Objective: This presentation will review evidence of efficacy of pharmacological treatments in acute phase treatment, continuation medication and resistant depression. It will be argued that although there is good evidence of efficacy in acute phase treatment for a range of antidepressants (Wilson et al, 2001; Katona & Livingston, 2002) there is rather less evidence that the prognosis has improved over the last 30-40 years. Improved tolerability and a wider choice of drugs has resulted in potentially more older depressed patients being considered for pharmacological treatment, including those with frailty and co-morbidity.
The most progress in recent years have been: 1) persistence in treatment: enough of the drug for a sufficient length of time, acknowledging that older people take longer to recover than younger adults; 2) the recognition that resistant depression can often be avoided, although particularly in late-onset patients therapeutic resistance may be associated with subtle brain pathology; 3) that keeping the patient well is as important a goal as acute phase treatment, and that there is strong evidence for the efficacy of drugs in this regard; 4) that psychological therapies are effective alternatives to drug treatment for less severe depressive illness; and that adjunctive psychological treatment can lead to improved outcomes compared to antidepressant drugs alone; 5) improvements in the delivery of care, such as the deployment of case managers in primary care which is associated with greatly improved outcomes (Unûtzer et al, 2002).
Whether there will be any truly novel treatments for late-life depression is unclear. Early experience with Trans-cranial Magnetic Stimulation (TMS) has not been encouraging. Interest in 'vascular' depression may lead to novel approaches but there are no definitive studies as yet.
References
Katona, C, Livingston, G. (2002) How well do antidepressants work in older people? Journal of Affective Disorders 69:47-52
Unûtzer, J, Katon, W, Callahan, C, Williams, JW, Hunkeler, E, Harpole, L, Hoffing, M, Della Penna, RD, Noel, PH, Lin, EHB, Arean, P, Hegel, M, Tang L, Belin, TR, Oishi, S, Langston, C. (2002) Collaborative care management of late-life depression in the primary care setting JAMA 288:2836-2845.
Wilson, K, Mottram, P, Sivanranthan, A, Nightingale, A. ((2001) Antidepressant versus placebo for depressed elderly (Cochrane Review). In: The Cochrane Library, Issue 2, Oxford: Update Software.
Design: Review of literature
Materials and Methods: Evidence-based review
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