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.

Compared with other cohorts of depressed patients, older patients bring varied life experiences that reflect the period of history through which they have lived. Frequently, older patients are immigrants who have witnessed great change in their lifetimes or who have been victims of trauma.

We define late life as 60 years and older. With the mean life span now approaching 80 years, and with more than 200,000 centenarians in the United States, we see a heterogeneous group of young-old (aged 60 to 75), middle-old (aged 75 to 85), and old-old (aged 85 and older); some would also be considered the frail-old.

Harry Stack Sullivan once said, "When you meet a new patient, ask them to begin to tell their story [from] a point before their problem began."¹¹ With the current cohort of older individuals, these explorations require patience and adequate time to create a context within which the depression developed. Of course, medical history, family history, drug lists, and metabolic integrity also need to be explored, but what constitutes an overwhelmingly stressful event or an accumulation of smaller burdens that threaten to undermine coping ability lies in the eyes of the beholder. To be able to optimally help him or her, the clinician must learn as much as he or she can about the cascade of events that led to the elderly patient becoming depressed.

Many older patients are reluctant to take additional medications, leaving psychotherapy as the only outpatient treatment option other than electroconvulsive therapy. Combination treatment has been shown to have a modest added benefit to pharmacotherapy in the acute stages of treatment, although one study showed a remission rate of 78% for combination treatment compared with the usual remission rate of 35% to 60% for pharmacotherapy alone.¹²

Psychotherapy may have more enduring effects on coping skills, and it may bring about better adaptation to dysfunctional relationships, lessen hopelessness, and allow the patient to better pursue pleasurable or fulfilling activity that may protect him against a recurrence in the long term compared with pharmacotherapy alone.^13,14 To paraphrase Dr Kay Jamison: "Lithium diminishes my depression, but psychotherapy heals."¹⁵

Psychotherapy often enhances compliance with antidepressant medications and, conversely, the rapid resolution of vegetative symptoms and cognitive slowing brought about by antidepressant medication often improves a patient's willingness to engage in psychotherapy. Some investigators have therefore proposed a sequenced approach to using antidepressant medication for rapid improvement of core vegetative symptoms and then adding psycho-therapy to teach more effective coping strategies to prevent recurrences.^15-22

Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:

• Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).
• Maximize the coping ability of the patient.
• Foster a more positive outlook of remaining strengths and opportunities.
• Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.

These factors might come together spontaneously if the depression severity is ameliorated by antidepressant medication alone, which might reinvigorate the patient's own coping strategies; however, I would argue from my experience, that this is more likely to occur in younger patients than in older patients for whom fewer options for change are typically available.

Every elderly patient deserves to have a supportive psychotherapy component integrated into his pharmacotherapy management. In interpersonal psychotherapy (IPT) parlance, many of the elderly are in some kind of role transition or are experiencing a change in social roles, such as retirement, moving, or facing declining physical ability, or they have begun to experience the deaths of peers and family members.

Role disputes can also flare when marital partners experience the proximity of retirement or caregiver strain. Even if an older patient is engaged in psychotherapy elsewhere, the treating psychiatrist who is managing phar- macotherapy should check in periodically on the stress points that were identified in the initial evaluation, screen for new stressors or further impingements on coping ability, and ask directly how helpful the patient finds the psychotherapy.

In a nationwide study linking Medicare claims to survey data, 70% of psychotherapy was provided by solo-practice psychiatrists but patients received more consistent psychotherapy if a mental health center was available to them. Patients with no college education were less likely to receive psychotherapy. The best consistency was achieved with a psychiatrist who provided the pharmacotherapy and another professional who provided the psychotherapy. These data argue for taking a more patient explanatory stance with non-college-educated patients who might otherwise benefit from psychotherapy. The same study reported that limited local availability of qualified providers was a significant barrier to obtaining psychotherapy.²³

Nowhere is a combined psychotherapy/pharmacotherapy approach more critical than in the management of depression in the elderly suicidal patient. Even though a guarantee against imminent lethality may be reasonably assured, the treating psychiatrist must quickly understand the true nature of the factors that are contributing to the current risk and must engage and follow up with the patient (and concerned family members) closely enough to determine whether he is moving in a safer or riskier direction. Risk factors for suicide in depressed elders are listed in Table 2.