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Am Fam Physician. 2004;70(6):1162

Depression is common among older adults with comorbid illnesses, especially cardiovascular disease. There is evidence that comorbidity and depression lead to increased morbidity, mortality, and health care costs. Selective serotonin reuptake inhibitors (SSRIs) have been used to treat depression in elderly patients and appear to be well tolerated. Few trials have evaluated the benefit of SSRIs in patients with comorbidities. Sheikh and colleagues conducted an eight-week, double-blind, placebo-controlled study to assess the benefits of sertraline in patients with one of three categories of comorbid medical conditions: vascular disease, diabetes, and arthritis.

The study divided 442 subjects with major depression into one of the three comorbidity groups. The vascular disease group included patients with hypertension alone, and those with manifested peripheral, cerebrovascular, or cardiovascular disease without hypertension. The study also included a so-called “none-plus” group of 159 patients without one of the three comorbidities, but with evidence of recent general ill health as suggested by current prescriptions or recent hospitalization. A third arm of the study included 127 patients who had no comorbidities. Primary outcome measures were the Hamilton Depression Scale (HAMD) and quality-of-life scores on the Clinical Global Impression—Severity/Improvement (CGI-S/CGI-I) assessment. All patients received sertraline or placebo. Adverse events and a medical outcomes scale also were included in the assessment.

Treatment with sertraline was associated with significantly greater improvements in all primary outcomes compared with placebo. Patients with diabetes and arthritis had rates of improvement equivalent to rates in those without these chronic conditions. In the vascular group, as evidenced by the HAMD score, the group with manifested vascular disease benefited most from sertraline compared with those with hypertension or no vascular disease. In patients with a comorbidity, patients taking sertraline improved faster than patients taking placebo. When each treatment group was divided into two subgroups based on presence or absence of comorbidity, there was no significant difference between groups, suggesting that sertraline is equally efficacious whether or not comorbidities are present. Adverse effects and discontinuation rates were similar to those occurring in younger adults. Patients taking sertraline were less likely to discontinue treatment if they had a comorbidity than if they had no comorbidity.

This study supports the hypothesis that an SSRI such as sertraline is efficacious, safe, and well tolerated in the treatment of older patients with depression and comorbidities. The authors conclude that patients treated with sertraline show a statistically significant greater improvement in all three outcome measures compared with patients taking placebo. Further analysis also found that sertraline is efficacious in treatment of late-life depression regardless of comorbidity status. Patients with evidence of cardiac, cerebral, or peripheral vascular pathology showed greater benefit than those with hypertension or no vascular pathology.

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