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Depressed Elderly Need Ongoing Care

Many older patients will relapse after treatment ends, study finds

WEDNESDAY, March 15, 2006 (HealthDay News) -- The longest study of its kind finds that medical treatment of depression in the elderly may not be a short-term proposition.

That's because depression tended to return after older patients completed the six-to-12-month course of antidepressants psychiatrists typically give to people suffering from the illness, researchers report in the March 16 issue of the New England Journal of Medicine.

Short-term antidepressant therapy is "really not good enough" when it comes to treating many elderly patients, said lead researcher Dr. Charles F. Reynolds III, a professor of geriatric psychiatry at the University of Pittsburgh School of Medicine.

Instead, he said, "people need to be offered antidepressant medication for at least two years beyond the end of the episode in order to stay well."

The study was funded by grants from the U.S. National Institute for Mental Health and the National Center for Minority Health and Health Disparities.

Reynolds said depression among the elderly is "a major public health problem in a graying America." Up to 10 percent of elderly people living in the community may be afflicted with the illness, he said, and that number rises to 25 percent among nursing-home residents. While depression is linked to physical ailments, the two are not always connected, Reynolds said.

Treatment of a first episode of depression usually involves an antidepressant -- typically one of the selective serotonin reuptake inhibitor (SSRI) class of drugs that includes Celexa, Paxil, Prozac and Zoloft, among others. Patients are usually placed on one of these drugs for between six months to a year.

Reynold's group tested the long-term effectiveness of this strategy, as well as a non-drug approach, psychotherapy, in a group of 116 patients over 70 years of age. The researchers tracked the mental health of participants for two years after the onset of depression. More than half (55 percent) had consulted their doctors after experiencing their first-ever bout of depression.

Patients received either Paxil (paroxetine) or a placebo, plus either psychotherapy or "clinical management" -- in which patients discussed their symptoms but received no psychotherapy.

The result: Within two years after first treatment, depression recurred frequently in all the groups studied. However, rates of relapse were highest among those taking psychotherapy or clinical management alone (68 percent and 58 percent, respectively), and much lower (35 percent) among those taking Paxil plus psychotherapy or clinical management.

Still, a 35 percent relapse rate is troubling, and higher than that seen in younger populations, Reynolds said.

The findings suggest that "even first episodes of depression in old age represent the appearance of a chronic, recurring illness," he said. "We need to take that perspective with our patients and their families, and offer them appropriate treatment."

That "appropriate treatment" most likely involves SSRI therapy, Reynolds added. Although his group used Paxil, "there's no reason to think that other SSRIs wouldn't perform equally well in the same context." The vast majority of patients who ended up taking Paxil for the full two years of the study showed no side effects, although a few did drop out after experiencing minor discomfort with the drug.

The Pittsburgh trial emphasizes "the importance of maintenance treatment for depression in late life," said Dr. Burton Reifler, a professor of psychiatry at Wake Forest University School of Medicine, and author of an accompanying editorial.

Praising the Pittsburgh study, he noted that "there hasn't been a follow-up that long in any previous controlled trial." While it's too early to make a "hard-and-fast rule" about the length of time elderly patients may need to be placed on antidepressants, Reifler said the findings should prompt doctors to ask the question, "'Do [many] individuals with depression in late life need to be on medication indefinitely?'"

He said the findings won't come as a total surprise to those who care for the elderly. "Many psychiatrists have already been treating their elderly patients longer," he said, "because clinically, anecdotally, we've seen exactly what this study reports -- that the risk of recurrence is very, very high."

Just why the elderly are more vulnerable than younger patients to relapse remains a mystery, the experts said. And Reynolds stressed that psychotherapy and other non-medical interventions -- such as exercise and an improved social life -- may still have a vital role to play in battling depression at any age.

The Pittsburgh expert also stressed that, overall, the news from the study is "really good," given the effectiveness of antidepressant medications.

"Treatment works, not only to get people well, but to keep them well," he said.

More information

For more on depression and the elderly, visit the U.S. National Institute on Aging.

SOURCES: Charles F. Reynolds III, M.D., professor, geriatric psychiatry, University of Pittsburgh School of Medicine; Burton Reifler, M.D., M.P.H., professor, psychiatry, Wake Forest University School of Medicine, Winston-Salem, N.C.; March 16, 2006, New England Journal of Medicine
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