Part II | Vascular risk factors for depression and apathy 151 8 disease should not overshadow other factors, such as high neuroticism, that may just as well or even more so underlie or maintain late-life depression. Research models for late-life depression may guide clinicians but they are no substitute for a thorough clinical assessment and analysis of all the risk-factors, sustaining and protective factors involved in the onset, treatment or (relapse) prevention of depression for each individual patient. Another important consideration for the physician treating older patients for apathy and depression, is that apathy in remitted depression was not significantly associated with CSVD (Chapter 5). This finding once more underscores the similarities between apathy and motivational symptoms of depression, prompting the question whether in remitted depression apathy might be a residual symptom. The etiology of apathy in depression and its treatment is not well understood. Should we recommend antidepressant treatment, further psychotherapy or structured daily activities, or all three? To date, research has not provided much support for one strategy or the other, but since the consequences of apathy can be wide-ranging, we would advise against therapeutic nihilism. In the general population and in populations with neurodegenerative diseases a causal association between CSVD and apathy was established in chapter 5 and 6. This information might help clinicians, their patients, and the caregivers of their patients, to understand and accept the presence of apathy in CSVD. However, once again, we would not recommend tunnel vision since apathy can have many causes, and in particularly often coincides with depression and cognitive impairment in elderly populations. Therefore, also in CSVD we would recommend the clinician to perform a broad analysis of all the other risk-factors and protective factors for each individual who suffers from apathy. Finally, we would like to remind clinicians seeing patients with late-life depression and apathy of the many gaps in our current knowledge, most particularly the lack of dedicated treatments for CSVD- or depression-related apathy, and urge them to join researchers in their quest by informing patients and their spouses or caregivers of research programs they might be willing to participate in. Considerations for the training of the next generation of psychiatrists: For those who train the next generation of psychiatrists our findings underscore the importance of epidemiology in the psychiatrist’s practice, where psychiatrists should be enabled to estimate the probability and relevance of age-specific risks of late-life depression and for apathy in a diversity of populations. They should learn about CSVD and how CSVD can alter motivational functioning, to thus help them interpret the symptoms they observe in their patients better, but equally or even more importantly, they should be trained in communicating this information to their patients and their partners, family or caregivers. They need to be informed about the limitations of the current disease models for late-life depression and apathy, and about the fact that more often than not multiple risk-factors
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