Predictors of Response and Remission to Antidepressants in Geriatric Depression: A Systematic Review

Cognitive Outcomes After Antidepressant Pharmacotherapy for Late-Life Depression: A Systematic Review and Meta-Analysis

OBJECTIVE

The authors evaluated whether treatment of late-life depression (LLD) with antidepressants leads to changes in cognitive function.

METHODS

A systematic review and meta-analysis of prospective studies of antidepressant pharmacotherapy for adults age 50 or older (or mean age of 65 or older) with LLD was conducted. MEDLINE, EMBASE, and PsycInfo were searched through December 31, 2022. The primary outcome was a change on cognitive test scores from baseline to after treatment. Secondary outcomes included the effects of specific medications and the associations between changes in depressive symptoms and cognitive test scores. Participants with bipolar disorder, psychotic depression, dementia, or neurological disease were excluded. Findings from all eligible studies were synthesized at a descriptive level, and a random-effects model was used to pool the results for meta-analysis.

RESULTS

Twenty-two studies were included. Thirteen of 19 studies showed an improvement on at least one cognitive test after antidepressant pharmacotherapy, with the most robust evidence for the memory and learning (nine of 16 studies) and processing speed (seven of 10 studies) domains and for sertraline (all five studies). Improvements in depressive symptoms were associated with improvement in cognitive test scores in six of seven relevant studies. The meta-analysis (eight studies; N=493) revealed a statistically significant overall improvement in memory and learning (five studies: effect size=0.254, 95% CI=0.103-0.404, SE=0.077); no statistically significant changes were seen in other cognitive domains. The evaluated risk of publication bias was low.

CONCLUSION

Antidepressant pharmacotherapy of LLD appears to improve certain domains of cognitive function, particularly memory and learning. This effect may be mediated by an improvement in depressive symptoms. Studies comparing individuals receiving pharmacotherapy with untreated control participants are needed.

MAOA uVNTR Polymorphism Influence on Older Adults Diagnosed with Diabetes Mellitus/Systemic Arterial Hypertension

Background

Monoamine oxidase (MAO) is involved in several biological processes associated with well-being and mental health, and alterations in its function might directly impact various mental disorders. Some mental disorders concomitantly occur in individuals with clinical characteristics, such as substance abuse and diabetes.

Objective

To analyze the functional MAOA uVNTR polymorphism genotype frequency in an older adult population with diabetes mellitus/arterial hypertension and associate this frequency with clinical characteristics impacting daily life. Methodology. Older adults diagnosed with diabetes mellitus, systemic arterial hypertension, or both (DM/SAH) were selected and had their MAOA gene genotyped for uVNTR polymorphism. The revised Beck Depression Inventory (BDI) and a questionnaire were also applied to determine their mental health and clinical characteristics.

Results

The allelic variants detected among the participants were the 2R, 3R, 4R, and 3R/4R heterozygous genotypes. Genotypes solely containing the 3R allele had patients who marked yes for smoking and alcoholism, and only those with the 3R genotypes (female 3R/3R homozygote or male 3R∗ hemizygote) were significant. Although not statistically significant, only 3R and 3R/4R genotypes presented cases of severe depression per the revised BDI interpretations.

Conclusion

The MAOA uVNTR polymorphism's low-activity 3R allele presence in an older adult population diagnosed with DM/SAH may represent a risk for developing substance use (alcohol and smoking) dependence.

Geriatric Depression

Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.

APOE ε4 Carrier Status as Mediator of Effects of Psychotropic Drugs on Clinical Changes in Patients With Alzheimer's Disease

OBJECTIVE

Neuropsychiatric syndromes have been associated with memory dysfunction and risk of and earlier onset of dementia, but how psychotropic drugs affect clinical changes in Alzheimer's disease is not entirely clear. This study aimed to assess the prospective effects of psychotropic drugs on cognitive and functional changes in Alzheimer's disease according to APOE ε4 carrier status.

METHODS

The study included consecutive outpatients with late-onset Alzheimer's disease (N=193) and examined score variations at 1 year on the following tests: Clinical Dementia Rating sum of boxes, Mini-Mental State Examination, Severe Mini-Mental State Examination (SMMSE), Brazilian version of the Zarit Caregiver Burden Interview, Index of Independence in Activities of Daily Living, and Lawton's Instrumental Activities of Daily Living Scale. Analyses of score variations accounted for the use of psychotropic drugs or the number of different medications in use, as well as APOE ε4 carrier status, with significance at p<0.05.

RESULTS

For APOE ε4 noncarriers (N=90), cholinesterase inhibitors were beneficial regarding caregiver burden (p=0.030) and basic functionality (p=0.046), memantine was harmful regarding SMMSE score changes (p=0.032), second-generation antipsychotics had nonsignificant harmful effects on SMMSE score changes (p=0.070), and antiepileptic therapy (p=0.001) and the number of different medications in use (p=0.006) were harmful in terms of basic functionality. APOE ε4 carriers (N=103) did not experience any effects of isolated psychotropic drugs on clinical changes, including antidepressants.

CONCLUSIONS

Results support the harmful prospective effects of second-generation antipsychotics and antiepileptic drugs on cognitive and functional changes in Alzheimer's disease, particularly for APOE ε4 noncarriers, whereas antidepressants may be safer options for behavioral enhancement.

Biomarkers as predictors of treatment response to tricyclic antidepressants in major depressive disorder: A systematic review

Tricyclic antidepressants (TCAs) are frequently prescribed in case of non-response to first-line antidepressants in Major Depressive Disorder (MDD). Treatment of MDD often entails a trial-and-error process of finding a suitable antidepressant and its appropriate dose. Nowadays, a shift is seen towards a more personalized treatment strategy in MDD to increase treatment efficacy. One of these strategies involves the use of biomarkers for the prediction of antidepressant treatment response. We aimed to summarize biomarkers for prediction of TCA specific (i.e. per agent, not for the TCA as a drug class) treatment response in unipolar nonpsychotic MDD. We performed a systematic search in PubMed and MEDLINE. After full-text screening, 36 papers were included. Seven genetic biomarkers were identified for nortriptyline treatment response. For desipramine, we identified two biomarkers; one genetic and one nongenetic. Three nongenetic biomarkers were identified for imipramine. None of these biomarkers were replicated. Quality assessment demonstrated that biomarker studies vary in endpoint definitions and frequently lack power calculations. None of the biomarkers can be confirmed as a predictor for TCA treatment response. Despite the necessity for TCA treatment optimization, biomarker studies reporting drug-specific results for TCAs are limited and adequate replication studies are lacking. Moreover, biomarker studies generally use small sample sizes. To move forward, larger cohorts, pooled data or biomarkers combined with other clinical characteristics should be used to improve predictive power.

Pharmacotherapy for late-life depression

Background: Late-life depression (LLD) is one of the most common psychiatric disorders. However, LLD is often undetected or inadequately treated by clinicians. This review summarizes the recent research on pharmacotherapy for LLD, updates information on monotherapy using recommended antidepressants, and discusses the clinical features and diagnostic criteria for LLD.Current Concepts: The diagnostic criteria for depression in both elderly and young adults are identical. Clinical features of the elderly with depression more likely include more comorbid medical conditions and cognitive impairment than those of young adults. Depression in the elderly tends to have a more chronic course with frequent recurrences or relapses.Discussion and Conclusion: The current pharmacological treatment guidelines for LLD recommend the use of selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor, bupropion, mirtazapine, and vortioxetine as first-line medications. SSRIs, among them, are recommended first because they present fewer serious adverse effects and more clinical evidence than those of other antidepressants. Before starting antidepressant treatment for LLD, clinicians should consider patients’ comorbid medical conditions, drug interactions, possible adverse effects of antidepressants, and polypharmacy. The starting dose of antidepressants for elderly patients should be half of that prescribed for young adults to minimize the adverse effects; however, most elderly patients need the same antidepressant doses as that prescribed for young patients. After remission, a 1-year maintenance treatment is required to prevent recurrence or relapse of LLD.

Vascular depression in Black Americans: A systematic review of the construct and its cognitive, functional, and psychosocial correlates

Objective: Vascular burden is associated with cognitive deficits and a form of late-life depression, vascular depression (VaDep), which is marked by decreased white matter integrity, executive dysfunction, poor treatment response, and functional disability. Older Black Americans represent a vulnerable population at risk of developing VaDep, but the literature in this group is limited. Thus, the goal of this systematic review is to summarize the existing literature that informs our understanding of VaDep in older Black Americans, including cognitive, functional, and psychosocial outcomes. Method: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, studies were identified that examined the relationship between vascular disease or vascular risk factors and that either had a sample of at least 75% Black participants or conducted race-specific analyses. Thirty studies met all inclusion criterion based on review of both authors. Results: Overall, studies support the construct of VaDep in older Black Americans. There is preliminary support for VaDep-related cognitive and functional deficits, and mixed findings regarding racial disparities in prevalence of VaDep. Conclusion: This review underscores the need for further neuroimaging and neuropsychological research in Black older adults with comorbid depression and vascular disease. Findings also highlight the importance of screening for depressive symptoms in Black individuals with multiple vascular risk factors.

Cognitive Impairment in Late-Life Depression: A Comparative Study of Healthy Older People, Late-Life Depression, and Mild Alzheimer's Disease Using Multivariate Base Rates of Low Scores

Late-Life Depression (LLD) is often associated with cognitive impairment. However, distinction between cognitive impairment due to LLD and those due to normal aging or mild Alzheimer's Disease (AD) remain difficult. The aim of this study was to present and compare the multivariate base rates of low scores in LLD, mild AD, and healthy control groups on a battery of neuropsychological tests. Participants (ages 60-89) were 352 older healthy adults, 390 patients with LLD, and 234 patients with mild AD (i.e., MMSE ≥ 20). Multivariate base rates of low scores (i.e., ≤ 5th percentile) were calculated for each participant group within different cognitive domains (verbal episodic memory, executive skills, mental processing speed, constructional praxis, and language/semantic memory). Obtaining at least one low score was relatively common in healthy older people controls (from 9.4 to 17.6%), and may thus result in a large number of false positives. By contrast, having at least two low scores was unusual (from 0.3 to 4.6%) and seems to be a more reliable criterion for identifying cognitive impairment in LLD. Having at least three low memory scores was poorly associated with LLD (5.9%) compared to mild AD (76.1%) and may provide a useful way to differentiate between these two conditions [χ ( 1 ) 2 = 329.8, p < 0.001; Odds Ratio = 50.7, 95% CI = 38.2-77.5]. The multivariate base rate information about low scores in healthy older people and mild AD may help clinicians to identify cognitive impairments in LLD patients, improve the clinical decision-making, and target those who require regular cognitive and clinical follow-up.

The association of markers of cerebral small vessel disease and brain atrophy with incidence and course of depressive symptoms - the maastricht study

BACKGROUND

Cerebral small vessel disease (CSVD) and neurodegeneration may be involved in the development and persistence of late-life depressive symptoms, but longitudinal evidence is scarce. We investigated the longitudinal associations of markers of CSVD and brain atrophy with incident depressive symptoms and the course of depressive symptoms, above and below 60 years of age.

METHODS

White matter hyperintensity volumes (WMH), presence of lacunar infarcts and cerebral microbleeds, and white matter, grey matter, and cerebral spinal fluid volumes were assessed at baseline by 3T MRI in The Maastricht Study (mean age 59.5±8.5 years, 49.6% women, n=4,347; 16,535 person-years of follow-up). Clinically relevant depressive symptoms (9-item Patient Health Questionnaire≥10) were assessed at baseline and annually over seven years. We used Cox regression and multinomial logistic regression analyses adjusted for demographic, cardiovascular, and lifestyle risk factors.

RESULTS

Above 60 years of age, larger WMH volumes were associated with an increased risk for incident depressive symptoms (HR[95%CI]:1.24[1.04;1.48] per SD) and a persistent course of depressive symptoms (OR:1.44[1.04;2.00] per SD). Total CSVD burden was associated with persistent depressive symptoms irrespective of age (adjusted OR:1.58[1.03;2.43]), while no associations were found for general markers of brain atrophy.

LIMITATIONSS

Our findings need replication in other large-scale population-based studies.

CONCLUSIONS

Our findings may suggest a temporal association of larger WMH volume with the incidence and persistence of late-life depression in the general population and may provide a potential target for the prevention of chronic late-life depression.

Neural substrates for late-life depression: A selective review of structural neuroimaging studies

Recent neuroimaging studies have characterized the pathophysiology of late-life depression (LLD) as a dysfunction of the brain networks involved in the regulation of emotion, motivational behavior, cognitive control, executive function, and self-referential thinking. In this article, we reviewed LLD-associated structural neuroimaging markers such as white matter hyperintensity (WMH), white matter integrity measured by diffusion tensor imaging, cortical and subcortical volumes, and cortical thickness, which may provide a structural basis for brain network dysfunction in LLD. LLD was associated with greater severity or volumes of deep, periventricular, or overall WMH and with decreased white matter integrity in the brain regions belonging to the fronto-striatal-limbic circuits and reduced white matter tract integrity which connects these circuits, such as the cingulum, corpus callosum, or uncinate fasciculus. Decreased volumes or cortical thickness in the prefrontal cortex, orbitofrontal cortex, anterior and posterior cingulate cortex, several temporal and parietal regions, hippocampus, amygdala, striatum, thalamus, and the insula were associated with LLD. These structural neuroimaging findings were also associated with cognitive dysfunction, which is a prominent clinical feature in LLD. Several structural neuroimaging markers including the WMH burden, white matter integrity, and cortical and subcortical volumes predicted antidepressant response in LLD. These structural neuroimaging findings support the hypothesis that disruption of the brain networks involved in emotion regulation and cognitive processing by impaired structural connectivity is strongly associated with the pathophysiology of LLD.

Relationship between multidimensional prognostic index and incident depressive symptoms in older people: Findings from the Irish Longitudinal Study on Ageing

OBJECTIVES

The multidimensional prognostic index (MPI) is a useful prognostic tool for evaluating adverse health outcomes in older individuals. However, the association between MPI and depressive symptoms has never been explored, despite depression being a common condition in older people. We therefore aimed to evaluate whether MPI may predict incident depressive symptoms.

METHODS

Longitudinal, cohort study, with 2 years of follow-up (W1: October 2009-February 2011; W2: April 2012-January 2013), including people aged ≥65 years without depressive symptoms at baseline. A comprehensive geriatric assessment including information on functional, nutritional, cognitive status, mobility, comorbidities, medications, and cohabitation status was used to calculate the MPI dividing the participants into low, moderate, or severe risk. Those who scored ≥16/60 with the Center of Epidemiology Studies Depression (CES-D) tool were considered to have depressive symptoms. Multivariable logistic regression models were built to explore the association between MPI and incident depressive symptoms.

RESULTS

The sample consisted of 1854 participants (mean age: 72.8 ± SD 5.1 years; females: 52.1%). The prevalence of incident depressive symptoms by MPI tertiles at baseline were: low 2.5%, moderate 3.9%, and severe 6.7%. In multivariable analyses, baseline MPI values were significantly associated with incident depressive symptoms (increase in 0.1 points in MPI: odds ratio, OR = 1.47; 95% confidence intervals, CI: 1.17-1.85; MPI tertile severe vs low: OR = 2.96; 95%CI: 1.50-5.85).

CONCLUSION

Baseline MPI values were associated with incident depressive symptoms indicating that multidimensional assessment of older people may lead to early identification of individuals at increased risk of depression onset.

Predictors of response to antidepressants in women with postpartum depression: a systematic review

Antidepressants are the mainstay of drug treatment for moderate or severe postpartum depression. Knowledge of predictors of response could help optimize treatment and reduce the adverse consequences of postpartum depression. The purpose of this systematic review was to ascertain predictors of response or remission to antidepressant treatment in women with postpartum depression. The electronic databases of MEDLINE/PubMed, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Evidence-based Medicine Reviews were searched through December 2019. The search was limited to studies published in the English language. Reference lists of articles that met the inclusion criteria were also searched. We identified some predictors of response and remission that could potentially assist in the optimization of drug treatment of postpartum depression; however, caution is needed to apply these findings in clinical practice due to the heterogeneous nature of postpartum depression. The results of our review highlight the urgent need to identify predictors of response, non-response, or remission to antidepressants in women with postpartum depression.

[Personalized approach to the treatment of depression in the elderly]

AIM

To develop a personalized approach to the appointment of a complex antidepressant therapy in combination with drugs of neuroprotective and neurotrophic action in depressed elderly patients based on the selection of predictors of low therapeutic response (LTR).

MATERIAL AND METHODS

The study included 152 hospitalized patients, aged 60 years and older, with moderate and mild depression (ICD-10) who received monotherapy (44 people) with antidepressants of the new generation and complex therapy (108 people) with the same antidepressants in combination with neuroprotective drugs. In the monotherapy group, correlations between treatment efficacy (change in average total HAMD-17 scores) and a set of parameters, including socio-demographic data, results of psychopathological, somatic, standardized assessment and neuroimaging (CT) of the brain were analyzed. The validity of the established correlations as predictors of LTR was estimated based on a comparison of their frequency among the responders (≥50% reduction) and non-responders (<50% reduction). Comparison of the efficacy of therapy in groups of patients with mono - and complex therapy was carried out depending on the presence or absence of predictors of LTR.

RESULTS

LTR predictors are living alone, complaints about memory loss and signs of pronounced diffuse lesions of the subcortical white matter of the brain, which are significantly more frequently observed in non-responders (p<0.05). The increase in the number of predictors (2 and more) correlates with a significant decrease in therapeutic efficacy (p<0.001). Patients with complex in structure and protracted depressions tend to decrease in efficiency, and in most of them (more than 87% of cases) LTR predictors are detected. In patients with LTR predictors, the complex therapy is significantly more effective than monotherapy, allowing in all cases to achieve 50% reduction of depressive symptoms by the 4th week of treatment.

CONCLUSION

Personalized indications for the appointment of complex antidepressant therapy in combination with neuroprotective drugs in depressed elderly patients are formulated.