Long-term antidepressant therapy best treatment for depression in old age

Antidepressant treatment is the most effective way to prevent recurrence of depression in people over the age of 70, according to results of University of Pittsburgh School of Medicine research published in the current issue of the New England Journal of Medicine. Left untreated, 50 to 80 percent of people in this age group will experience another episode of depression. Yet, researchers found that participants who took the serotonin-reuptake inhibitor (SSRI) paroxetine for two years after an initial depressive episode were much less likely to experience a relapse than those who received a placebo.

"Prior to this study there was no standard of treatment for the elderly with first episodes of depression in old age; however, many considered six to 12 months of antidepressant therapy to be appropriate. We found that this course of therapy to be entirely too short. Patients who discontinued therapy after six to 12 months were much more likely to experience another episode of depression than those who continued to take antidepressants for two years," said Charles F. Reynolds III, M.D., UPMC Professor of Geriatric Psychiatry, University of Pittsburgh School of Medicine, and principal investigator of the study. "By continuing antidepressant therapy for two years, we were able to reduce by 60 percent the chance that another depressive episode would occur."

This study represents the first long-term controlled trial of maintenance pharmacotherapy and psychotherapy in people over 70. It involved 116 participants age 70 and older who had experienced a first episode of major depression that responded to treatment consisting of both paroxetine and psychotherapy. To determine the best approach for preventing recurrence of depression, the researchers randomized the participants into four treatment groups in which they received either paroxetine or placebo combined with either monthly interpersonal psychotherapy (IPT) or clinical-management sessions. IPT is an effective form of therapy that focuses on relationships and events, such as bereavement or retirement, which may trigger depressive episodes. In clinical management sessions, participants only discuss their symptoms and no therapy is involved.

Major depression returned within two years in 35 percent of the participants treated with paroxetine and psychotherapy, 37 percent of those treated with paroxetine and clinical management therapy, 58 percent of those treated with placebo and clinical management therapy and 68 percent of those treated with placebo and psychotherapy.

Participants receiving placebo had a 2.4-times higher risk of recurrence than those receiving paroxetine. The results also indicated that interpersonal psychotherapy was not effective in preventing new episodes of depression in this age group.

Prior studies by Dr. Reynolds and colleagues have shown that psychotherapy is effective for treating people age 60 and older who had previously experienced depression. Of the current study, Dr. Reynolds and his co-authors believe that psychotherapy was not effective in the 70-and-older group in a larger part due to higher levels of cognitive decline that takes place in this age population. Future studies aim to determine if standard interpersonal psychotherapy can be altered to better suit the needs of the elderly.

"Depression takes a huge toll on society as a whole. It represents one of the leading causes of disability and has been linked to a number of other diseases including heart disease and diabetes. By preventing depression in the elderly, we can improve the quality of life significantly in this population," said David J. Kupfer, M.D., professor and chair, department of psychiatry, University of Pittsburgh School of Medicine, and co-author of the study. "This study provides evidence that SSRI treatment given for two years can improve the lives of the elderly with major depression and should be the gold standard of treatment for this population. As such, health care providers, PCPs and insurers should make this treatment accessible and affordable to all those who need it."

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The study was funded by the National Institute of Mental Health. GlaxoSmithKline provided study medication, but had no role in study design, data accrual or data analysis.

Also contributing to this study were Mary Amanda Dew, Ph.D.; Bruce G. Pollock, M.D., Ph.D.; Ellen Frank, Ph.D.; Mark D. Miller, M.D.; Patricia R. Houck, M.S.H.; Meryl A. Butters, Ph.D.; Jacqueline A. Stack, M.S.N.; Mary Ann Schlernitzauer, M.S.N.; Ellen M. Whyte, M.D.; Ariel Gildengers, M.D.; Jordan Karp, M.D.; Eric Lenze, M.D.; Katalin Szanto, M.D.; Salem Bensasi, B.S., all from the Advanced Center for Intervention and Services Research for Late-Life Mood Disorders, University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic; Benoit H. Mulsant, M.D., of the Geriatric Research Education and Clinical Center, Pittsburgh Veterans Affairs Health Care System; and Sati Mazumdar, Ph.D., of the department of biostatistics, University of Pittsburgh Graduate School of Public Health.

For more information on depression in the elderly, or to enroll in a study, please contact the Late-Life Depression Evaluation and Treatment Center at the University of Pittsburgh at (412) 246-6006 or visit their Web site at www.latelifedepression.org.

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Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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