High Risk of Depressive Relapse in the Elderly
Abstract & Commentary
Synopsis: Following recovery and two years of successful antidepressant treatment after a first lifetime episode of major depression, this open prospective study found a 60.6 % recurrence rate in elderly patients who were tapered off antidepressant medication.
Source: Flint AJ, Rifat SL. Recurrence of first-episode geriatric depression after discontinuation of maintenance antidepressants. Am J Psych 1999;156(6): 943-945.
Several naturalistic studies have found that older patients have a higher risk of suffering a recurrence of major depression following discontinuation of antidepressant medication. The current study prospectively examined the two-year outcomes of elderly patients with first-episode major depression following discontinuation of their maintenance antidepressant medication.
The study group consisted of 21 elderly patients (mean age, 74.4 years, SD = 6.6) who had recovered from a first lifetime episode of major depression with either nortriptyline (with or without adjunctive lithium) as a first line of treatment (n = 19) or phenelzine as a second line of treatment (n = 2). Following the two years of treatment without a return of symptoms, the antidepressant was then withdrawn over a period of eight weeks. Patients were then followed for another two years or until recurrence, whichever occurred first was used to estimate. The cumulative probability of a recurrence (Kaplan-Meier product limit method) of major depression was 60.6%. Fifty-eight percent of new episodes occurred within six months and 92% within 12 months from the start of discontinuation of medication. Other variables, such as age, gender, or severity of illness did not predict recurrence. If a patient had a recurrence, he or she restarted the discontinued antidepressant. Patients were treated with the same dose of antidepressant that they had previously responded to. Eleven (91.7%) of the 12 patients who had a recurrence agreed to restart antidepressant medication. Nine (81.8%) of the 11 patients responded to reintroduction of the antidepressant alone, and one (9.1%) of the 11 patients responded to the antidepressant and adjunctive lithium. The mean time for response to treatment was 4.5 weeks (SD = 1.8), which was not significantly different from the 4.6 weeks (SD = 2.3) needed to respond to treatment of the index episode (t = -0.12, df = 9, P = 0.91).
Comment by Lauren B. Marangell, MD
These preliminary findings from this small open study certainly bear replication in a larger population with a double-blind, placebo-controlled design. However, the cohort was prospectively followed with structured assessments and the findings are concordant with naturalistic data and clinical experience. The high risk of recurrence in the elderly has led some to recommend that antidepressant medications be continued for a longer, perhaps indefinite, period of time. Flint and Rifat note that given the favorable response to reinstated treatment, an alternative strategy is to treat first-episode patients for a shorter period of time (i.e., 6 months), and then treat recurrences when they arise. However, re-response to medication is not guaranteed and the time to re-response in the current study was 4.5 weeks. As such, the risks of medication discontinuation must be carefully weighed against the benefits. Given that long-term treatment with appropriately selected antidepressant medication is safe and well tolerated in most elderly patients, continuation treatment may be preferred for high-risk patients. Other factors that increase the likelihood of relapse are a higher number of previous episodes and residual symptoms of depression. If a decision is made to discontinue antidepressants, the patient should be educated about recurrence and followed on a regular basis for at least one year.
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