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EBM seminar: Treatment of severe depression in an elderly patient. Brian Mickey Gregory Dalack March 23, 2006. Brief case history.

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ebm seminar treatment of severe depression in an elderly patient

EBM seminar:Treatment of severe depression in an elderly patient

Brian Mickey

Gregory Dalack

March 23, 2006

brief case history
Brief case history
  • 77 year old man with recurrent unipolar depression. Currently in episode, BDI and HAM-D in severe range. Mild psychotic ideation. History of excellent response to ECT, but his comorbidities make this less favorable now.
initial clinical question
Initial clinical question
  • What would be the best treatment for this patient’s depression?
an answerable clinical question
For elderly patients with recurrent, moderate-to-severe, major depression...

...does one class of antidepressant medication or ECT...

...when compared to other classes of antidepressant...

...result in better improvement of depressive symptoms?

patient

intervention

comparison

outcome

An answerable clinical question
literature search
Literature search
  • goal: to (quickly) find evidence at the level of meta-analysis or systematic review
  • UM Medsearch (OVID)
  • difficulties
    • choosing a database, using limits
    • choosing search terms, sensitivity vs specificity
  • strategies
    • limit to “EBM review”
    • limit to English
    • restrict to “elderly” or “geriatric”
  • results
    • “antidepressant” → 88 hits
    • “electroconvulsive therapy” → 5 hits
selected results
Selected results
  • Antidepressant treatment
    • Mottram et al. Antidepressants for depressed elderly. The Cochrane Database of Systematic Reviews 2006, Issue 1.
    • Wijkstra et al. Pharmacological treatment for psychotic depression. The Cochrane Database of Systematic Reviews 2005, Issue 4.
  • Electroconvulsive therapy
    • van der Wurff et al. Electroconvulsive therapy for the depressed elderly. The Cochrane Database of Systematic Reviews 2003, Issue 2.
    • van der Wurff et al. The efficacy and safety of ECT in depressed older adults, a literature review. Int J Geriatr Psychiatry 2003; 18: 894–904.
cochrane review antidepressants for depressed elderly
Cochrane review: Antidepressants for depressed elderly
  • Objectives:
    • examine efficacy, withdrawal rate, and side effect profiles of antidepressant classes among elderly patients
  • Methods:
    • meta-analysis of all randomized controlled trials of at least two antidepressants
    • five classes: TCA, TCA-related, SSRI, MAOI, atypical
  • Results:
    • 29 trials (several thousand patients) were identified
    • no differences in efficacy were found
    • due to small samples, type II error is likely
    • SSRIs were better tolerated than TCAs and TCA-related agents
  • Limitations:
    • heterogeneity of depressive disorders and severity
cochrane review pharmacological treatment for psychotic depression
Cochrane review: Pharmacological treatment for psychotic depression
  • Objectives:
    • examine effectiveness of antidepressant vs antipsychotic vs combination therapy for psychotic depression
  • Methods:
    • meta-analysis of randomized controlled trials of psychotic depression
  • Results:
    • 10 trials (548 patients) were identified
    • both antidepressant alone and antidepressant + antipsychotic were superior to antipsychotic alone
    • antidepressant + antipsychotic was no more effective than antidepressant alone (N.B. Post-script- at the seminar, this was viewed as a controversial conclusion and will be the focus of another EBM seminar at a later date- stay tuned)
    • 2 trials compared TCA to non-TCA (fluvoxamine, mirtazapine): TCA more effective
  • Limitations:
    • no data available for elderly subgroup
cochrane review electroconvulsive therapy for the depressed elderly
Cochrane review: Electroconvulsive therapy for the depressed elderly
  • Objectives:
    • assess the efficacy and safety of ECT in depressed elderly people
  • Methods:
    • meta-analysis of randomized controlled trials of ECT vs simulated ECT or antidepressants
  • Results:
    • 3 trials (roughly 60 patients) were identified
    • the objectives of this review could not be addressed due to methodological shortcomings
  • Limitations:
    • restriction to RCTs results in no clinically useful conclusions!
ijgp review the efficacy and safety of ect in depressed older adults
IJGP review: The efficacy and safety of ECT in depressed older adults
  • Objectives:
    • assess the efficacy and safety of ECT in depressed elderly people
  • Methods:
    • review of randomized and non-randomized studies of ECT vs simulated ECT or antidepressants
  • Results:
    • 121 studies (roughly 1400 patients) were identified
    • ECT was found to be effective and generally safe in the acute treatment of late-life depression
  • Limitations:
    • questions that could not be answered include relative efficacy compared to antidepressants, long-term efficacy, morbidity and mortality, and efficacy in patient subgroups
results from an alternative search strategy
Results from an alternative search strategy
  • Amore. The pharmacological treatment of depression in the elderly. Minerva Psichiatrica. Vol. 46(4)(pp 261-272), 2005.
  • Karp and Reynolds. Pharmacotherapy of depression in the elderly: Achieving and maintaining optimal outcomes. Primary Psychiatry. Vol. 11(5)(pp 37-46), 2004.
  • Rudorfer and Potter. Metabolism of tricyclic antidepressants. Cellular & Molecular Neurobiology. Vol. 19(3)(pp 373-409), 1999.
  • Lane et al. The SSRIs: Advantages, disadvantages and differences. Journal of Psychopharmacology. Vol. 9(2 SUPPL.)(pp 163-178), 1995.
  • Cipriani et al. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database of Systematic Reviews. 1, 2006.
  • Flint. Pharmacologic treatment of depression in late life. CMAJ: Canadian Medical Association Journal. Vol. 157(8)(pp 1061-1067), 1997.