March 15, 2006 - Elderly patients who stay on antidepressant drugs after recovering from depression are much less likely to suffer recurrences than patients taken off the drugs or those treated with psychotherapy alone, an important new study suggests.
Elderly people over the age of 70 who received placebo were more than twice as likely to have their depression return compared with those who received the antidepressant drug Paxil, even after taking into account psychotherapy.
Monthly psychotherapy was not found to be effective for preventing new episodes of depression among the elderly. The groundbreaking findings suggest that in older patients depression should be thought of more as a chronic illness -- like hypertension or diabetes -- than an episodic one, the study's researcher tells WebMD.
The study is published in the March 16 issue of The New England Journal of Medicine.
"We want to change the way physicians think about this illness in the elderly, especially general medicine physicians, because they are the ones who write most of the prescriptions," says Charles F. Reynolds III, MD. "Just like hypertension, depression is often a chronic disease that should be treated indefinitely."
Depression in Elderly
Depression is common among the elderly, even in people who have no history of the disease. The goal of treatment is not only recovery but to prevent recurrences, write the authors.
Depression is widely undertreated in the elderly, and recurrences are common. Rates of recurrent depression during a two-year period range from 50% to 90%, according to the researchers.
Reynolds says depression in older people tends to be tied closely to overall health and health-related disabilities.
"Probably anywhere from 6% to 10% of older primary-care patients are experiencing clinically significant depression at any point in time," he says. "The figure is closer to 15% to 20% for older people in medical hospitals and 20% to 25% for people in nursing homes."
He points out that there is no standard medical treatment strategy for patients who have their first bout of depression very late in life. There is no consensus about whether long-term treatment with antidepressant medication is appropriate in this age group.
Preventing Recurrence of Depression
Most experts only treat depression in the elderly for six to 12 months. Reynolds says many older patients are taken off antidepressant drugs within six months or a year of initial treatment.
In the study, Reynolds and colleagues with the University of Pittsburgh School of Medicine looked at whether continuing drug treatment or psychotherapy could help prevent recurrences in elderly patients.
One hundred sixteen patients over the age of 70 who responded to treatment with Paxil in combination with monthly psychotherapy were treated with either continued antidepressant drugs or a placebo in combination with psychotherapy or monthly medical management sessions. The patients continued on these treatment therapies for two years or until major depression recurred.
Slightly more than one in three patients (35%) treated with the drug and psychotherapy became depressed again during this time, compared with 37% of patients treated with the drug and clinical management, 58% of those receiving placebo and monthly medical management, and 68% of those receiving placebo and psychotherapy.
Patients who received placebo were 2.4 times as likely to have their depression recur as those who continued on the antidepressant.
Depression Isn't Inevitable
In an editorial accompanying the study, Wake Forest University psychiatry professor Burton V. Reifler, MD, MPH, writes that doctors often wrongly regard depression in the elderly as an inevitable consequence of aging and declining health.
"Dismissing depression as inevitable denies the patient a fair chance of recovery from an illness that not only is potentially disabling but also increases the risk of death," he writes. "The available evidence suggests that advancing age does not diminish the potential for a response to antidepressant medication."
Reifler tells WebMD that he agrees with Reynolds' view that depression tends to be chronic in elderly people who have had it. But he added that it is premature to call for lifelong drug treatment for every elderly patient with the disease.
"In actual practice a lot of experienced geriatric psychiatrists, myself included, have begun recommending to elderly patients who respond to medication for depression that they remain on the medication indefinitely," he says. "The findings of this study are completely consistent with what we are seeing in practice, but they need to be replicated."
Montefiore Medical Center geriatric psychiatrist Gary Kennedy, MD, says the findings should change clinical practice by making doctors think twice about taking elderly patients off antidepressant drugs that seem to be working.
In his own research, Kennedy has found that older patients who have anxiety along with depression and patients who continue to have sleep problems despite successful depression treatment are at high risk for recurrences.
"If sleep starts to deteriorate, that could be a simple sign that patients need to continue drug treatment," he says.