Augmentation Treatment Improves Recovery in Some Elderly Patients With Major Depression

Some elderly patients with major depression who had inadequate response to or relapse with initial treatment were more than likely to recover if they had a second drug (bupropion, nortriptyline, or lithium) added to their standard treatment, according to the results of a study reported in the May issue of the American Journal of Psychiatry.
"Few data are available concerning the utility of augmentation in late-life depression treatment," write Mary Amanda Dew, PhD, from the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues. "The authors examined likelihood, speed, and predictors of recovery in older adults receiving augmentation pharmacotherapy after inadequate response to standardized treatment with paroxetine plus interpersonal psychotherapy."
The investigators monitored depression levels during open-label treatment in 195 adults aged 70 years or older and grouped patients based on whether they required augmentation with bupropion, nortriptyline, or lithium.
Of 105 patients requiring augmentation, 77 (73.3%) required it because of inadequate treatment response, and 28 (26.7%) patients because of response followed by relapse (N = 28). Of these 105 patients, 69 (65.7%) received augmentation and 36 (34%) did not, mostly because of withdrawal of consent or medical comorbidities.
Compared with patients never requiring augmentation, patients receiving augmentation had lower recovery rates. Recovery occurred in 50.0% of patients receiving augmentation because of inadequate response, in 66.7% of those receiving it after early relapse, and in 86.7% of patients who never required augmentation. Compared with other patients, patients receiving augmentation because of inadequate response recovered more slowly, with slightly more adverse effects. Greater medical burden and anxiety predicted slower recovery.
"Despite a lower likelihood of recovery in elderly people receiving augmentation, the recovery by over one half of such patients suggests the value of augmentation for those able to tolerate it," the authors write. "Need for augmentation presages slower recovery in patients showing initial inadequate response; those requiring it after early relapse recovered more quickly. Strategies to further improve the likelihood and speed of recovery after initial treatment failure are needed."
Study limitations include primarily European American sample, lack of placebo control, administration of augmentation by nonblinded clinicians and patients, and limited group sizes within the major study subgroups.
"Our findings suggest the promise of augmentation strategies in the treatment of late-life depression, but they indicate that the application of these strategies will ultimately depend on older adults' medical status and personal preferences for treatment," the authors conclude. "Within these constraints, we recommend that controlled studies of the efficacy of augmentation strategies be undertaken. Such studies are needed both in the context of failure of initial SSRI treatment and in first-line attempts to promote improved likelihood and speed of recovery."
The National Institute of Mental Health supported this study. Some of the authors have disclosed various financial relationships with Astellas Pharma, Pfizer, Johnson & Johnson, Forest Laboratories, Eli Lilly, Janssen Pharmaceuticals, AstraZeneca, Lundbeck, GlaxoSmithKline, and/or Bristol-Myers Squibb.
Am J Psychiatry. 2007;164:1-8.