Comijs et al.

BMC Psychiatry (2015) 15:20

DOI 10.1186/s12888-015-0401-5

RESEARCH ARTICLE Open Access

The two-year course of late-life depression; results

from the Netherlands study of depression in older
persons
Hannie C Comijs1,2*, Jasper Nieuwesteeg2, Rob Kok3, Harm W van Marwijk4, Roos C van der Mast5, Paul Naarding6,
Richard C Oude Voshaar7,8, Peter Verhaak9,10, Margot WM de Waal11 and Max L Stek2

Abstract
Background: We aimed to examine the course of depression during 2-year follow-up in a group clinically depressed
older persons. Subsequently, we studied which socio-demographic and clinical characteristics predict a depression
diagnoses at 2-year follow-up.
Methods: Data were used from the Netherlands Study of Depression in Older persons (NESDO; N = 510). Diagnoses of
depression DSM-IV-TR criteria were available from 285 patients at baseline and at 2-year follow-up. Severity of the
depressive symptoms, as assessed with the Inventory of Depressive Symptoms (IDS), was obtained from 6-monthly
postal questionnaires. Information about socio-demographic and clinical variables was obtained from the baseline
measurement.
Result: From the 285 older persons who were clinically depressed at baseline almost half (48.4%) also suffered from a
depressive disorder two years later. Patients with more severe depressive symptoms, comorbid dysthymia, younger age
of onset and more chronic diseases were more likely to be depressed at 2-year follow-up. 61% of the persons that were
depressed at baseline had a chronic course of depressive symptoms during these two years.
Conclusions: Late-life depression often has a chronic course, even when treated conform current guidelines for older
persons. Our results suggest that physical comorbidity may be candidate for adjusted and intensified treatment
strategies of older depressed patients with chronic and complex pathology.
Keywords: Late-life depression, Course, Determinants, Cohort study, Longitudinal

Background criteria. However, Beekman et al. [6] showed a gradient

Late-life depression is a complex mood disorder with with respect to the prognosis of late-life depression, in
various etiological pathways [1] and high comorbidity which those with sub threshold disorders had the best
with psychiatric and physical diseases, and cognitive de- outcome, followed by those with major depressive dis-
cline [2-5]. Late-life depression often has a chronic order (MDD), dysthymia and double depression (MDD
course and high relapse rates [6-15], probably worse and dysthymia). Only a few studies investigated the nat-
compared to younger age groups [16]. Previous studies uralistic course of late-life-depression in a large sample
were predominantly performed in community based or of older persons with formal depression diagnoses.
primary care samples, and some of them were targeting Magnil et al. [15] observed the two-year course of depres-
depressive symptoms or sub threshold depression, and sion in a cohort of primary care patients aged 60 years
not depression diagnoses according to formal diagnostic and older and found that, 15 of the 51 depressed patients
(29%) had a remitting course, 25 (49%) remained depres-
sive, and 11 (22%) had a fluctuating course. Hybels et al.
* Correspondence: [email protected]
1
Department Psychiatry/EMGO Institute for Health and Care Research VU
[13] were the first to study the course of severe depression
University Medical Center/GGZinGeest, Amsterdam, The Netherlands in older patients. They found that it took patients with a
2
GGZinGeest, Amsterdam, The Netherlands double depression longer to reach partial or full remission,
Full list of author information is available at the end of the article

© 2015 Comijs et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Comijs et al. BMC Psychiatry (2015) 15:20 Page 2 of 9

and that they had higher MADRS (Montgomery–Åsberg facilities and general practitioners. Participants were ex-
Depression Rating Scale) scores after 3 years, compared to cluded when they had a dementia diagnosis or were sus-
those with major depression alone. So, the results suggest pected for dementia based on clinician’s judgement. In
that the course of late-life depression in patients from addition, to be sure that participants were able to fully
mental health institutions may be as poor as in patients understand and answer the questions, they were only in-
from general practitioners or community based samples. cluded when they had a Mini Mental State Examination-
However, more studies among clinically depressed pa- score (MMSE) [23] of 18 or higher (out of 30 points), and
tients are necessary to confirm this assumption. when they had sufficient command of the Dutch language.
For a better scientific and clinical understanding of the The response rate of the depressed persons from the mental
poor prognosis of late-life depression, it is important to health institutions was estimated 48.7%, and from the gen-
study the clinical determinants of its course. This may eral practices 60.3% [22]. Non-depressed comparisons were
help us to improve the treatment of late-life depression recruited from general practitioners (response rate 66.7%),
and to develop tailor made interventions. Among youn- and were included when they had no lifetime diagnosis of
ger adults, clinical characteristics of the depression such depression, dementia or other serious psychiatric disorders,
as the severity of the depressive disorder, comorbid anx- and good command of the Dutch language [22]. The overall
iety symptoms and age of onset are consistently found sample of 510 persons had a mean age of 70.6 years (SD:
to be important predictors of the course [16-18]. In- 7.3; range 60–93) and consisted of 331 (64.9%) women and
creased time to recovery from late-life depression is pre- 179 (35.1%) men. The mean level of education was 11.0 years
viously found to be associated with severity of depressive (SD = 3.6; range 5–18 years). The majority of the sample
symptoms [19], but also with chronicity, later age of on- had the Dutch nationality (99.4%). The depressed persons
set, cognitive decline [19,20] and medical comorbidity did not differ from the non-depressed comparison group
[21]. To date there are few longitudinal studies that in- with respect to mean age and sex, but they had a lower level
cluded sufficient numbers of clinically depressed older of education, were more often divorced or widowed, and
persons enabling to study the course and determinants had a lower score on the MMSE [22].
of the course of late-life depression. In the Netherlands
Study on Depression in Older Persons (NESDO) depressed Materials and procedure
patients were included from both mental health care facil- Data collection
ities and general practitioners, thus including depressed pa- Data collection of the baseline NESDO measurement
tients in various developmental and severity stages [22]. started in 2007 and was finished in September 2010. It
We now have 2-year follow-up data available, which offers included an extensive assessment of psychopathology,
us the possibility to study the two-year course of late-life socio-demographic characteristics, physical health and
depression and its determinants in our cohort. physical health markers, cognitive functioning, psycho-
The aims of the present study were twofold. First, we ex- social functioning, and life style variables. The course of
amined the course of depression during 2-year follow-up late-life depression was followed up every 6 months by
in a sample of clinically depressed patients, and second we means of a postal assessment, including questionnaires
studied which socio-demographic and clinical characteris- on the severity of depressive symptoms and physical
tics predicted a depression diagnoses at 2-year follow-up. health in the past 6 months, incident (chronic) stressors
Based on the literature we expected to find a high percent- and functional limitations, and use of medications and
age of persons that are also depressed after 2-year, and that health care. The questionnaires were the same question-
the severity of the depression and physical comorbidity naires that were used during the face-to-face assessments
would be important determinants of the poor outcome. [22]. A second face-to-face assessment was performed
2 years after the baseline assessment. It started in 2009
Methods and was completed in September 2012. It consisted of all
Participants baseline measures (determinants and outcome variables)
The Netherlands Study of Depression in Older persons that were open to change, such as severity of psychopath-
(NESDO) is an ongoing multi-site cohort study designed to ology and diagnostics. Well-trained research assistants,
examine the (determinants of the) course and consequences mainly consisting of psychologists and mental health care
of depressive disorders in older persons (≥60 years). Detailed nurses, conducted the interviews. All interviews were
description of the design and study sample is given in audio taped and were regularly controlled for their quality.
Comijs et al. [22]. In short, NESDO included 378 depressed
patients (having MDD, dysthymia or minor depression ac- Ethical issues
cording to DSM-IV criteria) and 132 non-depressed adults, The study protocol of NESDO has been approved cen-
aged 60 through 93 years. Participants were recruited in five trally by the Ethical Review Board of the VU University
regions in the Netherlands from both mental health care Medical Center, and subsequently by the local ethical
Comijs et al. BMC Psychiatry (2015) 15:20 Page 3 of 9

review boards of the Leiden University Medical Center, 3. chronic depression, defined as all IDS scores > 14
University Medical Center Groningen and the Radboud and 38 and sub classified as:
University Medical Center in Nijmegen. Written informed a. chronic mild to moderate depression, defined as
consent was obtained from all participants at the start of all IDS scores between 14 and 26,
the baseline assessment. Written informed consent was b. chronic moderate to severe depression, defined as
asked for participating in the study, for permission to use all IDS scores between 26 and 84,
genetic information, to retrieve medical information from c. chronic depression with variable severity, defined
the GP’s, and to link information to external databases. A as IDS scores varying between 14 to 84.
privacy protocol has been developed in which confidenti-
ality of data is guaranteed by using a unique research ID Determinants of depressive disorder at 2-year follow-up
number for each respondent, which enables to identify in- Socio-demographic characteristics including age, sex, years
dividuals without using their names. Only the data man- of education, and partner status were assessed with stand-
ager has access to the record that links the ID number ard questions. Sampling characteristics included sampling
with the name of the participant [22]. All data are avail- site (Amsterdam, Leiden, Groningen, Apeldoorn/Zutphen
able on request (see http://nesdo.amstad.nl/). and Nijmegen) and sampling frame (primary care, ambu-
lant health care and clinical health care).
Course of depression Clinical variables included; first episode MDD (y/n),
Diagnoses of major depression, dysthymia and minor de- comorbid dysthymia (y/n), age of onset, comorbid anx-
pression according to DSM-IV-TR criteria [24] at base- iety disorder(s) (y/n), severity of depressive symptoms,
line and at two-year follow-up were assessed with the cognitive functioning and number of chronic diseases.
Composite International Diagnostic Interview (CIDI; WHO Information about the first episode MDD, recurrent
version 2.1). The CIDI is a structured clinical interview that MMD, dysthymia, and age of onset were all obtained
is designed for use in research settings and has high validity from the CIDI (WHO version 2.1). Comorbid anxiety
for depressive and anxiety disorders [25,26]. Questions were disorders (General Anxiety Disorder, Panic Disorder,
added to determine the DSM-IV research diagnosis of Agoraphobia and Social Phobia) were also assessed
current minor depression [22]. using the CIDI. The Mini-Mental State Examination
More detailed information about the severity of the (MMSE) [23] was used to assess global cognitive func-
depressive symptoms was obtained from the postal ques- tioning. The presence of chronic diseases was assessed
tionnaires, that were send to the respondents every by means of a self-report questionnaire. The partici-
6 months. Severity of the depressive symptoms was pants were asked whether they currently or previously
assessed with the Inventory of Depressive Symptoms had any of the following chronic diseases or disease
(IDS) [27]. The IDS is a 30-item self-report scale that events: cardiac disease (including myocardial infarction),
was developed to carefully assess all core criterion peripheral atherosclerosis, stroke, diabetes mellitus, COPD
diagnostic depressive symptoms. The scale has accept- (asthma, chronic bronchitis or pulmonary emphysema),
able psychometric properties in depressed outpatients arthritis (rheumatoid arthritis or osteoarthritis), cancer, or
e.g. [27,28] and depressed inpatients [29]. The IDS is any other chronic disease. The accuracy of self-reports of
sensitive to both change over time and to differences these diseases was compared to general practitioner infor-
between treatment conditions [30]. Chronbach’s alpha mation, and was shown to be adequate and independent of
for the IDS in our sample was 0.83. The IDS was also cognitive impairment [31]. Use of anti-depressive medica-
included in the baseline and 2-year follow-up assess- tion and benzodiazepines was determined by inspection of
ment, resulting in a total of 5 IDS ratings per partici- the medication that the participants brought in.
pant. The IDS-scores range between 0 and 84, and is
categorized according to severity as; < 14: no depres- Statistical analyses
sion, 14–25: mild depression, 26 – 38 moderate depression, Descriptive statistics were used to describe attrition and
39–48: severe depression and ≥ 49: very severe depression. its determinants according to depression status at base-
Course types of depressive symptoms were computed from line. Next, diagnoses at 2-years follow-up were described
patients from whom we had at least 4 out of 5 IDS scores. according to baseline diagnostic status. In addition,
We distinguished 5 course types: specific course types were described according to the
severity of depressive symptoms obtained from the five
1. remission, defined as at least the last two 6-monthly assessments with the IDS (see description IDS).
observations IDS score < 14, The socio-demographics, clinical and treatment char-
2. intermittent depression, defined as at least one of acteristics were described for the depressed patients ac-
the observations IDS < 14 (not being the last two cording to their depression diagnoses (MDD, dysthymia
observations), or minor depression) according to DSM-IV-R criteria at
Comijs et al. BMC Psychiatry (2015) 15:20 Page 4 of 9

2-year follow-up. Associations between baseline charac- Course of depression

teristics and the outcome measure depression diagnoses Depression diagnoses at two-year follow-up according to
(y/n) at 2-year follow-up, were first assessed with univariate baseline depression diagnoses are shown in Table 2.
logistic regression analyses. Subsequently, when p < 0.10 From the 285 persons who were suffering from a depres-
the variables were entered in a final multivariate model. All sive disorder at baseline, almost half (48.4%) also suf-
analyses were performed by using SPSS 21.0 (IBM SPSS, fered from a depressive disorder two years later. About
Chicago, IL). 59% of the persons with a double depression (MDD and
dysthymia) at baseline, also had a depression diagnoses
at 2-year follow-up. From the persons with a MDD at
Results baseline 44% were also depressed at follow-up. All four
Attrition and its determinants persons with dysthymia only at baseline were also de-
From the 510 persons that were included at baseline, pressed at FU. Among the persons with a minor depres-
401 persons participated in the 2-year follow-up assess- sion the highest remission rates were reached (63.6%).
ment (overall attrition rate of 21.4%). Twenty-eight per- Only 19% of the persons that was depressed at baseline
sons died during the two-year follow-up (5.5%). From was completely in remission, with at least the last two IDS
the 482 participants who were still available for the study assessments lower than 14, whereas 56% of the persons
at that time point, 401 persons (83.4%) participated in with a depressive disorder at baseline, but without a
second face-to-face measurement. In the patient group, depressive disorder at follow-up, still had IDS-score
the most important reasons for attrition were death (28.0%) higher than 14, suggesting residual depressive symp-
and mental problems (37.6%). In the non-depressed com- toms at follow-up.
parison group the most important reason for attrition was, According to the severity of depressive symptoms as
having no interest or no time (50%) (Table 1). assessed with the IDS every six months, 61% of the per-
Attrition was significantly higher among persons who sons that were depressed at baseline had a chronic
were depressed at baseline, and among those with lower (mild/moderate, severe, or variable) course (see Figures 1
education, more severe psychopathology and lower cog- and 2), whereas 20% had intermittent depression – with
nitive functioning (all p < 0.05). Recruitment area and at least one assessment during the 2-year period without
sampling frame also differed between respondents and depressive symptoms (IDS score <14).
non-respondents at follow-up. Non-respondents had more
often been recruited in Apeldoorn/Zutphen and Nijmegen Determinants of depressive disorder at 2-year follow-up
and from outpatient and inpatient mental health facilities Finally, we examined which baseline socio-demographic
(both p < 0.01). and clinical characteristics predicted a depression diag-
noses at 2-year follow-up (Table 3). Univariate analyses
showed that dysthymia, a younger age of onset, higher
Table 1 Attrition at 2-year follow-up according to depression IDS score, more chronic diseases and being recruited
status at baseline (n = 510) from primary care were associated with having a depres-
Patient group Control group sive disorder at follow-up. In multivariate regression ana-
(n = 378) (n = 132)
lyses, independent associations appeared to be a younger
N (%) N (%) age of onset, higher IDS score, and having more chronic
Respondents at 2-y follow-up 285 (75.4) 116 (87.9) diseases at baseline (Table 4).
Non-respondents at 2-y follow-up 93 (24.6) 16 (12.1)
Reasons of attrition Discussion
Deceased 26 (28.0) 2 (12.5) Our study showed that in a sample of clinically de-
pressed older patients nearly 50% still had a depression
Refusal
diagnoses at 2-year follow-up. Of our patients 61%
No interest/no time 14 (15.0) 8 (50.0)
showed a chronic course of the depressive symptoms
Bad experience with previous 1 (1.1) 0 (0) during the two-year period. Patients with more severe
interview
depressive symptoms, comorbid dysthymia, younger age
Unable of onset and more chronic diseases were more likely to
Due to physical reasons 12 (12.9) 2 (12.5) be depressed at 2-year follow-up.
Due to mental reasons 35 (37.6) 4 (25.0) Our findings are largely in line with expectations from
Noncontact community based, primary care and other clinical sam-
No contact 4 (4.3) 0 (0)
ples of older persons [6,10,13,15,32]. Consistent with the
findings of Hybels et al. [13], we found that the persons
Moved abroad 1 (1.1) 0 (0)
with a double depression (MDD and dysthymia) had the
Comijs et al. BMC Psychiatry (2015) 15:20 Page 5 of 9

Table 2 Depression diagnoses at 2-year follow-up according to baseline diagnoses

N 2 year follow-up
Baseline Double depression1 Major depression Dysthymia Minor depression No depression diagnoses
Double depression1, n (%) 71 20 (28.2) 17 (23.9) 3 (4.2) 2 (2.8) 29 (40.8)
Major depression, n (%) 199 38 (19.1) 36 (18.1) 6 (3.0) 8 (4.0) 111 (55.8)
Dysthymia, n (%) 4 0 1 (25) 3 (75.0) 0 0
Minor depression, n (%) 11 0 1 (9.1) 2 (18.2) 1 (9.1) 7 (63.6)
1
Major depression and dysthymia.

poorest prognosis, with 59% still suffering from a de- Since we assessed the severity of depressive symptoms
pressive disorder at two years follow-up. Compared to every 6 months, it was possible to study the course of
studies among adults aged 18 to 65 years, our remission depression in more detail. Of the depressed patients,
rates seem somewhat lower. In the Netherlands Study 61% showed a chronic course of the depressive symp-
on Depression and Anxiety (NESDA) [18], which has a toms during the two years of follow-up, whereas 20%
comparable design and uses largely the same instru- had intermittent depressive symptoms. These findings
ments as in NESDO, about 80% of the purely depressed suggest that most patients had clinically relevant levels
patient reached remission within 2 years, whereas from of depressive symptoms all the time during this 2-year
the persons with a comorbid anxiety disorder only 50% period, further stressing the persistence and chronicity
reached remission within that time frame. In our study, of the depressive symptoms, despite the fact that most
36.8% of the depressed persons had a comorbid anxiety of them were being treated in mental health care facil-
disorder, however, comorbidity was no predictor of a de- ities. Only 19% of the depressed older people reached
pression diagnoses at follow-up. Thus, we may conclude complete remission, whereas 56% of the persons without
that our study confirms the poorer prognosis of depres- a depression diagnoses at follow-up still had residual de-
sion in terms of chronicity among older persons com- pressive symptoms.
pared to younger adults. With respect to the determinants of the prognosis of de-
pression we found that patients with more severe depression
at baseline, comorbid dysthymia, younger age of onset and
more chronic diseases were more likely to be depressed at
2-year follow-up. None of the socio-demographic variables
appeared to be a predictor of the prognosis, neither was
comorbid anxiety disorder or cognitive functioning.

Figure 2 Severity of depressive symptoms according to course

Figure 1 Course of depression (percentages). [Remission: at least during 2-year follow-up. [Remission: at least the last two
the last two observations IDS score < 14; Intermittent: at least one of observations IDS score < 14; Intermittent: at least one of the
the observations IDS < 14 (not being the last two observations); observations IDS < 14 (not being the last two observations); Chronic
Chronic depression, defined as all IDS scores > 14 and sub classified depression, defined as all IDS scores > 14 and sub classified as:
as: chronic mild to moderate depression, defined as all IDS scores chronic mild to moderate depression, defined as all IDS scores
between 14 and 26; chronic moderate to severe depression, defined between 14 and 26; chronic moderate to severe depression, defined
as all IDS scores between 26 and 84; chronic depression with as all IDS scores between 26 and 84; chronic depression with
variable severity, defined as IDS scores varying between 14 to 84]. variable severity, defined as IDS scores varying between 14 to 84].
Comijs et al. BMC Psychiatry (2015) 15:20 Page 6 of 9

Table 3 Descriptives of patient who were depressed at Table 4 Univariate and multivariate determinants of a
baseline according to their depression status at 2-year depressive disorder (yes/no) at follow-up in the patient
follow-up group (n = 285)
Not depressed at Depressed at The presence of depression at
follow-up (n = 147) follow-up (n = 138) 2-year follow up
Socio-demographics at Univariate Multivariate1
baseline
OR (95% CI) OR (95% CI)
- Mean age (sd) 70.4 (7.1) 70.9 (7.9) Socio-demographics
- Female gender, n (%) 97 (66.0) 90 (65.2) - Age at baseline, in years 1.01 (0.98 – 1.04)
- Years of education, 10.7 (3.2) 10.5 (3.7) - Female gender 0.97 (0.59 – 1.58)
mean (sd)
- Education, in years 0.99 (0.92 – 1.05)
- No partner, n (%) 66 (44.9) 72 (52.2)
- No partner 1.34 (0.84 – 2.13)
- Sampling site, n (%)
- Sampling site
- Amsterdam 61 (48.8) 64 (51.2)
- Amsterdam Ref group Ref group
- Leiden 26 (44.1) 33 (55.9)
- Leiden 1.21 (0.65 – 2.25) 1.63 (0.81-3.29)
- Groningen 22 (55.0) 18 (45.0)
- Groningen 0.78 (0.38 – 1.59) 0.95 (0.42-2.11)
- Apeldoorn/Zutphen 21 (67.7) 10 (32.2)
- Apeldoorn/Zutphen 0.45 (0.20 – 1.04) 0.56 (0.21-1.53)
- Nijmegen 17 (56.7) 13 (43.3)
- Nijmegen 0.73 (0.33 – 1.63) 0.81 (0.32-2.06)
Clinical characteristics at
baseline Clinical characteristics at baseline
- First episode MDD, n (%) 70 (47.6) 65 (47.1) - First episode MDD 0.98 (0.62 – 1.56)
- Dysthymia, n (%) 29 (19.7) 46 (33.3) - Dysthymia 2.03 (1.19 – 3.49) 1.30 (0.71-2.37)
- Age of onset of 51.2 (19.5) 44.2 (20.7) - Onset of depression, in years 0.98 (0.97 – 0.995) 0.99 (0.98-1.00)
depression, mean (SD)
- Comorbid anxiety disorder 1.45 (0.90 – 2.35)
- Comorbid anxiety disorder, 48 (32.7) 57 (41.3)
- Severity depression symptoms 1.06 (1.04 – 1.08) 1.05 (1.03-1.07)
n (%)
Sampling frame
- Severity depression 25.6 (11.8) 33.9 (12.5)
symptoms - Primary care Ref group Ref group
Sampling frame, n (%) - Ambulant mental health care 0.63 (0.32 – 1.24) 0.57 (0.26-1.21)
- Primary care 17 (40.5) 25 (59.5) - Clinical mental health care 0.36 (0.13 – 0.96) 0.43 (0.13-1.42)
- Ambulant mental health 111 (51.9) 103 (48.1) - Use anti depressive medication 0.88 (0.53 – 1.47)
care
- Use of benzodiazepines 1.05 (0.83 – 1.34)
- Clinical mental health care 19 (65.5) 10 (34.5)
Comorbidity at baseline
- Use anti depressive 106 (72.1) 96 (69.6)
medication, n (%) - Number of chronic diseases 1.37 (1.16 – 1.63) 1.21 (1.01-1.46)

- Use of benzodiazepines, 54 (36.7) 57 (41.3) - MMSE 0.91 (0.80 – 1.04)

1
n (%) All variables with univariate p < 0.10 included.
MMSE: Mini Mental State Examination.
Comorbidity P-levels < 0.05 are printed bold.
- Number of chronic 1.8 (1.2) 2.4 (1.7)
diseases, mean (sd)
- MMSE, mean (sd) 28.0 (1.7) 27.7 (1.8)
persons with a supportive relationship improve more
MMSE: Mini Mental State Examination.
quickly. In our study, partner status was not statistically
significant. This may be the due to the severity of depres-
Our findings are partly in line with previous studies sion, our sample was mainly recruited in in- and outpa-
that reported severity and chronicity of depressive tients facilities, whereas the PROSPECT sample was
symptoms [19] and medical comorbidity [21] to be re- recruited in primary care.
lated with an increased time to recovery. In contrast Although we included important socio-demographic,
with Alexopoulos [19] however, we found an early on- and clinical characteristics as possible determinants for
set of depression to be associated with poor prognosis. the prognosis of depression, additional key biological,
Also in contrast with our results, Bogner [14] showed health and psychosocial determinants may be of rele-
in the PROSPECT study that married patients had a vance for the prognosis of depression. However, before
favourable course of depression, suggesting that depressed conducting such in-depth analyses in the NESDO sample,
Comijs et al. BMC Psychiatry (2015) 15:20 Page 7 of 9

we needed detailed insight in the course of late-life de- mechanism as depression in younger adults. Although
pression and its socio-demographic and clinical determi- pharmacological and psychotherapy are effective treat-
nants, as was the aim of the present paper. ments for late-life depression [35,36], it is suggested that
Attrition is an inevitable problem in studies among antidepressants may be less efficacious in in older de-
vulnerable older persons. We made extensive efforts to pressed patients compared to younger ones [37,38].
contact and invite persons to participate in the study Moreover, studies are generally limited to the youngest
and offering them shortened interviews when necessary. old, reflected by average samples ages below 70 years
We kept in touch with all participants every half year and minimal physical comorbidity [36].
and send them yearly newsletters. Nevertheless, the at- In older persons, depression treatment may need to be
trition at 2-year follow-up was highest in the depressed tailored to address underlying etiological factors and co-
group 24.6% compared to 12.1% in the non-depressed morbidity as well. The group of Alexopoulos [39] devel-
control group. In the depressed group 28% died and oped a personalized intervention for depressed patients
37.6% did not want to participate due to mental reasons. with severe chronic obstructive pulmonary dysplasia
Unfortunately attrition was selective; attrition was higher (COPD) and showed that this intervention reduced de-
among persons who were depressed at baseline and who pressive symptoms and dyspnea-related disability more
had severe psychopathology, lower cognitive functioning, than usual care over 28 weeks. However, thus far there
and were recruited from outpatient or inpatients mental is only limited evidence that such a multifactorial per-
health care settings. In the aforementioned comparable sonalized treatment is more effective than the regular
NESDA study among younger adults aged 18–65, the treatment. Nevertheless, personalizing depression treat-
two-year attrition rate was 12.9% which was relatively ment seems necessary to improve the treatment of depres-
low compared to other epidemiological studies in psy- sion, especially in this older age group. Our results suggest
chiatric samples and was mainly due to refusal to further that physical comorbidity may be candidate for adjusted
participate [33]. Among older adults, attrition rates are and intensified treatment strategies of older depressed
expected to be higher, because of a higher risk for death patients with chronic and complex pathology.
and diseases compared to younger adults. In the Longi-
tudinal Aging Study Amsterdam, a population based cohort Conclusions
study among older persons age 55 years and older, three- Our study showed that almost half of a group of older
year attrition rates were around 19% and was mainly due to patients with a depressive disorder were also suffering
death [34]. We may therefore conclude that the attrition rate from a depressive disorder two years later, and that most
in our study is not extremely high, when taking age and dis- of them had a chronic course of the depressive symp-
ease status of our sample into account, but it may limit the toms during the 2 years of follow-up. More serious de-
generalizability of the findings to some extent and needs to pression, a younger age of depression onset, and more
be reflected upon in future studies. somatic comorbidity were independent determinants of
It should be noted that our findings cannot be general- a poor prognosis of depression.
ized to community-dwelling older persons, as most of
our patients were recruited from specialized mental Competing interests
The authors declare that they have no competing interests.
health facilities and may represent a group with more re-
fractory depression at baseline. However, we were espe- Authors’ contributions
cially interested in this group because patients with HCC, principle investigator of NESDO, was responsible for the conception
and the design of the study and the acquisition of the data. She wrote the
clinical depression are often underrepresented in com- paper and supervised the data-analyses. JN supervised the data collection,
munity based samples. Thus far, few studies investigated performed the overall data management, and carried out the data-analyses.
the naturalistic course of late-life-depression in a large RK contributed to the local data collection and co-authored the paper.
HWJM was involved in the design of the study and co-authored the paper.
sample of older persons with formal depression diagno- RCM was involved in the conception and the design of the study, supervised
ses. Our findings are therefore important for clinical the local data collection and co-authored the paper. PN was involved in the
practice. conception and the design of the study, supervised the local data collection
and co-authored the paper. ROV was involved in the conception and the
design of the study, supervised the local data collection and co-authored
Clinical implications the paper. PV contributed to the local data collection and co-authored
As most of the diagnosed patients (85.3%) were under the paper. MWMW contributed to the local data collection and co-authored
the paper. MLS was involved in the conception and the design of the study,
treatment when they entered the NESDO study, the re- supervised the local data collection and co-authored the paper. All authors
sults may tell us something about the adequacy of the read and approved the final manuscript.
depression treatment in this older age group. Regular in-
terventions are mainly adapted from guidelines that are Acknowledgement
The infrastructure for the NESDO study (http://nesdo.amstad.nl) is funded
based on research performed in younger adults, assuming through the Fonds NutsOhra (project 0701–065), and the participating
that depression in older persons has the same underlying universities and mental health care organizations (VU University Medical
Comijs et al. BMC Psychiatry (2015) 15:20 Page 8 of 9

Center, Leiden University Medical Center, University Medical Center Netherlands Mental Health Survey and Incidence Study (NEMESIS). Br J
Groningen, UMC St Radboud, GGZ inGeest, GG Net, GGZ Nijmegen, GGZ Psychiatry. 2002;181:208–13.
Rivierduinen, Lentis, and Parnassia). 17. Spijker J, de Graaf R, Bijl RV, Beekman ATF, Ormel J, Nolen WA. Determinants
of persistence of major depressive episodes in the general population.
Author details Results from the Netherlands Mental Health Survey and Incidence Study
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2
GGZinGeest, Amsterdam, The Netherlands. 3Parnassia/BAVO groep, Two-year course of depressive and anxiety disorders: results from the
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