Long-Term Treatment Of Depression in the Elderly
Long-Term Treatment Of Depression in the Elderly
ABSTRACT & COMMENTARY
Source: Flint AJ, Rifat SL. Maintenance treatment for recurrent depression in late life: A four-year outcome study. Am J Geriatr Psychiatry 2000;8(2):112-116.
Individuals with a previous history of major depression are at increased risk of experiencing further episodes of depression. Studies conducted in young or middle-aged adults have shown that maintenance antidepressant medication and maintenance psychotherapy are superior to placebo in preventing subsequent episodes of depression. However, there is a paucity of data examining the effect of maintenance treatment in depressed elderly patients. Reynolds et al conducted the only study examining the effect of maintenance treatment on outcome in elderly patients who had a previous history of depression.1 He found recurrence rates over a three-year period were lowest for patients who received combined nortriptyline and monthly interpersonal therapy (20%) and highest for patients who received placebo and medication-clinic visits (90%).
The current study by Flint and Rifat presents the results of an open study that examined the four-year out- come of elderly patients who were given maintenance treatment for recurrent major depression. Individuals age 60 years and older who presented with an episode of nonpsychotic unipolar depression as determined by the Structured Clinical Interview for the DSM-III-R were included. All subjects had at least one previous episode of depression. Subjects were excluded if they had a concurrent Axis I diagnosis, any known neurological disorder affecting the central nervous system, acute uncontrolled medical illnesses, a diagnosis of dementia or any condition that contraindicated the use of the study medications. The following measures were used to rate the subjects conditions: 17-item Hamilton Depression Scale, the Anxiety subscale of the Hospital Anxiety and Depression scale, the Life Events and Difficulties Schedule modified for elderly subjects, and the Burvill et al’s physical illness rating scale.
All index episodes of depression had responded (response was defined as a Ham-D of £ 10) to either nor- triptyline monotherapy (n = 26) or nortriptyline and adjunctive lithium (n = 3) as first-line treatment, phenelzine monotherapy (n = 7) or phenelzine and adjunctive lithium (n = 1) as second-line treatment, or electroconvulsive therapy (ECT) as a third-line treatment (n = 1). All patients remained free of relapse for 16 con-secutive weeks from the time of response. Patients were maintained on full-dose regimens of medications to which they had responded. The ECT-responder was given 20 mg/day of fluoxetine as a maintenance therapy Patients were followed monthly for two years and every three months thereafter, for a total of four years from the time of response or until recurrence, whichever occurred first. Follow-up visits consisted of assessment of mental state and monitoring medication side effects and the patient’s compliance with treatment. Patients also received psychosocial support and education about their illness.
Thirty-eight subjects were included in the study (mean age 72.9 years, 68% women). The mean number of depressive episodes was 1.7 ± 1.0, and the mean time between index episode and the most recent previous episode was 11.8 ± 11.6 years. Ten patients (26%) did not complete the study for various reasons (none dropped out of the study because of adverse effects of medications) Ten patients (26%) had a recurrence during the study period. A recurrent episode occurred in 21% of the patients (6 patients) taking nortriptyline and in 40% of the patients (4 patients) taking phenelzine. Three of the four patients taking adjunctive lithium remained well. Forty percent of the recurrence episodes occurred within the first year of follow-up, and 80% within the first two years. Flint et al also found that higher anxiety scores at time of response and longer time to respond to treatment were significantly associated with shorter time to recur- rence.
COMMENT BY Claudia A. Orengo, MD, PhD
Flint et al have presented an open-study showing that full-dose antidepressant medication and regular support- ive care were associated with a favorable four-year out- come in a group of elderly patients with recurrent unipo- lar depression. The probability of remaining well without recurrence of major depression was 70%. An interest- ing finding was that residual anxiety was a significant predictor of recurrence in these patients. Few studies have examined the effect of residual anxiety on recurrence of illness. This is useful to know because more effective treatment of residual anxiety symptoms could improve the outcome of this group of patients. Also of importance is that patients not only received maintenance medication but also psychosocial support monthly for the first two years and every three months thereafter. The benefit of psychosocial support should not be ignored.
The study is limited by various factors. The study has a small sample size, is open and not controlled. Furthermore, the patients in the study had few previous episodes of depression (1.7 ± 1.0) and a long period of remission between index and most recent previous episodes of depression (11.8 ± 11.6). These factors may have improved the outcome of this study. The patients remaining well for the four years of the study may have coincided with the natural course of their illness and not the fact they were on maintenance therapy. Important to note, as well, is the population was relatively healthy with a low level of medical burden and with no neurological disorders including dementia. Often times the most difficult patients to treat and maintain symptom free are those with multiple medical problems or with a concurrent diagnosis of dementia. The generalizability of this study is limited.
Overall, this study provides useful information regarding the four-year outcome of relatively healthy elderly patients who were given maintenance antidepressant medication and psychosocial support for recurrent major depression. Clinically, when treating elderly patients with major depression we should consider: 1) the usefulness of full-dose maintenance therapy (70% cumulative prob- ability of remaining well); 2) the importance of regular of psychosocial support; and 3) the importance of evaluat- ing and treating residual anxiety symptoms.
Reference
1. Reynolds CF, et al. JAMA 1999;281:39-45.
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