Various psychotherapies have been adapted for treatment of late-life depression, including several forms of cognitive behavior therapy (), interpersonal psychotherapy () and psychodynamic psychotherapy (see Table Recommendations for psychotherapy in late-life MDD). One meta-analysis found that cognitive behavior therapy was an effective treatment as compared to waiting list or no-treatment control groups, but psychodynamic psychotherapy was not. Before concluding that psychodynamic psychotherapy is not a useful treatment for depressed elders, it is important to keep in mind the potential impact of the ‘allegiance effect’ to bias studies: in this case few of the studies of psychodynamic therapy were conducted or supervised by advocates of this form of treatment. Results of another meta-analysis of a broader grouping of time-limited psychotherapy studies suggested efficacy because response rates to psychotherapy were significantly higher than those observed in placebo-control groups in double-blind trials of anti-depressant medications. However, as there were no direct comparisons between psychological and pharmacological treatments included in this meta-analysis, confidence in the conclusion is limited by the simple fact that studies of psychotherapy and pharmacotherapy may enroll different types of elderly depressed patients.
Table Recommendations for psychotherapy in late-life MDD
|First||Cognitive behavior therapy and interpersonal psychotherapy for mild-to-moderate depression||Level 2|
Only a small number of controlled studies of psychotherapy in older depressed patients have included both an active comparator (pharmacotherapy) and a double-blind placebo. In the first study, patients with bereavement-related major depressive episodes were randomly assigned to either an antidepressant or a psychotherapy, singly or in combination. Overall, nor-triptyline was significantly more effective than placebo, whereas interpersonal psychotherapy was not. The combination tended to be more effective than nortriptyline alone. In the second study, patients who were depressed following myocardial infarction were randomized to either citalopram or placebo and to either interpersonal psychotherapy or clinical management using a factorial design. After 12 weeks of study therapy, the effects of the selective serotonin reuptake inhibitor (SSRI) were clinically and statistically significant; non-significant trends actually favored clinical management alone over interpersonal psychotherapy. In the only relevant published placebo-controlled study of treatment of late-life dysthymia and minor depression, a study based in primary care comparing paroxetine and problem-solving therapy, results overall favored the pharmacotherapy. However, the inconsistency of the effect of this brief psychosocial intervention was noteworthy, varying from the least to the most effective treatment group across the clinical sites of the trial.
Reynolds and colleagues have conducted the only long-term studies evaluating the role of interpersonal psychotherapy, alone and in combination with antidepressants, for the prevention of recurrent depression in later life. The first study, which utilized nortriptyline, was open to patients aged 60 and older. The second study, which used paroxetine, was limited to patients 70 and older. In both trials patients had initially received acute-phase therapy with the combination of interpersonal psychotherapy and antidepressants, and did not relapse during four months of continuation therapy. The randomized experiments thus did not begin until patients had fully recovered from the index episode of depression. In both studies, patients who were withdrawn from both medication and psychotherapy had the poorest outcomes, with those remaining on both therapies having the lowest risk of recurrence. In the first study, the advantage of combined treatment (as compared to the monotherapies) was particularly evident among those patients aged 70 and above, who were less likely to remain well on monotherapies than the patients aged 60-69. In the second study, interpersonal psychotherapy did not perform as well as in the first; patients on interpersonal psychotherapy alone were nearly as likely to suffer recurrences as patients on placebo.
The need for maintenance treatment after successful antidepressant therapy in the elderly is at least as important as it is for younger adults. Moreover, elderly patients may be even more likely to relapse after discontinuing antidepressants, so most antidepressant responders should receive maintenance pharmacotherapy for at least two years (). In a four-year outcome study of elderly patients with major depressive disorder, higher anxiety scores at the time of response and longer time to treatment response were risk factors for recurrence. Therefore, treatment of residual anxiety symptoms may improve the long-term treatment outcome.
With one exception, controlled studies of the SSRIs have documented sustained efficacy. There are few studies to compare the effectiveness of specific maintenance treatments in the elderly, and none specifically contrasting various types of newer antidepressants (e.g. SSRI vs. SNRI) and none comparing a newer antidepressant against an older standard such as nortriptyline. Phenelzine was superior to nortriptyline in a placebo-controlled, one-year maintenance study of elderly patients with depression, although high dropout rates compromised this study. As noted earlier, there is evidence from the first study of Reynolds and colleagues that nortriptyline is an effective maintenance pharmacotherapy, especially at higher serum levels and in combination with interpersonal psychotherapy. The TCA dosulpin has also been shown to be effective for prevention of recurrent depression in late-life depression.
Electroconvulsive therapy (ECT)
Electroconvulsive therapy (ECT) is a safe, rapidly effective and well-tolerated treatment for severe forms of major depressive disorder (). It has been repeatedly shown to be a useful treatment in late-life depression, even in the presence of significant medical comorbid conditions. In some regions, electroconvulsive therapy is used preferentially for the treatment of patients who are less able to tolerate prolonged response times to pharmacotherapy (i.e. intensely suicidal patients or those who are essentially starving to death from disinterest in food). electroconvulsive therapy is the treatment of first choice for severe depressive episodes with psychotic features, and should always be considered when multiple antidepressant trials have been ineffective. Good electroconvulsive therapy practice in the elderly requires careful pre-anesthetic medical consultation and management, minimization of concomitant pharmacotherapy that may adversely affect cognition and vigilant monitoring of intra- and post-ECT cardiac status.
Factors influencing the choice of bilateral versus unilateral electrode placement are similar to those in younger groups, balancing the higher probability of response, fewer missed seizures (and thus less required exposure to anesthetics) and longer times to relapse in bilateral placements with correspondingly greater likelihood of confusion, memory impairment or delirium.
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