Geriatric Depression Treatment in Nonresponders to Selective Serotonin Reuptake Inhibitors

Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 12/2004; 65(12):1634-41. DOI: 10.4088/JCP.v65n1208
Source: PubMed


Up to a third of elderly patients with major depressive disorder are treatment resistant, yet little objective evidence is available to guide the clinician in managing these patients. We report here our experience with elderly subjects with prospectively defined treatment-resistant depression in 2 separate research studies: one entailing an augmentation strategy, the other a change to venlafaxine extended release (XR).
Fifty-three elderly subjects with major depressive disorder according to DSM-IV criteria who failed treatment with paroxetine plus interpersonal psychotherapy received 1 to 3 trials of augmentation with bupropion sustained release, nortriptyline, or lithium. Successively fewer subjects entered each sequential trial of augmentation. Twelve subjects subsequently received venlafaxine XR monotherapy. Response to treatment was defined as a 17-item Hamilton Rating Scale for Depression score of < 10 for 3 weeks.
Sixty percent of subjects (N = 32) responded to some form of augmentation, with 45% (24/53), 31% (5/16), and 43% (3/7) responding to the first, second, and third augmentation trials, respectively. The mean time to response after starting the first augmentation trial was 6.0 (SD = 5.8) weeks. Forty-two percent (N = 5) of the venlafaxine XR-treated subjects responded with the mean time to response of 6.4 (SE = 0.9) weeks. Adverse effects leading to treatment discontinuation and falls were more common in the augmentation subjects than in the venlafaxine XR subjects.
We observed similar rates and speed of response with an augmentation strategy and a strategy of switching to venlafaxine XR in elderly subjects with prospectively defined treatment-resistant major depressive disorder. Venlafaxine XR was generally better tolerated than the augmentation strategies. Further investigation of venlafaxine XR as a preferred strategy for treatment-resistant geriatric depression is warranted.

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    • "A majority of physicians agree that medications for depression are effective. However, studies indicate that one third of older adults are treatment-resistant and that response time to remission can start at 2 weeks but may take up to 12 weeks to occur (Alexopoulos, 2008; Whyte et al., 2004). Our mediation model suggests that tailored daily recreation therapy for 2 weeks changes behaviors in a much shorter time period. "
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    • "Geriatric depression is a syndrome often characterized by a slow response to treatment, a failure to fully remit, and a high propensity for relapse (Dew et al., 2007, Little et al., 1998, Whyte et al., 2004). A number of neurobiological abnormalities, particularly in frontolimbic networks, often are present in the illness; however, the specific contributions of these abnormalities to the clinical presentation and the course of the illness remain unclear. "
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