Hostname: page-component-586b7cd67f-l7hp2 Total loading time: 0 Render date: 2024-11-22T12:54:41.603Z Has data issue: false hasContentIssue false
  • English
  • Français

Treatment-resistant Depression in Late Life

Published online by Cambridge University Press:  07 November 2014

Alastair J. Flint
Get access Rights & Permissions [Opens in a new window]

Abstract

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.

Type
Feature Articles
Information
CNS Spectrums , Volume 7 , Issue 10: Geriatric Psychiatry: Emerging Concepts , October 2002 , pp. 733 - 738
Copyright
Copyright © Cambridge University Press 2002

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Flint, AJ. Choosing appropriate antidepressant therapy in the elderly:a risk-benefit assessment of available agents. Drugs Aging. 1998;13:269–280.CrossRefGoogle ScholarPubMed
2.Georgotas, A, McCue, RE, Hapworth, W, et al.Comparative efficacy and safety of MAOIs versus TCAs in treating depression in the elderly. Biol Psychiatry. 1986;21:1155–1166CrossRefGoogle ScholarPubMed
3.Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62CrossRefGoogle ScholarPubMed
4.Doraiswamy, PM, Khan, ZM, Donahue, RM, Richard, NE. Quality of life in geriatric depression. A comparison of remitters, partial responders, and nonresponders. Am J Geriatr Psychiatry. 2001;9:423–428CrossRefGoogle ScholarPubMed
5.Paykel, ES, Ramana, R, Cooper, Z, et al.Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25:1171–1180CrossRefGoogle ScholarPubMed
6.Souery, D, Amsterdam, J, de Montigny, C, et al.Treatment resistant depression: methodological overview and operational criteria. Eur Neuropsychopharmacol. 1999;9:83–91CrossRefGoogle ScholarPubMed
7.Thase, ME, Rush, AJ, Kasper, S, et al.Tricyclics and newer antidepressant medications: treatment options for treatment-resistant depressions. Depression. 1994/1995;2:152–168CrossRefGoogle Scholar
8.Flint, AJ, Eastwood, MR. Frontal lobe syndrome and depression in old age. J Geriatr Psychiatry Neurol. 1988;1:53–55CrossRefGoogle ScholarPubMed
9.Burke, WJ, Roccaforte, WH, Wengel, SP, et al.Disagreement in the reporting of depressive symptoms between patients with dementia of the Alzheimer type and their collateral sources. Am J Geriatr Psychiatry. 1998;6:308–319CrossRefGoogle ScholarPubMed
10.Brodaty, H, Luscombe, G, Parker, G, et al.Increased rate of psychosis and psychomotor change in depression with age. Psychol Med. 1997; 27:1205–1213.CrossRefGoogle ScholarPubMed
11.Parker, G, Roy, K, Hadzi-Pavlovic, D, et al.Psychotic (delusional) depression: a meta-analysis of physical treatments. J Affect Disord. 1992;24:17–24.CrossRefGoogle ScholarPubMed
12.American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(suppl 4):1–45.Google Scholar
13.Guscott, R, Grof, P. The clinical meaning of refractory depression: a review for the clinician. Am J Psychiatry. 1991;148:695–704.Google ScholarPubMed
14.Harvey, AT, Preskorn, SH. Mechanism of action of venlafaxine in normal male volunteers. Clin Pharmacol Ther. 1997;61:175.Google Scholar
15.Abdelmawla, A, Langley, RW, Szabadi, E, et al.Comparison of venlafaxine, desipramine and paroxetine on the dorsal hand vein in man. J Psychopharmacol 1997;11(suppl 3):A28.Google Scholar
16.Quitkin, FM. The importance of dosage in prescribing antidepressants. Br J Psychiatry. 1985;147:593–597CrossRefGoogle ScholarPubMed
17.Flint, AJ. Management of anxiety in late life. J Geriatr Psychiatry Neurol. 1998;11:194–200.CrossRefGoogle ScholarPubMed
18.Lawrenson, RA, Tyrer, F, Newson, RB, et al.The treatment of depression in UK general practice: selective serotonin reuptake inhibitors and tricyclic antidepressants compared. J Affect Disord. 2000;59:149–157.CrossRefGoogle ScholarPubMed
19.Demyttenaere, K. Compliance during treatment with antidepressants. J Affect Disord. 1997;43:27–39.CrossRefGoogle ScholarPubMed
20.Kornstein, SG, Schneider, RK. Clinical features of treatment-resistant depression. J Clin Psychiatry 2001;62(suppl 16):18–25.Google ScholarPubMed
21.Baldwin, RC, Simpson, S. Treatment resistant depression in the elderly: a review of its conceptualisation, management and relationship to organic brain disease. J Affect Disord. 1997;46:163–173.CrossRefGoogle ScholarPubMed
22.Alexopoulos, GS. The depression-executive dysfunction syndrome of late life. A specific target for D3 agonists? Am J Geriatr Psychiatry. 2001;9:22–29.Google ScholarPubMed
23.Reifler, BV, Teri, L, Raskind, M, et al.Double-blind trial of Imipramine in Alzheimer's disease patients with and without depression. Am J Psychiatry. 1989;146:45–49.Google ScholarPubMed
24.Petracca, GM, Chemerinski, E, Starkstein, SE. A double-blind, placebo-controlled study of fluoxetine in depressed patients with Alzheimer's disease. Int Psychogeriatr. 2001;13:233–240.CrossRefGoogle ScholarPubMed
25.Fava, GA, Savron, G, Grandi, S, et al.Cognitive-behavioural management of drag-resistant major depressive disorder. J Clin Psychiatry. 1997;58:278–282.CrossRefGoogle Scholar
26.Fava, M. Augmentation and combination strategies in treatment-resistant depression. J Clin Psychiatry. 2001;62(suppl 18):4–11.Google ScholarPubMed
27.Bauer, M, Doffmer, S. Lithium augmentation in treatment-resistant depression: meta-analysis of placebo-controlled studies. J Clin Psychopharmacol. 1999;19:427–434.CrossRefGoogle ScholarPubMed
28.Joffe, RT, Singer, W, Levitt, AJ, et al.A placebo-controlled comparison of lithium and triiodothyronine augmentation of tricyclic antidepressants in unipolar refractory depression. Arch Gen Psychiatry. 1993;50:387–393.CrossRefGoogle ScholarPubMed
29.Gitlin, MJ, Weiner, H, Fairbanks, L, et al.Failure of T3 to potentiate tricyclic antidepressant response. J Affect Disord. 1987;13:267–272.CrossRefGoogle ScholarPubMed
30.Shelton, RC, Tollefson, GD, Tohen, M, et al.A novel augmentation strategy for treating resistant major depression. Am J Psychiatry. 2001;158:131–134.CrossRefGoogle ScholarPubMed
31.Landen, M, Bjorling, G, Agren, H, et al.A randomized, double-blind, placebo-controlled trial of buspirone in combination with an SSRI in patients with treatment-refractory depression. J Clin Psychiatry. 1998;59:664–668.CrossRefGoogle ScholarPubMed
32.Appelberg, BG, Syvalahti, EK, Koskinen, TE, et al.Patients with severe depression may benefit from buspirone augmentation of selective serotonin reuptake inhibitors: results from a placebo-controlled, randomized, double-blind, placebo wash-in study. J Clin Psychiatry. 2001;62:448–452.CrossRefGoogle ScholarPubMed
33.Moreno, FA, Gelenberg, AJ, Bachar, K, et al.Pindolol augmentation of treatment-resistant depressed patients. J Clin Psychiatry. 1997;58:437–439.CrossRefGoogle ScholarPubMed
34.Perez, V, Soler, J, Puigdemont, D, Alvarez, E, et al.A double-blind, randomized, placebo-controlled trial of pindolol augmentation in depressive patients resistant to serotonin reuptake inhibitors. Arch Gen Psychiatry. 1999;56:375–379CrossRefGoogle ScholarPubMed
35.Fava, M, Rosenbaum, JF, McGrath, PJ, et al.Lithium and tricyclic augmentation of fluoxetine treatment for resistant major depression: a double-blind controlled study. Am J Psychiatry. 1994;151:1372–1374.Google ScholarPubMed
36.Katona, CLE, Abou-Saleh, MT, Harrison, DA, et al.Placebo-controlled trial of lithium augmentation of fluoxetine and lofepramine. Br J Psychiatry. 1995;166:80–86.CrossRefGoogle ScholarPubMed
37.Flint, AJ. Augmentation strategies in geriatric depression. Int J Geriatr Psychiatry. 1995;10:137–146.CrossRefGoogle Scholar
38.Bauer, M, Bschor, T, Kunz, D, et al.Double-blind, placebo-controlled trial of the use of lithium to augment antidepressant medication in continuation treatment of unipolar major depression. Am J Psychiatry. 2000;157:1429–1435.CrossRefGoogle ScholarPubMed
39.Fahy, S, Lawlor, BA. Discontinuation of lithium augmentation in an elderly cohort. Int J Geriatr Psychiatry. 2001;16:1004–1009.CrossRefGoogle Scholar
40.Posternak, MA, Zimmerman, M. Switching versus augmentation: a prospective, naturalistic comparison in depressed, treatment-resistant patients. J Clin Psychiatry. 2001;62:135–143.CrossRefGoogle ScholarPubMed
41.Flint, AJ, Rifat, SL. The effect of sequential antidepressant treatment on geriatric depression. J Affect Disord. 1996;36:95–105.CrossRefGoogle ScholarPubMed
42.Georgotas, A, Friedman, E, McCarthy, M, et al.Resistant geriatric depressions and therapeutic response to monoamine oxidase inhibitors. Biol Psychiatry. 1983;18:195–205.Google ScholarPubMed
43.Joffe, RT, Levitt, AJ, Sokolov, ST, Young, LT. Response to an open trial of a second SSRI in major depression. J Clin Psychiatry. 1996;57:114–115.Google Scholar
44.Thase, ME, Blomgren, SL, Birkett, MA, et al.Fluoxetine treatment of patients with major depressive disorder who failed initial treatment with sertraline. J Clin Psychiatry. 1997;58:16–21.CrossRefGoogle ScholarPubMed
45.Prudic, J, Haskett, RF, Mulsant, B, et al.Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry. 1996;153:985–992.Google ScholarPubMed
46.Sackeim, HA, Prudic, J, Devanand, DP, et al.A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry. 2000;57:425–434.CrossRefGoogle ScholarPubMed
47.Flint, AJ, Rifat, SL. The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT. Int J Geriat Psychiatry. 1998;13:23–28.3.0.CO;2-J>CrossRefGoogle ScholarPubMed
48.Pascual-Leone, A, Rubio, B, Pallardo, F, et al.Rapid-rate transcranial magnetic stimulation of left dorsolateral prefrontal cortex in drug-resistant depression. Lancet. 1996;348:233–237.CrossRefGoogle ScholarPubMed
49.Loo, C, Mitchell, P, Sachdev, P, et al.Double-blind controlled investigation of transcranial magnetic stimulation for the treatment of resistant major depression. Am J Psychiatry. 1999;156:946–948.CrossRefGoogle ScholarPubMed
50.Padberg, F, Zwanzger, P, Thoma, H, et al.Repetitive transcranial magnetic stimulation (rTMS) in pharmacotherapy-refractory major depression: comparative study of fast, slow and sham rTMS. Psychiatr Res. 1999;88:163–171CrossRefGoogle ScholarPubMed
51.Sackeim, HA, Rush, AJ, George, MS, et al.Vagus nerve stimulation (VNS) for treatment-resistant depression: efficacy, side effects, and predictors of outcome. Neuropsychopharmacology. 2001;25:713–728CrossRefGoogle ScholarPubMed
52.Little, JT, Reynolds, CF, Dew, MA, et al.How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? Am J Psychiatry. 1998;155:1035–1038.CrossRefGoogle ScholarPubMed
53.Keller, MB, Boland, RJ. Implications of failing to achieve successful long-term maintenance treatment of recurrent unipolar major depression. Biol Psychiatry. 1998;44:348–360.CrossRefGoogle ScholarPubMed