Impact of close family members on older adults' early response to depression treatment

"The early bird catches the worm"-Prediction of early response and its importance for treatment outcome in a naturalistic setting of cognitive behaviour therapy

OBJECTIVE

Knowledge about predictors of early response (ER) remains limited. This study examined patient, process, and therapist variables to predict ER in a naturalistic setting.

RESEARCH DESIGN AND METHODS

Data from 493 psychotherapy outpatients were analysed. ER was defined by a ≥25% reduction in general psychological distress (ER percent) and by the reliable change index (ER RCI) within the first 10 sessions measured by the Brief Symptom Inventory-18. ER prediction was determined using logistic regression. General psychological distress (GSI) throughout treatment in patients with and without ER was modelled using a multilevel linear model. This model aimed to predict GSI over treatment using repeated measurements, considering group affiliation (ER percent vs. no ER percent), controlled for other predictors.

RESULTS

The prevalence of ER percent and ER RCI were 63.6% and 47.5%, respectively. GSI and therapeutic relationship significantly predicted ER (ER percent: χ2 (6) 70.32, p < .001, Nagelkerkes R2  = .19; ER RCI: χ2 (6) 134.71, p < .001, Nagelkerkes R2  = .35). Patients who rated the therapeutic relationship more positively were more likely to achieve ER (OR = 1.10). Difference in outcomes between patients with and without ER during treatment was influenced by factors such as therapeutic relationship, GSI, therapist experience, and mental comorbidities. Including these variables improved the predictive model from AIC = 17,042.98 to AIC = 16,730.24.

CONCLUSION

The therapeutic relationship is a crucial predictor of ER. Patients achieving ER tend to have better outcome than those without ER. The early phase of therapy warrants particular attention to enhance psychotherapy outcomes.

Psychosocial interventions to improve adherence in depressed and anxious older adults prescribed antidepressant pharmacotherapy: a scoping review

Medication nonadherence in depressed and anxious older adults is prevalent and associated with non-response to antidepressant pharmacotherapy. Evidence-based options to improve medication adherence are limited in this population. To review the state of the literature on the types and efficacy of psychosocial interventions for improving antidepressant pharmacotherapy adherence in depressed and anxious older adults. We conducted a scoping review according to PRISMA-ScR guidelines. PubMed/Medline and article references starting in 1980 up to 28 February 2023 were reviewed. Of the 710 records screened, 4 psychosocial interventions were included in the review. All studies included depressed older adults, and none included anxious older adults. Samples included racial and ethnic minorities and were primarily women. The psychosocial interventions consisted mainly of psychoeducation with usual care as the control comparison. Measures of antidepressant adherence included self-reported adherence or pill counting. Three of the four randomized controlled trials improved medication adherence rates and reduced depression symptom burden. Effective interventions exist for improving antidepressant medication adherence in depressed older adults. Improved adherence can reduce depression symptom burden. The lack of interventions for anxious older adults highlights the need to develop and deliver interventions for anxious older adults prescribed antidepressant pharmacotherapy.

Prevalence and Family Determinants of Geriatric Depression Among Elderly People in Elderly Support Groups in Rwanda

Background

The 1994 Tutsi genocide in Rwanda significantly impacted family structure, with many people growing old alone and lacking social bonds and connections with family members. However, little is known about the contribution of the family environment to geriatric depression which was highlighted by WHO as a psychological problem with a 10% to 20% prevalence rate among the elderly worldwide. This study aims to investigate geriatric depression and associated family determinants among the elderly in Rwanda.

Methods

With a community-based cross-sectional study design, we assessed geriatric depression (GD), quality-of-life enjoyment and satisfaction (QLES), family support (FS), loneliness, neglect, and attitude toward grief in a convenience sample of 107 participants (M=72.32, SD=8.79) aged between 60 and 95 years who were recruited from three groups of elderly people supported by the NSINDAGIZA organization in Rwanda. SPSS (version 24) was used for statistical data analysis; differences across various sociodemographic variables were tested for significance by an independent t-test; the relationship between study variables was tested by Pearson correlation analysis; and multiple regression analysis was performed to model the contribution of independent variables to dependent variables.

Results

A total of 64.5% of the elderly scored above the threshold of the normal range of geriatric depression (SDS>49), with higher symptoms in women than in men. Multiple regression analysis indicated that family support and quality-of-life enjoyment and satisfaction were contributors to geriatric depression in the participants.

Conclusion

Geriatric depression was relatively common in our participants. It is associated with the quality of life and family support received. Hence, adequate family-based interventions are needed to improve the well-being of geriatric people in their respective families.

Effect of an Educational Nursing Intervention on the Mental Adjustment of Patients with Chronic Arterial Hypertension: An Interventional Study

The objective of this analytical and interventional prospective quantitative study was to assess the effect of an educational intervention performed by nurses for mental adjustment to chronic disease in patients with hypertension. A convenience sample was studied, composed of 329 participants with chronic hypertension, followed in a primary healthcare unit in the Central Region of Portugal. Data collection was carried out by applying the Mental Adjustment to Disease Scale (MADS) before and 1 month after the educational nursing intervention between September 2017 and February 2018. Prior to the application of the educational intervention, 43.5% of the participants were classified as "unadjusted" in at least one of the subscales of MADS. After the educational intervention, 21.3% of the participants classified as "unadjusted" became "adjusted" in all MADS subscales. The success rate of the intervention varied from 26.9% (in the fatalism subscale) to 44.6% (for the anxious concern subscale). Participants were more likely to be mentally "unadjusted" to hypertension if they lived with other family members, had an active professional situation before the diagnosis of hypertension, still had an active professional situation now, were under 65 years old, had a shorter time to diagnosis (1-2 years), and measured blood pressure less regularly. The educational intervention performed by nurses is relevant for the mental adjustment of hypertensive patients, contributing to increased knowledge, as well as improvement in preventive and self-care practices, facilitating the experience of the health/disease transition process.

Future Well-Being Among People Who Attempt Suicide and Survive: Research Recommendations

Over 48,000 people died by suicide in 2018 in the United States, and more than 25 times that number attempted suicide. Research on suicide has focused much more on risk factors and adverse outcomes than on protective factors and more healthy functioning. Consequently, little is known regarding relatively positive long-term psychological adaptation among people who attempt suicide and survive. We recommend inquiry into the phenomenon of long-term well-being after nonfatal suicide attempts, and we explain how this inquiry complements traditional risk research by (a) providing a more comprehensive understanding of the sequelae of suicide attempts, (b) identifying protective factors for potential use in interventions and prevention, and (c) contributing to knowledge and public education that reduce the stigma associated with suicide-related behaviors.

Caregiver Reward and Burden: Differing Constructs in Family Members Providing Care for Medically Ill Homebound Older Adults

Objective: This study examined the relationship between caregiver burden and reward and how each relates to factors, such as depression, within the caregiving dyad. Method: A total of 101 older adults and their primary family caregivers were recruited upon enrolling in home health care services. Patients were assessed for sociodemographic information, depression, disability, pain, and caregiver support at baseline and at 8 weeks. Caregivers were assessed at baseline for sociodemographic information, depression, caregiver burden, caregiver reward, and caregiving tasks they provide. Results: Burden and reward were significantly inversely correlated, but differentially associated with distinct patient and caregiver variables. Patients whose caregivers reported higher baseline levels of caregiver reward were more likely to have lower depression scores at follow-up. Discussion: Given that different aspects of patients and caregivers influence reward and burden, assessing caregivers for both burden and reward may better target caregiver interventions at the individual and family levels, particularly for older adult depression.

Acute trajectories of neural activation predict remission to pharmacotherapy in late-life depression

Pharmacological treatment of major depressive disorder (MDD) typically involves a lengthy trial and error process to identify an effective intervention. This lengthy period prolongs suffering and worsens all-cause mortality, including from suicide, and is typically longer in late-life depression (LLD). Our group has recently demonstrated that during an open-label venlafaxine (serotonin-norepinephrine reuptake inhibitor) trial, significant changes in functional resting state connectivity occurred following a single dose of treatment, which persisted until the end of the trial. In this work, we propose an analysis framework to translate these perturbations in functional networks into predictors of clinical remission. Participants with LLD (N = 49) completed 12-weeks of treatment with venlafaxine and underwent functional magnetic resonance imaging (fMRI) at baseline and a day following a single dose of venlafaxine. Data was collected at rest as well as during an emotion reactivity task and an emotion regulation task. Remission was defined as a Montgomery-Asberg Depression Rating Scale (MADRS) ≤10 for two weeks. We computed eigenvector centrality (whole brain connectivity) and activation during the emotion regulation and emotion reactivity tasks. We employed principal components analysis, Tikhonov-regularized logistic classification, and least angle regression feature selection to predict remission by the end of the 12-week trial. We utilized ten-fold cross-validation and Receiver Operator Curves (ROC) curve analysis. To determine task-region pairs that significantly contributed to the algorithm's ability to predict remission, we used permutation testing. Using the fMRI data at both baseline and after the first dose of treatment yielded a sensitivity of 72% and a specificity of 68% (AUC = 0.77), a 15% increase in accuracy over baseline MADRS. In general, the accuracy at baseline was further improved by using the change in activation following a single dose. Activation of the frontal cortex, hippocampus, parahippocampus, caudate, thalamus, medial temporal cortex, middle cingulate, and visual cortex predicted treatment remission. Acute, dynamic trajectories of functional imaging metrics in response to a pharmacological intervention are a valuable tool for predicting treatment response in late-life depression and elucidating the mechanism of pharmacological therapies in the context of the brain's functional architecture.

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Neural activation changes after a single dose of antidepressants have been observed.

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Patients with late-life depression were treated with an antidepressant for 12 weeks.

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Neuroimaging data was recorded pre-treatment and after a single dose.

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Pre-treatment neuroimaging predicted remission at the end of the trial.

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Neuroimaging after a single dose improved prediction and may guide treatment.

Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study

OBJECTIVE

Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research.

METHODS

In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described.

RESULTS

The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study.

CONCLUSION

Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients' support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

AIDE-Acute Illness and Depression in Elderly Patients. Cognitive Behavioral Group Psychotherapy in Geriatric Patients With Comorbid Depression: A Randomized, Controlled Trial

BACKGROUND

Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression.

OBJECTIVES

To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness.

DESIGN

Randomized controlled trial with waiting list control group.

SETTING

Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients' homes.

PARTICIPANTS

A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness.

INTERVENTION

Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group.

MEASUREMENTS

HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician.

RESULTS

The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures.

CONCLUSIONS

CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients.

CLINICAL TRIAL REGISTRATION

www.germanctr.de German Trial Register DRKS 00004728.

Systematic review of dyadic and family-oriented interventions for late-life depression

OBJECTIVE

Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial.

METHODS

Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014.

RESULTS

We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder.

CONCLUSIONS

This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.

Behavioral activation for depression in older adults: theoretical and practical considerations

Late-life depression (LLD) is a major public health concern that can have devastating effects on older individuals and their families. Behavioral theories predict that decreases in response-contingent positive reinforcement and increases in negatively reinforced avoidance behaviors, often accompanied by aversive life events, result in the selection and maintenance of depression. Based on these theories, behavioral activation treatments for depression are designed to facilitate structured increases in enjoyable activities that increase opportunities for contact with positive reinforcement. We discuss the applicability of behavioral models for LLD, and we briefly review current behavioral activation interventions for LLD with an emphasis on implications for future behavior-analytic research. Behavioral activation has been demonstrated to be effective in reducing depression and increasing healthy behavior in older adults. Potential challenges and considerations for future research are discussed. We suggest that applied behavior analysts and clinical behavior analysts are particularly well suited to improve and expand on the knowledge base and practical application of behavioral activation interventions with this population.

Caregiver attributions for late-life depression and their associations with caregiver burden

Late-life depression (LLD) has detrimental effects on family caregivers that may be compounded when caregivers believe that depressive behaviors are volitional or within the patient's capacity to control. In this study we examined three person-centered caregiver attributions that place responsibility for LLD on the patient (i.e., character, controllability, and intention), and the impact of such attributions on levels of general caregiver burden and burden specific to patient depressive symptoms. Participants were 212 spouses and adult children of older adults enrolled in a depression treatment study. Over one third of caregivers endorsed character attributions, which significantly predicted greater levels of both general and depression-specific burden. Intention attributions were significantly associated with general burden, but not depression-specific burden. Contrary to our expectation, controllability attributions did not predict either type of burden. Our findings suggest that the assessment of family caregiver attributions for LLD may be useful in identifying caregivers at risk for burden and subsequent health effects, as well as those who may need education and support to provide effective care to a vulnerable population of older adults.

Citalopram versus other anti-depressive agents for depression

BACKGROUND

Recent US and UK clinical practice guidelines recommend that second-generation antidepressants should be considered amongst the best first-line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second-generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care.

OBJECTIVES

To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non-conventional antidepressants in the acute-phase treatment of major depression.

SEARCH METHODS

We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data.

SELECTION CRITERIA

Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side-effects).

MAIN RESULTS

Thirty-seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non-conventional, like hypericum). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively).

AUTHORS' CONCLUSIONS

Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials.

Late-life depression: evidence-based treatment and promising new directions for research and clinical practice

As the population ages, successive cohorts of older adults will experience depressive disorders. Late-life depression (LLD) carries additional risk for suicide, medical comorbidity, disability, and family caregiving burden. Although response and remission rates to pharmacotherapy and electroconvulsive therapy are comparable with those in midlife depression, relapse rates are higher, underscoring the challenge to achieve and maintain wellness. This article reviews the evidence base for LLD treatment options and provides an analysis of treatment options for difficult-to-treat LLD variants (eg, psychotic depression, vascular depression). Treatment algorithms are also reviewed based on predictors of response and promising novel treatment options.

Early response to psychotherapy and long-term change in worry symptoms in older adults with generalized anxiety disorder

OBJECTIVES

To determine the association of early and long-term reductions in worry symptoms after cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults.

DESIGN

Substudy of larger randomized controlled trial.

SETTING

Family medicine clinic and large multispecialty health organization in Houston, TX, between March 2004 and August 2006.

PARTICIPANTS

Patients (N = 76) aged 60 years or older with a principal or coprincipal diagnosis of GAD, excluding those with significant cognitive impairment, bipolar disorder, psychosis, or active substance abuse.

INTERVENTION

CBT, up to 10 sessions for 12 weeks, or enhanced usual care (regular, brief telephone calls, and referrals to primary care provider as needed).

MEASUREMENTS

Penn State Worry Questionnaire (PSWQ) administered by telephone at baseline, 1 month (mid treatment), 3 months (posttreatment), and at 3-month intervals through 15 months (1-year follow-up). The authors used binary logistic regression analysis to determine the association between early (1 month) response and treatment responder status (reduction of more than 8.5 points on the PSWQ) at 3 and 15 months. The authors also used hierarchical linear modeling to determine the relationship of early response to the trajectory of score change after posttreatment.

RESULTS

Reduction in PSWQ scores after the first month predicted treatment response at posttreatment and follow-up, controlling for treatment arm and baseline PSWQ score. The magnitude of early reduction also predicted the slope of score change from posttreatment through the 15-month assessment.

CONCLUSION

Early symptom reduction is associated with long-term outcomes after psychotherapy in older adults with GAD.

Understanding discrepancy in perceptions of values: individuals with mild to moderate dementia and their family caregivers

PURPOSE OF THE STUDY

We explore discrepancies in perceptions of values and care preferences between individuals with dementia (IWDs) and their family caregivers.

DESIGN AND METHODS

We interviewed 266 dyads consisting of an individual with mild to moderate dementia and his or her family caregiver to determine IWDs' beliefs for 5 values related to care (autonomy, burden, control, family, and safety). We used multilevel modeling to investigate if there are dyadic level discrepancies in beliefs and what factors are associated with such discrepancies.

RESULTS

Caregivers consistently underestimated the IWD's values for all five values. Discrepancies were associated primarily with caregivers' beliefs about the IWD's involvement in decision making. Race was also associated with the discrepancies for control and safety, whereas cognitive functioning of the IWD was associated with the discrepancy for burden.

IMPLICATIONS

Many caregivers do not have an accurate depiction of the IWD's values, yet, caregivers will become the surrogate decision makers for IWDs as dementia progresses. These findings indicate the need for assessments of values and preferences in care and to develop programs that assess values, consider the caregiver's beliefs about care, and improve communication within the dyad in the early stages of dementia.

Treating depression to remission in older adults: a controlled evaluation of combined escitalopram with interpersonal psychotherapy versus escitalopram with depression care management

OBJECTIVE

More than half of the older adults respond only partially to first-line antidepressant pharmacotherapy. Our objective was to test the hypothesis that a depression-specific psychotherapy, Interpersonal Psychotherapy (IPT), when used adjunctively with escitalopram, would lead to a higher rate of remission and faster resolution of symptoms in partial responders than escitalopram with depression care management (DCM).

METHOD

We conducted a 16-week randomized clinical trial of IPT and DCM in partial responders to escitalopram, enrolling 124 outpatients aged 60 and older. The primary outcome, remission, was defined as three consecutive weekly scores of 7 or less on the Hamilton rating scale for depression (17-item). We conducted Cox regression analyses of time to remission and logistic modeling for rates of remission. We tested group differences in Hamilton depression ratings over time via mixed-effects modeling.

RESULTS

Remission rates for escitalopram with IPT and with DCM were similar in intention-to-treat (IPT vs. DCM: 58 [95% CI: 46, 71] vs. 45% [33,58]; p = 0.14) and completer analyses (IPT vs. DCM: 58% [95% CI: 44,72] vs. 43% [30,57]; p = 0.20). Rapidity of symptom improvement did not differ in the two treatments.

CONCLUSION

No added advantage of IPT over DCM was shown. DCM is a clinically useful strategy to achieve full remission in about 50% of partial responders.

Empirically derived decision trees for the treatment of late-life depression

OBJECTIVE

Several predictors of treatment response in late-life depression have been reported in the literature. The aim of this analysis was to develop a clinically useful algorithm that would allow clinicians to predict which patients will likely respond to treatment and thereby guide clinical decision making.

METHOD

A total of 461 patients with late-life depression were treated under structured conditions for up to 12 weeks and assessed weekly with the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The authors developed a hierarchy of predictors of treatment response using signal-detection theory. The authors developed two models, one minimizing false predictions of future response and one minimizing false predictions of future nonresponse, to offer clinicians two clinically useful treatment algorithms.

RESULTS

In the first model, early symptom improvement (defined by the relative change in HAM-D-17 total score from baseline to week 4), lower baseline anxiety, and an older age of onset predict response at 12 weeks. In the second model, early symptom improvement represents the principal guide in tailoring treatment, followed by baseline anxiety level, baseline sleep disturbance, and--for a minority of patients--the adequacy of previous antidepressant treatment.

CONCLUSIONS

Our two models, developed to help clinicians in different clinical circumstances, illustrate the possibility of tailoring the treatment of late-life depression based on clinical characteristics and confirm the importance of early observed changes in clinical status.