Depression
Electroconvulsive Therapy ECT is indicated for patients who have failed to respond to or cannot tolerate pharmacologic treatment or who are imminently suicidal, severely psychomotor retarded, delusional, or unable or unwilling to eat.
Abstract
ed from data presented by Plotkin et al.1*8 *Among young controls, 65% responded to imipramine, and 30% responded to placebo. that the physician obtain a serum drug level to document sufficient exposure to the drug.lo0 Failure to respond should also be documented by unimproved Geriatric Depression Scale scores. Table 7 summarizes the results of controlled trials of antidepressant therapy in older people. Electroconvulsive Therapy ECT is indicated for patients who have failed to respond to or cannot tolerate pharmacologic treatment or who are imminently suicidal, severely psychomotor retarded, delusional, or unable or unwilling to eat. Memory should be carefully evaluated before ECT because even mild dementia may worsen after it. Nondemented elderly may also develop transient confusion and amnesia after ECT, particularly if treatments are prolonged. Consequently, a course of ECT in the elderly should consist of no more than 10 treatments.lo1 Antipsychotics should be avoided during the period of ECT administration. Unilateral ECT to the nondominant hemisphere may reduce amnestic effects in the elderly. It is not yet clear, however, if this approach is as effective in resolving major depression as the standard, bilateral approach. A number of studies have investigated the effectiveness and complications of ECT in older patients. Gaspar and Sumarasinghelo2 reported a good outcome in 78% and adverse effects in 12% of 33 patients with a mean age of 74 years. Burke et allo1 found an 83% improvement after ECT in 30 subjects with an average age of 72 years. Those over 75 years with a history of cardiovascular disease appeared to be particularly at risk for complications. These were frequently minor and transient. However, more serious complications have included myocardial infarction, arrhythmias, hypotension, falls, confusion, and pneumonia. A large series examining the morbidity of ECT in all ages suggested that, like the previous study, serious side-effects were more likely to occur in patients over the age of 75 with preexisting cardiorespiratory disease. O3 IAGS-MAY 1989-VOL. 37, NO. 5 UCLA GERIATRIC GRAND ROUNDS 469 The long-term benefits from ECT in older patients have not been well established. Some reports suggest that patients frequently return to their premorbid condition over time,*OO but this may be true of pharmacotherapy as well. ECT may be safer than antidepressants in medication-sensitive patients if prolonged exposure to these agents is required.lo4 Psychotherapy Psychosocial treatments for geriatric depression are varied. Individual psychotherapy is of demonstrated benefit in older individ~als.~" The life review, with reminiscence and recollection, is of benefit in those patients who are not overwhelmed by the residue of past experience.lo5 Group therapy may also be effective.lo6 Various orientations, including cognitive, behavioral, psychodynamic, and supportive, have been helpful. Group therapy has been especially recommended for patients suffering from social isolation and interpersonal loss. Marital therapy is indicated in depression associated with psychological and emotional problems between spouses. Family therapy may be useful for similar reasons. Caregiver support is important for those caring for the depressed elderly person. The provision of social, financial, and legal counseling, with appropriate referrals when necessary, may lessen stress and improve compliance. Recent literature suggests that optimal treatment for depression is based on combining psychological and somatic therapies.lo5 The treatment dropout rate with pharmacotherapy is reduced significantly if psychotherapy is also provided. Optimal treatment of elderly individuals depends on two central considerations: 1) an individualized approach and 2) interdisciplinary health care delivery. The interventions of an interdisciplinary team enhance therapeutic effectiveness through simultaneous management of diverse concurrent problems. This is especially true in the frail elderly because their entire situation affects treatment outcome and ultimately the quality of their lives.