Antidepressant Response in Late-Life Depression

When evaluating the literature on the treatment of late-life depression, it is most critical to considerthe methodology of each study, specifically: (1) Is the antidepressant treatment adequate withrespect to dosing duration? (2) How is response defined, e.g., is it simply a 50% reduction in a scalescore, or are there criteria for establishing which patients have truly recovered? (3) Are the outcomedata given for both the intent-to-treat and completer analyses? A review of studies that meet a rigorousstandard of methodology shows that (1) a therapeutic plasma nortriptyline level consistently producesa 70% to 80% remission rate in depressed patients over 60 years of age, (2) there is some scatter in theremission rates reported for fluoxetine with results ranging from 21% to 50%, and (3) studies of sertralineconsistently report a remission rate of 50% or higher. Contrary to the widely held clinical belief,tricyclic treatment is not associated with a higher dropout rate compared with treatment with aserotonin selective reuptake inhibitor (SSRI). However, patients who recovered using tricyclics havelower scores on health-related quality-of-life scales than patients who recovered using SSRIs, and thelong-term impact of the "tolerated" side effects of tricyclics, specifically, increased heart rate and anticholinergiceffects, may be deleterious.