Bupropion SR in the naturalistic treatment of elderly patients with major depression

Therapy Strategies for Late-life Depression: A Review

BACKGROUND

Depression in the elderly requires different treatment options because therapies that are commonly used for depression in younger patients show different effects later in life. Treatment options for late-life depression (LLD) are summarized in this article.

METHODS

A literature search in Medline/PubMed performed in June 2020 identified 83 relevant studies.

RESULTS

Pharmacotherapy with selective serotonin reuptake inhibitors can be an effective first-line treatment in LLD, but >50% of elderly patients do not adequately respond. Switching to other selective serotonin reuptake inhibitors or augmenting with mood stabilizers or antipsychotics is often effective in achieving a therapeutic benefit. Severely depressed patients with a high risk of suicidal behavior can be treated with electroconvulsive therapy. Psychotherapy provides a measurable benefit alone and when combined with medication.

LIMITATIONS

LLD remains an underrepresented domain in research. Paucity of data concerning the effect of specific therapies for LLD, heterogeneity in the quality of study designs, overinterpretation of results from meta-analyses, and discrepancies between study results and guideline recommendations were often noted.

CONCLUSIONS

Treating LLD is complex, but there are several treatment options with good efficacy and tolerability. Some novel pharmaceuticals also show promise as potential antidepressants, but evidence for their efficacy and safety is still limited and based on only a few trials conducted to date.

Advances in Pharmacotherapy of Late-Life Depression

This paper reviews recent research on late-life depression (LLD) pharmacotherapy, focusing on updated information for monotherapy and augmentation treatments. We then review new research on moderators of clinical response and how to use the information for improved efficacy.

RECENT FINDINGS

A recent review shows that sertraline, paroxetine, and duloxetine were superior to placebo for the treatment of LLD. There is concern that paroxetine could have adverse outcomes in the geriatric population due to anticholinergic properties; however, studies show no increases in mortality, dementia risk, or cognitive measures. Among newer antidepressants, vortioxetine has demonstrated efficacy in LLD, quetiapine has demonstrated efficacy especially for patients with sleep disturbances, and aripiprazole augmentation for treatment resistance in LLD was found to be safe and effective. Researchers have also been identifying moderators of LLD that can guide treatment. Researchers are learning how to associate moderators, neuroanatomical models, and antidepressant response. SSRI/SNRIs remain first-line treatment for LLD. Aripiprazole is an effective and safe augmentation for treatment resistance. Studies are identifying actionable moderators that can increase treatment response.

Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant

Bupropion has been used as an antidepressant for over 20 years, though its licence for such use varies and it is typically a third- or fourth-line agent. It has a unique pharmacology, inhibiting the reuptake of noradrenaline and dopamine, potentially providing pharmacological augmentation to more common antidepressants such as selective serotonergic reuptake inhibitors (SSRIs). This systematic review and meta-analysis identified 51 studies, dividing into four categories: bupropion as a sole antidepressant, bupropion coprescribed with another antidepressant, bupropion in 'other' populations (e.g. bipolar depression, elderly populations) and primary evaluation of side effects. Methodologically more robust trials support the superiority of bupropion over placebo, and most head-to-head antidepressant trials showed an equivalent effectiveness, though some of these are hindered by a lack of a placebo arm. Most work on the coprescribing of bupropion with another antidepressant supports an additional effect, though many are open-label trials. Several large multi-medication trials, most notably STAR*D, also support a therapeutic role for bupropion; in general, it demonstrated similar effectiveness to other medications, though this literature highlights the generally low response rates in refractory cohorts. Effectiveness has been shown in 'other' populations, though there is an overall dearth of research. Bupropion is generally well tolerated, it has very low rates of sexual dysfunction, and is more likely to cause weight loss than gain. Our findings support the use of bupropion as a sole or coprescribed antidepressant, particularly if weight gain or sexual dysfunction are, or are likely to be, significant problems. However there are notable gaps in the literature, including less information on treatment naïve and first presentation depression, particularly when one considers the ever-reducing rates of response in more refractory illness. There are some data to support bupropion targeting specific symptoms, but insufficient information to reliably inform such prescribing, and it remains uncertain whether bupropion pharmacodynamically truly augments other drugs.

Duloxetine and care management treatment of older adults with comorbid major depressive disorder and chronic low back pain: results of an open-label pilot study

OBJECTIVE

In older adults, major depressive disorder (MDD) and chronic low back pain (CLBP) are common and mutually exacerbating. We predicted that duloxetine pharmacotherapy and Depression and Pain Care Management (DPCM) would result in (1) significant improvement in MDD and CLBP and (2) significant improvements in health-related quality of life, anxiety, disability, self-efficacy, and sleep quality.

DESIGN AND INTERVENTION

Twelve week open-label study using duloxetine up to 120 mg/day + DPCM.

SETTING

Outpatient late-life depression research clinic.

PATIENTS

Thirty community-dwelling adults >60 years old.

OUTCOME MEASURES

Montgomery Asberg Depression Rating Scale (MADRS) and McGill Pain Questionnaire-Short Form (MPQ-SF).

RESULTS

46.7% (n = 14) of the sample had a depression remission. All subjects who met criteria for the depression remission also had a pain response. 93.3% (n = 28) had a significant pain response. Of the subjects who met criteria for a low back pain response, 50% (n = 14) also met criteria for the depression remission. The mean time to depression remission was 7.6 (SE = 0.6) weeks. The mean time to pain response was 2.8 (SE = 0.5) weeks. There were significant improvements in mental health-related quality of life, anxiety, sleep quality, somatic complaints, and both self-efficacy for pain management and for coping with symptoms. Physical health-related quality of life, back pain-related disability, and self-efficacy for physical functioning did not improve.

CONCLUSIONS

Serotonin and norepinephrine reuptake inhibitors like duloxetine delivered with DPCM may be a good choice to treat these linked conditions in older adults. Treatments that target low self-efficacy for physical function and improving disability may further increase response rates.

Incomplete remission in depression: role of psychiatric and somatic comorbidity

Depression is one of the most pressing public health issues, because of its high lifetime prevalence and because it is associated with substantial disability. In depressed patients, psychiatric and medical comorbidity is the rule rather than the exception. About 60% to 70% of depressed patients have at least one, while 30% to 40% have two or more, concurrent psychiatric disorders. Among these, anxiety disorders and substance use disorders are the most common axis I comorbidities. Furthermore, two thirds of depressed patients have at least one comorbid medical illness. Among depressed patients, those with a current comorbid psychiatric condition (in particular an anxiety or substance use disorder) or medical illness seem to have an impaired response and remission rate during treatment compared with those patients without comorbidity. However, in depressed patients who all have the same comorbid condition, the relative benefit of an antidepressant compared with placebo appears to be equal to those effects achieved in depressed patients without comorbidity. These findings raise important research and treatment issues regarding the generalizability from randomized controlled trials that tend to exclude patients with comorbidity.

Treatment considerations for depression in the elderly

While an episode of depression can first present in late life, it is more likely to be a recurrence of a disorder that began earlier in life or a continuation of a chronic form of depression. Depression in the elderly often occurs in the context of ongoing medical conditions. The treatment for these medical conditions may pose problems in treatment of depression due to increased likelihood of drug interactions. This article discusses pharmacotherapeutic and psychotherapeutic approaches to the treatment of depression in the elderly population.

Comorbidity and depression treatment

Comorbidity is common among patients with major depression, but in most instances it may be of little relevance. Nonetheless, it is a complex issue because of its relation to treatment response, and few studies have attempted to address this. Most have examined comorbidity after the fact in secondary analyses. In this article, I focus on whether comorbidity influences depression treatment response among patients who are primarily diagnosed as suffering from major depression. At least three comorbidities are believed to influence treatment response: medical, anxiety, and personality disorders. Whether studies find that these factors predict worse outcomes in patients with major depression appears to depend on the nature and severity of the medical illness, the study setting, and the study design. The best designed studies reported the least effects of these factors on treatment outcome. Clinically, this suggests that these factors should not be seen as impediments to treatment.

Evidence-based treatment of mood disorders

Currently, mental health care is seeking parity with medical health care for the first time. The readers of this article are informed, globally aware, expert clinicians. They have access to the latest resources for diagnostics and clinical guidelines for managing mental health problems. They can incorporate their use of self as a therapeutic agent to teach, listen, and negotiate effectively with patients and their families for optimal outcomes in treating the whole person, mind, body, emotions, and spirit. Advanced practice psychiatric mental health nurses are able to move with the changes in mental health care [7,33,35].

Mood disorders and chronic obstructive pulmonary disease: current research and future needs

The following review examines the interrelationships between chronic obstructive pulmonary disease (COPD), psychiatric illness, and tobacco use. The influence that these three entities have is very unclear, and this article attempts to address the current knowledge of how each contributes to the other and postulates future directions to explore regarding diagnosis, treatment, and predictive values. Other issues discussed include the pharmacologic treatment of patients with COPD and depression, and an overview of the clinical trial data regarding several different classes of antidepressants. Also reviewed is the impact of pulmonary rehabilitation on psychologic status and quality of life issues in the daily functioning of the COPD patient.