Geriatric depressed patients

IPT was initially used as an addition to a pharmacotherapy trial of geriatric patients with major depression to enhance compliance and to provide some treatment for the placebo control group (Rothblum et al., 1982; Sholomskas et al., 1983). Investigators noted that grief and role transition specific to life changes were the prime interpersonal treatment foci. These researchers suggested modifying IPT to include more flexible duration of sessions, more use of practical advice and support (for example, arranging transportation, calling physicians), and the recognition that major role changes (for example, divorce at age 75) may be impractical and detrimental. The 6-week trial compared standard IPT to nortriptyline in 30 geriatric, depressed patients. The results showed some advantages for IPT, largely due to higher attrition from side effects in the medication group (Sloane et al., 1985).

Reynolds et al. (1999) conducted a 3-year maintenance study for geriatric patients with recurrent depression in Pittsburgh, using IPT and nortriptyline in a design similar to the Frank et al. (1990) study. The IPT manual was modified to allow greater flexibility in session length under the assumption that some elderly patients might not tolerate 50-minute sessions. The authors found that older patients needed to address early life relationships in psychotherapy in addition to the usual "here and now" IPT focus. The study treated 187 patients, 60 years or older, with recurrent major depression, using a combination of IPT and nortriptyline. The 107 who acutely remitted and then achieved recovery after continuation therapy were randomly assigned to one of four 3-year maintenance conditions:

(1) medication clinic with nortriptyline alone, with steady-state nortriptyline plasma levels maintained in a therapeutic window of 80-120 ng/ml

(2) medication clinic with placebo

(3) monthly maintenance IPT with placebo

(4) monthly IPT (IPT-M) plus nortriptyline.

Recurrence rates were 20% for combined treatment, 43% for nortriptyline alone, 64% for IPT with placebo, and 90% for placebo alone. Each monotherapy was statistically superior to placebo, whereas combined therapy was superior to IPT alone and had a trend for superiority over medication alone. Patients 70 years or older were more likely to have a depressive recurrence and to do so more quickly than patients in their sixties. This study corroborated the maintenance results of Frank and colleagues, except that in this geriatric trial combined treatment had advantages over pharmacotherapy alone as well as psychotherapy alone.

It is easy to misinterpret the comparison of high-dose tricyclic antidepressants to low-dose IPT-M in both these studies. First, it should be noted that no patients in this study received only medication or IPT: even patients in the "medication-only" maintenance phase had received a longer course of acute and continuation IPT than most patients ever get. Second, had the tricyclics been lowered comparably to the reduced psychotherapy dosage, as had been the case in earlier antidepressant medication maintenance trials, recurrence in the medication groups might well have been greater. Meanwhile, there were no precedents for dosing maintenance psychotherapy, for which the choice of a monthly interval for IPT-M was reasonable, and indeed somewhat clinically beneficial. For less severely recurrent major depression, or at somewhat higher IPT doses, how might maintenance IPT fare?

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