Vol 1 n° 2 - Depression in the Elderly
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Depression in later life is usually a recurrent illness and often a chronic one, associated with increased health care utilization, amplification of the disabil- ity born of concurrent medical illness, decreased quality of life, increased risk for suicide, and cogni- tive impairment. The good news, however, is that maintenance treatments work and have a demon- strably positive impact on long-term illness course. Treatment response is especially variable, or brittle, in patients aged over 70; yet maintenance treat- ment with combined medication and psychother- apy is able to significantly reduce long-term treat- ment   response   variability,   ensuring   continued wellness. Further evaluation of cost-effectiveness is necessary in order to improve reimbursement for effective long-term treatment. etting well is not enough; it is staying well that counts. This theme has guided our research and clinical practice over the past decade, in completing the first long-term controlled studies of maintenance pharmacotherapy and psychotherapy ever conducted in geriatric depression.1 Recent data from the World Health Organization (WHO),2  clearly illustrate the importance of taking a long-term view of the clinical management of depression in later life (and, indeed, across the life cycle). According to the WHO, unipolar major depression and suicide accounted for 5.1% of the global burden of disease in 1990, as measured in disability-adjusted life years. Of relevance to inter- vention research in geriatric depression, the signifi- cance  of  illness  burden  attributable  to  depression increases with age weighting and thus will grow fur- ther by the year 2020 based upon projected demo- graphic shifts towards an older population. Hence, finding ways of preventing the return of depression in elderly patients and of maintaining the gains of acute and continuation treatment would represent a significant  treatment  advance  and  contribution  to public health. Data  from  naturalistic  studies  (not  controlling  for treatment or treatment intensity) have identified sev- eral correlates of relapse and recurrence in geriatric depression. Correlates, or predictors, of a relapsing course include a history of frequent prior episodes, dysthymia, a first onset of major depression after the age of 60, supervening medical illness, high pretreat- ment severity of depression and anxiety, incomplete recovery, and cognitive impairment, especially frontal lobe dysfunction as signaled by difficulties in initiation or perseveration.3-10  Our own studies have suggested that patients aged 70 and older show more variable, or brittle, long-term treatment response, probably reflect- ing the complex biological and psychosocial substrates of geriatric depression.11  It is also patients over age 70 who represent a rapidly increasing segment of the elderly population, whose response to antidepressant treatment may be the least predictable, and in whom Long-term course and outcome of depression in later life Charles F. Reynolds III, MD Address for correspondence: Prof Charles F. Reynolds III, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Room E-1135, Pittsburgh, PA 15213, USA
(e-mail: reynoldscf@msx.upmc.edu) Author affiliations:  Professor of Psychiatry and Neuroscience, University of Pittsburgh School of Medicine; and Director, Mental Health Clinical Research Center for Late-Life Mood Disorders, USA Keywords: geriatric depression; maintenance treatment C l i n i c a l   r e s e a r c h 9 5 G