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Psychotherapy, medication best Rx for senior depression
Wednesday, January 06, 1999 By Diana Block, Post-Gazette Staff Writer
Depression is increasingly recognized as a chronic condition, one that aggravates other ailments and can even hasten death, especially in the elderly.
A new study has found that older patients in particular need extensive maintenance treatment after recovering from depression to prevent relapses - follow-up that is rarely offered by most doctors.
Researchers from the University of Pittsburgh Medical Center have found that a combination of interpersonal psychotherapy and medication can best keep seniors' depression at bay. Their study, published in today's Journal of the American Medical Association, is the first to focus on keeping older adults mentally healthy once they have been treated for a major episode of depression.
"I think the note here is a very hopeful one, particularly for long-term treatment," said Dr. Charles Reynolds, professor of psychiatry and neuroscience at the Western Psychiatric Institute and Clinic.
Reynolds and eleven of his colleagues followed 107 adults over age 60 who had been successfully treated for depression. The patients were randomly assigned to one of four maintenance plans.
One group was given the anti-depressant nortriptyline, also known as Pamelor, and monthly psychotherapy sessions. Other groups either took placebos and underwent psychotherapy, took nortriptyline and went to a medical clinic, or took placebos and went to a medical clinic.
Under normal conditions, 25 to 33 percent of elderly patients are still well three years after treatment for depression. In the UPMC study, 80 percent of the patients taking nortriptyline and undergoing monthly psychotherapy had not suffered a recurrence of depression after three years.
Fifty-seven percent of those taking nortriptyline and attending a medical clinic remained well. But only 36 percent of those taking a placebo and receiving psychotherapy, and 10 percent of those taking a placebo and visiting a medical clinic had not experienced recurrences of depression.
Although the study found that long-term combination treatment was most effective, only a small minority of elderly patients are treated this way.
"Most of the really great depressions are treated in primary care practice, not by specialists. And there are several studies which have shown that the primary care physicians may miss depression, or may not diagnose depression, in a significant number of cases," said Dr. Dilip Jeste, president of the American Association for Geriatric Psychiatry.
"When it is treated, it is usually acute treatment, which means giving some medication. And there is rarely a follow-up to that," he added.
While past studies have shown that medication can effectively treat depression, the UPMC researchers were surprised to confirm how important psychotherapy was to elderly patients. Older adults were not as strongly affected by the medication as younger people, so the interpersonal treatment was more significant.
For the many older adults who already take an average of six medications, Reynolds said, another pill for preventive purposes may not sound too good. But correct treatment of depression could lessen not only the number of pills but also the impact of other illnesses.
"Many older adults with unrecognized depression in fact wind up receiving a larger amount of medication than they otherwise would," Reynolds said. "We think that if the depression is recognized and adequately treated, the vague, somatic complaints will go away."
As the number of the oldest and frailest adults burgeons in the next thirty years, long-term strategies will become increasingly important, Jeste said. He said studies had also shown that older baby boomers may experience more late-life depression than the current generation of elderly.
In spite of the growing needs for longer and better care, care givers have resisted more time-intensive, long-term solutions to depression.
"Mental health care is often carved out of a number of managed care programs, so unless the specific managed care program is particularly attuned to health care needs, a patient has really limited access" to the kind of therapy found most effective in the UPMC study, Jeste said.
The National Institute of Health is funding a second study to test the prevention potential of a less reactive medication, called paroxetine or Paxil, on adults over the age of 70. To learn more, or to find out how to participate in the maintenance therapies study in late life depression, call 412-624-1886.
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