Half of elderly depressed patients who initially responded poorly to
selective serotonin reuptake inhibitors (SSRIs) achieved recovery after a
second medication was added to their regimen, according to University of
Pittsburgh researchers. They also found that patients with clinically
significant anxiety and higher medical burden took longer to recover than did
Augmenting antidepressant therapy is not a new idea in treating younger
adults, but it has been used less commonly in older patients, study leader
Mary Amanda Dew, Ph.D., a professor of psychiatry, psychology, and
epidemiology at the University of Pittsburgh School of Medicine, told
The findings appear in the June American Journal of
"Doctors have hesitated to add medications for older patients because
they are concerned about the risks of polypharmacy, but this study shows
response rates as good as those among younger ones," said Dew. Untreated
or undertreated depression also carries risks, she said.
Many older individuals diagnosed with major depression do not respond well
to the initial drug regimen prescribed for them, said Dew. Guidelines have
been developed clinically, but there have been no studies in this age group
following a protocol specifying the steps for augmentation.
So, Dew and her team monitored depression levels of 195 patients over age
70 during their treatment for unipolar major depressive disorder. They were
being treated openly with the SSRI paroxetine, titrated from 10 mg to 40 mg,
as needed. These patients also received interpersonal psychotherapy weekly
until registering a clinical response, then biweekly for up to 16 weeks.
At that point, 90 patients (46.2 percent) had responded without relapse; 77
(39.5 percent) had an inadequate response; and 28 (14.4 percent) responded but
experienced an early relapse. These last two groups were eligible for
augmentation treatment, but 36 of them did not receive it, because they either
withdrew consent or had worsening medical conditions that precluded
The treatment teams used a standardized protocol and expert consensus to
decide which of three drugs to add to the paroxetine members of the target
study group were receiving: sustained-release bupropion, nortriptyline, or
Patients who required and received augmented treatment had lower recovery
rates than did those who responded well initially. After nearly a year, 86.7
percent of patients who didn't need augmentation had recovered. However, half
(24 of 48) with an initial inadequate treatment response recovered, as did
66.7 percent (14 of 21) of those who relapsed.
The researchers recorded a variety of demographic, clinical, and medical
comorbidity information in an attempt to predict outcomes. Besides their first
response to treatment, only anxiety and a high general medical burden appeared
to be associated with a longer time to recovery. Given the sample size, they
did not break out response by the drugs used to augment treatment.
"Our findings show that the response to treatment and to augmentation
among older people is at odds with the conventional thinking that assumes the
young do better," said Dew. The study indicates the value of a wider
range of options for treating this age cohort, she said.
"For older adults, we need a wider set of strategies for treating
depression," said Dew. "Although many patients can't or won't take
an additional drug, augmentation is one more possibility, like switching
medications or using psychotherapy."
Dew and her colleagues are continuing research that compares switching
medications with augmenting them.
The study was funded by the National Institute of Mental Health.
"Recovery From Major Depression in Older Adults Receiving
Augmentation of Antidepressant Pharmacotherapy" is posted at<http://ajp.psychiatryonline.org/cgi/content/full/164/6/892>.▪