Psychiatr News February 1, 2008
Volume 43, Number 3, page 19
© 2008 American Psychiatric Association
Age of Onset Doesn't Affect Treatment Response in Elderly
Jun Yan
While depression in some elderly patients may have distinctive vascular
causes, they can achieve recovery through the same treatment approach used for
patients with more "typical" depression.
Elderly patients who have their first episode of major depression late in
life may differ from those with early-onset depression in disease pathology,
but their responses to antidepressant treatment appear similar, a group of
University of Texas researchers concluded after parsing data from the large
Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.
Among the participants in the STAR*D study, the authors focused on 574 who
were 55 to 75 years old with a diagnosis of major depression. They compared
the patients (72 percent) who had their first depressive episode at or before
age 55 (early-onset depression) and the patients who had their first episode
after age 55 (late-onset depression) (28 percent), and found that both groups
had similar outcomes after getting up to 14 weeks of treatment with
citalopram. The dosage of citalopram was adjusted according to the study
protocol for all
participants.
The percentage of patients who achieved remission was similar in both types
of patients (see chart), as were several other clinical measurements, such as
rates of response, percent change from baseline in standardized depression
assessment score, and time to remission. There were, however, some subtle
differences between elderly patients with early- and late-onset depression.
Patients in the early-onset group reported that their first depressive episode
occurred on average at 31 years old, and thus they had lived with the illness
for decades; the late-onset group reported that their first episode occurred
around age 62. The early-onset group also had a higher proportion of comorbid
social phobia and posttraumatic stress disorder than the late-onset group.
The authors also noted that the average citalopram dose at the end of the
study was statistically significantly higher in the early-onset patients than
the late-onset patients, with the actual mean doses at 39.2 mg versus 35.7 mg,
respectively.
Previous research has suggested that depression emerging later in life may
be related to vascular changes in the brain and different from the etiology of
the early-onset type, according to the authors. Such changes, however, do not
seem to affect the treatment of elderly patients with depression and their
outcomes.
"The findings should inspire some enthusiasm for clinicians to treat
depression aggressively and keep at it," said Robert Roca, M.D., chair
of APA's Council on Aging and vice president and medical director of Sheppard
Pratt Health System. He cited past research indicating that patients with
cerebral vascular diseases, especially after a stroke, are at heightened risks
for depression.
"There has been a presumption that these patients with late-onset
depression might be less responsive to treatment for mood disorder." He
believes physicians should maintain "an expectation of recovery or
remission for their patients" despite the vascular aspects of the
disorder as the study findings support the effectiveness of antidepressant
treatment.
Roca also emphasized that treating elderly patients for depression requires
a comprehensive approach and collaboration with the patient's primary care
physician, specialists, and caregivers.
"We must employ other modalities and be mindful of comorbidities such
as pain and medical conditions that can be very demoralizing for the
patient," he said. "In these elderly patients, the social network
and connection with other people are particularly important to their
psychiatric recovery."
To achieve optimal outcomes, he recommended that psychiatrists attend to
patients' psychosocial needs and make appropriate interventions in addition to
pharmacological treatment.
The study was funded by grants from the National Institute of Mental Health
and published in the January American Journal of Geriatric
Psychiatry.
An abstract of "Treatment Outcomes for Older Depressed
Patients With Earlier Versus Late Onset of First Depressive Episode" is
posted at
<www.ajgponline.org/cgi/content/abstract/16/1/58>.
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American Psychiatric Association.
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