Major Depressive Disorder in Older Adults: Benefits and Hazards of Prolonged Treatment
ABSTRACT Antidepressants have been shown to reduce the risk of depression recurrence in adults, justifying prolonged antidepressant maintenance therapy for most if not all patients. However, older depressed adults may be at increased risk for antidepressant adverse effects. This article discusses the benefits and hazards of continued treatment in elderly depressed patients, and indicates which patients should and should not receive maintenance phase antidepressants. Most clinical trials conducted so far suggest that prolonged antidepressant use in older adults is efficacious to reduce recurrence rates. The benefits of prolonged antidepressant use may not be restricted to preventing recurrence but also include preservation of overall well-being, social functioning, reduced mortality risk from medical disorders, and reduced risk of dementia. Although generally safe, the prolonged use of antidepressants has been associated with higher risk of osteopenia/osteoporosis (in particular the selective serotonin reuptake inhibitors) and cardiovascular toxicity (tricyclic antidepressants). Fewer data are available for special populations, like those with multiple medical comorbidities or those with dementia; thus, the benefits of prolonged antidepressant use are not clear in these individuals.
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ABSTRACT: Although studies indicate that community-dwelling elderly have a lower prevalence of major depression compared with younger age groups, prevalence estimates in Brazil show that clinically significant depressive symptoms (CSDS) and depression are frequent in the older population. However, a systematic review and meta-analysis of prevalence of and factors associated with depressive disorders and symptoms in elderly Brazilians has not previously been reported. The aims were (i) to perform a survey of studies dating from 1991 to 2009 on the prevalence of depressive disorders and CSDS in elderly Brazilians residing in the community; (ii) to determine depression prevalence and identify associated factors; and (iii) develop a meta-analysis to indicate the combined prevalence and the influence of gender on depressive morbidity in this population. Studies were selected from articles dated between January 1991 and May 2009, extracted from Medline, LILACS and SciELO databases. A total of 17 studies were found, 13 with CSDS, 1 with major depression alone and 3 with major depression and dysthymia, involving the evaluation of 15,491 elderly people. The average age of participants varied between 66.5 and 84.0 years. Prevalence rates of 7.0% for major depression, 26.0% for CSDS, and 3.3% for dysthymia were found. The odds ratios for major depression and CSDS were greater among women. There was a significant association between major depression or CSDS and cardiovascular diseases. The review indicates greater prevalence of both major depression and CSDS compared to rates reported in the international literature, while the prevalence of dysthymia was found to be similar. The high prevalence of CSDS and its significant association with cardiovascular diseases reinforces the importance of evaluating subthreshold depressive symptoms in the elderly in the community.International Psychogeriatrics 08/2010; 22(5):712-26. DOI:10.1017/S1041610210000463 · 1.89 Impact Factor
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ABSTRACT: Effective antidepressants, including imipramine and monoamine oxidase (MAO) inhibitors, were discovered serendipitously in the 1950s. Many additional agents have been introduced since then, but most are chemically or pharmacologically similar to those known for nearly four decades. Some recently introduced antidepressants offer either lesser or dissimilar side effects, but none exceeds older treatments in efficacy. Selective serotoninpotentiating agents and short-acting MAO-A inhibitors promise efficacy with greater safety. Progress is made difficult because atypical or treatment-resistant patients are more often available for study than typical patients, and because most studies must rely heavily on potentially misleading "standard drug versus new drug" comparisons. Rational development of novel or better agents is slow, in part, due to limited understanding of the biological basis of major affective disorders and some circularity in relating actions of known drugs to pathophysiologic hypotheses. Action mechanisms of antidepressants are subtle and complex: adaptive changes occur in brain monoaminergic neurotransmission following repeated administration of agents of the tricyclic antidepressant (TCA) type that may lead to net facilitation of alpha 1-adrenergic transmission. Important advances have been made in using plasma TCA levels to guide individualization of dosing, in exploring higher doses of antidepressants when ordinary doses prove ineffective, and in recognizing a broadening spectrum of possible indications for antidepressants in adults and children. These indications include panic disorder, obsessive compulsive disorder, attention deficit disorder, and bulimia. Evidence for the prophylactic effects of antidepressants after the first months following recovery from an index episode of major depression is weak, and the treatment of common recurrent or chronic depression remains unsatisfactory. Gains have been made in increasing clinicians' and the general public's awareness of the common occurrence and appropriate treatment of major depression, even when the depression is associated with other medical or psychiatric disorders.The Journal of Clinical Psychiatry 05/1989; 50(4):117-26. · 5.14 Impact Factor
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ABSTRACT: Elderly depressed patients are vulnerable to recurrence of depression and benefit from long-term antidepressant therapy. Physicians increasingly use selective serotonin re-uptake inhibitors (SSRIs) as maintenance therapy, although in the absence of data showing that SSRIs are as efficacious as tricyclic antidepressants (TCAs) in the prevention of depression relapse and recurrence. Our objective was to evaluate, in an open trial, the efficacy of paroxetine versus nortriptyline for preventing recurrence of depression in the elderly. Elderly patients with major depression were randomly assigned in a double-blinded fashion to receive either paroxetine or nortriptyline for the acute treatment of depression. Patients who did not respond or tolerate their assigned medications were crossed over openly to the comparator agent. Patients whose depression remitted continued antidepressant medication (paroxetine n = 38; nortriptyline n = 21) during an open 18-month follow-up study. We examined the rates of and times to relapse and to termination of treatment for any reason. Paroxetine (PX) and nortriptyline (NT) patients had similar rates of relapse (16% vs. 10%, respectively) and time to relapse (60.3 weeks vs. 58.8 weeks, respectively) over 18 months. A lower burden of residual depressive symptoms and side effects during continuation and maintenance treatment was evident in nortriptyline-treated patients. Paroxetine and nortriptyline demonstrated similar efficacy in relapse and recurrence prevention in elderly depressed patients over an 18-month period.Depression and Anxiety 02/2001; 13(1):38-44. DOI:10.1002/1520-6394(2001)13:13.0.CO;2-7 · 4.29 Impact Factor