Thursday, 21 August 2003
This presentation is part of : Pharmacotherapy of Depression

S083-001 Choice of Antidepressant Strategies by West Midlands Old Age Psychiatrists

Jorge Calderon, Department of Psychiatry, Pontificia Universidad Catolica de Chile, Santiago, Chile and Peter Bentham, Department of Old Age Psychiatry, Queen Elizabeth Psychiatric Hospital, Birmingham, England.

Objective: Treatment resistant depression is as common in the elderly as it is in the younger adult. However, the evidence base for alternative treatment strategies remains limited. We aim to describe prescribing preferences for depression and resistant depression in consultants and specialist registrars in old age psychiatry within the West Midlands Region in order to inform the design of a prospective randomized trial comparing treatment strategies.

Design: A questionnaire was designed by the authors and sent to all consultants and specialist registrars within the region. A second questionnaire was sent if no reply was received after 8 weeks.

Materials and Methods: Physicians were first asked to list in order of preference their choice of antidepressant when treating major depression in an elderly patient if there was no significant risk of self-harm. Secondly, they were asked how long they would wait before considering an alternative strategy if the patient had not responded adequately. Thirdly, physicians were asked to list in order of preference 6 treatment options (dose increase, inter-class switch, intra-class switch, lithium augmentation, ECT, and other specified treatment) if their patient had not responded to the first antidepressant trial. Finally, those using lithium augmentation were asked to specify what blood level they thought was adequate.

Results: 33 of the 41 consultants (80%) and 10 of the 12 specialist registrars (83%) replied. SSRIs (65%) were the most frequent first choice, followed by tricyclics (19%) and venlafaxine (14%). Venlafaxine was the most common second or other choice followed by lofepramine. The majority of respondents (56%) opted for a 4 to 6 week period of treatment before considering an alternative strategy, but none felt it necessary to extend beyond 8 weeks. Following an inadequate response to the initial antidepressant trial, the commonest strategy employed was an increase in antidepressant dosage (93%). This was also popular (89%) in those using SSRIs as first choice. The next most common initial strategy was an inter-class switch (5%), followed by lithium augmentation (2%). An impression of the longer-term treatment sequence for resistant depression was estimated by calculating an average preference score for each treatment. This produced the following hierarchy of preference for the 6 options: dose increase>inter-class switch>lithium augmentation>ECT>intra-class switch>other. The sequence of dose increase, inter-class switch, lithium augmentation followed by ECT was reported by 42% of respondents. The vast majority of respondents (81%) considered lithium levels in the 0.4-0.8 mEq/L to be adequate; however, 29 respondents gave the lowest acceptable level as 0.4 mEq/L, and one considered 0.2 mEq/L to be sufficient.

Conclusion: We think there are good clinical, economic, and ethical grounds for conducting a prospective randomized comparison of treatment strategies in resistant depression in the elderly.

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