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Getting Better, Getting Well

Understanding and Managing Partial and Non-Response to Pharmacological Treatment of Non-Psychotic Major Depression in Old Age

  • Therapy In Practice
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Abstract

In general, the pharmacological treatment of non-psychotic major depressive disorder in old age is only partially successful, with only approximately 50% of older depressed adults improving with initial antidepressant monotherapy. Many factors may predict a more difficult-to-treat depression, including coexisting anxiety, low self-esteem, poor sleep and a high coexisting medical burden. Being aware of these and other predictors of a difficult-to-treat depression gives the clinician more reasonable expectations about a patient’s likely treatment course. If an initial antidepressant trial fails, the clinician has two pharmacological options: switch or augment/combine antidepressant therapies. About 50% of patients who do not improve after initial antidepressant therapy will respond to either strategy. Switching has several advantages including fewer adverse effects, improved treatment adherence and reduced expense. However, as a general guideline, if patients are partial responders at 6 weeks, they will likely be full responders by 12 weeks. Thus, changing medication is not indicated in this context. However, if patients are partial responders at 12 weeks, switching to a new agent is advised. If the clinician treats vigorously and if the patient and clinician persevere, up to 90% of older depressed patients will respond to pharmacological treatment. Furthermore, electroconvulsive therapy is a safe and effective non-pharmacological strategy for non-psychotic major depression that fails to respond to pharmacotherapy. Getting well and staying well is the goal; thus, clinicians should treat to remission, not merely to response. Subsequently, maintenance treatment with the same regimen that has been successful in relieving the depression strongly improves the patient’s chances of remaining depression free.

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Acknowledgements

Funding for the preparation of this review was obtained from the National Institute of Mental Health P30 MH071944, R01 MH43832, R01 MH37869, T32 MH19986 and KL2 RR024154; the John A. Hartford Foundation; and the University of Pittsburgh Medical Center endowment in geriatric psychiatry. Dr Karp has acted as an advisory board consultant to Eli Lilly and received medication supplies from Eli Lilly for an investigator-initiated trial. The other authors have no conflicts of interest that are directly related to the content of this review.

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Authors and Affiliations

  1. Advanced Center for Interventions and Services Research for Late-Life Mood Disorders, and the John A. Hartford Center for Excellence in Geriatric Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

    Henry C. Driscoll,  Jordan F. Karp, Mary Amanda Dew & Charles F. Reynolds III

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  1. Henry C. Driscoll
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  2. Jordan F. Karp
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  3. Mary Amanda Dew
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  4. Charles F. Reynolds III
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Correspondence to Jordan F. Karp.

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Driscoll, H.C., Karp, J.F., Dew, M.A. et al. Getting Better, Getting Well. Drugs Aging 24, 801–814 (2007). https://doi.org/10.2165/00002512-200724100-00002

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