Treatment of Depression in the Elderly: A Review of the Recent Literature on the Efficacy of Single- Versus Dual-Action Antidepressants

Background: Despite the prevalence of depression in the elderly, there is a shortage of randomized controlled studies comparing the efficacy of various antidepressant classes in this population. Objectives: This review of recent data on the treatment of depression in the elderly examined the relative efficacy of the selective serotonin reuptake inhibitors (SSRIs) and 2 antidepressant classes having broader neuroreceptor activity-the tricyclic antidepressants (TCAs) and the serotonin-norepinephrine reuptake inhibitors (SNRIs). Tolerability was examined as a secondary objective. Methods: A systematic review of MEDLINE, PsycINFO, and PubMed (January 2003-January 2009) was performed using the terms antidepressant, SSRI, SNRI, TCA, depression, randomized controlled trials, human trials, and individual antidepressant names. The criteria for inclusion in the review were a double-blind design, a placebo control or active comparator group, a population exclusively aged >= 59 years, and enrollment of patients with a diagnosis of major depressive disorder. Results: The literature search identified 18 trials of the treatment of depression in the elderly: 10 compared SSRIs either head to head or versus placebo, 2 compared TCAs with SSRIs, and 6 examined SNRIs (2 vs placebo, 1 vs a TCA, and 3 vs SSRIs). In 2 head-to-head trials, one of which measured efficacy in terms of change in Hamilton Depression Rating Scale (HAM-D) scores and response rates, and the other in terms of a preset 90% CI, TCAs and SSRIs had comparable efficacy. The data from 5 studies using various measures (including changes in Montgomery-Asberg Depression Rating Scale, HAM-D, or Geriatric Depression Scale [GDS] scores; response rates; and remission rates) suggested no additional efficacy benefit for the SNRI venlafaxine compared with SSRIs or TCAs. In a single trial, duloxetine was significantly more effective than placebo in terms of reductions in HAM-D and GDS scores (both, P < 0.001). Conclusion: The available data, although limited, suggest that the dual-action agents (TCAs and SNRIs) do not appear to confer any additional benefits in efficacy over single-action agents (SSRIs) in the treatment of depression in the elderly. (Clin Ther. 2009;31: 945-961) (C) 2009 Excerpta Medica Inc.