Deconstructing Depression Dormancy and Dysphoria

By Michael Stones, Wendy Kirkpatrick
Go into a nursing home and you’ll see residents sitting around doing nothing much of the day. If this was your lifestyle, chances are that you’d be depressed. Are these nursing home residents depressed, or have diseases that ravage the brain or body made them dormant?

This paper will argue that anhedonic depression is a cause of dormancy in long-term care. Anhedonia is a loss of pleasure or interest, which like dysphoria – a depressed mood – is a defining symptom of depression. The generic terms for states that subsume these symptoms are low positive affect and high negative affect, respectively. Not everyone understands that these two states are different rather than opposite, and that the presence of one does not necessarily imply the other. Some people show depression by anhedonia, some by dysphoria, and some show both symptoms.

Old and new findings show how important the distinction between anhedonia and dysphoria is for care planning in long-term care. The old findings include the following:

The new findings discussed in this paper suggest that long-term care residents showing anhedonia without dysphoria are less likely to receive treatment for adverse mood. These findings derive mainly from the Resident Assessment Instrument Health Infomatics Project (RAIHIP). This project used the Minimum Data Set (MDS) in health care institutions and agencies across Ontario during 1999-2001. Versions of the MDS include tools for long-term care (MDS 2.0), home care (MDS-HC), and mental health (MDS-MH). The findings reported are from 159 home care clients and 401 long-term care residents from a single city.

Later Life Depression

Depression has effects in later life that include a high risk of mortality from physical illness or suicide. Although frequent in early dementia, depression causes cognitive decline even among people without dementia. It is the most common psychiatric problem in older people after anxiety disorders and diseases that waste the brain, with an overall prevalence rate of about 5%6.

A diagnosis of depression is more frequent in long-term care residents than among older people living at home. The rate in chronic care settings in Ontario was 13.4% in 1996, with a rate for RAIHIP nursing homes of 15.5%. When based on symptom ratings (rather than diagnosis), the rates are even higher. Nearly one third of residents in the chronic care had symptoms of depression, with 24% of the RAIHIP nursing home residents scoring beyond the cut-off point on the MDS Depression Rating Scale (MDSDRS).

The disparity between rates based on diagnosis and symptom ratings is a cause for concern – either diagnosis is too stringent or the scale cut-off points too lenient. The following sections review the criteria for diagnosis and use of symptom or self-ratings for detection, and comment on the distinction between anhedonia and dysphoria.

Psychiatric Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM-4) uses two main rules in the diagnosis of major depression. There are defining symptoms and symptoms that add to an overall sum. The defining symptoms are anhedonia and dysphoria, at least one of which must be present in any diagnosis. The summed symptoms include poor sleep, appetite, energy, concentration, and self-esteem, disturbed psychomotor function, and thoughts about suicide. For diagnosis, at least five symptoms, including anhedonia or dysphoria, must be present almost all the time for a period of one month. These rules allow major depression to take anhedonic or dysphoric forms, or to include both types of symptom.

Critiques of the DSM-4 suggest that the rules are too stringent when applied to late life depression. Many older people with depressive symptoms fail to meet the DSM-4 criteria because their symptoms are too few in number or brief in duration. These people suffer distress, undergo mental decline, and may respond well to treatment, but still fail to qualify for diagnosis. The U.S. Surgeon General’s report on Mental Health recommends a new diagnosis of minor depression. This diagnosis would require fewer symptoms than major depression and involve less impairment.

Symptom Ratings

Depression ratings have a longer background in psychiatry than long-term care. The MDS 2.0 uses symptom ratings for purposes of care planning in long-term care. A symptom scale for depression extracted from the tool (the MDSDRS) tested well for validity against other such scales.

A weakness of the MDSDRS is that all the items relate negative affect, including dysphoria (e.g., negative statements, anger, unrealistic fears, complaints, sad expression, crying), and none to anhedonia. Although the mental health version of the MDS measures anhedonia by an item on loss of pleasure, the MDS 2.0 contains only items on loss of interest. Findings that the MDSDRS proved valid against other symptom rating scales could suggest that this class of tool has low content validity with respect to anhedonia.

Self-Ratings

The main use of self-rated depression is in survey research. Such measures differ from symptom ratings in two ways. First, the content includes thoughts or feelings rather than symptoms. Second, self-ratings enfranchise the rater as the person most able to reveal his or her own inner state. Although self-ratings have good validity , a constraint on their use is that the rater must have intact awareness.

Self-ratings of depression measure poor affect. Repeated findings over the past fifty years show affect measures to contain positive and negative subscales that are distinct and not opposite poles of the same axis. This dichotomy is true of short-term (state) and long-term (trait) affect, and with informant ratings as well as self-ratings. The term ‘low positive affect’ subsumes anhedonia, and ‘high negative affect’ subsumes dysphoria.

Quite a few studies found self-rated affect to relate to major depression. The patients scored low on positive affect (anhedonia) but high on negative affect. High negative affect was common to other mental disorders (e.g., chronic anxiety), but anhedonia related only to depression. Therefore, only anhedonia distinguished depression from the other disorders studied.

Anhedonia and Dysphoria

The following paragraphs deal with detection, frequency, relationships, and treatment with respect to anhedonia and dysphoria.

Detection

Although it is simple to detect dysphoria and realize its meaning, anhedonia is not so easy to interpret. Symptoms of dysphoria include negative statements, frequent complaints, sad thoughts, and unhappy behavior (e.g., anger, crying) or facial expression. A person with a chronically depressed mood shows some or all of these symptoms on a recurrent basis.

There are fewer ways to express anhedonia verbally. Statements such as ‘I don’t enjoy anything anymore’ or ‘I have no interest in anything’ are pensive and require intact cognition. Such depth of thought is beyond the mental means of many residents in long-term care. Therefore, the only way to infer anhedonia in many residents is from behavior.

Anhedonic behavior includes a retreat from activity (including social exchange) normal to a person. However, the origins and reasons for that retreat can be diverse.

Therefore, the risk of failure to detect anhedonia is high in long-term care because many residents have co-morbid conditions, low powers of verbal expression, and dislike their options in life. There is a danger that a defining symptom of depression often goes unrecognized.

Frequency

Dysphoria is more frequent over the lifespan than anhedonia. A study of lifetime histories of depression in people over 65 years of age showed 15% of men and 33% of women to report dysphoria lasting at least two weeks. Eight percent of men and 16% of women had anhedonia for the same length of time. Therefore, dysphoria occurs with twice the frequency of anhedonia, and females are twice as likely as males to report either state.

These lifetime rates may not apply to older people. Table 1 shows findings with the MDS and informant rated affect scales (PGC) for home care clients and nursing home residents. The data were from RAIHIP and other sources . The MDS dysphoria items were from the MDSDRS, with anhedonia measured by loss of pleasure and/or interest. The scores are probabilities that an item within an index would show a daily problem.

Table 1 shows daily mood problems to be at least as frequent on the anhedonia as the dysphoria items. Daily problems were more frequent on the anhedonia than the dysphoria measure from the PGC affect scale (p=.002). These findings confirm earlier findings that loss of interest is frequent in older people under care.

Table 1: Probabilities of Daily Mood Problems in Home Care and Nursing Home Samples [avaiable in the print version of Stride]

Relationships

Findings from analysis of the new data from RAIHIP and other sources included relationships between anhedonia and dysphoria, and with other measures. The findings confirmed an expected relationship between the anhedonia and dysphoria items of two separate scales showing a low correlation. The anhedonia scale included items on loss of interest and loss of pleasure, while the dysphoria items were from the MDSDRS. These scales showed validity against informant ratings of affect.

Other measures derived from the MDS included time spent in activity, problem behaviors (e.g., abusive, socially inappropriate, resists care), low involvement in the life of the facility, and poor relationships with other residents. Residents with any daily loss of interest or pleasure spent more of the day dormant. In the RAIHIP nursing home data, 96% of residents with loss of interest were active for less than one third of the day compared with 74% of those showing only dysphoria and 60% with neither symptom.

Figure 1 shows the percent of RAIHIP residents with scoring higher than average on the other measures. The findings showed the following. Residents with any mood symptom were less involved with the life of the nursing home.

These findings suggest that anhedonia relates to dormancy, whereas the presence of dysphoric symptoms may disrupt everyday life in a nursing home.

Figure 1: Percent of Residents with Any Daily Loss of Interest, Dysphoria, Both, or Neither Showing Behavior Problems, Low Involvement and Poor Relationships is available in the print edition of STRIDE.

Treatment

Care planning includes assessment, treatment and re-assessment. A care plan for mood might include assessment by a specialist, the use of medication (e.g., antidepressive, antipsychotic, or antianxiety drugs) and psychological treatment. Diagnosis is part of an assessment by a medical specialist. Findings from RAIHIP confirmed other findings that symptoms of dysphoria, but not anhedonia, relate to a diagnosis of depression.

Medication is the most frequent treatment for mood problems in long-term care. The RAIHIP data showed that 58% of nursing home residents received psychotropic drugs compared with only 6% getting psychological treatment. This is not surprising because few staff have the skill or time to carry out the latter. Of the residents clinically diagnosed as depressed, two thirds received antidepressive, one half antianxiety, and one quarter antipsychotic drugs.

Findings from RAIHIP suggest that nursing home residents with any daily signs of dysphoria are the more likely to be treated for mood. Figure 2 shows this trend for any mood treatment (including psychological treatment) and the use of antidepressives. However, other findings show an opposite trend for psychological treatment, which was more frequent for residents with loss of interest.

The most likely explanation for the overall failure to diagnose or treat anhedonic residents for mood disorder is that they disrupt the life of the nursing home less than do residents with dysphoria. Because they present less of a problem, there is less incentive to treat the symptoms. An alternative possibility – that mood therapy is more successful in reducing anhedonic than dysphoric symptoms – seems less plausible but gives good reason to target anhedonia for mood treatment.

Figure 2: Percent of Residents with Any Daily Loss of Interest, Dysphoria, Both, or Neither Treated with Antidepressives or Any Mood Therapy is available in the print edition of STRIDE.

Conclusions

Deconstruction refers to splitting apart something previously put together. Depression is a composite of mental symptoms that includes anhedonia, dysphoria or both. The medical hierarchies understand that the under-diagnosis and under-treatment of late life depression life is a serious problem, and especially for long-term care. Indeed, the U.S. Surgeon General’s report on Mental Health recommends a new diagnosis with fewer symptoms and less impairment needed to qualify for minor depression. This article supports that conclusion but suggests that attention to the kind of symptom might be more important than to the number of symptoms.

Although anhedonic behavior is not exclusive to depression, it is among the most frequent defining symptoms in old people. The problems we cited in long-term care are as follows.

Although psychological treatment is infrequent in long-term care, good responses to procedures meant to increase positive affect show that anhedonia is amenable to mood treatment. Such treatment need not be expensive nor beyond the skills of nursing staff. A study in Newfoundland used retired nurses to facilitate treatment groups in five nursing homes. The findings were impressive, showing increased trait affect and decreased mortality compared with residents not treated. The Case of Mrs. X, reported in Box 1, provides an example of simple but effective treatment from Thunder Bay.

Our challenge for long-term care is to take a second look at those residents sitting around doing nothing much of the day, question again whether their dormancy might not be of affective origin, and plan care accordingly. Remember that all of us – whatever our age, health, or background – need meaning, hope, and affection to maintain positive affect. In simple terms, these needs are for something meaningful to do, something to look forward to, and something to love. Can we, in all good conscience, neglect these needs and still say we care?

Box 1: The Case of Mrs. X

Seventy-two year-old Mrs. X had a stroke resulting in severe physical problems. After several months on a Rehabilitation Unit, she reached her apparent potential. Her subsequent admission to long-term care was because she had no family and was unable to care for herself.

She presented as a quiet, frail woman older than her years. She adjusted quickly to life in the home and in some ways was an ‘ideal resident’ – complying with the routines for daily care and causing no problems for the staff. However, she soon began to withdraw from life in home, refused to participate in outings and programs, and sat for hours staring out the window in her room. She remained compliant but always looked very sad.

The nursing staff noted this behavior and notified a physician that Mrs. X was ‘depressed’. The physician ordered an antidepressant, which seemed to change her mood but not her withdrawal. Her main activity continued to be sitting and staring out the window.

Around that time, a student social worker on placement at the home visited all the residents. After spending some time talking with Mrs. X, the student asked for a meeting with the primary nurse on the unit. The student had discovered that Mrs. X felt a major loss of autonomy and identity. These problems seemed to relate to the loss of her dog, put up for adoption following her stroke. The dog had been Mrs. X’s only friend and companion for many years, and gave her life meaning and purpose. She did not know where the dog was, if he was even alive, and this distressed her greatly.

The nurse contacted a former neighbor of Mrs. X and found that the dog was indeed alive and adopted by another neighbor living in that area. The dog’s new owner was very willing to bring the animal to the home every two weeks to spend time alone with Mrs. X in her room.

The subsequent changes in Mrs. X seemed miraculous to the home’s staff. She looked forward to the dog’s visits so much, went on outings to buy it treats, and because of her new outlook began to take part in social activities in the home. The dog’s visits dissipated her anhedonia, replacing it with purpose, hope, and affection. She smiled for the first time since her admission six months earlier.

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