The effectiveness of antidepressants in elderly depressed outpatients: a prospective case series study.

BACKGROUND: This study examined the effectiveness of antidepressants in a group of elderly depressed outpatients by assessing depression prevalence and recording adverse events over time. METHOD: A prospective practice-based observational study (1991-1994) included consecutive outpatients at least 65 years of age with a DSM-III-R diagnosis of major affective disorder and who were prescribed antidepressant medications. Depressive symptoms were examined over time (stage 1 = 0 to 2 months; stage 2 = 2 to 6 months; stage 3 = 6 months to 2 years) with the Montgomery-Asberg Depression Rating Scale (MADRS). The cutoff scores of MADRS <18 and MADRS > or =18 were used in survival statistics. Adverse events were recorded systematically. RESULTS: A total of 213 patients were seen over 2677 visits (mean +/- SD age = 75.5+/-6.1 years). MADRS scores for 85.8% of patients declined to below 18 within the first 2 months of antidepressant treatment. MADRS scores were above 18 for 37.3% of patients after 6 months and for 37.1% after 2 years. The mean time to decline in MADRS scores to below 18 in stage 1 was 36.1 days, and there was a significant difference between the antidepressant classes (log rank = 8.3, df = 3, p = .04), with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)/reversible inhibitors of monoamine oxidase A (RIMAs) having shorter times to response. The mean time to reach scores above cutoff during stage 2 was 144.3 days (log rank = 5.7, df = 3, p = .13) and during stage 3, 538.6 days (log rank = 9.8, df = 3, p = .02). Patients receiving TCAs and MAOIs/RIMAs had longer durations of MADRS scores below cutoff during stage 3 than those taking atypical antidepressants and selective serotonin reuptake inhibitors. All antidepressant classes reported similar adverse event profiles. CONCLUSION: This study systematically examined antidepressant effectiveness in a prospective design. TCAs and MAOIs/RIMAs were shown to be superior in effectiveness during 2 of the 3 treatment stages.

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.

Intensive early exposure to geriatric psychiatry in residency training: impact on career choice and practice.

The authors examined the impact of intensive early exposure to geriatric psychiatry on the career choice of trainees. All psychiatrists who had completed a six month inpatient rotation on a general hospital psychogeriatric unit as part of their first year of residency were interviewed three to 12 years later with a questionnaire designed to elicit practice patterns, prior interest in geriatrics, and the major influences of the rotation. Nine of 16 trainees had spent more than 50% of their time since graduation treating elderly patients. Those surveyed who were not practicing geriatrics spontaneously reported positive influences of the rotation on psychiatry training in general. The nature of geriatric psychiatry and the clinical issues, as well as the supervisors and educational activities were rated as the most important influences of the rotation. Early experience in psychogeriatrics seems valuable for subspecialty recruitment as well as general psychiatry training.

Pitfalls and pratfalls in consultation-liaison psychiatry in a general hospital.

As Consultation-Liaison Services continue to develop and expand in general hospitals, psychiatrists must be aware of pitfalls and pratfalls inherent in dealing with medical colleagues and other allied health professionals, as well as with the patients. Practical considerations in answering consultation requests are discussed with respect to "hidden agendas" of the consultee, role and expectations of the psychiatrist, and problem referrals. It is only through mutual respect and collaboration that Consultation-Liaison Services can truly be effective.

Geriatric psychiatry in the general hospital: the integration of services and training.

This article describes the development of a new psychiatric service for the elderly based in a university general hospital. The service aims to provide and coordinate comprehensive psychiatric care for a defined population and also to serve as a tertiary care unit with academic responsibilities. As part of the Department of Psychiatry, this specialized service is fully integrated into all the major clinical and teaching components of the department. As the demand for more geriatric psychiatry services and training increases over the next decade, innovative ways of responding to this need will have to be developed. This integrative model in a general hospital setting has enhanced the quality of health care delivery to the elderly at the same time as improving training and recruitment.

Hysterical seizures as a manifestation of "depression" in old age.

A case of hysterical seizures is presented which is ultimately diagnosed as depression and treated successfully with tricyclic antidepressants. The need to re-examine our understanding of illness and the effect of classification on treatment decisions is emphasized.