal of a new diagnostic entity named hoarding disorder. This article reviews the neuropsychological and neuroimaging research on pathological hoarding. Most research in humans has been conducted in the context of individuals with brain damage, dementia, or OCD. Studies of well-characterized samples of individuals with hoarding disorder are extremely rare. Although not possible to establish firm conclusions at this stage, we conclude with a series of observations and recommendations for clinical practice.

Background:Many factors have been associated with the onset and maintenance of depressive symptoms in later life, although this knowledge is yet to be translated into significant health gains for the population. This study gathered information about common modifiable and non-modifiable risk factors for depression with the aim of developing a practical probabilistic model of depression that can be used to guide risk reduction strategies.Methods:A cross-sectional study was undertaken of 20,677 community-dwelling Australians aged 60 years or over in contact with their general practitioner during the preceding 12 months. Prevalent depression (minor or major) according to the Patient Health Questionnaire (PHQ-9) assessment was the main outcome of interest. Other measured exposures included self-reported age, gender, education, loss of mother or father before age 15 years, physical or sexual abuse before age 15 years, marital status, financial stress, social support, smoking and alcohol use, physical activity, obesity, diabetes, hypertension, and prevalent cardiovascular diseases, chronic respiratory diseases and cancer.Results:The mean age of participants was 71.7 ± 7.6 years and 57.9% were women. Depression was present in 1665 (8.0%) of our subjects. Multivariate logistic regression showed depression was independently associated with age older than 75 years, childhood adverse experiences, adverse lifestyle practices (smoking, risk alcohol use, physical inactivity), intermediate health hazards (obesity, diabetes and hypertension), comorbid medical conditions (clinical history of coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease, emphysema or cancers), and social or financial strain. We stratified the exposures to build a matrix that showed that the probability of depression increased progressively with the accumulation of risk factors, from less than 3% for those with no adverse factors to more than 80% for people reporting the maximum number of risk factors.Conclusions:Our probabilistic matrix can be used to estimate depression risk and to guide the introduction of risk reduction strategies. Future studies should now aim to clarify whether interventions designed to mitigate the impact of risk factors can change the prevalence and incidence of depression in later life.

Aim: To examine the utility of the Cornell scale for depression in dementia (CSDD), following its introduction as a routine measure in nursing homes. Methods: The CSDD is administered in Australian nursing homes as section 10 of the Aged Care Funding Instrument. CSDD, cognitive and behavioural ratings, and medication use, recorded in three Sydney nursing homes in 2008–2009 were reviewed. Staff discussed what actions were taken if CSDD scores indicated depression. Results: Of 223 residents, 23% scored >12 on the CSDD, indicating probable depression. Another 21% were possibly depressed and 29% not depressed. The CSDD had not been completed for 27%, commonly because preliminary screening indicated no depression, but sometimes because severe cognitive impairment made various CSDD items impossible to rate. Second CSDD assessments had usually not been made. Conclusion: Nursing homes need to document policies that will ensure best use is made of CSDD findings.

Senior nursing staff of the 58 nursing homes in one health area of Sydney were interviewed concerning mental health services and staff education. One or more psychiatrically trained staff were employed in 45 per cent of the nursing homes. Most nursing homes received services from a psychiatrist or another mental health professional, but the average time per month provided by them to see residents was less than one hour in 18 (31 per cent), one to two hours in 16 (28 per cent), and three hours or more in only 11 (19 per cent). Forty-four (76 per cent) wanted more mental health services to be provided, especially for advice on management of disturbed behaviour. A substantial number of the nursing homes (at least 28 per cent) provided no ongoing education to their staff about dementia or other psychiatric problems. There is good reason to encourage greater use of mental health professionals in Sydney nursing homes; enhanced funding of area psychiatric services for elderly people is desirable to allow these services to be more readily available.

Background: Little has been published concerning how best to intervene in cases of severe domestic squalor.Methods: Background literature and reports on how best to intervene in cases of severe domestic squalor were reviewed.Results: Reports by groups in London (Ontario), and Sydney (Australia) have provided recommendations for development of coordinated services to intervene in cases of squalor. Guidelines have been issued. Treatments for compulsive hoarding may contribute to improvement in cases where squalor is attributable to restricted access due to clutter.Conclusions: Effective interventions in cases of severe domestic squalor are commonly expensive and require good inter-agency collaboration. Budgetary support must be available to enable appropriate services to take on cases and provide case management.

OBJECTIVES: To determine whether childhood physical and sexual abuse are associated with poor mental and physical health outcomes in older age. DESIGN: Cross-sectional, postal questionnaire survey. SETTING: Medical clinics of 383 general practitioners (GPs) in Australia. PARTICIPANTS: More than 21,000 older adults (aged >/=60) currently under the care of GPs participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) Study. Participants were divided into two groups according to whether they acknowledged experiencing childhood physical or sexual abuse. MEASUREMENTS: Main outcome measures targeted participants' current physical health (Medical Outcomes Study 12-item Short Form Survey, Version 2 and Common Medical Morbidities Inventory) and mental health (Patient Health Questionnaire-9 and Hospital Anxiety and Depression Scale). RESULTS: One thousand four hundred fifty-eight (6.7%) and 1,429 participants (6.5%) reported childhood physical and sexual abuse, respectively. Multivariate models of the associations with childhood abuse indicated that participants who had experienced either childhood sexual or physical abuse had a greater risk of poor physical (odds ratio (OR)=1.35, 95% confidence interval (CI)=1.21-1.50) and mental (OR=1.89, 95% CI=1.63-2.19) health, after adjustments. Older adults who reported both childhood sexual and physical abuse also had a higher risk of poor physical (OR=1.60, 95% CI=1.33-1.92) and mental (OR=2.40, 95% CI=1.97-2.94) health. CONCLUSION: The effects of childhood abuse appear to last a lifetime. Further research is required to improve understanding of the pathways that lead to such deleterious outcomes and ways to minimize its late-life effects. Language: en

An increasing proportion of the world's population is over the age of 65 years. Specialist mental health services for older people have been developed in many countries. The way services develop depends partly on how healthcare arrangements have evolved in that jurisdiction, as well as on finances, culture and attitudes towards elderly and disabled individuals. Health planners in developing countries recognize that considerable increases in their elderly populations and numbers of individuals with disability are imminent. It will be important to ensure that older people with mental disorders receive appropriate treatment. This review discusses recent findings and observations about psychogeriatric services in the community and in long-term care facilities, and aims to suggest how to improve or develop such services.The prevalence of mental disorders in long-term care facilities is high, but services to deal with them are usually not optimal. When appropriately staffed and organized, community psychogeriatric services, day care and collaborative care can be effective in reducing mental health problems and preventing admissions.Recent reviews and research have provided useful guidance regarding aspects of current psychogeriatric services that work well and those that need to be improved. A person-centred approach is favoured.

Studies have shown a high prevalence of depressive disorders among nursing home residents around the world. Various losses in old age may precipitate depression, and physical illness and disability are major factors that contribute to the development and persistence of depressive disorders. Demoralization (existential distress) is common. Recognition of what a nursing home resident has lost is often a key to developing plans for management. The prognosis for recovery from depression is worse for patients who face an ongoing distressing situation or physical condition. For ongoing loss-related distress, including sadness about loss of health, it is important for patients to ventilate feelings, and to either re-acquire what is lost or to grieve and then adapt to the new situation. For major depression with melancholia, psychotic depression and bipolar disorders, biological treatments are of prime importance. Non-melancholic major depression is best treated with a combination of antidepressants and psychosocial therapies, the latter being particularly indicated when the depression has been precipitated by stressful and depressing events or situations. Psychosocial and environmental interventions are important in all types of depression and may prove more effective than the use of antidepressants for milder disorders. There has been a welcome increase in the recognition of depression in nursing homes and in the prescription of newer antidepressants, but the published evidence to date does not allow definitive recommendations regarding which antidepressants to use in this setting. Outcome research is needed to assess antidepressant efficacy and to better plan multifaceted treatment strategies for depressions of varying types and aetiologies among nursing home residents.

Objective: This paper considers the meaning of the terms hoarding, collecting and accumulation, with a focus on what is abnormal and what is not. Conclusions: Hoarding is an adaptive behaviour. When hoarding is excessive and interferes with people’s lives, it is a disorder. A central feature of hoarding disorder is accumulation of items due to unwillingness to discard them. This must be distinguished from abnormal accumulation of material caused by poor motivation or unawareness concerning the need to discard.

Objective: To compare the perceptions of aged care services, adult mental health services and mental health services for older people regarding aspects of mental health service delivery for older people in New South Wales, Australia. Method: The NSW Branch of the Faculty of Psychiatry of Old Age in association with the NSW Centre for Mental Health, sent a postal survey to all aged care services, adult mental health services and mental health services for older people in NSW. The survey canvassed issues ranging across service profiles, regional variations, availability of resources, processes of care, views on working relationships between services, difficulties and gaps experienced, and ways to improve co-ordination and service delivery. Clinical issues such as the management and practice of psychiatric disorders of old age, educational/training requirements and skill and experience in working with older people were explored. Results: An overall response rate of 86% was achieved, including 95% from aged care services (n = 58), 74% from adult mental health services (n = 62) and 90% from mental health services for older people (n = 20). Only 59% of aged care services and adult mental health services considered that their local mental health services for older people provided an adequate service; resource and budget limitations were portrayed as the main constraint. Mental health services for older people varied widely in structure, settings and activities undertaken. Access to mental health beds for older people was also variable, and alongside staffing levels was considered problematic. Lack of staff training and/or inexperience in psychogeriatrics posed a challenge for aged care services and adult mental health services. Conclusion: Relationships between aged care services, adult mental health services and mental health services for older people are affected by lack of access to psychogeriatric staff, resource limitations of mental health services for older people, and inadequate liaison and support between the service types. Joint case conferences, education, increased funding of mental health services for older people, and cross referrals were considered ways to address these issues.

Objective: To determine the outcome of treatments for vocally disruptive behaviour (VDB) in nursing homes provided by psychogeriatric and geriatric outreach services. Method: Nursing home residents referred to six psychogeriatric and geriatric outreach services for treatment of VDB were examined pre- treatment and followed-up for three months by a research nurse. All recommended treatments for VDB and the effects of implementation were recorded. Main outcome measures were the Cornell Scale for Depression in Dementia, the Dementia Behaviour Disturbance Scale and measures of nurse satisfaction. Results: Three-month outcome data was available for 22 residents, of whom four had died. Of the remainder, six (33%) had objective improvement in VDB. The nursing home staff rated the outreach teams as at least ‘somewhat’ helpful in 61% of cases surviving three months and was particularly satisfied with medication advice. No specific treatment appeared to be more effective. Conclusions: Reduction in VDB obtained through interventions by psychogeriatric and geriatric outreach teams was modest, but nursing home staff found most of the teams to be helpful. Aged care outreach services should provide support to nursing home staff in the management of challenging behaviours.

Depressive symptoms are highly prevalent in late life - in Brazil and around the world. Some experts have argued that depression is less common in old age, quoting studies that show a lower prevalence of major depression in late life. Results from cross-age studies have been remarkably inconsistent, both regarding which age-group has the peak rate and regarding actual rates. A majority of surveys of the prevalence of depressive conditions in old age (not just major depression), warranting clinical interventions, report it to be over 10%. Physical ill-health is the most significant associated factor, but it may distract doctors from recognising depression. Clinical interventions for late life depression are worthwhile. It is recommended that funding be allocated to training in assessment and management, environmental initiatives to counter feelings of helplessness and lowered self-esteem, and research. Sintomas depressivos são altamente prevalentes em fases tardias da vida - no Brasil e no mundo todo. Alguns "experts" argumentam que a depressão é menos comum na terceira idade e citam estudos que mostram prevalência menor de depressão maior entre idosos. Os resultados de estudos que avaliam diferentes grupos etários são inconsistentes no que se refere à faixa etária que apresenta a taxa de pico e em relação à própria freqüência da depressão. A maioria dos estudos de prevalência de transtornos depressivos entre idosos (não limitados à depressão maior) que requerem intervenção clínica indica que mais de 10% dos idosos apresentam quadros depressivos. Doença física é um dos fatores de risco mais significativos, embora essa associação possa impedir os clínicos de reconhecerem a depressão. Intervenções clínicas para depressão na velhice valem a pena, e se recomenda a alocação de recursos adequados para treinar profissionais na avaliação e no manejo desses pacientes, desenvolver iniciativas ambientais dirigidas aos sentimentos de desalento e baixa auto-estima dessa população e promover a pesquisa.

OBJECTIVE: To examine age, period and cohort effects on Australian suicide rates. METHOD: Male suicide rates for successive 5-year periods between 1919 and 1998, and for 1999 were displayed graphically to examine interactions between age, period and cohort effects. RESULTS: There has been a pronounced period effect on male suicide rates in all age groups over the last few decades, with lower rates in wartime and peak rates for most cohorts in the 1960s. Peak rates of all adult female 5-year age cohorts occurred in the 1960s or early 1970s. CONCLUSION: Most so-called cohort effects appear to be associated with environmental changes that may not be a function of the cohort itself. While much attention has focused on the rising suicide rates in young males in Australia, local media and health authorities have given little emphasis to the high rates found in elderly males. Language: en

Objective: To describe a population-based, multifaceted shared-care intervention for late-life depression in residential care as a new model of geriatric practice, to outline its development and implementation, and to describe the lessons learned during the implementation process. Setting: A large continuing-care retirement community in Sydney, Australia, providing three levels of care (independent living units, assisted-living complexes, and nursing homes). Participants:) The intervention was implemented for the entire non-nursing home population (residents in independent and assisted living: N = 1,466) of the facility and their health care providers. Of the 1,036 residents who were eligible and agreed to be interviewed, 281 (27.1%) were classified as depressed according to the Geriatric Depression Scale. Intervention Description: The intervention included: (a) multidisciplinary collaboration between primary care physicians, facility health care providers, and the local psychogeriatric service; (b) trainning for primary care physicians and other facility health care providers about detecting and managing depression; and (c) depression-related health education/promotion programs for residents. Conclusions: The intervention was widely accepted by residents and their health care providers, and was sustained and enhanced by the facility after the completion of the study. It is possible to implement and sustain a multifaceted shared-care intervention for late-life depression in a residential care facility where local psychogeriatric services are scarce, staff-to-resident ratios are low, and the needs of depressed to residents are substantial.

If we can better understand why people kill themselves, it should be possible to reduce suicide rates. The major aim of this article is to consider whether any factors associated with higher rates of suicide in old age are amenable to preventive interventions.It is said that epidemiology is the basic science of prevention. Multiple interacting factors contribute to the causation of suicide, though commonly, in the individual case, a single circumstance or condition can be identified as the major precipitant of suicidal behaviour. Cross-sectional studies may reveal factors that correlate with high suicide rates in particular populations, while long-term studies can show associations between changes in suicide rate and in socio-environmental conditions.

○ Clinical trials and independent reviews support the use of cholinesterase inhibitors for treating the symptoms of patients with mild to moderate Alzheimer's disease (AD). ○ Before initiating cholinesterase inhibitor therapy, patients should be thoroughly assessed, and the diagnosis confirmed, preferably by a specialist. ○ Compliance with cholinesterase inhibitor therapy should be monitored and the response (in global, cognitive, functional and behavioural domains) reassessed after 2-3 months of treatment. ○ Vitamin E may be protective against AD, and therapy with 1000 IU twice daily may be considered. ○ There is insufficient evidence to support the use of other antioxidant agents, anti-inflammatory agents, monoamine oxidase B inhibitors, folate/homocysteine or antihypertensive drugs in patients with AD, or hormone replacement therapy in affected women.

Objective: The purpose of this review is to highlight the prevalence of mental disorders in Australian nursing homes and to provoke discussion of the current inadequacy of mental health services in these facilities. Method: Comparisons were made between mental health care in Australian and United States (US) nursing homes. Relevant literature was reviewed. Results and Conclusions: In both US and Australian nursing homes, the prevalence of mental disorders is high, but there is under-recognition and under-treatment of these conditions. When adequately resourced, old age psychiatry services can have a beneficial impact on mental health care in nursing homes.

BACKGROUND Large epidemiological studies of adult populations have reported depression to be less prevalent in old age than among younger adults, whereas studies limited to older persons have reported rates that vary considerably, some showing high rates of depression. There was, therefore, reason to check data from a study that reported high rates, and to review evidence in relation to diagnosis and outcome. METHOD Re-examination of data from a 1985 survey of elderly people living at home (n = 146). Depression and cognitive impairment were also assessed in a local hostel (n = 42) and nursing home (n = 74). DSM diagnoses were made by an old age psychiatrist. In the nursing home, 23 other residents could not respond to interview questions but were considered to have severe dementia. Subjects in all three settings were followed up after 4 years. RESULTS Seven community subjects (4.5%; confidence interval 1.3-8.3%) and three in residential care fulfilled criteria for major depression. The estimated total prevalence of depressive disorders among elderly in Botany was between 13.0 and 13.6% (4.6% major depression, 3.6% dementia with depression, 5.4% other depressive disorders). In 1985, the prevalence of dementia among those living at home was 11%. Four-year mortality in the dementia cases was 60%. CONCLUSIONS Botany has a high prevalence of dementia and depression among elderly people. The recent cross-age. Australian study of mental health and well-being provided an inaccurate report concerning the pattern of mental disorders in old age.

Objective: To review the proposition that antidepressants have a delayed onset of action by employing measurement and analytic strategies that overcome problems confounding interpretation of many efficacy studies. Method: A subset of patients was recruited to the longitudinal component of the Australasian database study, was assessed at baseline, and then completed measures of depression and anxiety when treatment commenced, and every 3 days over the next 4 weeks. The trajectories of defined 4-week outcome responders and non-responders were compared. Results: Both groups showed a similar decrease in depression (and anxiety) over the first 3 days. A clear trend break then occurred, with little further improvement in the non-responders, as against distinct and progressive improvement in the responders. Ongoing early improvement (across days 3–6) was a strong predictor of responder status. Conclusions: The small sample size limits firm interpretation, although distinct interpretive advantages to the study design are evident. Findings are compatible with a number of recent studies arguing against any extensive delayed onset of action for the antidepressant drugs, but argue for caution in interpreting immediate improvement as predicting likely responder status, and more for examining early and sustained improvement as such a marker.

Objective: To distinguish psychotic, melancholic and a residual non-melancholic class on the basis of clinical features alone. Previous studies at our Mood Disorders Unit (MDU) favour a hierarchical model, with the classes able to be distinguished by two specific clinical features, but any such intramural study risks rater bias and requires external replication. Method: This replication study involved 27 Australasian psychiatrist raters, thus extending the sample and raters beyond the MDU facility. They collected clinical feature data using a standardized assessment with precoded rating options. A psychotic depression (PD) class was derived by respecting DSM-IV decision rules while a cluster analysis distinguished melancholic (MEL) and non-melancholic classes. Results: The MELs were distinguished virtually entirely by the presence of significant psychomotor disturbance (PMD), as rated by the observationally based CORE measure, with over-representation on only three of an extensive set of ‘endogeneity symptoms’. Conclusion: In comparison to PMD, endogeneity symptoms appear to be poor indicators of ‘melancholic’ type, confounding typology with severity. Results again support the hierarchical model.

Objective: The aim of this study was to determine, in a clinical panel sample, the extent to which patients with depression (and melancholic and non-melancholic subtypes) judged the effectiveness of previously received antidepressant treatments, particularly the comparative effectiveness of the older and newer antidepressant drugs. Method: Twenty-seven Australasian psychiatrists assessed 341 non-psychotic depressed patients and rated the extent to which previous antidepressant treatments had been effective. Patients were assigned to ‘melancholic’ and residual ‘non-melancholic’ categories by two processes (DSM-IV decision rules, and a cluster analysis-derived allocation) and treatment effectiveness examined within each category. Results: Electroconvulsive therapy (both bilateral and unilateral) was judged as highly effective by both melancholic and non-melancholic patients. Antipsychotic medication similarly rated highly (but was judged as more effective by the non-melancholic than melancholic patients). The tricyclics and irreversible monoamine oxidase inhibitors (MAOIs) were rated as more effective by the whole sample than several newer antidepressant classes (including the selective serotonin re-uptake inhibitors [SSRIs], venlafaxine, mianserin and moclobemide), whether effectiveness was examined dimensionally or categorically. Comparison of the overall tricyclic and SSRI classes indicated that any superior tricyclic effectiveness was specific to the melancholic subjects. Conclusions: Despite methodological limitations intrinsic to such clinical panel data, the judged greater effectiveness of the older antidepressants (tricyclics and irreversible MAOIs) for melancholic depression is of importance. If valid, such data are of intrinsic clinical relevance but also have the potential to inform us about the neurobiological determinants of ‘melancholia’ and pharmacological actions which contribute to its effective treatment.

Nursing staff administered three instruments to screen for depression among residents in three nursing homes: the 30-item Geriatric Depression Scale (GDS), Gilleard scale and a visual analogue scale. A clinical psychologist then used the same questionnaires when assessing 50 residents in one of the nursing homes. Residents in the nursing homes were interviewed by the psychologist, using the Brief Assessment Schedule (BAS), Hamilton Depression Rating Scale (HDRS) and Mental Status Questionnaire (MSQ) and (in two nursing homes) the Mini-Mental State Examination (MMSE). A psychiatrist reassessed 25 residents whose BAS scores indicated possible or definite depression. Of the 208 residents, 129 were interviewed by the psychologist and assessed by the nurses. The mean GDS score was 11.1, with 32% scoring 14 or more. Some 27% scored in the depressed range (8 or more) on the BAS depression scale. Correlations between scores on the screening instruments and on the depression rating scales were high, except among t...

Assessment is the vital first step in management of late-life depression. Somatic treatments are more likely than psychological approaches to be effective in relieving melancholia, psychotic depression and bipolar depressive swings. However, if severe depressions are associated with brain changes (eg. white matter lesions), recovery is less likely. A complex interplay of psychological and organic factors may account for depressions associated with medical conditions. Physical handicap has a strong association with depression. Psychological and psychosocial interventions may be appropriate in managing non-melancholic, loss-related or situational depressions, though antidepressants are also effective in many cases. Research is needed to compare the effectiveness of antidepressants and non-pharmacological treatments in non-melancholic and ‘;understandable’ depressions. An optimistic and persistent approach will lead to a good and maintained outcome in most cases of depression, in spite of the losses of old age.

OBJECTIVES: The two major aims of this study were (1) to assess senior medical students' knowledge of the age pattern of suicides in Australia, and (2) to note changes in the pattern of suicide in recent years. DESIGN: (1) Two groups of medical students were asked to graph the age distribution of Australian male and female suicides. (2) Suicide statistics (up to 1994) were provided by the Australian Bureau of Statistics. RESULTS: (1) Only 40% of the 75 medical students were aware that suicide in Australia is much more frequent among males. Only two of the 75 drew graphs that were similar to the true pattern. (2) The male rate of suicide at age 20-40 years was almost 35 per 100000 in 1989-94; above 80 years it was nearly 40 per 100000. The female suicide rate of all age groups from 20 years to late old age was about 7 per 100000. The most striking changes in method of suicide in Australia in recent years have been the doubling of male rates of suicide by hanging and car exhaust fumes, increases being greater in younger age groups. Elderly females are more likely than younger females to use hanging as a means of suicide. CONCLUSIONS: Male suicide rates peak in young adulthood and (higher) in late old age. Senior medical students were unaware of the true age and sex patterns of suicide in Australia. Treating depressions and preventing suicides of elderly people (as well as of young people) should be top priorities. Language: en

Personality traits were examined using the NEO Five-Factor Inventory-Revised in an Australian psychological autopsy study involving 259 suicide deaths and 181 sudden death controls aged 35 years and over. Interviews included the Structured Clinical Interview for DSM-IV to determine the presence of psychiatric disorder. Personality traits of suicide deaths differed significantly from those of controls, scoring higher in the Neuroticism and Openness to Experience domains and lower on the Agreeableness and Extraversion domains. These findings varied with the presence of psychiatric disorder and by age. High Neuroticism scores were the most consistent finding in people who died by suicide, although these scores decreased in older suicides.

Background: Most people who collect and hoard, and then have difficulty discarding items, do not live in squalor, even though accumulation of hoarded items can make cleaning very difficult. Commonly, people living in squalor accumulate garbage, but relatively few fulfill proposed criteria for “hoarding disorder.” We examined the overlap between hoarding and squalor among people referred because of unacceptable living conditions.Methods: Ongoing collection of data by a Squalor Project team, including ratings on the Environmental Cleanliness and Clutter Scale (ECCS), allowed (1) description of characteristics of cases and (2) examination of ratings of uncleanliness, and of the effect of accumulation of items or material on access within dwellings. Principal component analysis was used to examine latent variables underlying the ECCS.Results: The mean age of the referred occupants (108 male, 95 female) was 61.9 years. The mean ECCS score in 186 rated cases was 18.5. Factor analysis of ECCS data showed a two-factor solution as the most plausible. Factor 1, comprising seven squalor items, accounted for 33.7% of the variance. Factor 2 comprised reduced accessibility and accumulation of items of little value (variance 17.6%). Accumulation of garbage loaded equally on the two factors. High levels of squalor and/or accumulation were recorded in 105 (56%) of the 186 dwellings. One-third scored high on accumulation/hoarding, while 38% scored high on squalor; 15% scored high on both squalor and accumulation. A quarter of those scoring high on squalor scored low on hoarding/accumulation.Conclusions: The ECCS is useful when describing whether referred cases show high levels of squalor, hoarding, or both.