The objective of this study was to describe the correlates of prior antidepressant exposure and its association with response to protocolized treatment in older patients with major depression.
Based on their prior antidepressant treatment exposure, 193 elderly patients with a major depressive episode were divided into three groups: those with no prior treatment for their current episode (not treated [TN]), those with antidepressant trials of inadequate dose or duration ("treatment-inadequate" [TI]), and those with at least one adequate trial but persisting depression ("treatment-resistant" [TR]). All patients then received protocolized treatment with interpersonal psychotherapy (IPT) and paroxetine plus pharmacologic augmentation if needed. The demographic, clinical, and outcome information were compared among these three groups.
Approximately one-third of the patients referred to the study had been adequately treated (TR), one-third had been inadequately treated (TI), and one-third were not treated for the current episode (TN). Treatment completion rates and reasons for dropping out did not differ statistically among TR, TI, and TN patients. TR patients took longer to respond (13.0 weeks) than either TI or TN patients (7.6 and 8.0 weeks, respectively). TR and TI patients had lower response rates (67% and 71%) than TN patients (86%).
Prior treatment exposure is an important correlate of course and outcome in late-life depression. Most TR and TI patients eventually respond, but TR patients may require more intensive and longer courses of treatment than TI and TN patients.
"In other words, a higher degree of treatment resistance is associated with worse outcomes. In addition, this study extends to patients with MDpsy a finding previously reported in patients with non-psychotic MDD: inadequate treatment trials ( " pseudo-treatment resistance " ) is associated with a good outcome, similar to the outcome observed in treatment naïve patients (Tew et al., 2006). This emphasizes the clinical importance of distinguishing true treatment failure vs. inadequate treatment in patients who report that they have not responded to previous treatment trials. "
[Show abstract][Hide abstract] ABSTRACT: Having failed to respond to an adequate antidepressant treatment course predicts poorer treatment outcomes in patients with major depression. However, little is known about the impact of prior treatment on the outcome of major depression with psychotic features (MDpsy). We examined the effect of prior treatment history on the outcome of pharmacotherapy of MDpsy in patients who participated in the STOPD-PD study, a randomized, double-blind, clinical trial comparing a combination of olanzapine plus sertraline vs. olanzapine plus placebo. The strength of treatment courses received prior to randomization was classified using a validated method. A hierarchy of outcomes was hypothesized based on treatments received prior to randomization and randomized treatment. A high remission rate was observed in subjects with a history of no prior treatment or inadequate treatment who were treated with a combination of olanzapine and sertraline. A low remission rate was observed in subjects who had previously failed to respond to an antidepressant alone and who were treated with olanzapine monotherapy. A low remission rate was also observed in subjects who had previously failed to respond to a combination of an antipsychotic and an antidepressant. Similar to patients with major depression, these results emphasize the impact of prior pharmacotherapy on treatment outcomes in patients with MDpsy.
Journal of Psychiatric Research 02/2011; 45(7):896-901. DOI:10.1016/j.jpsychires.2011.01.003 · 3.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article focuses on recent research into depression, bipolar disorder and anxiety in older people.
Many physical illnesses are associated with a high prevalence of depression but overall medical burden may largely account for this. The relationship between depression and vascular disease is two way. Frontal brain dysfunction may underlie depression both in cerebrovascular disease and neurodegenerative disorders. Besides antidepressants, psychological treatments, psychosocial interventions and enhanced primary care services are effective. Longer-term outcomes are poor but preventive strategies show promise. Medical and psychiatric comorbidity are also important themes in later-life anxiety and bipolar disorders.
Improving prognosis is a key concern and more research into novel pharmacological approaches (including vasoprotection), psychological interventions and prevention is needed.
Current Opinion in Psychiatry 12/2007; 20(6):539-43. DOI:10.1097/YCO.0b013e3282c8c86f · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objectives of the present review were to summarise the key findings from the clinical literature regarding the neurobiology of major depressive disorder (MDD) and their implications for maximising treatment outcomes. Several neuroanatomical structures in the prefrontal and limbic areas of the brain are involved in affective regulation. In patients with MDD, alterations in the dynamic patterns of activity among these structures have profound implications for the pathogenesis of this illness.
The present work reviews the evidence for the progressive nature of MDD along with associated changes in neuroanatomical structure and function, especially for the hippocampus. The role of glucocorticoids, inflammatory cytokines and brain-derived growth factors are discussed as mediators of these pathological alterations. From this integrated model, the role of antidepressant therapy in restoring normative processes is examined along with additional treatment guidelines.
Major depressive disorder is an illness with significant neurobiological consequences involving structural, functional and molecular alterations in several areas of the brain. Antidepressant pharmacotherapy is associated with restoration of the underlying physiology. Clinicians are advised to intervene with MDD using an early, comprehensive treatment approach that has remission as the goal.
International Journal of Clinical Practice 01/2008; 61(12):2030-40. DOI:10.1111/j.1742-1241.2007.01602.x · 2.57 Impact Factor
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