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Prevalent mental health conditions vary significantly between men and women. Men have more substance use disorders, autism, and ADHD, while women have twice the prevalence of depressive and anxiety disorders as men. These differences in prevalent mental health conditions may be mediated in part by androgens. Testosterone has effects on brain structure and function including increased cerebral blood flow, serotonergic neural firing, neurogenesis, and neurotransmitter regulation. With aging, testosterone levels decline, and depressive illness and medical morbidity increase. Most cross-sectional and prospective studies have reported an association between low serum testosterone levels and depressive symptoms. This association may be due to a physiologic effect of low serum testosterone, but also could be related to confounders such as medical morbidity. The results of testosterone treatment trials on mood have been conflicting with particular subgroups of men appearing to be more responsive to testosterone treatment. Men who were more likely to respond to testosterone treatment were hypogonadal, middle-aged men with less severe depressive disorders or treatment refractory depression. Men who were less likely to respond were eugonadal or older than 60 years. Due to conflicting findings from prior studies, testosterone cannot be recommended as routine treatment for men with depressive illness, particularly for major depression. However, in men diagnosed with hypogonadism, potential beneficial mood effects could be considered when assessing the overall benefits and risks of treatment. Further studies are needed to clarify the effects of testosterone on mood and to identify subgroups of men who may be more responsive to it.

BACKGROUND: Decline in serum androgens is common among older men and has been associated with cardiovascular disease, although its role in risk of atrial fibrillation (AF) has not been well defined. HYPOTHESIS: Low serum androgens are associated with an increased risk of AF. METHODS: We examined the prospective associations between testosterone, its more active metabolite dihydrotestosterone (DHT), and sex-hormone binding globulin (SHBG) with risk of AF among 1019 otherwise healthy men of average age 76.3±4.9 years in the Cardiovascular Health Study. RESULTS: After median follow-up of 9.5 years, 304 (30%) men developed AF. We detected a nonlinear association with risk of incident AF in both free and total DHT, in which subjects with the lowest levels had a higher risk of incident AF. After adjustment for demographics, clinical risk factors, left atrial diameter, and serum NT-proBNP levels, men with free DHT less than 0.16 ng/dL were at increased risk compared with men with higher levels (HR 1.48, CI 1.01–2.17, p

Over the past decade, there has been a substantial increase in the number of men who are treated with testosterone. Despite this increase in the use of testosterone, the risks of adverse cardiovascular events are unclear as meta-analyses have reported conflicting findings and no clinical studies have been large enough or long enough to adequately assess for cardiovascular risks. The goal of this paper is to review large prescription database studies of testosterone treatment and adverse cardiovascular events and mortality with the aim of providing some guidance for clinicians and researchers in this controversial area.

Background Little is known about the relationships of dihydrotestosterone (DHT), a more potent androgen than testosterone (T), with bone mineral density (BMD) and fracture risk. Our objectives were to evaluate the relationships of T, DHT and sex hormone binding globulin (SHBG) with BMD, fracture risk, and lean body mass (LBM). Methods We evaluated 1128 older men free of cardiovascular disease in a prospective cohort study using data from the Cardiovascular Health Study. T and DHT were measured by liquid chromatography–tandem mass spectrometry and SHBG by fluoroimmunoassay. Our outcomes included incident hip fracture (n = 106) over a median of 10.2 years and BMD and LBM by dual-energy x-ray absorptiometry (n = 439). Results In Cox regression models mutually adjusted for T, SHBG, and covariates, each standard deviation increment in DHT (0.23 ng/ml) was associated with a 26% lower risk of hip fracture (adjusted hazard ratio [aHR] 0.74, 95% confidence interval (CI) 0.55–1.00, p = 0.049). Similarly, SHBG was associated with fracture in mutually adjusted models (aHR HR 1.26, 95% CI, 1.01–1.58, p = 0.045). In contrast, T (aHR, 1.16, 95% CI, 0.86–1.56, p = 0.324) was not significantly associated with fracture in mutually adjusted models. T, DHT and SHBG were not associated with BMD. T and DHT were both positively associated with LBM in individual models. Conclusions In older men, DHT was inversely associated with hip fracture risk and SHBG was positively associated with hip fracture risk, while T was not. Future studies should elucidate the mechanisms by which DHT affects bone health.

Purpose Testosterone treatment of men with low testosterone is common and, although relatively short-term, has raised concern regarding an increased risk of prostate cancer (CaP). We investigated the association between modest-duration testosterone treatment and incident aggressive CaP. Materials and methods Retrospective inception cohort study of male Veterans aged 40 to 89 years with a laboratory-defined low testosterone measurement from 2002 to 2011 and recent prostate specific antigen (PSA) testing; excluding those with recent testosterone treatment, prostate or breast cancer, high PSA or prior prostate biopsy. Histologically-confirmed incident aggressive prostate cancer or any prostate cancer were the primary and secondary outcomes, respectively. Results Of the 147,593 men included, 58,617 were treated with testosterone. 313 aggressive CaPs were diagnosed, 190 among untreated men (incidence rate (IR) 0.57 per 1000 person years, 95% CI 0.49–0.65) and 123 among treated men (IR 0.58 per 1000 person years; 95% CI 0.48–0.69). After adjusting for age, race, hospitalization during year prior to cohort entry, geography, BMI, medical comorbidities, repeated testosterone and PSA testing, testosterone treatment was not associated with incident aggressive CaP (HR 0.89; 95% CI 0.70–1.13) or any CaP (HR 0.90; 95% CI 0.81–1.01). No association between cumulative testosterone dose or formulation and CaP was observed. Conclusions Among men with low testosterone levels and normal PSA, testosterone treatment was not associated with an increased risk of aggressive or any CaP. The clinical risks and benefits of testosterone treatment can only be fully addressed by large, longer-term randomized controlled trials.

Testosterone levels in men slowly decline with aging and also decline more abruptly due to medical illness or medications. Prescriptions for testosterone have increased dramatically over the past decade, since a testosterone-gel formulation was approved and since numerous studies reported an association between low serum testosterone and increased mortality. However, recent observational studies of testosterone treatment have reported conflicting results with some studies reporting decreased risks for mortality while others reported increased mortality risks with testosterone treatment. This paper will summarize recent studies of low serum testosterone and mortality and testosterone treatment and mortality and what the potential implications of these studies are for the clinician.

The purpose of this study is to review recent studies that examined the association of endogenous and exogenous testosterone and mortality in older men.Over the past several years, there has been a steep rise in testosterone prescriptions. The increased use of testosterone occurred in the context of several studies that reported an association between low serum testosterone and increased cardiovascular events and mortality. In contrast, recent studies have reported an association between testosterone treatment and adverse events. A testosterone treatment trial of mobility-impaired elderly men with prevalent cardiovascular disease was stopped due to increased cardiovascular events in the T-treated men and a meta-analysis reported increased cardiovascular events in T-treated men. In two recent large observational studies, testosterone treatment was associated with an increased risk for serious adverse cardiovascular events.Low testosterone is associated with mortality in multiple cohort studies; however, it is unclear if this is a causal association or due to low testosterone being a biomarker of poor health. Given recent reports of adverse outcomes associated with testosterone treatment, a conservative use of testosterone is warranted in men with cardiovascular disease who may be at greater risk for adverse outcomes.

SummaryObjective Ischaemic stroke is a major cause of morbidity and mortality in elderly men. Our main objective was to examine whether testosterone (T) or dihydrotestosterone (DHT) was associated with incident ischaemic stroke in elderly men. Design Cohort study. Participants Elderly men in the Cardiovascular Health Study who had no history of stroke, heart disease or prostate cancer as of 1994 and were followed until December 2010. Measurements Adjudicated ischaemic stroke. Results Among 1032 men (mean age 76, range 66–97), followed for a median of 10 years, 114 had an incident ischaemic stroke. Total T and free T were not significantly associated with stroke risk, while DHT had a nonlinear association with incident stroke (P = 0·006) in analyses adjusted for stroke risk factors. The lowest risk of stroke was at DHT levels of 50-75 ng/dl, with greater risk of stroke at DHT levels above 75 ng/dl or below 50 ng/dl. Results were unchanged when SHBG was added to the model. Calculated free DHT had an inverse linear association with incident ischaemic stroke with HR 0·77 (95% CI, 0·61, 0·98) per standard deviation in analyses adjusted for stroke risk factors. Conclusions Dihydrotestosterone had a nonlinear association with stroke risk in which there was an optimal DHT level associated with the lowest stroke risk. Further studies are needed to confirm these results and to clarify whether there is an optimal androgen range associated with the least risk of adverse outcomes in elderly men.

Although sex hormone-binding globulin (SHBG) and testosterone (T) have been inversely associated with risk of diabetes, few studies have examined dihydrotestosterone (DHT), a more potent androgen than T, in older adults, whose glycemic pathophysiology differs from younger adults.To determine the associations of SHBG, T, and DHT with insulin resistance and incident diabetes in older adult men.In a prospective cohort study, we evaluated baseline levels of SHBG, T, and DHT using liquid chromatography-tandem mass spectrometry among 852 men free of diabetes and cardiovascular disease in the Cardiovascular Health Study in 1994.Insulin resistance estimated by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and insulin sensitivity estimated by the Gutt index in 1996, and incident diabetes (n = 112) ascertained over a mean follow-up of 9.8 years.In linear regression models adjusted for demographics, alcohol consumption, current smoking, body mass index, and other androgens, SHBG [HOMA-IR 0.30 units lower per doubling; 95% confidence interval (CI), 0.08 to 0.52; P = 0.01] and total DHT (HOMA-IR 0.18 units lower per doubling; 95% CI, 0.06 to 0.30; P = 0.01), but not free T (P = 0.33), were inversely associated with insulin resistance. In corresponding Cox proportional hazards models, total DHT was again inversely associated with risk of diabetes (adjusted hazard ratio per doubling, 0.69; 95% CI, 0.52 to 0.92; P = 0.01), but SHBG (hazard ratio, 1.09; 95% CI, 0.74 to 1.59; P = 0.66) and free T (hazard ratio, 1.15; 95% CI, 0.92 to 1.43; P = 0.23) were not.Among older men, higher levels of DHT were inversely associated with insulin resistance and risk of diabetes over the ensuing 10 years, whereas levels of T were not. Future studies are still needed to clarify the role of SHBG in risk of diabetes in this population.

OBJECTIVE Prior studies found that chronic low testosterone levels are associated with an increased risk of depression. We investigated whether low testosterone levels in older men predict depressive illness over 2 years, while controlling for age and medical morbidity. METHOD Participants were 748 men, aged 50 years or older, without prior ICD-9-diagnosed depressive illness, with a testosterone level obtained between 1995 and 1997. Measures were age, mean total testosterone levels (low: < or = 2.5 ng/mL), medical morbidity, and incidence and time to depressive illness. RESULTS Men with low testosterone levels had a greater 2-year incidence of depressive illness (18.5% vs. 10.4%, df = 1, p = .006) and a shorter time to onset of depressive illness (log-rank chi(2) = 8.1, df = 1, p = .004). The unadjusted hazard ratio (HR) for depressive illness in men with low testosterone levels was 1.9 (95% confidence interval [CI] = 1.2 to 3.0, p = .005). After adjustment for age and medical morbidity, men with low testosterone levels continued to have a shorter time to depressive illness (adjusted HR = 2.1; 95% CI = 1.3 to 3.2, p = .002). Due to a significant interaction between age and medical morbidity, we conducted stratified Cox regression analyses and found that low testosterone levels and high medical morbidity or an age of 50 to 65 years were associated with increased depressive illness (p = .002). CONCLUSION Low testosterone levels are associated with an earlier onset and greater incidence of depressive illness. Men with low testosterone levels who had high medical morbidity or were aged 50 to 65 years had an increased risk for depressive illness. Further prospective studies are needed to examine the role of testosterone in depressive illness in older men.

Objectives: To evaluate whether low testosterone levels are associated with greater depression or poorer function in a geriatric rehabilitation unit. Design: Retrospective review. Setting: Geriatric rehabilitation unit. Measurements: Low testosterone levels were defined as total testosterone of 3.0 ng/mL or less or free testosterone of 9.0 pg/mL or less. Age, ethnicity, weight, depression, ambulation, length of rehabilitation, and 6-month rehospitalization and mortality rates were obtained. Overall illness severity was determined using the Cumulative Illness Rating Scale for Geriatrics. Results: Low testosterone levels were present in 29 of 44 (65.9%) men. There were no significant differences between men with low and normal testosterone levels in ethnicity, age, weight, depression, and overall illness severity. Lower testosterone levels were correlated with decreased ability to ambulate and transfer (Spearman P>.34; P

METHODS: We used a 20% sample of national Medicare claims to identify urologists and gynecologists who performed SNM procedures from 2005 to 2010. We then determined physician-level rates of device testing [number of tests/number of patients with diagnoses of overactive bladder (OAB) or non-obstructive urinary retention] and of device implantation (number of implants/number of tests). We then fit a Poisson model to examine factors associated with device testing. RESULTS: The number of physicians performing SNM test procedures tripled from 2005 to 2010. During the same time period, average rates of SNM testing per physician increased from 2.8 tests to 4.9 tests (p

Low testosterone (T) is associated with prevalent cardiovascular disease (CVD) and mortality. DHT, a more potent androgen, may also be associated with CVD and mortality, but few studies have examined this.The study objective was to examine whether T and DHT are risk factors for incident CVD and mortality.In a longitudinal cohort study, we evaluated whether total T, calculated free T (cFT), DHT, and calculated free DHT were associated with incident CVD and mortality in men in the Cardiovascular Health Study (mean age 76, range 66-97 years) who were free of CVD at the time of blood collection.The main outcomes were incident CVD and all-cause mortality.Among 1032 men followed for a median of 9 years, 436 incident CVD events and 777 deaths occurred. In models adjusted for cardiovascular risk factors, total T and cFT were not associated with incident CVD or all-cause mortality, whereas DHT and calculated free DHT had curvilinear associations with incident CVD (P.002 and P = .04, respectively) and all-cause mortality (P.001 for both).In a cohort of elderly men, DHT and calculated free DHT were associated with incident CVD and all-cause mortality. Further studies are needed to confirm these results and to clarify the underlying physiologic mechanisms.

Depression in the patient who has recently suffered a myocardial infarction is common, with an estimated prevalence of 20%. However, despite this high prevalence, depression in the post-myocardia infarction patient is poorly diagnosed and treated. In addition, depression in these patients has been associated with increased cardiac morbidity and mortality as well as increased disability and health care cost. The pathophysiology relating these two conditions remains unclear but may be related to autonomic dysfunction and enhanced risk of arrhythmias. Few well-designed trials have evaluated treatment options for these patients, although several large trials are underway. Of the antidepressant medications available, they all have potential interactions with the cardiac system. However, the serotonin selective reuptake inhibitors seem to be emerging as the best first line treatment option for these patients.

Low testosterone levels in men have been associated with increased mortality. However, the influence of testosterone treatment on mortality in men with low testosterone levels is not known.The objective of the study was to examine the association between testosterone treatment and mortality in men with low testosterone levels.This was an observational study of mortality in testosterone-treated compared with untreated men, assessed with time-varying, adjusted Cox proportional hazards regression models. Effect modification by age, diabetes, and coronary heart disease was tested a priori.The study was conducted with a clinical database that included seven Northwest Veterans Affairs medical centers.Patients included a cohort of 1031 male veterans, aged older than 40 yr, with low total testosterone [≤250 ng/dl (8.7 nmol/liter)] and no history of prostate cancer, assessed between January 2001 and December 2002 and followed up through the end of 2005.Total mortality in testosterone-treated compared with untreated men was measured.Testosterone treatment was initiated in 398 men (39%) during routine clinical care. The mortality in testosterone-treated men was 10.3% compared with 20.7% in untreated men (P0.0001) with a mortality rate of 3.4 deaths per 100 person-years for testosterone-treated men and 5.7 deaths per 100 person-years in men not treated with testosterone. After multivariable adjustment including age, body mass index, testosterone level, medical morbidity, diabetes, and coronary heart disease, testosterone treatment was associated with decreased risk of death (hazard ratio 0.61; 95% confidence interval 0.42-0.88; P = 0.008). No significant effect modification was found by age, diabetes, or coronary heart disease.In an observational cohort of men with low testosterone levels, testosterone treatment was associated with decreased mortality compared with no testosterone treatment. These results should be interpreted cautiously because residual confounding may still be a source of bias. Large, randomized clinical trials are needed to better characterize the health effects of testosterone treatment in older men with low testosterone levels.

In situ hybridization for the norepinephrine transporter (NET) was performed in rats receiving short-term (2 days) treatment with either an alpha-2 (alpha 2) receptor agonist (clonidine) or antagonist (yohimbine) followed by saline or desipramine (DMI). The 'saline' group received intraperitoneal injections of either clonidine, yohimbine or saline followed by an injection of saline. The 'DMI' group received intraperitoneal injections of either clonidine, yohimbine or saline followed by an injection of DMI. Dosages given were clonidine (0.10 mg/kg), yohimbine (0.5 mg/kg) and DMI (10 mg/kg). In the 'saline' group, the clonidine/saline animals had significantly less NET mRNA expression compared to the saline/saline animals. In the 'DMI' group an attentuation of the DMI-induced increase in NET mRNA was observed in the clonidine/DMI animals compared to the saline/DMI animals. In both treatment groups, administration of yohimbine did not alter the expression of NET mRNA compared to the appropriate control animals. These findings suggest that the DMI-induced increase in NET mRNA is not mediated via alpha 2 receptors for, although clonidine attenuates DMI's effect, there is no reciprocal enhancement with the alpha 2 antagonist yohimbine. Clonidine's attenuation of DMI's effect may occur via the imidazole receptor as clonidine is an agonist at the imidazole receptor but yohimbine has no known activity at it. Additional studies are needed to clarify the mechanism of the DMI-induced increase in NET mRNA and to correlate changes in NET mRNA with transporter expression at the synaptic membrane.

This study examined the prevalence, comorbidity, and clinical correlates of personality disorders in an outpatient sample (N = 352) with anxiety and depression. Subjects were diagnosed using the Structured Clinical Interview for DSM-III-R (SCID) on Axes I and II, and they also completed interview and self-report measures of symptoms. Subjects with a personality disorder were less likely to be married, more likely to be single or divorced, had lower family incomes, had more severe symptoms of both anxiety and depression, and had a greater number of lifetime Axis I diagnoses. Subjects with dysthymic and bipolar disorders were more likely, and subjects with panic disorder uncomplicated by agoraphobia were less likely to have a personality disorder compared to the rest of the sample. The most prevalent personality disorders were Avoidant, Obsessive-Compulsive, Paranoid, and Borderline. Paranoid co-occurred with Narcissistic, and Borderline co-occurred with Histrionic personality disorder significantly more often than chance and base rates would predict.

Patients with chronic obstructive pulmonary disease (COPD) and comorbid mental disorders are known to have worse health status. The association between these variables remains complex and poorly understood. We sought to better understand the association between COPD severity, mental disorders (depression/anxiety), and health status.This cross-sectional study compared participants without COPD or with mild COPD (n = 162) to those with moderate (n = 25), severe (n = 38), and very severe (n = 26) COPD. We recruited participants from a primary care and a pulmonary clinic at a veterans affairs medical center between July 2001 until September 2002. We used the Patient Health Questionnaire to screen for depression and anxiety and the Posttraumatic Stress Disorder Checklist to screen for posttraumatic stress disorder. Health status was assessed with the veteran's version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Shortness of Breath Questionnaire (SOBQ).COPD severity was associated with worse physical status and dyspnea as measured by the SF-36 physical component summary and the SOBQ but was not associated with worse mental status as measured by the SF-36 mental component summary. At each level of COPD severity, participants with mental disorders had worse health status and dyspnea as measured by the SF-36 physical component summary, mental component summary, and SOBQ. Significant linear trends with COPD severity were associated with increased prevalence of any depressive disorder, major depressive disorder, and nonpanic/non-PTSD anxiety disorders (all tests for linear trend, P.01).Independent of COPD severity, comorbid mental disorders were associated with worse health status and dyspnea. Studies are needed to determine whether patients with comorbid mental disorders may have more significant improvement in physical symptoms and functioning if providers focus more on psychiatric conditions.

725 Objective: This study compared the quality of end-of-life care between veterans with and without schizophrenia who died of cancer in the northwestern United States. Methods: In this cross-sectional study, medical records of 60 veterans with schizophrenia and 196 with no major mental illness who died of cancer were compared on hospice enrollment, palliative and life-sustaining interventions, advance directives, and site of death. Results: Among veterans with schizophrenia, 58% had an advance directive, 73% received an opiate before hospice enrollment, 63% had a physician order to forgo cardiopulmonary resuscitation, 55% were hospice enrolled, and 27% died in the hospital. Schizophrenia patients had longer hospice stays (107±144 versus 63±96 days, p=.05) and more physician orders for life-sustaining treatment (15% versus 5%, p=.006) compared with veterans without mental illness. Conclusions: On most measures, veterans with schizophrenia who died of cancer received comparable or better endof-life care than veterans without mental illness. (Psychiatric Services 61:725–728, 2010) T he goals of palliative care are relief of suffering and improvement in quality of life for patients facing life-threatening illness. Such improvements are made through prevention, assessment, and treatment of pain and other symptoms and the provision of psychological, emotional, and spiritual support (1). Palliative care is patient and family centered and emphasizes patient autonomy and advance planning for care. By 2003, 25% of U.S. hospitals sponsored a palliative care program (2). Patients become eligible for palliative care delivered by a hospice organization at the point they are expected to have less than six months of remaining life. The primary goals of hospice care are comfort and preservation of quality of life; cure of the terminal illness is no longer being pursued. Hospice care is delivered by an interdisciplinary cadre of physicians, nurses, social workers, and chaplains. Most often care is in patients’ homes, but it also occurs in long-term care settings and, rarely, in inpatient hospice units. Although originally developed as an approach for patients with advanced cancer, currently over half of hospice enrollees in the United States have noncancer diagnoses. In 2007, 39% of all decedents in the United States were hospice enrolled before death (3). Hospice and palliative care are intu

This study examined the relationship between the chronic disorders, generalized anxiety disorder (GAD) and dysthymic disorder (DD), and the more acute disorders, panic disorder (PD) and major depressive disorders, panic disorder (PD) and major depressive disorder (MDD) in 110 psychiatric outpatients with diagnoses of either PD, MDD, GAD, or DD. Pure, mixed, and early-/late-onset forms of the chronic disorders were compared with each other and then with PD and MDD on clinical measures and psychiatric history. Minimal differences were found between pure GAD and mixed GAD or between pure DD and mixed DD. The chronic disorders, DD and GAD, had distinct clinical symptom profiles when compared with each other and appeared more closely related to their parent disorders than to each other. However, despite these similarities, there were significant differences between DD and MDD in contrast to the minimal differences between GAD and PD, providing less support for GAD as a valid diagnostic category separate from PD. Comparisons of early-/late-onset DD and GAD showed more severe symptoms in late-onset DD, in contrast to more severe symptoms in early-onset GAD. These varying patterns of symptom severity may warrant study for further syndromal delineation.

The incidence and prevalence of epilepsy increases with age, with the majority of cases having a known cause, and approximately half of elderly patients with epilepsy experiencing complex partial seizures that often present initially as neuropsychiatric symptoms. This presentation often delays diagnosis of the epileptiform disorder. To illustrate, we present the case of a 75-year-old man who was initially misdiagnosed with bipolar affective disorder later to be revealed as a frontal lobe seizure disorder.

Background Dementia is a common but frequently undiagnosed problem in aging. Barriers to early diagnosis include a lack of routine screening for dementia and a lack of access to specialty consultative services. We conducted a pilot study to see if telemedicine could provide reliable, accurate geriatric consultative services to evaluate patients for dementia who were residing at remote sites. Methods This was a prospective cohort study that compared the diagnostic reliability of telemedicine to an in-person examination for dementia. Eligible subjects were residents of a Washington State Veterans' Home, age 60 years or older, with no prior diagnosis of dementia. Eligible subjects were screened for dementia using the 7-Minute Screen. Veterans who screened positive and consented to participate in the study received an in-person neuropsychiatric evaluation at baseline, and then both telemedicine and in-person examinations for dementia conducted by experienced geriatric psychiatrists. The accuracy of the telemedicine diagnosis was estimated by comparing it to the diagnosis from the clinical examination. Three geriatric psychiatrists who were blinded to the results of the clinical examination conducted the telemedicine and in-person examinations. We also assessed attitudes of the subjects and geriatric psychiatrists towards the telemedicine sessions. Results Eighteen of 85 subjects screened were ‘positive’ for dementia on the 7 Minute Screen. Of these, 16 consented to participate in the telemedicine study. Twelve of the 16 subjects were subsequently diagnosed with dementia by the telemedicine examination. The telemedicine diagnoses were in 100% agreement with the diagnoses from the in-person clinical examinations. Moreover, the subjects reported a high degree of satisfaction with the telemedicine experience and that they would like to have further care through telemedicine in the future. The geriatric psychiatrists reported technical difficulties with the audio-visual quality of telemedicine in the initial phases of the project that resolved as familiarity with the telemedicine equipment increased. None of these problems had an adverse impact on the diagnostic accuracy of telemedicine. Conclusions We found that telemedicine was as accurate as an in-person clinical examination in establishing the diagnosis of dementia. In addition, subjects reported a high degree of satisfaction with telemedicine and a willingness to participate in telemedicine clinical care in the future. Given the large increase in the aging population and the shortage of geriatric psychiatrists nationally, it appears that telemedicine may be a promising means to expand the availability of geriatric psychiatric consultation to remote areas. Published 2004 John Wiley & Sons, Ltd.

Context Age-associated hypogonadism (testosterone deficit) occurs in 30% of men after the age of 55; it is associated with decreased muscle mass, bone mineral density, and libido, and with anorexia, fatigue, and irritability. Although some of these symptoms overlap with those of depression, the association between the 2 disorders is unclear. Objective To determine if hypogonadal men have an increased incidence of depressive illness compared with eugonadal men. Design Historical cohort study using computerized medical records, followed by a manual medical record review. Setting Veterans Affairs Puget Sound Health Care System. Participants Two hundred seventy-eight men 45 years and older, without prior diagnosed depressive illness and with consistently normal or low testosterone levels (total testosterone level ≤200 ng/dL [≤6.94 nmol/L]; or free testosterone level ≤0.9 ng/dL [≤0.03 nmol/L]) at baseline and during a 2-year follow-up period. Main Outcome Measures Incidence of, and time to, a depression diagnosis. Results The 2-year incidence of diagnosed depressive illness was 21.7% in hypogonadal men vs 7.1% in others (χ 2 1 = 6.0, P = .01). A Kaplan-Meier survival analysis showed a significant difference between hypogonadal and eugonadal men in time to diagnosed depression (log-rank test χ 2 1 = 6.9, P = .008). We used Cox proportional hazards regression models to examine the association of hypogonadism and time to depression diagnosis, adjusting for age, race, number of clinic visits, alcohol use disorders, prostate cancer, and overall medical comorbidity. The unadjusted hazard ratio for depression with hypogonadism was 3.5 (95% confidence interval, 1.3-9.4) ( P = .01). Controlling for all covariates, hypogonadism remained significantly associated with depression (adjusted hazard ratio, 4.2; 95% confidence interval, 1.5-12.0) ( P = .008). Conclusions Hypogonadal men showed an increased incidence of depressive illness and a shorter time to diagnosis of depression. Further prospective studies are needed to confirm these preliminary findings and to clarify the role of testosterone in the treatment of depressive illness in older men.

Increased sympathetic nervous system (SNS) activity has been associated with stress, major depression, aging, and several medical conditions. This study assessed the effect of the selective serotonin reuptake inhibitor (SSRI), sertraline, on sympathetic nervous system (SNS) activity in healthy subjects. Twelve healthy volunteers participated in a double-blind, placebo-controlled, norepinephrine (NE) kinetic study, in which the effects of sertraline on SNS activity were ascertained by determining NE plasma concentrations and NE plasma appearance rates and clearance rates in sertraline or placebo conditions. Subjects received 50 mg of sertraline or placebo for two days and then one week later underwent the same protocol with the other drug. By single compartmental analysis, plasma NE appearance rates were significantly lower in the sertraline compared to the placebo condition (0.26+/-0.10 vs 0.40+/-0.23 microg/m(2)/min; P=0.04). Our study found that the net effect of short-term SSRI treatment is an apparent suppression of SNS activity as indicated by a decreased plasma NE appearance rate in the sertraline condition. If this preliminary finding can be extended to long-term treatment of patients, this could have significant therapeutic relevance for treating depression in elderly patients or those with cardiac disease, in which elevated SNS activity may exacerbate underlying medical conditions.

In normal aging, cell loss occurs in the locus coeruleus (LC), the major noradrenergic nucleus in the brain. This study examined changes in the LC of aged rats by measuring mRNA expression for tyrosine hydroxylase (TH) and the norepinephrine uptake transporter (NET). TH and NET mRNA expression were measured by in situ hybridization in young, middle-aged and aged rats. It appears that in middle age, the transporter system responds initially to LC cell loss by decreasing NET mRNA expression. Then, with further aging and cell loss, TH mRNA expression increases which may potentially increase NE synthesis in the remaining neurons. These findings suggest that multiple regulatory components are used to maintain stable noradrenergic synaptic levels despite neuronal loss. Published by Elsevier Science B.V.

Low serum testosterone is a common condition in aging associated with decreased muscle mass and insulin resistance. This study evaluated whether low testosterone levels are a risk factor for mortality in male veterans.We used a clinical database to identify men older than 40 years with repeated testosterone levels obtained from October 1, 1994, to December 31, 1999, and without diagnosed prostate cancer. A low testosterone level was a total testosterone level of less than 250 ng/dL (8.7 nmol/L) or a free testosterone level of less than 0.75 ng/dL (0.03 nmol/L). Men were classified as having a low testosterone level (166 [19.3%]), an equivocal testosterone level (equal number of low and normal levels) (240 [28.0%]), or a normal testosterone level (452 [52.7%]). The risk for all-cause mortality was estimated using Cox proportional hazards regression models, adjusting for demographic and clinical covariates over a follow-up of up to 8 years.Mortality in men with normal testosterone levels was 20.1% (95% confidence interval [CI], 16.2%-24.1%) vs 24.6% (95% CI, 19.2%-30.0%) in men with equivocal testosterone levels and 34.9% (95% CI, 28.5%-41.4%) in men with low testosterone levels. After adjusting for age, medical morbidity, and other clinical covariates, low testosterone levels continued to be associated with increased mortality (hazard ratio, 1.88; 95% CI, 1.34-2.63; P.001) while equivocal testosterone levels were not significantly different from normal testosterone levels (hazard ratio, 1.38; 95% CI, 0.99%-1.92%; P=.06). In a sensitivity analysis, men who died within the first year (50 [5.8%]) were excluded to minimize the effect of acute illness, and low testosterone levels continued to be associated with elevated mortality.Low testosterone levels were associated with increased mortality in male veterans. Further prospective studies are needed to examine the association between low testosterone levels and mortality.