Sandra L. Rifat

Anxious Depression in Elderly Patients: Response to Antidepressant Treatment

The authors asked whether elderly patients with anxious depression were less responsive to antidepressant treatment than nonanxious depressed patients. A group of 101 depressed patients were treated with 6 weeks of nortriptyline and then, if necessary, 2 weeks of adjunctive lithium. Patients who did not respond to or were intolerant of this first line of treatment were then given 6 weeks of phenelzine (+/- lithium augmentation). Finally, patients failing this second line of treatment were given either a course of electroconvulsive therapy or 6 weeks of fluoxetine (+/- lithium augmentation). Based on their score on the Hospital Anxiety and Depression Scale at index assessment, subjects were divided into anxious and nonanxious groups. Anxious depressed patients were significantly less responsive to nortriptyline on both intent-to-treat and efficacy analyses. They were also more likely to discontinue treatment and, as a result, were significantly less responsive on the intent-to-treat analysis for overall treatment. These results suggest that concurrent symptoms of anxiety have prognostic importance in geriatric depression.

The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT

Objective. Response to combination pharmacotherapy and to electroconvulsive therapy (ECT) was evaluated in elderly patients with psychotic depression.

Two-year outcome of elderly patients with anxious depression

The purpose of this study was to determine whether there was a difference in the long-term outcome between elderly patients with anxious depression and those with non-anxious depression. Eighty-three patients with non-bipolar, non-psychotic major depression who had responded to treatment of the index episode were maintained on full-dose antidepressant medication and followed on a monthly basis over a period of 2 years. Anxiety status at index assessment was not related to outcome as defined by rates of relapse and recurrence or time to these events. However, the few patients who remained anxious at the point of remission of the index episode had a significantly shorter time to relapse/recurrence. These findings suggest that, once they achieve remission and are given adequate prophylactic treatment, most older patients with anxious depression have a similar long-term outcome to patients without anxiety.

The effect of sequential antidepressant treatment on geriatric depression

This study evaluated the outcome of elderly depressed patients who were refractory to, or intolerant of, an initial trial of nortriptyline and who then underwent systematic treatment with other antidepressant therapies. 101 patients entered the study and 61% responded to nortriptyline, 64% of patients who did not improve with nortriptyline eventually responded to other antidepressant treatments. Response to second-line treatment (phenelzine) was significantly slower than response to the tricyclic antidepressant. Treatment nonresponders were more likely to have a longer episode length at index assessment and higher baseline anxiety scores compared with responders. This study demonstrates the importance of persisting with systematic antidepressant therapy in elderly patients who do not respond to the first trial of treatment.

A prospective study of lithium augmentation in antidepressant-resistant geriatric depression

This open, prospective study investigated the efficacy of lithium augmentation in elderly patients who had failed to respond to a 6-week course of antidepressant medication. Twenty-one patients (age range, 64 to 88 years) with DSM-III-R unipolar, nonpsychotic major depression refractory to a 6-week course of nortriptyline, fluoxetine, or phenelzine underwent a minimum of 2 weeks of lithium augmentation. Five patients had a complete response, 3 had a partial response, and 13 did not respond. Half of the patients developed dose-limiting side effects, most commonly neuromuscular or neurologic. Patients developing side effects were significantly older (p = 0.05), and there was a tendency for side effects to occur more frequently in patients treated with fluoxetine. The rate of response to lithium augmentation in this elderly population was lower than that reported for most open and controlled studies in younger patients. Possible reasons for this are discussed.

VALIDATION OF THE HOSPITAL ANXIETY AND DEPRESSION SCALE AS A MEASURE OF SEVERITY OF GERIATRIC DEPRESSION

The purpose of this study was to evaluate the Hospital Anxiety and Depression Scale (HAD) as a measure of severity of geriatric depression. One hundred and one elderly patients with DSM‐III‐R non‐psychotic non‐bipolar major depression were rated by the interviewing psychiatrist on the Hamilton Rating Scale for Depression (HRSD) and the Montgomery–Asberg Depression Rating Scale (MADRS) at index assessment and at the completion of treatment. In a blind fashion, patients completed the HAD at the same time points. At initial assessment, correlations between the depression subscale of the HAD (HAD‐D) and the HRSD and MADRS were 0.51 (p<0.001) and 0.54 (p<0.001) respectively, and at final assessment the correlations were 0.73 (<0.001) and 0.79 (p<0.001) respectively. The HAD‐D was also sensitive to change in the severity of depression (rs=0.58,p<0.001). These correlations were not of sufficient magnitude for the HAD‐D to be used as an alternative to the HRSD or MADRS. However, in certain circumstances, the HAD‐D may be a useful adjunct to these observer‐rated scales.

Effect of demographic and clinical variables on time to antidepressant response in geriatric depression

The authors examined the effect of demographic and clinical variables on time to treatment response in geriatric depression. One hundred and one patients, aged 60–92 years, with nonpsychotic, nonbipolar major depression were treated in an open fashion with 6 weeks of nortriptyline followed, if necessary, by 2 weeks of lithium augmentation. Univariate Cox proportional hazards analyses showed that 3 of 19 variables predicted time to response: high baseline anxiety was associated with delayed response (median of 5 weeks vs. 4 weeks for patients with low anxiety scores), whereas hospitalization for the index episode of depression and attempted suicide predicted shorter time to response. In the final multivariate Cox regression model, baseline anxiety and inpatient status were most predictive of outcome; attempted suicide did not significantly improve the predictive power of the model. Our findings strengthen existing evidence that concomitant anxiety can adversely affect the outcome of geriatric depression. Depression and Anxiety 5:103–107, 1997.