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Evid Based Nurs 9:119 doi:10.1136/ebn.9.4.119
  • Treatment

Maintenance treatment with paroxetine, but not psychotherapy, prevented recurrent major depression in older people


 
 Q In elderly patients with major depression who respond to treatment, does maintenance treatment with paroxetine, psychotherapy, or a combination thereof prevent recurrence of depression?

METHODS

GraphicDesign:

randomised, 2 × 2 factorial design, placebo controlled trial.

GraphicAllocation:

concealed.*

GraphicBlinding:

blinded (clinicians, patients, and outcome assessors). Clinicians and patients were not blinded to the psychotherapy intervention.

GraphicFollow up period:

2 years.

GraphicSetting:

specialised university based clinic in Pittsburgh, Pennsylvania, USA.

GraphicPatients:

116 patients ⩾70 years of age (mean age 77 y, 65% women) who had major depression according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria, scores ⩾15 on the Hamilton Rating Scale for Depression (range 0–52 [worst]), scores ⩾17 on the Folstein Mini Mental State Examination (range 0−30 [best]), and a sustained clinical response after several months of treatment with paroxetine, 10–40 mg/day, and psychotherapy (weekly, then biweekly).

GraphicIntervention:

paroxetine plus psychotherapy (n = 28), paroxetine plus clinical care (n = 35), placebo plus psychotherapy (n = 35), or placebo plus clinical care (n = 18) for 2 years. Paroxetine was continued at the individually titrated dose. Psychotherapy or clinical care was provided monthly by the same clinician (nurse, social worker, or psychologist) who previously treated the patient.

GraphicOutcomes:

recurrence of major depression, according to DSM-IV criteria and a Hamilton Rating Scale for Depression score ⩾15, confirmed by a geriatric psychiatrist.

GraphicPatient follow up:

81% of patients completed the study (100% included in the intention to treat survival analysis).

MAIN RESULTS

Major depression recurrence rates were lower in the 2 paroxetine groups than in the 2 placebo groups (relative risk 0.42, 95% CI 0.24 to 0.71; NNT 4, 95% CI 3 to 11) (table). Psychotherapy did not reduce risk of recurrence (table).

CONCLUSIONS

In elderly patients with major depression who responded to treatment, long term maintenance treatment with paroxetine prevented recurrence of depression. Monthly psychotherapy did not prevent recurrent depression or increase the efficacy of paroxetine.

A modified version of this abstract appears in ACP Journal Club.

Commentary

  1. Celia E Wills, RN, PhD
  1. College of Nursing, Michigan State University
 East Lansing, Michigan, USA

      Major depression is often chronic and associated with serious negative health outcomes.1 Although several maintenance trials have shown that selective serotonin-reuptake inhibitors (SSRIs) and other non-tricyclic agents are effective for prevention of recurrence of depression in adults, few randomised trials have evaluated these maintenance therapies in elderly adults.2,3 Recently, trials testing SSRIs against placebo found that citalopram, but not sertraline, was effective for preventing depression recurrence in elderly adults.2,3 The discrepancy in the findings of these 2 studies could have been caused by various factors, including the specific medication tested, characteristics of the patient samples, medication adherence and pharmacokinetic factors, and study methods.

      Similar to the citalopram trial,2 the study by Reynolds et al supports the use of SSRI long term maintenance therapy in elderly adults with a first episode of depression. The study is important because it had a long follow up time (2 y) for monitoring for depression recurrence. As well, the authors examined whether a non-medication treatment (monthly maintenance psychotherapy) could prevent recurrence of depression; the trial had sufficient power to show, and indeed revealed, no effect.

      Replication of these findings will be needed to confirm the effectiveness of SSRI maintenance therapy among depressed, community dwelling, elderly adults seen in routine outpatient practice settings. Other research is needed to provide information about the care of specific subpopulations of elderly adults not included in previous trials.

      References

      Paroxetine or placebo, plus psychotherapy or clinical care, to prevent recurrence of major depression in elderly patients

      
 
 Q In elderly patients with major depression who respond to treatment, does maintenance treatment with paroxetine, psychotherapy, or a combination thereof prevent recurrence of depression?

      Footnotes

      • * Information provided by author.

      • For correspondence: Dr C F Reynolds, Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA. reynoldscf{at}upmc.edu

      • Sources of funding: National Institute of Mental Health and National Center for Minority Health and Health Disparities.

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