|Maintenance Treatment Prevents Recurrence in Older Adults
with Single-Episode Depressions
People age 70 and older who continued taking the antidepressant that helped
them to initially recover from their first episode of depression were 60 percent
less likely to experience a new episode of depression over a two-year study period
than those who stopped taking the medication, according to a study funded by
the National Institute of Mental Health (NIMH), part of the National Institutes
of Health. The study addresses a major question in the treatment of depression — when
to discontinue medication.
Published today in the March 16, 2006 New England Journal of Medicine, the study
showed that long-term treatment (for at least 2 years) after a patient is symptom-free
is effective in preventing future depressive episodes.
“This study demonstrates the benefits of keeping older patients on an antidepressant
long after they become symptom-free,” said NIMH’s director Thomas R. Insel, M.D.
The clinical trial tested whether maintenance therapy — long-term treatment
given to patients to enable them to maintain a symptom-free or disease-free state — is
effective in preventing future episodes of depression in patients 70 years and
older. It also tested whether antidepressant medication and psychotherapy were
effective, and whether the extent of patients’ medical burden had an impact on
rates of recurrence.
According to Charles F. Reynolds III, M.D., and colleagues at the University
of Pittsburgh, the study speaks directly to the controversy over the benefits
and risks of administering long-term antidepressant treatment to elderly patients
who have only one lifetime occurrence of major depression. To date, the consensus
has been that older patients experiencing their first episode of depression should
be treated to full remission and then have a limited period of continuation treatment
for 6 to 12 months to ensure the stability of the remission and further improve
“Most geriatric psychiatrists would not have thought that elderly 70 and older
who experienced one episode of depression were candidates for longer term maintenance
treatment of up to two years,” said Reynolds. “They would agree that elderly
with two or more episodes are appropriately prescribed maintenance treatment,
but these data allow us to go one step further and suggest that, in fact, even
those with single episodes fare considerably better out to two years if they
continue use of the medication that got them well.”
Patients ages 70 and older with depression who achieved full remission of symptoms
after treatment using a combination of paroxetine (a selective serotonin reuptake
inhibitor) and interpersonal psychotherapy (IPT) (psychotherapy that focuses
on interpersonal relationships) were administered maintenance treatment where
researchers tested the effectiveness of different treatment regimens in keeping
patients symptom-free for up to 2 years. These patients were randomly assigned
to one of four maintenance treatment groups: (1) paroxetine; (2) placebo; (3)
paroxetine and monthly interpersonal psychotherapy (IPT); and (4) placebo and
The study found maintenance treatment was effective in older people with depression.
Across all four treatment groups, rates of remission significantly differed.
Among patients who received paroxetine in the maintenance phase, 63 percent remained
in remission; 42 percent of those who received placebo remained in remission;
65 percent of patients who received paroxetine and IPT remained in remission;
and 32 percent of patients who received placebo and IPT remained in remission.
Contrary to the researchers’ hypothesis, which predicted that IPT would significantly
reduce rates of recurrence, according to the study, IPT did not show preventive
efficacy in people 70 years and older.
“But that does not mean that other types of psychotherapy are not effective,” said
Reynolds. “It could be that this population needs a more structured and focused
type of psychotherapy — one that works better with cognitive impairment and greater
disability than does IPT — such as problem-solving psychotherapy. Involving caregivers
to a greater extent may also help.”
The study also showed that older people with multiple chronic physical disorders
did not do as well on paroxetine as those with fewer medical problems, although
they did show some benefit. The burden associated with more chronic and disabling
diseases often drives the depression, making it more difficult to treat, the
authors conclude. Despite this, the researchers indicate that maintenance antidepressant
medication may be effective in primary care settings where patients have multiple
“What makes this study so practical is that it shows you can combine chronic
disease management of depression with the chronic disease management of other
illnesses to benefit both the patient’s mental illness as well as their physical
illness,” he said.
The study is part of an overall NIMH effort to conduct practical clinical trials
in “real world” settings that address public health issues important to persons
affected by major mental illnesses.
For more information on depression and how to treat it in older adults, visit
http://www.nimh.nih.gov/healthinformation/depressionmenu.cfm and http://www.nimh.nih.gov/healthinformation/depoldermenu.cfm.
NIMH is part of the National Institutes of Health (NIH), the Federal Government's
primary agency for biomedical and behavioral research. NIH is a component of
the U.S. Department of Health and Human Services.
The National Institutes of Health (NIH) — The Nation's Medical Research
Agency — includes 27 Institutes and Centers and is a component of
the U.S. Department of Health and Human Services. It is the primary federal
agency for conducting and supporting basic, clinical and translational medical
research, and it investigates the causes, treatments, and cures for both common
and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.