Augmentation And Novel Treatment Strategies

Lithium has demonstrated some benefits when used as augmentation to antidepressants in older patients, with a 50% response acute rate (Zullino et al., 2001). Lithium augmentation significantly reduced relapse rates compared to antidepressants alone over two years (Wilkinson et al., 2002). However, it is recommended that special care be taken when treating elderly patients with lithium, because of a higher risk of adverse effects.

No benefit was seen when total sleep deprivation was added to paroxetine; in fact, the two interventions seem to counteract each other (Reynolds et al., 2005). Light therapy significantly improved depressive symptoms in a study in older depressed patients (Tsai et al., 2004). A small randomized trial comparing repetitive transcra-nial magnetic stimulation (rTMS) and sham treatment in older patients with treatment-resistant MDD reported antidepressant effects in both groups, with no significant benefits associated with rTMS (Mosimann et al., 2004). St John's Wort has been shown to have antidepressant effects (Linde et al., 2005). St. John's Wort was shown to be equivalent to fluoxetine, in a randomized trial in elderly patients with mild or moderate depressive episodes (Harrer et al., 1999).

ELECTROCONVULSIVE THERAPY (ECT)

Although patients who receive ECT tend to be older than those who do not (de Carle et al., 2000), there are few good studies of the use of ECT in the elderly population. ECT has been reported to be effective in elderly patients in several open or retrospective case series (Bosworth et al., 2002; Kujala et al., 2002; Little et al., 2004), with improvement in about 80% and adverse events in about 35% (Kujala et al., 2002; Little et al., 2004). Safety has been generally acceptable, with only minor complications during ECT among older patients with preexisting cardiovascular disease; falls are reported with increasing frequency as the number of treatments increases (de Carle et al., 2000).

In meta-analyses, ECT has been found to be an effective treatment option compared to both placebo and pharmacotherapy (2003; Pagnin et al., 2004). Several open, prospective, follow-up studies have compared one-year outcomes in elderly patients treated with ECT or antidepressants (Huuhka et al., 2004; Navarro et al., 2004a; Navarro et al., 2004b). One study reported a 41% rehospitalization rate, which was similar in both treatment groups (Huuhka et al., 2004). In patients who remained euthymic for one year, there were no brain perfusion abnormalities, and the significant anterior hypofrontality seen at baseline disappeared with sustained remission of depression in both treatment groups (Navarro et al., 2004a; 2004b).

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