Vol 1 n° 2 - Depression in the Elderly
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P h a r m a c o l o g i c a l   a s p e c t s This paper updates the 1996 review of treatment approaches published in the Am J Geriatr Psychiatry (1996;4[suppl 1]:S51-S65 [see ref 33]) and a chapter in A Guide to Treatments that Work  (Nathan PE, Gorman  JM,  eds),  Oxford  University  Press,  New York, 1998 [see ref 54]:. The major focus is on psy- chopharmacology, with attention also to the evi- dence for the efficacy of psychotherapeutic and somatic approaches. he treatment of depression in elderly patients can be differentiated into acute, continuation,  and maintenance phases. The treatment goals in each phase vary. The primary goal of acute treatment is to achieve symptom remission. Once a patient has improved symptom-atically, continuation phase treat- ment attempts to prevent relapse back into the same episode. The goals of maintenance treatment involve sustaining   recovery   and   preventing   recurrences. Related   treatment   objectives   include   improving longevity  and  quality  of  life,  enhancing  functional capacity, and improving general medical health status. These issues must be considered in selecting treat- ments and evaluating their outcomes. Older adults with depression require active treatment, particularly when symptoms interfere with everyday functioning. Research has generally confirmed that standard treatment approaches with proven efficacy in  younger  populations  are  likely  to  be  successful when extended to the elderly, and that old age in itself should not be considered a contraindication to their use. However, even though safe and effective treat- ments are available, nihilistic attitudes on the part of professionals  and  negative  attitudes  of  the  elderly themselves about psychiatric treatment remain barri- ers to treatment. Coexisting   factors   that   frequently   accompany advanced age—for example, comorbid medical and neurological illness, substance abuse, dementia, and cognitive impairment—are probably greater influ- ences than age itself on the effectiveness of antide- pressant treatments in elderly patients. Such comor- bidities may interfere with the modes of action of specific treatments. Conversely, effective treatment can improve outcomes of medical treatments and rehabilitation  efforts  for  physical  illness  in  the elderly, and influence survival (ie, depression is a risk factor for mortality). Finally, depression is a risk fac- tor for medical illness, and can complicate its treat- ment. Thus, there may be serious risks of not treating depression  in  physically  ill  elders  (Reynolds,  this issue, pp 95-99). Much of the treatment of depression in the elderly occurs within the primary medical health care con- text, if it occurs at all. Moreover, family members, typ- ically spouses or daughters, provide the bulk of care for older patients with mental disorders, often expe- riencing considerable stress in the process. A  high  proportion  of  patients  experiencing  an episode of major depression in late life will have had at least one previous episode, or will have a subse- quent recurrence. The literature pertaining to the long-term prevention of a recurrence of depression is discussed elsewhere in this volume (Reynolds, this issue, pp 95-99). These studies indicate that the long- term  prevention  of  new  episodes  of  disorder  in elderly patients can be best achieved by maintaining patients on the same dosage of antidepressant med- ication that was used to treat the acute episode, and by maintaining psychotherapy. Current recommen- dations are for treatment to be continued for at least 6 months after remission1 (Agency for Health Care Policy and Research [AHCPR], 1993). Newer infor- mation, however, suggests a longer treatment period may be necessary (Reynolds, this issue, pp 95 -97). Treatment of depression in late life Lon S. Schneider, MD Keywords: depression; mood disorder; late life; elderly; clinical trial; treatment; antidepressant; psychotherapy; electroconvulsive therapy Author affiliation: Professor of Psychiatry, Neurology, and Gerontology, University of Southern California School of Medicine, Los Angeles, Calif, USA Address for correspondence: Prof Lon S. Schneider, University of Southern California School of Medicine, 1975 Zonal Avenue, KAM-400, Los Angeles, CA 90033, USA
(e-mail: lschneid@hsc.usc.edu) T 1 1 3