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Anxiety symptoms influence course of depression in elderly. (May Lower Response to Medication).

ORLANDO, FLA. -- Anxiety has a complex impact on the course of depression in the elderly, Dr. Alistair Flint said at the annual meeting of the American Association for Geriatric Psychiatry.

While anxious patients tend to respond more poorly to antidepressant medication, those who are treated successfully are no more likely to experience depression recurrence or relapse. Residual anxiety that develops after treatment, on the other hand, is associated with a higher rate of recurrence, said Dr. Flint of the University of Toronto.

"Anxious depression" in this age group is not, apparently, a distinct subtype. It does not breed true in subsequent episodes, he said.

Anxiety and depression frequently coexist in elderly patients, both as concurrent disorders and as a mixture of symptoms that may not separately satisfy syndromal criteria. In geriatric psychiatry, a common presentation is a major depressive episode with associated anxious symptoms.

Earlier studies have suggested that depressed patients with significant anxiety are more seriously ill, are less responsive to treatment, and have a worse long-term prognosis, compared with those without anxiety. But methodologic problems limit the validity of these studies. There are few data on relapse and recurrence, Dr. Flint said.

The current study involved 99 patients, aged 60 years or older, with a DSM-IIIR diagnosis of major depression and Hamilton Rating Scale for Depression scores of 16 or above. The patients had no preexisting anxiety disorders, psychotic features, central nervous system disorders, or significant concurrent medical illness.

Forty-six of the patients were classified as "nonanxious," with scores of 10 or below on the anxiety subscale of the Hospital Anxiety and Depression Scale; 53 patients, with higher scores, were classified as "anxious".

The patients were treated according to a stepped-care algorithm that began with nortriptyline, added lithium when necessary and progressed to phenelzine, fluoxetine, and electroconvulsive therapy for nonresponse. Response rates were higher in nonanxious than anxious patients (94% vs. 76%), and discontinuation rates were higher in the anxious group (17% vs. 4%).

When controlled for depression severity, anxious patients had a significantly worse response to nortriptyline alone. Their response to overall treatment was worse only by intent-to-treat analysis, suggesting that the discontinuation factor was responsible for poorer outcome, Dr. Flint said.

The patients were followed for 2 years, maintained on the medication doses that had affected acute recovery There was no difference in recurrence or relapse rates between patients who had been anxious before treatment of the index episode and those who had not. Patients whose anxiety symptoms remained after depressive symptoms had resolved were more likely to experience recurrence.

The findings raise the possibility that residual anxiety after treatment of depression represents a trait, rather than state variable in some older patients, for which conventional treatment is inadequate, Dr. Flint said.
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Author:Sherman, Carl
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Jun 1, 2002
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