2. Pharmacologic vs Non-pharmacologic Treatments for Depression Ferris State University Brittany Torok, Heather Torre, Erin VanderHorst, and Jamie Wilson NURS 315

3. Introduction  Depression is common in the terminally ill person and frequently these symptoms will go unrecognized.  It is important to remember “persistent feelings of helplessness, hopelessness, inadequacy, and suicidal ideations are not normal at the end of life” (Dodds, Kumar & Veering, 2014).

4.  Depressive symptoms can respond quickly and positively to pharmacological and non- pharmacolgic treatment.  Medications – Used alone of in combination with other psychotropics.  Antidepressants - (SSRI’s- fluoxetine, sertraline & citalopram)  Stimulants – (methylphenidate, Concerta/Ritalin)  Non-benzodiazepines – (Buspirone hydrocholoride)

5. Analysis of Pharmacological Studies Brown University Report 300 participants over the age of 60 years in a 12- week, double blind, placebo-controlled trial yielded: o 86% of the patients treated with paroxetine and 55% of the patients given the placebo responded to treatment o 12.3% patients receiving paroxetine discontinued treatment due to adverse side effects, compared to 8.3% of the placebo- treated patients that stopped use. (Paxil CR has favorable tolerability in elderly depression, 2003)

6. Analysis: Non-Pharmacological Studies Psychotherapy: Cognitive Behavior Therapy  Meta-analysis of literature from 23 randomized controlled trials (RCTs) were chosen from 485 studies.  Participants were older adults with major or minor depressive symptoms, and selected from the community and clinical settings.  In most studies, the subjects were from similar demographics and not very generalized.  Active controls = social support, placebo, case management, discussion group, etc.  Non-active controls = Treatment as usual. (Gould et al., 2012)

7. Psychotherapy: Cognitive Behavior Therapy This research is competitive since:  Meta-analyses, as well as randomized controlled trials, are considered to have stronger levels of evidence. ______________________ Results: CBT is “more effective at reducing depressive symptoms than nonactive, but not active controls.” (Gould et al., 2012)

8. Analysis: Pharmacological + Non-pharmacological Combination Reynolds’ Study of paroxetine+therapy 116 patients over 59 years participated. 28 took paroxetine plus psychotherapy. 35 took placebo plus psychotherapy. 35 took paroxetine and only clinical management. 18 took placebo and only clinical management. (Reynolds, et al., 2006)

9. Reynolds’ Study of paroxetine+therapy o Paroxetine plus psychotherapy had the lowest recurrence rate of depression. o Paroxetine and only clinical management was more effective than placebo plus psychotherapy (Renyolds et al., 2012)

10. Descriptive Summary Psychotherapy  There is an abundance in opportunities for psychotherapy interventions in our aging population  Psychotherapy can assist family members and other care givers to provide enhanced care to the elderly  Psychotherapy can be a life-saving measure for elderly who are considering suicide

11. Psychotherapy Psychotherapy can be an effective non- pharmacological option to treat depression in elderly. Especially when:  Pharmacological treatment produces undesired side effects.  Noncompliance or forgotten doses are a problem.

12. Descriptive Summary Psychotherapy Combination  When used in combination with Paxil lead to a reduction of reoccurrence of depression in the elderly  Where as a placebo use in combination with psychotherapy did not show a reduction in reoccurrence of depression

13. Descriptive Summary Pharmalogical Intervention –Paxil  Reynolds 2-year study revealed: the risk of reoccurrence in depression was 2.4 times higher in individuals who took a placebo rather than Paxil.  Many elderly have comorbidities, which can lead to drug interactions with Paxil

14. Recommendations Psycotherapy VS paroxetine  According to the analysis of evidence above, depression is best treated with both Paroxetine and psychotherapy.  Using both treatments together can lower the recurrence rate of depression.  Treatment also depends on how depressed the patient is. In patients that are severely depressed, antidepressant drug therapy is more effective than psychotherapy. (Long, 1988)

15.  Patients that have non-severe depression usually recover in less than 4 months.  “If the average episode of major depression lasts 4 months, then for these mild cases, all that is required is seeing a therapist frequently for brief, supportive visits until the depression spontaneously recovers. (Long, 1988)”

16.  If a patient has severe major depression an antidepressant is highly effective and must be given.  In this case the drug must be given for at least 6-12 months (Long, 1988)  “Severely depressed patients suffer greatly and are high suicide risks. It takes weeks before antidepressant drug therapy starts to work, thus these patients desperately need a caring professional who will emotionally support them and their family until their body recovers. (Long, 1988)”

17. Conclusion/Summary  Psychotherapy is an effective treatment for mild cases of depression  Paxil is effective for mild-severe depression  The combination of psychotherapy and Paxil can improve effectiveness rather than when used alone  Similar to other medications used to treat depression Paxil or psychotherapy may not be effective for every patient and different pharmalogical or nonpharmalogical interventions may need to be tried before finding the right medication or combination

18. References  Anderson, D., Wattis, J. (2014). Psychotherapeutic approaches in the elderly. GM. 8. Retrieved from http://www.gmjournal.co.uk/psychotherapeutic_ap proaches_to_the_elderly_25769815462.aspx  Dodds, C.,Kumar, C., Veering, B. (2014). Oxford textbook of anesthesiology for the elderly patient. New York, NY. Oxford University Press.  Long, P. (1988, February 9). Major Depressive Disorder: Treatment. Retrieved February 28, 2015, from http://www.mentalhealth.com/rx/p23- md01.html#Head_2av  Paxil CR has favorable tolerability in elderly depression. (News Updates). (2003, January). The Brown University Geriatric Psychopharmacology Update, 7(1), 8. Retrieved from http://0- go.galegroup.com.libcat.ferris.edu/ps/i.do?id=GALE %7CA96381216&v=2.1&u=lom_ferrissu&it=r&p=ITOF&s w=w&asid=7f608b010d1c0a973cba307164e48e7b

19. References  Frank, C. (2014). Pharmacologic treatment of depression in the elderly. Canadian Family Physician, 60(2), 121-126. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC39 22554/  Reynolds, Frank, E., Perel, J. (2006). Trial tests maintenance paroxetine and psychotherapy in elderly patients. The Brown University Pshychopharmacology Update.(17.6)p1. Retrieved from: http://0- go.galegroup.com.libcat.ferris.edu/ps/i.do?&id=G ALE|A146790178&v=2.1&u=lom_ferrissu&it=r&p=IT OF&sw=w

20. References  Gould, R., Coulson, M., Howard R. (2012). Cognitive Behavioral Therapy for Depression in Older people: A meta-analysis and meta- regression of randomized controlled trials. Journal of the American Geriatrics Society (60)pp1817- 1830. Retrieved from: http://0- onlinelibrary.wiley.com.libcat.ferris.edu/doi/10.111 1/j.1532-5415.2012.04166.x/epdf