A number of studies(2 ,27,28 and 29> have shown that elderly depressed patients have a two- to threefold increase in expected mortality over periods of between 1 and 4

years, with an excess of deaths due to cardiovascular causes. This is not simply due to depressed people experiencing greater overall physical ill-health. (29)

O'Brien and Ames(39 have proposed several possible mechanisms for the increased mortality in depression: comorbid physical illness; occult illness (e.g. a carcinoma); illness effects (e.g. related to pneumonia secondary to psychomotor retardation); treatment effects; biological effects, such as abnormality of the hypothalamic-pituitary- adrenal axis or endocrine abnormalities which may affect the immune system. Undertreatment is another plausible explanation. (31 In most studies, suicide comprised a very small percentage of deaths(2 ,2Z) and so is not the main cause of additional mortality.

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