Pharmacologic treatment of geriatric depression: key issues in interpreting the evidence

A framework for critical appraisal of antidepressant trial literature involving geriatric subjects is presented. Among older adults, treatment decisions are complicated by comorbid medical and cognitive illness, the variable course of recovery, and the overlap of depressive symptoms with other disease symptoms. Consumers of the literature on competing antidepressant therapies for older adults must consider disease and population-specific outcome assessment issues.

An appraisal guide, adapted for geriatric depression, is developed from literature on methodological challenges of outcome assessment and published clinical trials comparing competing antidepressant therapies in older subjects.

The clinical utility of pharmacologic treatment of depression can be difficult to assess because depression scales in current use provide an important but limited perspective on treatment outcome and because the scales vary in actual content and ability to detect change. The use of indicators of function, independence, and self-perceived well-being as outcomes offers additional patient relevance and should be included. Key considerations involve (1) general characteristics: whether the depression outcome measure is valid and reproducible for the aged population under study, whether the outcome measure is sensitive to treatment-related change, and whether the time-frame of outcome assessment is appropriate for the treatment goal; (2) cognitive impairment: how subjects with dementia are assessed, and whether the impact of the intervention on caregivers and healthcare systems is considered as a relevant outcome; (3) pharmacologic issues: whether the comparator agent is a reasonable usual-care standard in the older adult and whether ascertainment for adverse effects is similar for all agents under study; and (4) broader general health status issues: whether functional or quality of life measures are used as outcome indicators.