Managing Late-Life Depression With Combined Medication and Psychotherapy

Managing Late-Life Depression With Combined Medication and Psychotherapy

There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.1,2 For nonresponders or partial responders, clinicians must decide between switch strategies or augmentation with another medication or psychotherapy.3,4

Evidence-based psychotherapy has shown efficacy as monotherapeutic treatment for late-life depression. Treatment effect sizes ranging from 0.43 to 1.03 have been cited in several meta-analyses, and 2 of these reviews found that individual therapy was superior to group therapy.5-10 Psychotherapy alone may suffice for mild to moderately severe depression, particularly when it stems from obvious stressors, such as bereavement. Given the clear consensus that psychotherapy is effective in late-life depression, the decision to combine it with pharmacotherapy may be determined more by whether it is available for a given patient. Table 1 lists several potential barriers.

Barriers to the added benefits of psychotherapy in late life
• Unavailability of qualified psychotherapists
• Cost: lower reimbursement rates compared with those for pharmacotherapy
• Many solo-practice psychiatrists favor pharmacotherapy alone over combined treatment
• Transportation for regular attendance, particularly in rural areas (use of the telephone may improve consistency, but it requires intact hearing and adequate privacy)
• Patient refusal because of unfamiliarity with potential benefits (correlated with the lack of a college education)
• Poor integration of care between medication prescribers and psychotherapists
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