Pharmacological and Psychological Treatments for Depressed Older Patients: A Meta-analysis and Overview of Recent Findings

Abstract

A meta-analysis was carried out to evaluate data published between January 1974 and February 1998 comparing rates of treatment response and tolerability of pharmacological and psychological treatments for depression in persons over age 55. Drugs (tricyclic antidepressants, selective serotonin-reuptake inhibitors, and a mixed group of other drugs) were significantly better than placebo, with an average reduction in symptom severity of 48.0% versus 31.3% (analysis weighted by sample size; 50.6% vs. 21.4% unweighted). No single drug or group of drugs was superior in terms of efficacy, and no statistically significant differences in tolerability emerged between tricyclic antidepressants and selective serotonin-reuptake inhibitors, whether measured by total dropouts or by dropouts due to side effects. Compared to the data on pharmacological treatments, those for outcomes of psychological treatments are very limited. Existing data indicate that cognitive-behavioral, behavioral, and psychodynamic therapies are significantly better than placebo. In the current meta-analysis, response rates to these nondrug therapies did not differ significantly from those observed with tricyclic antidepressants or selective serotonin-reuptake inhibitors, but direct comparison data are insufficient for firm conclusions to be drawn about comparative efficacy. It is possible, even likely, that not only different subtypes of depression but also different patients vary in their treatment responses. However, lack of adequate data prevented the current meta-analysis from addressing these issues. Rigorously designed prospective studies on treatment outcome, taking into account the above differences, are urgently needed to provide robust data on which to base clinical recommendations for the treatment of depression in older patients.

Psychological Therapy for Depression and Anxiety in Older Adults

“…While meta-analyses reported thus far have considered psychosocial treatments, Gerson et al (1999) investigated the effectiveness of pharmacological and psychological treatments for depression in older people. Gerson et al (1999) reviewed 45 studies published from 1974 to 1998.…”

“…Gerson et al (1999) reviewed 45 studies published from 1974 to 1998. Four of these used non-drug (psychological) methods of treatment for depression in later life.…”

“…All patients were diagnosed with major depressive disorder and to be included in the analyses had to report outcomes using observer-rated data as well as self-report. Gerson et al (1999) also used stricter inclusion criteria for their analyses, such as a minimum of 15 patients in each treatment group, description of dose regime in both treatment and control groups, documentation of side-effects by self-report or questionnaire, specification of attrition rates and, lastly, statistical evaluation. Using the stricter criteria reduced the number of studies entered into the meta-analysis to 28, two of which used psychological methods of treatment.…”

“…Analyses also revealed no significant difference in attrition rates between pharmacological and psychological treatments (29.2 % and 29.4 % respectively). Gerson et al (1999) noted that both pharmacotherapy and psychotherapy were superior to placebo. In a very well written and thoughtful conclusion Gerson et al (1999) state Effective psychological interventions constitute a much-needed addition to antidepressant medication for depressed older patients, particularly in light of these patients' high prevalence of medical problems, their use of multiple medications, their increased sensitivity to adverse drug effects, and the many psychological stresses to which they are exposed.…”

“…Cognitive-behaviour therapy alone is a good treatment alternative for those patients who cannot tolerate medication, or for those older adults who do not wish to be prescribed antidepressants. For more severe levels of depression, there is evidence that CBT in combination with adequate dosages of medication constitutes an appropriate treatment regime (Gerson et al, 1999;Thompson et al, 2001). The main criticism is that the evaluations of individual CBT have mainly been carried out on healthy, community-dwelling older adults who are mainly young-old rather than old-old.…”