Effectiveness of treatments of depression in older ambulatory patients

Objective: To determine the effectiveness of acute-phase pharmacological and psychological treatments of depression in older ambulatory patients by systematically reviewing original research relevant to this topic. Methods: Searches in MEDLINE and PsycINFO and manual reviews of bibliographies located 233 articles. Of these, 40 (37 different studies) met our 8 inclusion criteria: original research, written in English or French, subjects 55 years and older, diagnosis of depression, outpatient or community setting, prospective controlled study design, acute-phase pharmacological or psychological treatment, and outcome measure of depression. Two independent reviewers assessed the methodological quality of each article using a standard form and a quality score was computed. Quantitative data on levels of depression at the end of treatment were abstracted. Results were grouped by specific treatment comparison (type of treatment and type of control group). For comparisons that used the Hamilton Depression Rating Scale, we computed mean posttreatment differences. Effect sizes were computed from the Hamilton Depression Rating Scale or an alternative scale. Results: In studies that compared active drugs with placebo, the heterocyclic drugs significantly reduced the posttreatment Hamilton Depression Rating Scale score (mean difference, -5.78; 95% confidence interval, -8.31 to -3.25); other drugs had smaller effects. In studies that compared active drugs, there were no significant differences overall between different classes of drugs; selective serotonin reuptake inhibitors appeared to be as effective as heterocyclic drugs. Rational psychological treatments performed significantly better than no treatment (mean posttreatment Hamilton Depression Rating Scale difference, -7.25; 95% confidence interval, -10.10 to -4.40) but not significantly better than that for controls who received similar attention. Adjustment for the study quality score did not affect these results. Conclusions: Based on comparisons with untreated controls, heterocyclic antidepressants and rational psychological therapies appear to be the most effective treatments for older ambulatory patients with mild to moderate depression. Based on drug-drug comparisons, selective serotonin reuptake inhibitors appear to be as effective as heterocyclic drugs. However, overall, the magnitude of the treatment effects is modest, limitations in the quantity and quality of appropriate studies suggest a sober approach to treatment in this population.