Treatment of depression in the elderly: a review of the recent literature on the efficacy of single- versus dual-action antidepressants.

BACKGROUND Despite the prevalence of depression in the elderly, there is a shortage of randomized controlled studies comparing the efficacy of various antidepressant classes in this population. OBJECTIVES This review of recent data on the treatment of depression in the elderly examined the relative efficacy of the selective serotonin reuptake inhibitors (SSRIs) and 2 antidepressant classes having broader neuroreceptor activity-the tricyclic antidepressants (TCAs) and the serotonin-norepinephrine reuptake inhibitors (SNRIs). Tolerability was examined as a secondary objective. METHODS A systematic review of MEDLINE, PsycINFO, and PubMed (January 2003-January 2009) was performed using the terms antidepressant, SSRI, SNRI, TCA, depression, randomized controlled trials, human trials, and individual antidepressant names. The criteria for inclusion in the review were a doubleblind design, a placebo control or active comparator group, a population exclusively aged > or = 59 years, and enrollment of patients with a diagnosis of major depressive disorder. RESULTS The literature search identified 18 trials of the treatment of depression in the elderly: 10 compared SSRIs either head to head or versus placebo, 2 compared TCAs with SSRIs, and 6 examined SNRIs (2 vs placebo, 1 vs a TCA, and 3 vs SSRIs). In 2 head-to-head trials, one of which measured efficacy in terms of change in Hamilton Depression Rating Scale (HAM-D) scores and response rates, and the other in terms of a preset 90% CI, TCAs and SSRIs had comparable efficacy. The data from 5 studies using various measures (including changes in Montgomery-Asberg Depression Rating Scale, HAM-D, or Geriatric Depression Scale [GDS] scores; response rates; and remission rates) suggested no additional efficacy benefit for the SNRI venlafaxine compared with SSRIs or TCAs. In a single trial, duloxetine was significantly more effective than placebo in terms of reductions in HAM-D and GDS scores (both, P < 0.001). CONCLUSION The available data, although limited, suggest that the dual-action agents (TCAs and SNRIs) do not appear to confer any additional benefits in efficacy over single-action agents (SSRIs) in the treatment of depression in the elderly.