Treatment Of Late-life Depression Research Articles

Fluvoxamine in the Treatment of Late-Life Depression: How Much We Know Coming From Randomized Controlled Trials

*Instituto de Neurociencias, Universidad de Granada, Granada, Spain and †Department of Psychiatry, Hospital Ramón y Cajal Universidad de Alcalá Madrid, Spain [email protected]

Models of Care for Treating Late-Life Depression in Primary Care

The aim of this review is to highlight the need for treating late-life depression in primary care settings, review obstacles to doing so and introduce evidence-based models of depression care for older primary care patients. While interventions focusing on depression screening, provider education and referral to mental health specialists have had only limited success, several recent trials have demonstrated that programs in which primary care providers and mental health professionals effectively collaborate to treat depression using evidence-based treatment algorithms are more effective than usual care. Future research should address the problem of persistent depression, which has been identified in recent collaborative care studies, and focus on how to translate evidence-based approaches for late-life depression treatment into real world practice.

Expanding the usefulness of Interpersonal Psychotherapy (IPT) for depressed elders with co‐morbid cognitive impairment

The utility of Interpersonal Psychotherapy (IPT) has been documented as a maintenance treatment for late life depression as mono-therapy or in combination with antidepressant medication. Late life depression, however, is frequently co-morbid with declining memory or other cognitive abilities such that the usefulness of one-to-one psychotherapies is called into question for this subgroup. Additionally, concerned caregivers often accompany these patients to request help and their role in the presenting symptoms and in their potential resolution must also be addressed by any successful psychotherapy in this population. To explore ways in which IPT could be modified to better serve the particular presentation and needs of depressed elders with cognitive decline along with their caregivers. Various modifications of traditional IPT techniques were experimented with and refined in our collaborative late life research center using regular group supervision and feedback from patients and their caregivers. A key component of these modifications involves the integration of the caregiver into the treatment process in flexible ways that recognize their own role transition that is taking place simultaneously with that of the patient's role transition from a greater to a lesser functional state. Other techniques for resolving role conflicts, particularly those directly involving care issues for the patient, are also delineated. These modifications are collectively referred to as IPT-CI for cognitive impairment. A brief case vignette is presented. The modifications outlined in this communication reflect an evolving work-in-progress and serve as a framework for the future development of a manual of guidelines to assist healthcare personnel to optimally treat this population and their caregivers.

Treating late‐life depression with interpersonal psychotherapy in the primary care sector

Interpersonal psychotherapy (IPT) is an empirically-validated intervention for treating late-life depression. To determine the manner in which IPT is utilized by primary care physicians in relation to antidepressant medications. The authors reviewed treatment logs prepared by care managers during the first 12 months of a patient's participation in the PROSPECT clinical trial to determine initial and longitudinal treatment patterns utilized by physicians, and clinical outcomes associated with initial treatment assignment. Primary care physicians in practices randomized to PROSPECT's intervention arm initially prescribed an antidepressant medication for 58% of eligible patients and referred only 11% of them to IPT. Over time, however, 27% of patients participated in IPT as monotherapy or augmentation therapy. Initial treatment assignment was not associated with depressive status at 4 and 12 months nor with suicidal ideation at 4, 8, and 12 months. IPT is an effective treatment for late-life depression whose greater use by primary care physicians should be encouraged.

Gender Disparities in the Treatment of Late-Life Depression: Qualitative and Quantitative Findings From the IMPACT Trial

The objectives of this study were to examine gender differences in recruitment, depression presentation, and depression treatment history in a large effectiveness trial; and to use qualitative data to generate hypotheses about reasons for observed gender differences. Data from IMPACT, a multisite trial of a disease management program for late-life depression in primary care were used to examine gender differences quantitatively. Qualitative interviews were conducted with 30 key informants from IMPACT (referring physicians, depression care managers, and study recruiters) to learn more about challenges in recruiting and treating depressed older men and then analyzed thematically. Compared with older women, older men were significantly less likely to be referred to IMPACT, to endorse core depressive symptoms, and to have received prior depression treatment. Gender differences in prior depression treatment persisted after adjustment for covariates. Qualitative themes identified as important contributors to gender disparities included 1) how men experience and express their depression, 2) traditional masculine values, and 3) the stigma of chronic mental illness. This study provides further evidence of the gender gap in depression care, identifies possible contributing factors, and suggests avenues for future research.

Cardiovascular Changes Associated With Venlafaxine in the Treatment of Late-Life Depression

Potential cardiovascular side effects from venlafaxine-XR must be considered when prescribing this medication, especially in geriatric patients, who often present with comorbid medical conditions. Participants age 60 and older with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of a major depressive episode without psychotic features were treated openly with venlafaxine-XR for 12 weeks during which venlafaxine-XR was titrated based on tolerability and response according to predefined guidelines. Sitting and standing blood pressures and heart rates were measured. A 12-lead electrocardiogram was obtained at baseline and at week 12. Sixty-two participants started treatment; 59 completed at least two weeks of the 12-week study. The mean final dose of venlafaxine-XR was 195.5 mg/day (standard deviation: 72.2). Twenty-four percent (95% confidence interval [CI]: 7.3%-40.7%) of initially normotensive participants and 54% (95% CI: 34.3%-74%) of those with preexisting hypertension experienced an increase in blood pressure. Twenty-nine percent (95% CI: 14.6%-43.4%) of participants developed orthostatic hypotension. Two participants experienced a clinically significant increase in QTc interval. One participant reported new-onset mild dizziness, whereas four participants reported new-onset tachycardia or palpitation. Overall, 17 unique participants (28.8%; 95% CI: 17.3%-40.4%) experienced a new-onset cardiovascular problem, potentially related to the study medication. Overall, venlafaxine-XR was well tolerated. However, similar to previous reports, venlafaxine-XR was associated with some undesirable cardiovascular effects in some of the participants. Systematic monitoring of cardiovascular parameters during treatment with venlafaxine-XR should be strongly recommended, especially in the elderly.

Treatments for Later-Life Depressive Conditions: A Meta-Analytic Comparison of Pharmacotherapy and Psychotherapy

To improve interventions for depressed older adults, data are needed on the comparative effects of pharmacotherapy versus psychotherapy. Given that most older adults with clinically significant depressive symptoms do not have major depression, data on treatments for minor depression and dysthymia are especially needed. Meta-analysis was used to integrate the results of 89 controlled studies of treatments focused on acute major depression (37 studies) and other depressive disorders (52 studies conducted with mixed diagnostic groups, including patients with major depression, minor depression, and dysthymia). A total of 5,328 older adults received pharmacotherapy or psychotherapy in these studies. Clinician-rated depression scores improved, on average, by 0.80 standard deviation (SD) units; self-rated depression scores improved by 0.76 SD units. Clinician-rated depression improved by 0.69 SD units in pharmacotherapeutic studies and by 1.09 SD units in psychotherapeutic studies. Self-rated depression improved by 0.62 SD units and 0.83 SD units, respectively. An interesting finding was the stronger improvements in clinician-rated depression among control subjects participating in medication studies, compared to those in psychotherapeutic studies. Available treatments for depression work, with effect sizes that are moderate to large. Comparisons of psychotherapy and pharmacotherapy must be interpreted with caution, in part because medication studies are more likely to use a credible active placebo, which may lead to smaller adjusted effect sizes in medication studies. Given that psychotherapy and pharmacotherapy did not show strong differences in effect sizes, treatment choice should be based on other criteria, such as contraindications, treatment access, or patient preferences.

Emergence, persistence, and resolution of suicidal ideation during treatment of depression in old age

Introduction To determine the rate and clinical correlates of emergent, persistent, and resolved suicidal ideation during treatment of major depression in the elderly. Methods Based on the course of suicidal ideation before and during 12 weeks of antidepressant treatment, we classified 437 elderly patients (234 treated with paroxetine; 203 with nortriptyline) as either non-suicidal or as having “emergent”, “persistent”, or “resolved” suicidality. We compared the four groups on pretreatment demographic and clinical measures and with respect to depression, anxiety, and akathisia during treatment. Results: Rates of emergent, persistent, and resolved suicidality were 7.8%, 12.6%, and 15.6%, respectively. Patients with persistent suicidal ideation were more likely to have recurrent depression than non-suicidal patients or patients whose suicidality resolved with treatment. At the start of treatment, patients in all three suicidal groups had lower self-esteem than non-suicidal patients. During the course of treatment, emergent suicidality was not associated with akathisia, nor did rates of emergent suicidality differ between paroxetine- and nortriptyline-treated patients. While at baseline the levels of depression and anxiety and agitation were similar in the four groups, patients with resolved suicidality had a favorable treatment response, while patients with emergent and persistent suicidality were more likely to maintain higher depression scores and had higher levels of anxiety and agitation during treatment. Discussion Emergence of suicidal ideation is not common but is clinically significant during treatment of late-life depression and may signal more difficult-to-treat-depression.

Cognitive Predictors of Response to Treatment for Depression in Multiple Sclerosis

Cognitive Predictors of Response to Treatment for Depression in Multiple Sclerosis

Treatment of Late-Life Depression: Utilization of Interpersonal Psychotherapy

Treatment of Late-Life Depression: Utilization of Interpersonal Psychotherapy

International Medical Graduates and the Diagnosis and Treatment of Late-Life Depression

International medical graduates (IMGs) constitute a significant number of physicians in the United States. Because of cultural differences in the manifestations and acceptance of mental disorders, depression may be less recognized in countries where IMGs train than in the United States. Differences in medical training may affect IMGs' recognition of depression. The authors hypothesized that the diagnosis and treatment of late-life depression would differ between United States medical graduates (USMGs) and IMGs. Physicians, both USMGs and IMGs, at two different professional physician association meetings in 2002 were asked to view a multimedia computer program including a vignette of an elderly patient-actor with late-life depression. They completed a computerized survey, including their diagnosis and recommendations for management. Statistical analyses were performed to compare the two groups for physician characteristics and patient treatment recommendations. Study subjects were 178 primary care physicians and 321 psychiatrists. Three hundred fifty-three (71%) respondents were USMGs and 146 (29%) were IMGs. IMGs were significantly less likely than USMGs to make the correct diagnosis of depression (p < .004) or recommend treatment with a first-line antidepressant (p < .001). When specialty, other physician characteristics, and patient race and gender were controlled for, IMGs still differed significantly in their diagnoses (p = .006) and treatment (p = .006) of depression. The authors found significant differences between USMGs and IMGs for the diagnosis and treatment of late-life depression. This could be due to IMGs' lesser familiarity with depressive symptoms or different cultural conceptions of depression. These findings may point to the need for additional depression training initiatives for IMGs.

Commentary: Coming to America: The Integration of International Medical Graduates into the American Medical Culture

This Commentary is a companion piece to two Research Reports appearing in this issue: "Behavioral Science Education and the International Medical Graduate," by Searight and Gafford, and "International Medical Graduates and the Diagnosis and Treatment of Late-Life Depression," by Kales et al. International medical graduates (IMGs) come to America from diverse cultures around the world to complete their graduate medical education (GME). These residents are and will continue to be a fundamental part of the American health care delivery system. IMGs' acculturation into the norms and standards of medicine as practiced in the U.S. is crucial to their education as well as to quality patient care. The time has come for GME to begin to systematically and effectively address the cultural challenges that IMGs face not only within the context of American medicine and GME, but in the larger context of American culture. Specific programs and strategies need to be developed and put in place early in the GME experience-or even before entry into GME-to assist IMGs in understanding the context for, and issues associated with, providing optimum health care in the United States. The author reflects on the findings of the two Research Reports, and calls for increased attention in the medical education community to acculturating and educating IMGs for optimal patient care.

Utilization of mental health care services among older adults with depression

Despite the availability of effective treatments for late life depression, data indicate that only a small minority of adults over the age of 65 years with depression access any kind of care for emotional or mental health problems. Using data from the Canadian Community Health Survey (Cycle 1.1), we compared patterns of mental health service utilization among middle-aged (45-64 years), younger old (65-74 years), and older old (75 years and older) adults with and without depression and identified predictors associated with accessing different services (n=59,302). Compared to middle-aged adults with depression, individuals aged 65 and older with depression were less likely to report any mental health consultation in the past year and especially unlikely to report consulting with professionals other than a family physician. Age remained a significant predictor of mental health service utilization even after accounting for other relevant variables such as gender, marital status, years of education, depression caseness, and number of chronic medical conditions. Although the prevalence of depression is lower in older age groups, the present study provides compelling evidence that mental health services are particularly underutilized by depressed older adults.

Cost-effectiveness of Improving Primary Care Treatment of Late-Life Depression

Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. Randomized controlled trial with recruitment from July 1999 to August 2001. Eighteen primary care clinics from 8 health care organizations in 5 states. A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). Total outpatient costs, depression-free days, and quality-adjusted life-years. Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

Objective This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Method Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. Results Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Conclusions Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.

Impact of Cluster C Personality Disorders on Outcomes of Acute and Maintenance Treatment in Late-Life Depression

Personality disorders (PDs) have been associated with poor treatment outcomes in acute treatments for late-life depression and with persistent functional impairment after recovery from an episode of depression. Using survival analysis and mixed-effects models, the authors examined the impact of Cluster C PDs on time-to-response and several aspects of functioning in acute and maintenance treatment of major depression in later life. Cluster C PDs were associated with longer time-to-response during acute treatment and non-response in continuation or maintenance treatment. Although not statistically significant, there was evidence of a cumulative negative impact of Cluster C PDs and residual depressive symptoms on instrumental activities of daily living (IADLs) during maintenance treatment. These findings suggest that screening for PD may be important for clinicians treating late-life depression and that the combination of Cluster C PDs and residual depressive symptoms may predict functional declines even after recovery from the index episode of depression.

Impact of Cluster C Personality Disorders on Outcomes of Acute and Maintenance Treatment in Late-Life Depression

Personality disorders (PDs) have been associated with poor treatment outcomes in acute treatments for late-life depression and with persistent functional impairment after recovery from an episode of depression.Using survival analysis and mixed-effects models, the authors examined the impact of Cluster C PDs on time-to-response and several aspects of functioning in acute and maintenance treatment of major depression in later life.Cluster C PDs were associated with longer time-to-response during acute treatment and non-response in continuation or maintenance treatment. Although not statistically significant, there was evidence of a cumulative negative impact of Cluster C PDs and residual depressive symptoms on instrumental activities of daily living (IADLs) during maintenance treatment.These findings suggest that screening for PD may be important for clinicians treating late-life depression and that the combination of Cluster C PDs and residual depressive symptoms may predict functional declines even after recovery from the index episode of depression.

The Efficacy of Antidepressants in the Treatment of Late-Life Depression

This review addresses the question of whether there is evidence that antidepressants are more efficacious than placebo in the treatment of late-life depression and what is the rate of response that physician and patient can expect when antidepressant medication is prescribed in a typical clinical setting. To date, 5 placebo-controlled and 10 comparison trials have study designs of sufficient rigor to provide evidence of antidepressant efficacy and effectiveness in the treatment of late-life depression. The results suggest that antidepressant medications are more effective than placebo. However, placebo-controlled trials are not a simple comparison of only medication versus placebo. Rather, the amount of nonspecific psychosocial interventions included in these trials is considerable and often not systematically measured. Trial design also affects outcome: response and remission rates in comparison trials consistently are 20% to 30% higher than those reported in placebo-controlled trials. Clinical trials do not consistently assess the many moderators that are believed to affect treatment outcome in late-life depression, and therefore, comparisons across studies are problematic because of an inability to determine whether patient samples are truly comparable. For future clinical trials to have maximal relevance, study design should evolve to reflect as closely as possible a typical clinical setting especially with respect to frequency and duration of patient visits.

Late-onset major depression: clinical and treatment-response variability

To explore clinical and treatment-response variability in late-onset vs early-onset non-bipolar, non-psychotic major depression. We grouped patients from a late-life depression treatment study according to illness-course characteristics: those with early-onset, recurrent depression (n = 59), late-onset, recurrent depression (n = 27), and late-onset, single-episode depression (n = 95). Early-onset was defined as having a first lifetime episode of major depression at age 59 or earlier; late-onset was defined as having a first episode of major depression at age 60 or later. We characterized the three groups of patients with respect to baseline demographic, neuropsychological, and clinical characteristics, use of augmentation pharmacotherapy to achieve response, and treatment outcomes. Rates of response, remission, relapse, and termination were similar in all three groups; however, patients with late-onset, recurrent major depression took longer to respond to treatment than those with late-onset, single-episode depression (12 weeks vs 8 weeks) and had more cognitive and functional impairment. Additionally, patients with recurrent depression (whether early or late) were more likely to require pharmacotherapy augmentation to achieve response than patients with a single lifetime episode. Late-onset, recurrent depression takes longer to respond to treatment than late-onset single-episode depression and is more strongly associated with cognitive and functional impairment. Further study of biological, neuropsychologic, and psychosocial correlates of late-onset, recurrent depression is needed.

Treatment of late-life depression complicated by alcohol dependence.

Among elderly patients, mental and physical illness are often present along with alcohol dependence. The interaction between alcohol use and concurrent physical or mental disabilities is complex and complicates treatment planning. The aim of this study was to test the efficacy of naltrexone combined with sertraline for the treatment of older adults with major depression and alcohol dependence. The sample was 74 subjects, age 55 and older, who met criteria for a depressive disorder along with alcohol dependence. All subjects were randomly assigned to 12 weeks of naltrexone 50 mg/day or placebo. Also, all subjects received sertraline 100 mg/day and individual weekly psychosocial support. Treatment response for alcohol consumption and depression was measured during the 12 weeks of treatment. At baseline, the average age of subjects was 63.4, and subjects were drinking an average of 10.7 drinks per drinking day. The overall results are encouraging; 42% of the subjects had a remission of their depression and had no drinking relapses during the trial. There was no evidence for an added benefit of naltrexone in combination with sertraline, but there was significant correlation between any alcohol relapse during the trial and poor response to depression treatment. Patients with concurrent mental disorders, such as major depression and alcohol dependence, are increasingly prevalent in clinical practice and have been demonstrated to show poorer treatment response and higher treatment costs. The results of this trial underscore the importance of addressing alcohol use in the context of treating late-life depression.