Antidepressants versus placebo for the depressed elderly

  • Review
  • Intervention

Authors


Abstract

Background

Depression warranting intervention is found in ten percent of people over the age of 60. Older depressed people are more likely to die than non-depressed. Relatively few receive therapeutic interventions, and those that do, tend to receive low dose antidepressant therapy. Depression in older people is thought to differ in terms of aetiology, presentation, treatment and outcome than in younger people. Concomitant physical illness and increasing social, physical and neurophysiological diversity are associated with the ageing process. Consequently drug treatment of older patients is often carried out in institutions and on patients suffering from multiple physical problems.

Objectives

To determine the efficacy of antidepressant medication compared with placebo in the treatment of depression in older patients.

Search methods

The search strategy incorporated: electronic literature searches of databases held by the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDAN) (see Collaborative Review Group Search Strategy). Reference lists of related reviews and references of located studies. Contact was made with authors working in the field.

Selection criteria

All randomised, placebo controlled trials using antidepressants in the treatment of the presenting episode of depression in patients described as elderly, geriatric senile or older adult.

Data collection and analysis

Two types of data were extracted (if available) from each study. The first type of data was dichotomous data, this consisted of recovered/not recovered. The second, continuous data,included: Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Rating Scale (MADRS) and other depression rating scale scores. An analysis using Peto Odds ratios for the dichotomous data and weighted mean difference for continuous data was performed using RevMan 3.1. The presence of heterogeneity of treatment effect was assessed.

Main results

Seventeen trials contributed data to the analyses comparing the efficacy of antidepressant treatment and placebo. Analyses of efficacy were based on 245 patients treated with Tricyclic antidepressants (223 with placebo), 365 patients treated with SSRIs (372 with placebo) and 58 patients treated with MAOIs (63 with placebo). The results using a fixed effect model, for the three groups respectively were, TCAs; OR: 0.32 (95% CI: 0.21,0.47), SSRIs; OR; 0.51 (95% CI: 0.36,0.72), MAOIs: OR 0.17 (95% CI: 0.07,0.39).

Authors' conclusions

TCAs, SSRIs and MAOIs are effective in the treatment of older community patients and inpatients likely to have severe physical illness. At least six weeks of antidepressant treatment is recommended to achieve optimal therapeutic effect. There is little evidence concerning the efficacy of low dose TCA treatment. Further trials are required before low dose TCA treatment is routinely recommended.

Resumo

Antidepressivos versus placebo na depressão em idosos

Introdução

A depressão é encontrada em dez por cento das pessoas com mais de 60 anos. Os idosos deprimidos são mais propensos a morrer do que os não deprimidos. Relativamente poucos idosos tratam a depressão, e aqueles que o fazem, tendem a receber uma dose baixa da terapia antidepressiva. A depressão em idosos difere em relação aos jovens em termos de etiologia, apresentação, tratamento e evolução. Doença física concomitante e crescente diversidade social, física e neurofisiológica são fatores associados com o processo de envelhecimento. Consequentemente, o tratamento medicamentoso de pacientes idosos é muitas vezes realizado em instituições e em pacientes que sofrem de vários problemas físicos.

Objetivos

Determinar a eficácia de medicamentos antidepressivos em comparação com o placebo, no tratamento da depressão em idosos.

Métodos de busca

A estratégia de busca ocorreu em bases eletrônicas da literatura de bancos de dados mantidos pelo the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDAN). Listas de referências de revisões relacionadas e referências de estudos localizados relacionados. O contato foi feito com os autores especialistas na área.

Critério de seleção

Todos os ensaios clínicos randomizados controlados com placebo que verificaram o uso de antidepressivos no tratamento da depressão em idoso, senil ou adulto idoso.

Coleta dos dados e análises

Foram extraídos dois tipos de dados dos estudos (quando disponíveis). O primeiro tipo de dados foi dicotômico (este consistiu em recuperado/não recuperado). O segundo tipo foram os dados contínuos que incluíram: a escala de depressão de Hamilton, a escala de depressão de Montgomery-Asberg e outros escores de escalas de classificação da depressão. Uma análise utilizando peto odds ratio (OR, razão de chances de Peto) para os dados dicotômicos e a diferença de média padronizada para os dados contínuos foi realizada utilizando o programa RevMan 3.1. A presença de heterogeneidade do efeito do tratamento foi avaliada.

Principais resultados

17 ensaios clínicos contribuíram com dados para as análises que compararam a eficácia do tratamento antidepressivo em relação ao placebo. As análises de eficácia foram baseadas em 245 pacientes tratados com antidepressivos tricíclicos (e 223 tratados com placebo), 365 pacientes tratados com inibidores seletivos da recaptação de serotonina (ISRS) (372 tratados com placebo) e 58 pacientes tratados com inibidores da monoaminooxidase (IMAO) (63 tratados com placebo). Os resultados utilizando um modelo de efeito fixo, para os três grupos foram, respectivamente, para os tricíclicos OR 0,32 (IC 95% 0,21, 0,47), ISRS OR 0,51 (IC 95% 0,36, 0,72) e IMAO OR 0,17 (IC 95% 0,07, 0,39).

Conclusão dos autores

As três classes de antidepressivos são eficazes no tratamento de idosos e pacientes que possam ter uma doença física grave. Pelo menos seis semanas de tratamento antidepressivo é recomendado para conseguir o efeito terapêutico ótimo. Há pouca evidência sobre a eficácia dos antidepressivos tricíclicos quando utilizados em baixa dose, sendo necessária a realização de estudos para que estes medicamentos possam ser recomendados para uso em baixa dose.

Plain language summary

Antidepressants compared with placebos for depressed older people

Seventeen RCTs were identified by the systematic literature search that met our inclusion criteria and provide suitable data for analysis. We analysed these 17 placebo trials examining the efficacy of antidepressant treatment in older people. Just under 2000 patients were entered into the meta analysis. TCAs, SSRIs and MAOIs proved effective in both institutionalised and community patients. Low dose TCA treatment may be effective but further studies are needed.

Resumo para leigos

Antidepressivos versus placebo na depressão em idosos

17 ensaios clínicos randomizados que preencheram os critérios de inclusão foram utilizados neste estudo. Foram avaliados 17 ensaios clínicos que examinaram a eficácia do tratamento com antidepressivo em pessoas idosas em relação a placebo. Pouco menos de 2.000 pacientes foram utilizadas na metanálise. As três classes dos antidepressivos foram eficazes para os pacientes institucionalizados e os da comunidade. O uso de antidepressivos em baixa dose pode ser eficaz, mas são necessários mais estudos para comprovar sua eficácia.

Notas de tradução

Traduzido por: Cristiane de Cássia Bergamaschi, Universidade de Sorocaba- Uniso; Unidade de Medicina Baseada em Evidências da Unesp, Brasil Contato: portuguese.ebm.unit@gmail.com

எளியமொழிச் சுருக்கம்

மனச்சோர்வு கொண்ட வயதான மக்களில் மனச்சோர்வு நீக்கி மருந்துகளோடு ஒப்பிடப்பட்ட போலி சிகிச்சைமுறை

எங்களின் முறைப்படுத்தப்பட்ட தேடலின் சேர்க்கை விதியை பூர்த்தி செய்து மற்றும் பகுப்பாய்விற்கு தகுந்த தரவை வழங்க முடிந்த பதினேழு சீரற்ற கட்டுப்பாட்டு சோதனைகளை நாங்கள் அடையாளம் கண்டோம். வயதான மக்களில் மனச்சோர்வு சிகிச்சையின் பலனை ஆராய்ந்த 17 போலி சிகிச்சை சோதனைகளை நாங்கள் பகுப்பாய்வு செய்தோம். எங்களின் பகுப்பாய்வில் 2000-க்கும் குறைவான நோயாளிகளை மட்டுமே சேர்க்க முடிந்தது. ட்ரைசைகிளிக் ஆன்டிடிப்ரேஷன்ட்ஸ் (டிசிஏ'ஸ் ), செலெக்ட்டிவ் செரடோனின் ரீஅப்டேக் இன்ஹபிடார்ஸ்,(எஸ்எஸ்ஆர்ஐ'ஸ்) மற்றும் மோனோஅமின் ஆக்ஸ்சிடேஸ் இன்ஹபிடார்ஸ் (எம்ஏஓஐ'ஸ்) ஆகியவை பராமரிப்பு இல்லங்கள் மற்றும் சமூகத்தில் வாழும் நோயாளிகள் இருவரிலும் திறன் மிக்கதாக காணப்பட்டன குறைந்தளவு டிசிஏ சிகிச்சை திறன் மிக்கதாக இருக்கக் கூடும், ஆனால், மேற்படியான ஆய்வுகள் தேவைப்படுகின்றன.

மொழிபெயர்ப்பு குறிப்புகள்

மொழிபெயர்ப்பாளர்: சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன்

Ringkasan bahasa mudah

Antidepresan berbanding plasebo untuk penyakit kemurungan bagi orang tua

Tujuh belas kajian terkawal secara rawak telah dikenal pasti dengan carian kesusasteraan sistematik yang memenuhi kriteria kemasukan kami dan memberikan data yang sesuai untuk analisis. Kami telah menganalisis 17 kajian menggunakan plasebo yang menguji keberkesanan rawatan antidepresan untuk orang tua. Sejumlah 2000 peserta dimasukkan ke dalam meta analisis. TCAs, SSRIs dan MAOIs terbukti berkesan kepada kedua-dua pesakit-pesakit institusi dan juga komuniti. Dos rendah bagi rawatan menggunakan TCA mungkin berkesan, tetapi kajian lanjut masih diperlukan.

Catatan terjemahan

Diterjemahkan oleh Nur Farahim Daud (Penang Medical College). Disunting oleh Tan May Loong (Penang Medical College). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi nfarahim@ms.pmc.edu.my

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