Background: Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders.

Methods: Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established.

Results: Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants.

Conclusions: Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Background: There is a paucity of past research concerning longitudinal changes in loneliness in old age and in the factors that correlate with loneliness in older persons. This study examines (a) whether loneliness increases with age, (b) characteristics of the lonely older population, and (c) predictors of becoming lonely in old age.

Methods: Data are from the Cross-Sectional and Longitudinal Aging Study, a national longitudinal study on the health, mental, and social status of people aged 75 and older living in Israel. Loneliness was measured as the frequency at which participants had felt lonely during the last month (range: 0–3). The analysis included two waves of data, with an average gap of 3.5 years between them, with 1147 participants at wave 1 and 588 participants at wave 2.

Results: Data showed an increase in the mean level of loneliness over time, rising from 0.62 to 0.80, p<0.001. The strongest correlate of being lonely at wave 1 was unmarried status. Different variables predicted loneliness in the married and the unmarried. Among the married, lonelier persons tended to have experienced more traumatic events, had more doctor's visits, and manifested less cognitive vitality. In contrast, among the unmarried, loneliness was higher in those with financial difficulties, poor health, and less social network support. The longitudinal transition to becoming lonely was more likely in women, those with insufficient financial resources, and people with poorer health.

Conclusions: Results highlight the following implications for the development of preventive programs: (a) helping older persons maintain and develop social networks for preventing increased loneliness, (b) taking demographic factors, health factors, and previous trauma into account when designing interventions, and (c) targeting unmarried women for interventions.

Background: Depression is a common psychological problem among older people. Health-related quality of life (HRQoL) is now recognized by healthcare providers as an important treatment goal for people with depression. This study aimed to identify predictors of change in HRQoL among older people with depression.

Methods: In a longitudinal study, data were collected when participants were newly diagnosed with a depressive disorder at a regional outpatient department in Hong Kong and 12 months later. Seventy-seven Chinese participants aged 65 years or older completed the study. Measures included the Physical Health Condition Checklist (PHCC), Geriatric Depression Scale (GDS), Modified Barthel Index (MBI), Instrumental Activities of Daily Living (IADL) scale, Social Support Questionnaire (SSQ), and World Health Organization Quality of Life Scale-Brief Version (WHOQOL).

Results: Significant improvements between the first and second assessments were noted in the total WHOQOL scores, GDS scores, and the number of the social support. The results of linear regression models showed that the increases in the IADL scores and decreases in the PHCC and GDS scores were significantly associated with higher final WHOQOL scores.

Discussion: Treatment for depression was effective in improving the participants’ overall condition and their perceived HRQoL. The results suggest that interventions to alleviate older people's level of depression, manage their physical ill health and enhance their instrumental activities of daily living ability could help improve their perceived HRQoL.

Background: Depression is common in old age and is often associated with stigma. However, to date, little is known about self-stigma (internalization of stigmatic beliefs) in depressed older people despite its importance and consequences. The aim of this study was to examine self-stigma and its correlates in depressed older people.

Methods: Phone interviews were conducted with 54 persons diagnosed with major depression (78% female, average age = 74) from a psychogeriatric clinic in the central area of Israel. Self-stigma was assessed using an adapted version of the Internalized Stigma of Mental Health (ISMI) scale. Symptoms of depression were assessed using the short form of the Geriatric Depression Scale (GDS). Self-esteem was measured using Rosenberg's Self Esteem Scale. Information regarding sociodemographic and psychiatric health characteristics was also collected.

Results: Self-stigma was relatively moderate with 10% to 20% of the participants reporting self-stigma. Those who reported higher levels of self-stigma were younger than those who did not report it. Income and education were lower in persons who reported high levels of stigmatization. Persons who reported stigmatization scored higher on the GDS and reported lower self-esteem than those without stigmatization.

Conclusions: This study represents an effort to examine the correlates of self-stigma in depressed older people. Since self-stigma exists among older adults, further studies are required to extend this body of knowledge.

Background: The elderly are at high risk of developing tuberculosis. The prevalence and incidence of depression and anxiety are higher in those with tuberculosis than in the general population. A positive correlation between national suicide rates and rates of mortality due to tuberculosis has been reported.

Methods: The relationships between elderly suicide rates and (i) the prevalence of tuberculosis, (ii) the proportion of detected cases of tuberculosis, and (iii) the proportion of cured cases of tuberculosis were examined in a cross-national study using data from the World Health Organization and the United Nations.

Results: There were no significant correlations between elderly suicide rates and the prevalence of tuberculosis and the proportion of detected cases of tuberculosis. There were weak but significant negative correlations between the proportion of cured cases of tuberculosis and suicide rates for both sexes in both elderly age-bands.

Conclusion: Caution should be exercised in interpreting the findings and the direction of the causal relationship from this cross-sectional ecological study because of ecological fallacy. However, if the findings are true then potentially the study has important implications for prevention of elderly suicides, particularly in countries with a high prevalence of tuberculosis.

Aggression and violence are frequent events in healthcare settings across the globe, with mental health and old age settings often frequenting top spot in incidence lists (Hodgson et al., 2004, Behar et al., 2008). Some may underestimate the challenging nature of older age psychiatric patients, but the reality is that this population can display high levels of aggressive and violent behavior (Stewart et al., 2008). The potentially challenging nature of this population was revealed in a recent study in the U.K., which reported 2753 episodes of aggressive behavior over a three month period (Stewart et al., 2008). Over half of these aggressive displays were in the form of physical aggression, and displays of this type of behavior increase the likelihood of healthcare staff having to employ physical intervention (Stewart et al., 2008). Physical intervention is a form of hands-on physical restraint that involves trained staff employing physical holding techniques to move and restrict the movement of the aggressive patient.

A recent cross-national study reported that elderly suicide rates in both sexes were significantly negatively correlated with household size and the percentage of extended households and positively correlated with the percentage of single-person households (Shah, 2009). Speculative explanations for these findings were based on cultural factors, including (i) a mismatch between the traditional dependence of elderly relatives on their children for emotional and financial support and their children's ability to provide this support (Yip et al., 1998, 2000; Liu et al., 2006); (ii) the unmet traditional expectation of the elderly person being able to live with their children or grandchildren (Yip et al., 2000; Liu et al., 2006); (iii) the effect on the elderly of their children's negative attitudes (Yip et al., 2000); (iv) the migration of children to urban areas or to other countries (Yip and Tan, 1998; Yip et al., 2000); and, (v) the number of available caregivers, household size and family size (Kua et al., 2003). Countries with larger household sizes and a greater number of extended households potentially have a greater number of people available within the household and within close geographical proximity who can contribute positively to these cultural issues, and this may ultimately lead to a reduction in elderly suicide rates – the “emotional proximity” explanation. However, there may also be other explanations for these findings (Shah, 2009). Having more people in a household implies that there are more people to identify suicidal ideation and support the suicidal individual in seeking approprate help. Also, in larger households elderly people are likely to be alone for shorter periods of time, which would reduce the opportunity to implement any suicidal plans. Both these possibilities form part of the “geographical proximity” explanation.

Because suicide rates have traditionally increased with age (Shah and De, 1998; Shah, 2007), the observed reduction in suicide rates among older people may be an important contributor to the U.K. government's target to reduce suicide rates in the general population by at least one-sixth of the 1996 baseline by 2010 (Department of Health, 1999). Previous studies have observed that suicide rates in older people have declined in both sexes over the 12-year period (1985–1996) and 24-year period (1979–2002) in England and Wales (Hoxey and Shah, 2000; Shah et al., 2001), although the rates are still considerably higher than those among younger adults. It is believed that a better understanding of the methods used by older people for suicide may lead to the development of targeted preventative strategies, which are expected to meet the challenge of sustaining this observed decline in suicide rates among older people over time in England and Wales (Lindesay, 1991; Dennis and Lindesay, 1995).

Alcohol-use disorders have been reported to be associated with the risk of suicide in the general population (Schneider et al., 2009) and in the elderly (Shah and Ganesvaran, 1997). This allows identification of individuals potentially at increased risk for suicide and target preventative interventions at an individual level. Moreover, alcohol is often taken during the process of committing suicide (Conwell et al., 1990). Identification of the relationship between the national consumption of alcohol and suicide rates would support generation of public health measures to reduce the national consumption of alcohol to facilitate reduction in suicide rates. Thus, a cross-national ecological study examining the relationship between national per capita consumption of alcohol and suicide rates was undertaken.

On 30 May 2009, shortly after completing this book review, Dr Johann Claassen died suddenly while out running. He was 47 years old. His colleagues and students acknowledged him as a first-rate psychiatrist and an outstanding teacher, especially of medical students, which is why he was asked to undertake this review. To all his former colleagues in Western Australia, New Zealand and South Africa, and to his surviving family, especially his wife and two young boys, I and the entire International Psychogeriatrics team extend our sincere condolences.