EBM seminar: Treatment of severe depression in an elderly patient

1
EBM seminarTreatment of severe depression in an
elderly patient

• Brian Mickey
• Gregory Dalack
• March 23, 2006

2
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.

3
Initial clinical question

• What would be the best treatment for this
  patients depression?

4
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

5
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

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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
  894904.

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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

8
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

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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!

10
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

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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.