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• W2126734951 abstract "As a board member of the Canadian Academy of Geriatric Psychiatry since 2006 and, more importantly, in the course of practicing inpatient geriatric psychiatry in an academic health centre since 2002, I have found a creeping nihilism and cynicism over the last five years among colleagues in general psychiatry and geriatric psychiatry trainees about the treatment of psychiatric disorders in older adults. On further questioning, the pessimism is generally rooted in the anxiety surrounding the publication of large-scale, negative data in this population, and can tend to lead clinicians to a frozen state of uncertainty about how to apply these research results in everyday clinical practice. A prime example of this is the topic of pharmacological treatment of major depression in late life. Generally speaking, meta-analyses are seen as the highest levels of evidence, and this was certainly the case with the Canadian Coalition for Seniors’ Mental Health Guidelines, which were published in 2006. (1) There are a number of meta-analyses of antidepressants in later life that have been published, particularly in recent years. In 2001, Wilson et al. (2) conducted a Cochrane review of randomized controlled trials of antidepressants versus placebo among patients 55 years of age and older. They reported remission rates of 28% for 245 patients on TCA compared with 17% for 223 patients on placebo in 10 trials (OR 0.34, 95% CI 0.21–0.47), and remission rates of 49% for 365 patients on SSRI versus 25% for 372 patients on placebo in two clinical trials (OR 0.51, 95% CI 0.36–0.72), corresponding with numbers needed to treat (NNT) of nine for remission with TCA and four for remission with SSRIs. There were more studies of newer antidepressants to incorporate into the next major meta-analysis on the subject, which was published in 2008. Nelson et al. (3) conducted a meta-analysis of second-generation antidepressants versus placebo among outpatients 60 years of age and older. They pooled 10 studies, and reported a response rate of 44% among 2,377 patients on second-generation antidepressants compared with 35% among 1,788 patients on placebo (OR 1.40, 95% CI 1.24–1.57), and remission rates of 34% of these patients on drug versus 26% on placebo (OR 1.27, 95% CI 1.12–1.44), corresponding with a calculated NNT of 11 for response and 13 for remission, with better results and less heterogeneity in trials of 10 to 12 weeks in duration. In December of 2011, Tedeschini et al. (4) conducted a meta-analysis of studies of any class of antidepressant versus placebo among patients 55 years of age and older. They found 15 studies, 14 of which were conducted among outpatients, and reported a response rate of 45% of 2,752 patients on antidepressants compared with 33% of 2,004 patients on placebo (RR 1.30, 95% CI 1.15–1.48), corresponding to a NNT of eight. However, when the authors restricted their analysis to the six trials done in patients aged 65 years and older, they reported a non-significant difference in response, with 42% of 1103 patients on antidepressant versus 39% of 637 patients on placebo responding (RR 1.28, 95% CI 0.93–1.37). It should also be noted, however, that there was substantial heterogeneity in their analyses. The heterogeneity of results found in both of these recent meta-analyses likely comes from two sources. Firstly, the individual studies incorporated into the metas differed in inclusion and exclusion criteria, drug, dose, number of visits, age, MMSE cut off, and number of sites. Secondly, the sample sizes, confidence intervals, and results of the different studies were quite varied. We should, therefore, be quite cautious in interpreting the pooled response and remission rates, as well as the odds and risk ratios, as the basic assumption of a meta-analysis—that all the stud" @default.
• W2126734951 created "2016-06-24" @default.
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• W2126734951 date "2012-07-03" @default.
• W2126734951 modified "2023-10-16" @default.
• W2126734951 title "Translating Geriatric Psychiatry Research into Practice: Coping with Uncertainty" @default.
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• W2126734951 doi "https://doi.org/10.5770/cgj.15.43" @default.
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