Effective low dose tricyclic antidepressant treatment for depressed geriatric rehabilitation patients. A double-blind study

Late-Life Depressive and Anxiety Symptoms Following Rehabilitation Services in Medicare Beneficiaries

OBJECTIVE

The aim of this study was to determine whether patients who received rehabilitation services had an increased risk of having late-life depressive or anxiety symptoms within the year following termination of services.

METHODS

The National Health and Aging Trends Study (NHATS) is a population-based, longitudinal cohort survey of a nationally representative sample of Medicare beneficiaries aged 65years and older. This study involved 5,979 participants from the 2016 NHATS survey. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder 2-item assessed for clinically significant depressive and anxiety symptoms.

RESULTS

The prevalence of depressive and anxiety symptoms was higher in older adults who had received rehabilitation services in the year prior and varied by site: no rehabilitation (depressive and anxiety symptoms): 10.4% and 8.8%; nursing home or inpatient rehabilitation: 38.8% and 23.8%; outpatient rehabilitation: 8.6% and 5.5%; in-home rehabilitation: 35.3% and 20.5%; multiple rehabilitation sites: 20.3% and 14.4%; and any rehabilitation site: 18.4% and 11.8%. In multiple logistic regression analyses, nursing home and inpatient and in-home rehabilitation services, respectively, were associated with an increased risk of having subsequent depressive symptoms (odds ratio: 3.51; 95% confidence interval [CI]: 1.85-6.63; OR: 2.15; 95% CI: 1.08-4.30) but not anxiety symptoms.

CONCLUSION

Older adults who receive rehabilitation services are at risk of having depressive and anxiety symptoms after these services have terminated. As mental illness is associated with considerable morbidity and may affect rehabilitation outcomes, additional efforts to identify and treat depression and anxiety in these older adults may be warranted.

Efficacy of treatment in older depressed patients: a systematic review and meta-analysis of double-blind randomized controlled trials with antidepressants

BACKGROUND

This systematic review evaluated all published double-blind, randomized controlled antidepressant trials (RCTs) of acute phase treatment of older depressed patients.

METHODS

Meta-analyses were conducted in 51 double-blind RCTs of antidepressants in older patients. The results were also compared with 29 double-blind RCTs that did not produce extractable data to enter the meta-analysis.

RESULTS

All classes of antidepressant (TCA's, SSRIs and other antidepressants) were more effective than placebo in achieving response. In achieving remission however, only pooling all 3 classes of antidepressants together showed a statistically significant difference from placebo. No differences were found in remission or response rates between classes of antidepressants. TCAs were also equally effective compared with SSRIs in achieving response in more severely depressed patients. The numbers needed to treat (NNT) were 14.4 (95% CI 8.3-50) for one additional remission to antidepressants compared with placebo and 6.7 (95% CI 4.8-10) for response. The results of the double-blind RCTs that did not produce extractable data to enter the meta-analysis were in concordance with the RCTs that were included in the meta-analysis.

LIMITATIONS

Only 4 RCTs were found that have not been published. Few studies have focused on severely depressed older people.

CONCLUSIONS

Antidepressant treatment in older depressed patients is efficacious. We could not demonstrate differences in effectiveness between different classes of antidepressants; this was also the case in more severely depressed patients.

Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy

BACKGROUND

Antidepressant drugs are widely used in the treatment of depression in people with chronic physical health problems.

AIMS

To examine evidence related to efficacy, tolerability and safety of antidepressants for people with depression and with chronic physical health problems.

METHOD

Meta-analyses of randomised controlled efficacy trials of antidepressants in depression in chronic physical health conditions. Systematic review of safety studies.

RESULTS

Sixty-three studies met inclusion criteria (5794 participants). In placebo-controlled studies, antidepressants showed a significant advantage in respect to remission and/or response: selective serotonin reuptake inhibitors (SSRIs) risk ratio (RR) = 0.81 (95% CI 0.73-0.91) for remission, RR = 0.83 (95% CI 0.71-0.97) for response; tricyclics RR = 0.70 (95% CI 0.40-1.25 (not significant)) for remission, RR = 0.55 (95% 0.43-0.70) for response. Both groups of drugs were less well tolerated than placebo (leaving study early due to adverse effects) for SSRIs RR = 1.80 (95% CI 1.16-2.78), for tricyclics RR = 2.00 (95% CI 0.99-3.57). Only SSRIs were shown to improve quality of life. Direct comparisons of SSRIs and tricyclics revealed no advantage for either group for remission, response, effect size or tolerability. Effectiveness studies suggest a neutral or beneficial effect on mortality for antidepressants in participants with recent myocardial infarction.

CONCLUSIONS

Antidepressants are efficacious and safe in the treatment of depression occurring in the context of chronic physical health problems. The SSRIs are probably the antidepressants of first choice given their demonstrable effect on quality of life and their apparent safety in cardiovascular disease.

Antidepressants for depression in physically ill people

BACKGROUND

There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill's Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context.

OBJECTIVES

To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness.

SEARCH STRATEGY

Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009.

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria.

DATA COLLECTION AND ANALYSIS

The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model.

MAIN RESULTS

Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant.

AUTHORS' CONCLUSIONS

This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.

Novel therapeutic usage of low-dose doxepin hydrochloride

Low-dose doxepin hydrochloride (1, 3 and 6 mg) is a tricyclic antidepressant currently being investigated for the treatment of primary insomnia in adult and geriatric patients. Although it has been used at much higher doses to treat depression effectively for a number of decades, it offers a unique potency and selectivity for antagonizing the H1 (histamine) receptor at low doses. This mechanism of action may prove to be advantageous compared with other medications currently approved for the treatment of insomnia. This article reviews previous clinical studies using doxepin for insomnia and the recent clinical trial data, and briefly discusses other potential roles of this compound in clinical practice.

Correlates of low-dosage treatment with antidepressants by psychiatrists and general practitioners

BACKGROUND

The prescribing of low dosages of antidepressants has for many years been a matter of concern in the scientific literature. There is a little understanding of why physicians do not follow dosage recommendations and what factors influence medical decision-making.

METHOD

In a drug utilisation observation study, treatment of 692 patients was monitored who were prescribed the tricyclic antidepressant doxepin by 80 general practitioners and 85 psychiatrists.

RESULTS

The mean maximum dosage per day was 83 mg/d. One hundred and fifty milligrams per day or more were prescribed for only 6.1% of the patients. There were significant differences between dosage groups: patients older than 65 received lower dosages (68 mg/d) as younger patients (84 mg/d), male patients higher dosages (94 mg/d) than females (79 mg/d), patients who had a mild depression with a score of 1-35 on the depression symptom scale received on average 68 mg/d, while patients with 36-74 got 100 mg/d. Physician speciality was not significantly related to dosage levels. In a logistic regression analysis, gender and Clinical Global Impression (CGI) at first examination remained factors that significantly predicted dosages of >or=125 mg/d.

CONCLUSION

Low-dosage treatment with antidepressants is a rule rather than an exception. The prescribing pattern is not indiscriminate, but physicians follow an adaptive strategy and there is medical and theoretical evidence which supports their practice. Outcome research will have to be clarified in future studies as to what extent reference to such intervening variables can help to optimise individual dosage finding.

Steroids versus other immune modulators in the management of allergic dermatoses

PURPOSE OF REVIEW

The classic role of topical and systemic corticosteroids for allergic dermatoses is discussed, with special attention to the impact on the current clinical treatment paradigm by newer systemic and topical therapies. These products are reviewed and recommendations presented on how to effectively assimilate them into clinical practice.

RECENT FINDINGS

Current knowledge about the etiopathogenesis of atopic dermatitis has resulted in drug development focused on agents with less toxicity than current topical and systemic corticosteroids. Some agents with ceramide/cholesterol/acid combinations demonstrate efficacy in restoring the dysfunctional skin barrier of atopic patients. Concerns resulting from the recent Federal Drug Administration announcement regarding a theoretical risk of cancer associated with topical calcineurin inhibitors are also addressed. Novel therapeutic entities are presented.

SUMMARY

Patients seeking relief from atopic dermatitis have historically had few really effective and safe therapeutic options. Topical calcineurin inhibitors represent an exciting new therapy for atopic dermatitis without the side-effect profile associated with topical corticosteroids. Nonsteroidal formulations incorporating glycyrrhetinic acid/telmesteine/Vitis vinifera extract and palmitoylethanolamide as 'active' ingredients recently entered the market, stressing antipruritic, antiinflammatory, and skin barrier repair. This confabulates against previously designed topical therapy paradigms. These new products may be used as monotherapy or alternatives to steroid agents.

The participation of cognitively impaired elderly in research

It is critical that cognitively impaired adults be permitted to participate in research in order to develop a greater understanding of the underlying causes of the impairments and strategies to prevent or ameliorate their impact. Significant ethical and legal issues may arise in the recruitment and enrollment of these persons as study participants, due to difficulties in understanding information, uncertainty regarding the existence of sufficient mental capacity to provide informed consent to participate, and the potential for coercion to participate as a function of limited capacity and dependence on others for care. This article explores these issues and suggests mechanisms to maximize the understanding of information and facilitate the cognitively impaired elders' expression of choice during incapacity.

Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE

To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients.

METHODS

Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching).

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia.

CONCLUSIONS

Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.

Antidepressant versus placebo for depressed elderly

BACKGROUND

Depression warranting intervention is found in ten percent of people over the age of 60. Older depressed people are more likely to die than non-depressed. Relatively few receive therapeutic interventions, and those that do, tend to receive low dose antidepressant therapy. Depression in older people is thought to differ in terms of aetiology, presentation, treatment and outcome than in younger people. Concomitant physical illness and increasing social, physical and neurophysiological diversity are associated with the ageing process. Consequently drug treatment of older patients is often carried out in institutions and on patients suffering from multiple physical problems.

OBJECTIVES

To determine the efficacy of antidepressant medication compared with placebo in the treatment of depression in older patients.

SEARCH STRATEGY

The search strategy incorporated: electronic literature searches of databases held by the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDAN) (see Collaborative Review Group Search Strategy). Reference lists of related reviews and references of located studies. Contact was made with authors working in the field.

SELECTION CRITERIA

All randomised, placebo controlled trials using antidepressants in the treatment of the presenting episode of depression in patients described as elderly, geriatric senile or older adult.

DATA COLLECTION AND ANALYSIS

Two types of data were extracted (if available) from each study. The first type of data was dichotomous data, this consisted of recovered/not recovered. The second, continuous data,included: Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Rating Scale (MADRS) and other depression rating scale scores. An analysis using Peto Odds ratios for the dichotomous data and weighted mean difference for continuous data was performed using RevMan 3.1. The presence of heterogeneity of treatment effect was assessed.

MAIN RESULTS

Seventeen trials contributed data to the analyses comparing the efficacy of antidepressant treatment and placebo. Analyses of efficacy was based on 245 patients treated with TCAs (223 with placebo), 365 patients treated with SSRIs (372 with placebo) and 58 patients treated with MAOIs (63 with placebo). The standardised effect size for the three groups respectively were: TCAs; OR: 0.32 (0.21,0.47), SSRIs; OR; 0.51 (0.36,0.72), MAOIs: 0.17 (0.07,0.39).

REVIEWER'S CONCLUSIONS

TCAs, SSRIs and MAOIs are effective in the treatment of older community patients and inpatients likely to have severe physical illness. At least six weeks of antidepressant treatment is recommended to achieve optimal therapeutic effect. There is little evidence concerning the efficacy of low dose TCA treatment. Further trials are required before low dose TCA treatment is routinely recommended.

Diagnosis and management of late life depression: a guide for the primary care physician

OBJECTIVE

The purpose of this article is to provide a brief and practical approach for the primary care physician regarding the recognition, diagnosis, and management of depression in elderly patients.

METHOD

Empirical evidence and current recommendations regarding the recognition, diagnosis, and treatment of depression are reviewed as the basis for this approach. Appropriate modifications for geriatric depression are added where indicated.

RESULTS

The recommendations are listed by category and briefly explained.

CONCLUSIONS

It is important to be vigilant for the variety of depressive presentations that occur in older primary care patients. Neurological causes of depression (such as stroke), suicide, and a longer time to recovery are all more frequent concerns in older depressed patients.

The efficacy, safety and tolerability of antidepressants in late life depression: a meta-analysis

BACKGROUND

To determine the efficacy, safety and tolerability of antidepressants in depressed elderly patients.

METHODS

Search for randomized controlled double-blind studies evaluating atypical antidepressants (ATYPs), reversible inhibitors of monoamine oxidase-A, selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants in moderate/severe depressed patients > or = 60 years for > or = four weeks. The random effects model (single-arm; comparative) was used to aggregate efficacy, safety and dropout.

RESULTS

No difference in single-arm aggregation of outcomes for four antidepressant classes. Comparative analyses showed no statistical difference between outcomes, except SSRIs had a higher response rate than ATYPs.

CONCLUSION

Elderly show no differences in antidepressant class outcomes.

LIMITATIONS

Heterogeneity and lack of power.

CLINICAL RELEVANCE

There is little advantage for antidepressant classes over another in the aged.

Alcohol and drug misuse in the nursing home

The misuse of alcohol or drugs is a common and frequently neglected problem among nursing home residents. The misuse of prescription medications is particularly prevalent, but tobacco, alcohol, and illicit drugs are all subject of misuse by nursing home residents. This article reviews the epidemiologic and clinical aspects of substance misuse in nursing homes, including alcohol, illicit drugs, tobacco, and pyscho-active medications. Regulations regarding the prescription of psycho-active drugs in nursing homes is also discussed.

Recent developments in geriatric psychopharmacotherapy

This paper highlights recent advances in the pharmacological management of geriatric affective disorders and dementia. The current roles of tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs) in the treatment of depression in old age are discussed. Recent findings pertaining to continuation and maintenance of antidepressant treatment are also addressed. The treatment of bipolar affective disorder in the elderly has received much less study than has unipolar depression. A number of issues relating to efficacy, side-effects and optimal blood levels of lithium, carbamazepine and valproate in bipolar disorder remain unresolved and await further study. Finally, drug treatment of the cognitive impairment and psychiatric complications of Alzheimer's disease is reviewed.

The applicability of antidepressants in the depressed medically ill: an open clinical trial with fluoxetine

In the literature the side-effects and medical complications of tricyclic antidepressants (TCAs), in the medically ill have been extensively reviewed. This study uses a prospective design to examine these issues' questions in an almost solely in-patient C-L population (N = 37) treated with a serotinergic antidepressant (fluoxetine). A first remarkable finding is the fact that 83% of the patients have complaints comparable with the side-effects of the drug, prior to its administration. Second, although the drop-out rates (DO) are comparable with those in earlier studies, in this study DO do not seem to be related to the seriousness of the side-effects of the drug. The more serious side-effects were hyponatremia (N = 1) and gastrointestinal symptoms (N = 3). In contrast to TCAs no psychiatric side-effects have to be reported. Therefore this study suggests that with good medical supervision fluoxetine can be used in the treatment of seriously medically ill patients with depressive co-morbidity.

Antidepressant Treatment of Very Old Patients

Most studies of the elderly use age 65 as the definition of the onset of old age, and most studies of the pharmacologic treatment of depression in the elderly focus on patients between the ages of 60 and 70. Very few patients over the age of 75 have been specifically studied, and virtually none over the age of 80. Data for this review of treatment of depressed patients over the age of 75 were derived from a larger review prepared for a 1992 NIMH consensus development conference on the diagnosis and treatment of depression in late life. Available studies were divided into three categories: 1) mixed-age studies that include subjects over 75 (n = 18); 2) mixed-age reports of patients having a mean age of 75 or older (n = 13); and 3) reports including only patients with minimum age of 75 years or older (>n = 5). Data are available from only 171 identifiable patients over the age of 75. Consequently, available data for patients in this very old age category are too limited for reliable or valid treatment recommendations to be made; further research is necessary.

Antidepressant therapy in the physically ill: a therapeutic opportunity for the selective 5-HT re-uptake inhibitors?

Depression is common in physically ill populations, although it is frequently unrecognized and untreated. Diagnosis and antidepressant treatment are discussed. The side-effect profiles of the selective 5-HT re-uptake inhibitors suggest they may offer new therapeutic opportunities in physically ill patients. Sertraline may be of particular benefit in some patients due to its distinct pharmacological profile and the potential for fewer drug interactions. Further evaluation is necessary to determine the risk-benefit ratio for drugs of this class.

Should physicians screen for depression in elderly medical inpatients?: Results of a decision analysis

OBJECTIVE

We wish to determine whether or not elderly medical inpatients should be screened for depressive disorder using either 1) a self-rated depression scale (Geriatric Depression Scale), 2) "usual clinical assessment," or 3) neither, assuming that treatment with tricyclic antidepressants (TCAs) is the primary mode of intervention.

METHOD

Based on recent data from epidemiological studies on the prevalence and course of depression, the test characteristics of available screening tests, and the efficacy and side-effects of traditional antidepressants, decision analysis is used to help decide whether or not clinicians should screen for depression in this setting.

RESULTS

These calculations indicate that if screening is done solely to identify depressed patients for treatment with TCAs, then the highest utility lies in not screening; however, the difference in utilities between that decision and the decisions to either screen with GDS or screen by usual clinical assessment was only .04 units on a 0 to 100 scale, making the decision virtually a toss-up. Furthermore, even a small variation in one of several clinical factors or test characteristics could give screening a higher utility. In particular, if psychotherapy is considered as the primary intervention, then the utility of screening exceeds that of not screening.

CONCLUSION

Characteristics of the screening test, clinical setting, types and safety of available treatments, each impact on the usefulness of screening and must be kept in mind when diagnosing and treating depressed medically ill elders hospitalized in acute care settings.

Pharmacotherapy of depression in the medically ill: directions for future research

A common problem facing the psychiatric consultant and the medical practitioner is evaluating depression in patients with concurrent medical illnesses. Depression is difficult to recognize in the medically ill, often presenting with "masked" symptoms and organized into unique syndromes. A primary concern of the clinician is identifying those patients who are likely to benefit from an antidepressant trial. Although antidepressants have been shown to sometimes be of benefit in medical populations, the symptoms predicting antidepressant response remain poorly defined. Important directions for future research include 1) evaluating the safety and efficacy of newer antidepressants in the medically ill and 2) identifying those depressive syndromes that may be responsive to pharmacotherapy.

Feasibility and efficacy of verbal consents

Refusal rates for participation in geriatric research have been surprisingly high. This may be due in part to inherent difficulties with a written consent procedure. A simple, easily administered, standardized verbal consent procedure (VCP) for the institutionalized elderly was developed to address this problem. Of 114 patients eligible for enrollment in a study evaluating outcomes of group psychotherapy, 100 gave verbal consent. When written consent was requested, 60 signed immediately; 35, only after substantial coaxing. Five patients refused to sign a consent form, although verbally agreeing to participate. It is estimated that the number of study participants would have been reduced by 40% had written consent been required. The findings raise ethical and logistical issues pertaining to a verbal consent procedure.

Formal geriatric assessment instruments and the care of older general medical outpatients

To improve identification of cognitive, affective, gait, and nutritional problems in older medical outpatients, non-physician clinic personnel administered formal geriatric assessment tools to 183 medical outpatients age 70 years and older. Definite impairments were demonstrated in 7% to 23% of patients (depending on the function being assessed), and borderline abnormal results were common as well. Overall, 56% of patients had at least one meaningful impairment identified. Few of these problems had been recognized before the survey. Assessment required 10 to 15 minutes of interviewer time per patient (approximately 22 minutes for each problem newly uncovered). A simple education and information intervention led to physicians addressing the newly identified problem in 30% to 55% of cases. These results suggest that formal geriatric assessment instruments provide an efficient mechanism for case finding in older medical outpatients. Further studies are necessary to determine whether such interventions will lead to improved outcomes in older medical outpatients.

Use of antidepressants in medically ill older patients

Major depression is common in older medical patients, and it can exert a deleterious effect on the treatment, course, and outcome of physical illnesses. Tricyclic or tetracyclic antidepressants (TCAs) and psychosocial interventions often play a role in the treatment of depressed medically ill patients, but well-founded doubts about the efficacy and the safety of TCAs in older, frail medical patients have developed. Based on a review of current knowledge about antidepressant use in these patients, the authors recommend the cautious use of TCAs in medically ill older patients until more data are available.

Comparative plasma levels of doxepin and desipramine in the elderly

Although tricyclic antidepressants remain a principal mode of treatment of depression in the elderly, concomitant medical illness in this subgroup creates particular concern regarding the safety of these drugs. Doxepin has gained favour for use in the geriatric population due to claims of low cardiovascular side effects. This perceived safety has been questioned, however, since few investigators have actually reviewed plasma levels. A recent finding of interest revealed that two patients on 150 mg of doxepin daily with assured compliance had undetectable levels of doxepin or desmethyldoxepin in their plasma. A prospective study was consequently undertaken to compare oral doses and plasma levels of doxepin with desipramine as a standard reference compound. Data was collected for 19 females (12 on doxepin, seven on desipramine) and 12 males (five on doxepin, seven on desipramine) with a mean age of 76. Eight patients on doxepin showed undetectable plasma levels as compared with none on desipramine. This is a highly significant difference. Although the therapeutic plasma range for doxepin remains controversial, it is unlikely that patients can respond to levels of zero. The authors recommend routine monitoring of doxepin levels in the elderly and question poor bioavailability or absorption of this tricyclic antidepressant in some patients.

Antidepressant use in elderly medical inpatients: lessons from an attempted clinical trial

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was balted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was conducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antidepressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy.

Antidepressants in the medically ill: prediction of benefits

Although depression secondary to medical illness occurs frequently, little is known about its response to conventional antidepressant therapy. In this retrospective study of 50 patients, the authors assessed the charted therapeutic effect of antidepressants and sought to define pretreatment features associated with good outcome. Half (9/18) of the patients with a previous history of depression improved while only 22% (7/32) of the patients without a previous history of depression showed improvement in mood. Those patients meeting DSM-III criteria for major depressive disorder were no more likely to benefit from antidepressants than were patients meeting criteria for adjustment disorder with depressed mood. The authors conclude that previous history of depression should be considered when assessing risks and benefits for antidepressants for medically ill patients with depressive syndromes.

Severe illness in older patients: the association between depressive disorders and functional dependency during the recovery phase

An association between depression and physical dependency arising from a recent illness has been generally accepted. To clarify this relationship over time, 30 medical rehabilitation patients aged 54 to 94 years were assessed 1 week after admission and at discharge to quantify symptoms of depression, physical dependency, and cognitive functioning using the Hamilton Depression Scale (HAM-D), the Geriatric Depression Scale (GDS), the Barthel Index for physical function, and the Mini-Mental State Examination (MMSE). Significant depressive symptomatology was found by HAM-D in 25 patients on admission and 14 on discharge. No significant associations were present between either admission or discharge depression scores and all other variables. The HAM-D change score was significantly correlated with the Barthel change score (r = 0.57, P less than 0.001) and with the MMSE change score (r = 0.48, P = 0.01). All patients whose mood improved also improved in physical functioning, whereas 75% of those whose mood did not improve failed to make headway in physical functioning. This implies that it is not the degree of physical incapacity but rather the failure to regain prior abilities which is strongly associated with persisting depression following a catastrophic illness. Furthermore, characteristics found commonly in the group whose mood did not improve included physicians' failure to diagnose and treat depression or a setback from a significant medical or surgical complication.

Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness

Until now, no self-rated depression scale had been validated as a screening measure for major depression in the older patient hospitalized with medical illness. The present report establishes the validity of two brief, easily administered depression screening tests, the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS), in this population. Structured psychiatric interviews were performed and self-rated depression measures administered to 128 men, aged 70 and over, consecutively admitted to medical and neurological services of a VA hospital. The GDS and BCDRS were both shown to have high sensitivity and specificity for detecting major depression in this setting. Optimal cut-off scores determined by the receiver operating curve characteristics of these tests were 11 for the GDS and 6 for the BCDRS. At a cutoff score of 11, the GDS had a sensitivity of 92%, a specificity of 89%, and a negative predictive value of 99%; lowering the break point to 8 did not increase sensitivity. At a cutoff score of 6, the BCDRS achieved a 100% sensitivity, 93% specificity, and 100% negative predictive value. Whether clinicians decide to implement either of these depression screens in their practice will depend to a large degree on the importance ascribed to the detection of these disorders and on attitudes toward the benefits of treatment.