Study Favours Drugs as Maintenance Therapy for Elderly Individuals with Depression

According to the article published in the New England Journal of Medicine, the study:

…tested the efficacy of maintenance paroxetine and monthly interpersonal psychotherapy in patients 70 years of age or older who had depression (55 percent of whom were having a first episode) in a 2-by-2, randomized, double-blind, placebo-controlled trial. Among patients with a response to treatment with paroxetine and psychotherapy, 116 were randomly assigned to one of four maintenance-treatment programs (either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions) for two years or until the recurrence of major depression. Clinical-management sessions, conducted by the same nurses, social workers, and psychologists who provided psychotherapy, involved discussion of symptoms.

The central result was that major depression recurred within two years at the following rates:

• in 35 percent of the patients receiving paroxetine and psychotherapy,
• in 37 percent of those receiving paroxetine and clinical-management sessions,
• in 68 percent of those receiving placebo and psychotherapy, and
• in 58 percent of those receiving placebo and clinical-management sessions

In other words, the patients receiving both paroxetine and psychotherapy fared the best in terms of recurrence of major depression, while those receiving just the placebo and psychotherapy fared the worst.

The first thing that comes to my mind about this clinical trial is this: is it a surprise that meeting once a month with elderly patients who had already suffered at least one bout of major depression did relatively little to lower the probability of them experiencing depression again?

Once a month?

If I were in such a position and had a choice of daily drug therapy or once-a-month ‘maintenance psychotherapy’, I think I probably would have chosen the drugs without ever having read the report.

Once a month?

But the second and more important thing that comes to mind about this trial is that all the individuals assigned to the 4 treatment groups being tested had already demonstrated responsiveness to the drug paroxetine together with psychotherapy. How might the results have differed if the test subjects had been chosen from an unbiased pool more broadly representative of elderly patients who had experienced major depression — including those who had responded to different drugs, those who had responded to psychotherapy alone, and those who had responded to combinations of the two? If I have understood the experimental design correctly, this study sheds light only on outcomes for those patients already known in advance to respond well to therapy that includes the specific medication, not the broader population of elderly individuals who have experienced major depression.

Or to put it a different way, this study shows primarily that individuals who are already known to have responded well to treatment involving paroxetine fare worse when that drug is taken away than when it is continually provided. A different study with a different design would apparently be needed to establish the efficacy of drug maintenance therapy for individuals who had not already been found to respond well to the drug.

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