Older Patients with Depression Respond to Augmentation

PITTSBURGH, June 1 -- Adding another drug when older patients don't respond well to an initial course of antidepressants may be of benefit, researchers here suggested.

Half of depressed patients age 70 and older who had an inadequate initial response to treatment with a selective serotonin reuptake inhibitor (SSRI) recovered from depression after treatment was augmented with another drug, reported Mary Amanda Dew, Ph.D., and colleagues, of the University of Pittsburgh.

In addition, two-thirds of patients who received augmentation after an early relapse also recovered, the authors wrote in the June issue of the American Journal of Psychiatry.

"In young and middle-aged adults, a growing body of work suggests that augmentation can play an important role in optimizing antidepressant response, symptom relief and recovery from major depression," the authors wrote.

"In contrast," they noted, "little systematic work has examined progress toward recovery in older adults receiving augmentation, especially in the context of newer antidepressants, such as selective serotonin reuptake inhibitors and dual-reuptake inhibitors."

To see whether older adults might also benefit from augmentation, the authors monitored depression levels in an open-label study. The study sample included 128 women and 67 men age 70 and older (mean age 77.1 + 5.6 years).

The patients all had current, non-delusional unipolar major depressive disorder, determined by the Structured Clinical Interview for DSM-IV, and a score of 15 or higher on the 17-item version of the Hamilton Depression Rating Scale, 17 or higher on the Mini-Mental State Examination, and no evidence of substance abuse within the past six months.

The patients were treated with paroxetine (Paxil) at an initial dose of 10 mg per day, titrated over eight weeks to a maximum of 40 mg/day. They also received weekly psychotherapy until they achieved a clinical response, defined as a Hamilton Depression Scale score of 10 or less for three consecutive sessions, and then biweekly for 16 weeks of continued treatment.

Patients who had an inadequate response or clinical relapse were then offered augmentation with bupropion (Wellbutrin) 150 mg/day to a maximum of 400 mg/day. If that didn't work, they were then offered, in order, nortriptyline (Aventyl, Pamelor) to maintain a plasma level of 80 to 120 ng/liter or lithium titrated to a plasma level of 0.5 to 0.7 meq/liter.

The researchers found that 105 patients (53.8%) required augmentation at a mean of 12.7 weeks. The reason for adding the second drug was inadequate treatment response in 77 patients and relapse in 28 patients.

In all, 69 patients went on to augmentation, with the remainder either withdrawing or having comorbid medical conditions that precluded augmentation.

Half of patients on augmentation because of inadequate response to paroxetine recovered during the treatment period, as did 66.7% of those who received it after a relapse. The recovery rate among patients who never needed augmentation was 86.7%.

Recovery was slower among those patients with an initial inadequate response, and among patients with clinically significant anxiety symptoms and a higher general medical burden. The odds ratio for a slower recovery among patients with anxiety was 2.33 (P