Maintenance Treatment of Major Depression in Old Age

University of Pittsburgh, Pittsburgh, Pennsylvania, United States
New England Journal of Medicine (Impact Factor: 55.87). 04/2006; 354(11):1130-8. DOI: 10.1056/NEJMoa052619
Source: PubMed


Elderly patients with major depression, including those having a first episode, are at high risk for recurrence of depression, disability, and death.
We tested the efficacy of maintenance paroxetine and monthly interpersonal psychotherapy in patients 70 years of age or older who had depression (55 percent of whom were having a first episode) in a 2-by-2, randomized, double-blind, placebo-controlled trial. Among patients with a response to treatment with paroxetine and psychotherapy, 116 were randomly assigned to one of four maintenance-treatment programs (either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions) for two years or until the recurrence of major depression. Clinical-management sessions, conducted by the same nurses, social workers, and psychologists who provided psychotherapy, involved discussion of symptoms.
Major depression recurred within two years in 35 percent of the patients receiving paroxetine and psychotherapy, 37 percent of those receiving paroxetine and clinical-management sessions, 68 percent of those receiving placebo and psychotherapy, and 58 percent of those receiving placebo and clinical-management sessions (P=0.02). After adjustment for the effect of psychotherapy, the relative risk of recurrence among those receiving placebo was 2.4 times (95 percent confidence interval, 1.4 to 4.2) that among those receiving paroxetine. The number of patients needed to be treated with paroxetine to prevent one recurrence was 4 (95 percent confidence interval, 2.3 to 10.9). Patients with fewer and less severe coexisting medical conditions (such as hypertension or cardiac disease) received greater benefit from paroxetine (P=0.03 for the interaction between treatment with paroxetine and baseline severity of medical illness).
Patients 70 years of age or older with major depression who had a response to initial treatment with paroxetine and psychotherapy were less likely to have recurrent depression if they received two years of maintenance therapy with paroxetine. Monthly maintenance psychotherapy did not prevent recurrent depression. ( number, NCT00178100.).

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Available from: Katalin Szanto, Oct 06, 2015
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    • "With vigorous and persistent treatment, up to 90 percent of older depressed patients will respond to drug therapy [12]. Within two years 60% of community-dwelling older adults with MDD became depressed again unless they were maintained on antidepressant medication [13]. Poor adherence to taking medications may account for a substantial proportion of treatment failures [14] [15]. "
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    ABSTRACT: Objectives. Describe older patients' perceptions about depression and characteristics associated with acceptance of treatments. Design. Cross-sectional study. Setting. Three primary care clinics in Iowa. Participants. Consecutive sample of 529 primary care patients. Measurements. Depression screening tool (a 9-item patient health questionnaire [PHQ-9]) and questionnaire including sociodemographic data, patient attitudes about depression, and acceptability of different treatments. Results. Mean age was 71.9 years (range 60-93 years), 314 (59%) female. Among the 529 participants, 93 (17.5%) had history of depression and 60 (11.3%) had PHQ-9 scores of 10 or greater. Participants believed depression is a disease for which they would use medication and counseling. Accepting medications from primary physicians was strongly associated with a past history of depression (P < 0.01) and with agreeing that depression needs treatment (P < 0.01). Counseling was not acceptable for those believing that they can control depression on their own (P < 0.01). Older patients (P < 0.001) and those with higher education levels (P < 0.01) were less likely to accept herbs or supplements as treatment options. Willingness to discuss treatments with family was associated with not using alcohol as a treatment and acceptance of all other treatment options (P < 0.001). Conclusions. Attitude that depression is a disease and the willingness to discuss depression with family may enhance treatment acceptance.
    The Scientific World Journal 10/2013; 2013:207493. DOI:10.1155/2013/207493 · 1.73 Impact Factor
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    • "Even when physician education does result in better outcomes, the effects are only short-term (Rutz, Von Knorring, & Walinder, 1992; Tiemens et al., 1999). There is a consensus now that the treatment of common mental disorders in primary care requires multifaceted, collaborative care approaches that include education for health staff, patients, and families, provision of different options for treatment (medication and individual or group psychotherapy), and primary care staff whose job it is to coordinate care and follow patients (Craven & Bland, 2006; Katon, Von Korff, Lin, & Simon, 2001; Katon et al., 2004; Reynolds et al., 2006; Simon, 2006; Unutzer et al., 2002). Research is now beginning to produce evidence that it is possible to treat common mental disorders in primary care settings in low-income countries (Bolton et al., 2003; Patel, Araya, & Bolton, 2004; Patel et al., 2003a). "
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    • "Additional covariates were selected based on previously identified relationships with either depression or use of health-oriented control strategies (Bruce et al., 2004; Alexopoulos et al., 2005; Dombrovski et al., 2007; Andreescu et al., 2007; Reynolds et al. 2006; Wrosch et al., 2000, 2002, 2003; Gitlin et al., 2007; Wrosch and Heckhausen, 1999). These covariates were anxiety measured by the Clinical Anxiety Scale (CAS) (Snaith et al., 1982), hopelessness measured by the Beck Hopelessness Scale (BHS) (Beck et al., 1975), cognitive impairment measured by the Mini Mental State Exam (MMSE) (Folstein et al., 1975), burden of physical illness measured by the Charlson Comorbidity Index (CCI) (Charlson et al., 1987), diagnosis of major depressive disorder, intervention assignment and other demographic characteristics. "
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    ABSTRACT: Identifying the predictors of late-life depression that are amenable to change may lead to interventions that result in better and faster remission. Thus, the authors investigated the impact of two different strategies for coping with physical illness on depression in older, primary care patients. Health-oriented goal engagement strategies involve the investment of cognitive and behavioral resources to achieve health goals. Conversely, disengagement strategies involve the withdrawal of these resources from obsolete or unattainable health goals, combined with goal restructuring. The participants were 271 adults aged >59 years who took part in a two-year randomized clinical trial for treating depression in older adults (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). The use of engagement and disengagement strategies, along with other risk factors for depression, were included in a tree-structured survival analysis to identify subgroups of individuals at risk for not achieving depression remission. The use of disengagement strategies predicted earlier remission of depression, particularly among more severely depressed older patients. The use of engagement strategies did not predict earlier remission. Interventions that encourage disengagement from unattainable health goals may promote remission from depression in older, primary care patients.
    International Journal of Geriatric Psychiatry 02/2012; 27(2):178-86. DOI:10.1002/gps.2706 · 2.87 Impact Factor
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