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Am Fam Physician. 1998;58(4):953-955

Although five published meta-analysis studies and a consensus conference have concluded that pharmacologic and psychologic treatments for depression in the elderly are effective, the studies were performed on psychiatric inpatients with far more severe depression than is usually observed in the outpatient setting. McCusker and associates performed a meta-analysis to determine the effectiveness of acute pharmacologic and psychologic treatments of depression in older ambulatory patients.

A total of 40 quality ratings were performed on 37 studies (26 quality ratings were of pharmacologic treatments and 14 were of psychologic treatments). Most of the studies were performed in the United States. Among 12 comparisons of a heterocyclic drug with placebo, nine were statistically significant. Buspirone was significantly more effective than placebo in decreasing depressive symptoms, but alprazolam was not. Overall, antianxiety drugs were not significantly better than placebo and there was no significant heterogeneity. Among other randomized comparisons, significant benefits were found for fluoxetine, trazodone and phenelzine.

In the drug-drug comparisons, the mean differences were smaller than those in the placebo comparisons, and none was statistically significant. Significant heterogeneity was noted among the five comparisons of selective serotonin reuptake inhibitors (SSRIs) and heterocyclic drugs.With regard to the comparison of psychologic treatments and controls, none of the four comparisons of emotive treatments with untreated controls was significant. Five of the six comparisons of rational treatments with untreated controls were significant. Overall, rational treatments performed significantly better than untreated controls.

This meta-analysis demonstrated that in comparison with placebo, only heterocyclic drugs and SSRIs are effective in older ambulatory patients. The evidence for SSRIs is based on one study and is therefore less convincing than the evidence for heterocyclic drugs.

Most of the evidence of the effectiveness of SSRIs comes from comparisons with active treatment control subjects who received heterocyclic drugs. In the latter studies, the two classes of drugs appeared to be equally effective. However, these results must be tempered by the absence of a significant post-treatment difference in the severity of depression. Only three drug-placebo trials have been conducted in the primary care setting, only one of which found a treatment (fluoxetine) to be even marginally effective. For the psychologic treatments, rational therapies (cognitive or behavioral therapy) appeared more effective than emotive therapies. It seems that much of the effects of psychologic treatment can be attributed to the nonspecific effects of paying extra attention to older ambulatory patients during the sessions.

The authors conclude that heterocyclic antidepressants and rational psychologic therapies appear to be more effective treatments in older ambulatory patients with mild to moderate depression. Both SSRIs and heterocyclic drugs are effective, although the significance of the effectiveness is modest. Caution should be maintained because of the limitations of the quality and quantity of studies using active drug therapy, and physicians may want to consider using psychologic or attention interventions, particularly in patients with mild depressive symptoms.

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