Maintenance treatment of major depression in old age
Reynolds CF 3rd, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, et al.;
Commented by , 28 Apr 2006
Background
Elderly patients with major depression are at high risk of recurrence of depression which in turn, leads to increased disability and death. There is no consensus on relapse prevention, particularly after a first episode.
Methods
The study group was over 70 years old with major depression, defined by DSM-IV criteria, in Pittsburgh, USA. 116 subjects who responded to treatment with paroxitene and interpersonal therapy over a 4 month period, were then randomly assigned to 4 maintenance groups, with outcome monitored over 2 years. The study design was a 2 by 2, randomized double-blind placebo controlled trial, independent of the pharmaceutical industry.
The maintenance groups comprised:
- paroxitene + monthly interpersonal therapy
- paroxitene + monthly “clinical management” sessions
- placebo + monthly interpersonal therapy
- placebo + monthly “clinical management” sessions.
“Clinical management” sessions, conducted by the same nurses/social workers/psychologists who performed the psychotherapy, simply involved discussion of symptoms.
Results
69/116 participants were recovering from a first episode of depression. Of the 116, during the 2 year maintenance period, major depression recurred in 35% of those having paroxitene and psychotherapy; 37% of those having paroxitene and clinical management; 68% of those having placebo and psychotherapy; and 58% of those having placebo + clinical management. Outcome was relatively unaffected whether it was first episode or recurrent depression.
After adjustment for the effect of psychotherapy, the relative risk of recurrence among those having placebo was 2.4 times greater than those receiving paroxitene (95% confidence interval, range 1.4 – 4.2). The number needed to treat with paroxitene to prevent recurrence was 4. Patients with fewer/less severe co-existing medical conditions (e.g., hypertension, ischaemic heart disease) received greater benefit from paroxitene.
Dr Seymour's comments
The headline finding from this well-designed and executed study is that antidepressants help to prevent recurrence of major depression in older people, but psychotherapy does not. Further, psychotherapy has no additive benefit for those maintained on antidepressants. This rather surprising finding contradicts the findings of the only other major study in this area by the same research group (ref. 1) which used nortriptyline and interpersonal therapy, and did find a positive additive effect of psychotherapy.
These studies raise 3 main questions that remain unanswered in the literature:
- does the antidepressant class effect outcome/risk of relapse (e.g., are tricyclics or SNRIs better than SSRIs?)
- does the modality of psychotherapy matter (e.g., is cognitive behavioural therapy better than interpersonal therapy?)
- are there a subgroup of patients who will benefit from a psychotherapeutic approach after recovering from depression?
In conclusion, maintenance antidepressant therapy for at least 2 years – using the same antidepressant that helped the individual out of the index episode of depression – is a mainstay of relapse prevention in older people with both first episode and recurrent depression.
My personal approach additionally includes:
- close follow up in secondary care of most older patients following an episode of major depression – because of the high risk and severe consequence of relapse
- concomitant treatment of medical factors and cognitive impairment
- psychotherapy reserved for people traumatized by recent or past events, psychotherapy modality tailored to individual need.
References
1. Reynolds CF 3rd, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. Journal of the American Medical Association 1999; 281 (1); 39-45