Mohammed T. Abou-Saleh

PSYCHOTHERAPY OF DEPRESSION AND DYSTHYMIA 449from an episode of major depression are at high risk forrelapse. Reynolds et al. 8 used a combination of medication andpsychotherapy for the acute treatment of depression in order toempirically test the most effective maintenance therapy forremitted elderly. In their study, the 107 patients who fullyrecovered in open acute treatment with nortriptyline andinterpersonal therapy were randomly assigned to one of fourmaintenance therapies: nortriptyline and IPT; nortriptyline andmedication clinic; placebo and IPT; or placebo and medicationclinic. Combined psychotherapy (IPT plus medication) wassuperior (80% effect) to medication alone (57% effect),psychotherapy alone (43% effect) or placebo (10% effect) forthe maintenance of treatment gains and prevention of relapse.Reynolds et al. 8 concluded that combined psychotherapy andmedication treatment appears to be the optimal long-termstrategy in preserving depression remission and recommendedthat all older patients with recurrent depression be referred forpsychotherapy. Research is currently under way testing thehypothesis that combination treatment is the most cost-effectiveway to treat recurrent depression in the elderly.TREATMENT-RESISTANT POPULATIONSWhile Reynolds and colleagues have established that combinationtherapy is the preferred means for maintenance of remission, thereis an alarming number of elderly depressed patients who do notrespond to medication, psychotherapy or the combination.Although acute remission rates of 50–70% are impressive, thereremains another 30–50% of patients who do not respond. It hasbeen found that elderly patients with co-morbid personalitydisorder, irrespective of level of depression, are less likely tobenefit from short-term therapy than patients without comorbidity67 (see review 68 ); hence, part of the population notresponding to treatment may have personality disorders. However,with the exception of case studies, no outcome study hasspecifically focused on treating late-life personality disorders, andthose studies reporting outcomes for personality-disorderedelderly have suffered from varied methodological problems 68 .Nevertheless, poorer outcome and increased likelihood of relapseamong personality-disordered elders, as well as continuedobservations that depression in the elderly is often a recurringphenomenon, require that revisions to existing treatments bemade and implemented.DYSTHYMIADespite the growing interest in studying treatment of depressionin the elderly, we did not find any research specificallyinvestigating the treatment of dysthymia in elderly patients.Although the research on treatment of recurrent old-agedepression 8 may reflect issues associated with treating dysthymicindividuals, research protocols up to now have focused primarilyon a diagnosis of major depression. However, minor depressionor less severe forms of depression remain important areas ofinvestigation. Partial responses to treatment are associated withhigher rates of relapse 69 and minor depression is more prevalentthan MDD and subsequently has a greater number of disabilitydays associated with it 70 . In addition, researchers have foundthat patients with endogenous depression (an older term with asymptom profile similar to dysthymia) responded less favorablyto psychotherapy than non-endogenous depression patients, andthat improvement occurred more quickly for the non-endogenoussubtype 57 . Thus, more research is needed to examine thepublic health challenges posed by old-age chronic recurringdepressive experience, partial responses to treatment, and minordepression.CONCLUSIONSThere is a growing body of research demonstrating thatpsychotherapy offers significant promise for the treatment ofelderly depression, preventing depressive relapse, and at timesmay be the preferred treatment modality in terms of bothefficacy and patient choice. Referral to psychotherapy remains aproblem, and current research on underdiagnosis and undertreatmentof depression in older adults focuses more ondescribing the problem than on understanding it. However,with more insight into the reasons why elderly depression isinadequately diagnosed and treated, health providers can beginto develop operative means to ensure that this disabling yettreatable disorder is not ignored. General practitioners andmental health professionals do have the means to treatdepression in the elderly with medication and/or psychotherapy;the work now lies in getting out into the ‘‘real world’’ andputting these techniques into practice.REFERENCES1. Scogin F, McElreath L. Efficacy of psychosocial treatments forgeriatric depression: a quantitative review. J Consult Clin Psychol1994; 62: 69–74.2. Teri L, McCurry SM. Psychosocial therapies. In Coffey CE,Cummings JL et al., eds, American Psychiatric Press Textbook ofGeriatric Neuropsychiatry. Washington, DC: American PsychiatricPress, 1994: 662–82.3. Zeiss AM, Breckenridge JS. Treatment of late life depression: aresponse to the NIH Consensus Statement. Behav Ther 1997; 28: 3–21.4. Schneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ. Diagnosisand Treatment of Depression in Late Life. Washington DC: AmericanPsychiatric Press, 1994.5. Schneider LS. Meta-analysis from a clinician’s perspective. InSchneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ, eds,Diagnosis and Treatment of Depression in Late Life. WashingtonDC: American Psychiatric Press, 1994: 361–73.6. Lebowitz BD, Pearson JL, Schneider LS et al. Diagnosis andtreatment of depression in late life: consensus statement update. JAm Med Assoc 1997; 278: 1186–90.7. Koder D, Brodaty H, Anstey KJ. Cognitive therapy for depression inthe elderly. Int J Geriat Psychiat 1996; 11: 97–107.8. Reynolds CF III, Frank E, Perel JM et al. Nortriptyline andinterpersonal psychotherapy as maintenance therapies for recurrentmajor depression: a randomized controlled trial in patients older than59 years. J Am Med Assoc 1999; 281: 39–45.9. Koenig HG. Late-life depression: how to treat patients with comorbidchronic illness. Geriatrics 1999; 54: 56–61.10. Hirschfeld R, Keller M, Panico S et al. The National Depressive andManic Depressive Association consensus statement on the undertreatmentof depression. J Am Med Assoc 1997; 277: 333–40.11. Bortz J, O’Brien K. Psychotherapy with older adults: theoreticalissues, empirical findings and clinical applications. In Nussbaum P,ed., Handbook of Neuropsychology and Aging: Critical Issues inNeuropsychology. New York: Plenum, 1997: 431–51.12. Cooper-Patrick L, Powe NR, Jenckes MW et al. Identification ofpatient attitudes and preferences regarding treatment of depression. JGeriat Intern Med 1997; 12: 431–8.13. Koenig HG, George LK, Meador KG. Use of antidepressants bynon-psychiatrists in the treatment of medically ill hospitalizeddepressed elderly patients. Am J Psychiat 1997; 154: 1369–75.14. Friedhoff A. Consensus Development Conference statement:diagnosis and treatment of depression in late life. In Schneider LS,Reynolds CF, Lebowitz BD, Friedhoff AJ, eds, Diagnosis andTreatment of Depression in Late Life. Washington DC: AmericanPsychiatric Press, 1994: 491–511.