{"id":624,"date":"2015-03-04T11:00:05","date_gmt":"2015-03-04T11:00:05","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=624"},"modified":"2017-08-21T11:53:27","modified_gmt":"2017-08-21T11:53:27","slug":"primary-care-corner-with-geoffrey-modest-md-depression-treatment-in-the-elderly","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/03\/04\/primary-care-corner-with-geoffrey-modest-md-depression-treatment-in-the-elderly\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Depression treatment in the elderly"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

\"elderly\"The treatment of depression in the elderly can be very difficult. The usual meds (SSRIs) tend to be less effective in the elderly, with some studies not finding much difference from placebo. And psychotherapy, which does help\u00a0some, is often also less effective, given that many elderly do not have much insight into their condition and many also find it difficult to change. There have been studies in the past\u00a0showing significant efficacy of stimulants, especially in those with\u00a0severe depression\u00a0(eg, a study at Mass General Hosp of 129 geriatric inpatients with severe major depression found 66% with significant improvement within 1-2\u00a0days, and only 8% with adverse reactions\u00a0and none with\u00a0reduction in appetite. Average doses of dextroamphetamin was 8.2 mg and methylphenidate 8.2 mg (see\u00a0J Geriatr Psychiatry Neurol. 1990;3(3):146<\/strong>). Other old studies have found an overall response rate of 81%. \u00a0I am unaware of newer studies).<\/p>\n

In this context, a 16 week\u00a0RCT was done of\u00a0143 geriatric outpatients with major depression, comparing methylphenidate to citalopram to the combination of the two\u00a0(see\u00a0doi: 10.1176\/appi.ajp.2014.14070889<\/strong>). In brief:<\/p>\n

–mean age 70, 1\/2 women, 75% white, 16 years of education,\u00a0age at depression onset mean 42 yo, duration of episode mean of 48 months and\u00a080% with >24 months of depression.<\/p>\n

–inclusion criteria: unipolar major depressive disorder, score >15 in Hamilton\u00a0Depression Rating Scale HAM-D (mean in study was 18.9) and >25 on Mini-Mental State Exam (mean was 28.7)<\/p>\n

–patients seen weekly for 4 weeks\u00a0to titrate methyphenidate dose,\u00a0then every 2 weeks for the 16-week study (ultimate methylphenidate\u00a0range was\u00a05-40 mg, with average of 16.3 mg in both groups). citalopram started at 20mg, then increased to 40mg after 1 months if insufficient improvement, then 60mg after 7-8 weeks if needed, with average dose of approx\u00a035\u00a0mg in both\u00a0groups.<\/p>\n

Results:<\/p>\n

–the HAM-D was significantly improved in the combo group within 2 weeks and maintained for the rest of the study (62%\u00a0\u200b\u00a0remission rate\u00a0at 16 weeks). the citalopram only group was intermediate\u00a0(42% at 16 weeks), and the methylphenidate group did the least well\u00a0(29% at 16 weeks). all of these results were significantly better than placebo\u00a0for depression severity, assessment of\u00a0global clinical improvement, and\u00a0cognitive function (methylphenidate did not add to the improvement of cognitive function).<\/p>\n

–the citalopram dose was significantly associated with achieving remission: 29.8% in those without citalopram, 41.9% in those on 20mg, 56.4% in those on 40mg, and 69.2% in those on 60mg. there was no clear dose-response curve in those on methylphenidate.<\/p>\n

So, pretty impressive results. the combination therapy was pretty well-tolerated (did not increase the incidence of adverse reactions or the number of people who dropped out of the study —\u00a045 dropped out, for a variety of reasons). The symptom\u00a0response to the combination was faster (evident within a couple of weeks) and more profound. The issues that come up are:<\/p>\n

–The FDA limits the citalopram dosing to 20mg for elderly. I did note in a\u00a0blog<\/a>\u00a0post\u00a0“there is a pretty dramatic increase in QTc with citalopram, but it is important to note that the actual clinical effect of this prolongation is NOT clear: the FDA looked at a large VA database and found that the risk of ventricular arrhythmias and mortality were LOWER in depressed patients on greater than 40mg citalopram\/day, similar results to those found in patients on sertraline”.<\/p>\n

–One other concern is that methylphenidate can increase citalopram levels<\/p>\n

It would be great to have studies looking at the combo of another, perhaps safer SSRI (eg sertraline) with methylphenidate….<\/p>\n","protected":false},"excerpt":{"rendered":"

Depression treatment in the elderly […]<\/p>\n

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