Am Fam Physician. 1999 May 1;59(9):2589a-2592.
Depression is common in old age, affecting an estimated one in six elderly patients in medical practice and even more in nursing homes and hospitals. The risk of recurrence is higher if the first episode of depression occurs in old age. To study the effectiveness of measures to prevent recurrent depression in the elderly, Reynolds and colleagues conducted a randomized, placebo-controlled trial to compare the effects of nortriptyline, interpersonal psychotherapy and a combination of the two on the prevention of recurrence of major depression in the elderly.
The study included 107 patients who were 60 years of age or older and had been diagnosed as having unipolar major depression. This also had to be at least their second lifetime episode of major depression. The study patients were selected from a group of 180 patients who were enrolled in a study of the acute treatment of depression. The 107 patients continued their participation in the study during the maintenance therapy phase, after depression had been in remission for 16 weeks. There were 69 patients who were 60 to 69 years of age and 38 patients who were 70 years of age or older.
Patients enrolled in the maintenance phase of the study were randomized to one of four treatment groups: nortriptyline plus medication clinic visits (where symptoms and adverse effects were assessed); placebo plus medication clinic visits; monthly interpersonal psychotherapy sessions plus nortriptyline; or monthly psychotherapy sessions plus placebo. For those assigned to the placebo group, the active drug was tapered over a six-week period. Patients continued receiving their assigned therapy for three years or until recurrence of major depression developed. Psychotherapy consisted of 50-minute sessions with experienced psychotherapists.
Assessment of outcomes confirmed that older patients were more likely to have a recurrence of depression. In patients older than 70 years, recurrence developed during the three-year study in three of the nine patients (33 percent) who received nortriptyline and psychotherapy; in six of 11 patients (55 percent) who received nortriptyline and medication clinic visits; in five of eight patients (63 percent) who received placebo and psychotherapy; and in nine of 10 patients (90 percent) who received placebo and medication clinic visits.
In patients between 60 and 69 years of age, recurrence of depression developed in two of 16 patients (13 percent) who received nortriptyline and psychotherapy; in six of 17 patients (35 percent) who received nortriptyline and clinic visits; in 11 of 17 patients (65 percent) who received placebo and psychotherapy; and in 17 of 19 patients (89 percent) who received placebo and clinic visits.
The authors acknowledge that tricyclic antidepressants such as nortriptyline are often not prescribed for the elderly and that selective serotonin reuptake inhibitors (SSRIs) are favored over tricyclic antidepressants. Further studies are warranted to test the use of SSRIs for prevention of recurrence of major depression in the elderly. However, the long-term strategy of psychotherapy plus antidepressant medication (specifically, nortriptyline) may be a cost-effective and clinically effective method of intervention for preventing recurrence of depression in elderly patients.
Reynolds CF, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA. January 6, 1999;281:39–45.
Copyright © 1999 by the American Academy of Family Physicians.
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