Many older people with depression don’t respond to their first antidepressant, so doctors will switch them to another to see if it does the trick.
Now, new research suggests that the best strategy for these people may instead be to add the antipsychotic drug Abilify (aripiprazole) to the original antidepressant.
“This is good news for older adults with hard-to-treat depression,” said study author Dr. Eric Lenze, chief of the department of psychiatry at the University of Washington School of Medicine. in St. Louis. “The addition of a second drug produces improvements in psychological well-being (eg, positive mood, life satisfaction) and, often, remission of depression, and these improvements are more important than the change in medications.”
The two-part study included 742 people aged 60 and over with depression who had failed to respond to at least two antidepressants.
In the first part, 619 people who were taking an antidepressant were randomly assigned to three groups. Some stayed on their original medication and added aripiprazole, others continued on their antidepressant but added the antidepressants Wellbutrin or Zyban (bupropion), and a third group reduced their original antidepressant and switched to bupropion.
Patients were followed for 10 weeks and their medications were adjusted accordingly.
Nearly 30% of people who continued on their original antidepressant but added aripiprazole showed improvement in symptoms of depression, compared with 20% of those who switched to bupropion alone, the study found.
There was no difference between adding aripiprazole or bupropion in the study, but bupropion is linked to an increased risk of falls, which can be a significant problem for older people. This finding may tip the balance in favor of aripiprazole in older people with hard-to-treat depression.
In the second part, 248 people taking antidepressants were treated with lithium or nortriptyline, two older drugs. Neither was effective in relieving depression, the investigators found.
The findings were published March 3 in the New England Journal of Medicine and were simultaneously presented at the annual meeting of the American Association for Geriatric Psychiatry in New Orleans.
Major depressive disorder is common among older adults, said Dr. Aaron Kaufman, clinical professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at the University of California, Los Angeles.
“Primary care physicians or psychiatrists will often start with a selective serotonin reuptake inhibitor (SSRI) to treat depression, and it usually takes two to three months to see the full impact of this intervention,” Kaufman said. , who did not participate in the study. but reviewed the conclusions.
If they don’t respond, people can stop and try another under the guidance of a doctor. “If there was a partial response to the antidepressant, then treating clinicians may consider switching agents, or alternatively, they may choose to add another agent to further optimize that response,” he said. explain.
Sometimes the drug added is another antidepressant, but it can also be another type of drug, Kaufman added.
“With each failed drug trial, the likelihood of responding on the next trial is statistically lower, and unfortunately many people continue to experience treatment-resistant depression, despite adequate drug trials of appropriate dose and duration” , did he declare.
It’s important to weigh the risks and benefits of each drug, Kaufman said.
“The increase with bupropion (which is commonly used) and the increase with aripiprazole were similar in the results on depression, but the increase in bupropion is associated with a greater risk of falls, which does not is not insignificant in populations of older adults who are at risk for medical complications from falls,” he said.
Still, Kaufman said some people may gain significant weight on aripiprazole. Additionally, there are other side effects that affect some people who take aripiprazole, including an internal feeling of restlessness and symptoms of movement disorders.
“There needs to be a discussion of these risks and benefits before starting treatment,” he noted.
“Less than 30% of participants achieved depression remission from any of these strategies, which means that for many patients, these evidence-based strategies still won’t be enough,” Kaufman said.
In these cases, other treatments such as individual or group therapy, exercise and increased social interaction all have a role to play, he suggested.
“Depression in older people is often under-recognized or downplayed, perhaps mistakenly seen as a normal or inevitable part of aging,” Gemma Lewis and Glyn Lewis, both of University College London, wrote in a accompanying editorial. “The results of this trial should help clinicians and older adult patients make informed decisions about next steps in the absence of response to conventional pharmacological approaches.”