Current issues of ACP Journal Club are published in Annals of Internal Medicine


Review: Heterocyclic antidepressants and rational psychological therapies reduce depression in older ambulatory patients

ACP J Club. 1998 Sep-Oct;129:35. doi:10.7326/ACPJC-1998-129-2-035

Source Citation

McCusker J, Cole M, Keller E Bellavance F, Berard A. Effectiveness of treatments of depression in older ambulatory patients. Arch Intern Med. 1998 Apr 13;158:705-12.



In older ambulatory patients with depression, how effective are acute-phase pharmacologic and psychological treatments?

Data sources

Studies were identified by searching MEDLINE (1981 to March 1995) using the subject headings depressive disorder, depression, aged, and clinical trials and by searching PsycINFO (1984 to March 1995) using the subject headings major depression, aged, and therapy or treatment. Additional studies were identified by reviewing bibliographies.

Study selection

English- or French-language original studies were selected if they used a prospective, controlled study design to evaluate the effectiveness of acute-phase pharmacologic or psychological treatment in patients ≥ 55 years of age with depression in an outpatient, community, or nursing home setting.

Data extraction

Data were extracted on sample size, pre- and post-treatment mean depression scores, standard deviations for the post-treatment scores, and the P value for the post-treatment comparison.

Main results

233 articles were identified; 40 (37 different studies) met the selection criteria. There were 26 articles on pharmacologic treatment and 14 articles on psychological treatment. 21 studies compared active drugs with placebo. In the 9 studies that compared heterocyclic drugs with placebo, heterocyclic drugs reduced the Hamilton Depression Rating Scale (HDRS) score after treatment more than placebo (mean difference -5.78, 95% CI -8.31 to -3.25; effect size -0.72, CI -1.14 to -0.31). Other drugs had less effect than placebo, and some showed a significant benefit (fluoxetine, trazodone, and phenelzine; HDRS differences -2.40, -7.50, and -0.75, respectively). Overall, antianxiety drugs were not better than placebo. In the 17 studies that compared various types of active drugs, no differences existed between the treatment groups. Serotonin reuptake inhibitors seemed to be as effective as heterocyclic drugs.

12 studies compared psychological treatments with control treatments. Psychological treatments were classified as “rational” (cognitive or behavioral) or “emotive” (supportive or dynamic). In the 4 studies that compared rational psychological treatment with an untreated control group, rational treatment reduced post-treatment HDRS scores (mean difference -7.25, CI -10.10 to -4.40; effect size -1.23, CI -1.83 to -0.63). Rational psychological treatment did not reduce post-treatment HDRS scores when compared with a control group that received similar attention (2 studies; effect size -0.50, CI -1.37 to 0.37) or emotive therapy (4 studies; effect size -0.35, CI -0.93 to 0.22). None of the 4 studies comparing emotive treatment with an untreated control group found a significant benefit for emotive therapy.


In older ambulatory patients with mild to moderate depression, antidepressant drugs are more effective than placebo, and rational psychological therapies are more effective than no treatment.

Source of funding: No external funding.

For correspondence: Dr. J. McCusker, Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital, 3830 Lacombe Avenue, Room 2508, Montreal, Quebec H3T 1M5, Canada. FAX 514-734-2652.


There are no high-quality, randomized, placebo-controlled trials of pharmacologic or psychological therapy in the acute phase of depressive illness in elderly persons, and none can be done now because of ethical reasons (1). Thus, researchers performing a meta-analysis of this type must deal with unsatisfactory raw material. Within these limitations, this meta-analysis is sound, and the validity of its conclusions must ultimately be judged on the degree to which the studies analyzed were methodologically flawed.

First, elderly populations with depression are heterogeneous. Samples that include outpatients, primary care patients, and persons in residential or nursing homes are barely comparable (e.g., members of the last group are likely to be more physically ill than members of the other groups). The authors accurately conclude that sample selection could account for the observed differences.

Second, many studies were too short (about 1 in 4 lasted only 4 weeks). The recommended duration for a trial of antidepressant drugs at therapeutic doses in older patients is now 6 weeks (2) and possibly longer.

Third, the HDRS was the most commonly used outcome measure. The authors correctly state that the HDRS might have been unsatisfactory for less severely ill patients because of the heavy weight it places on somatic items. In fact, it may be unsuitable for any older depressed patients because nondepressed older persons may score positively on these items.

The observation that “attention alone may be an effective treatment” supports the recent finding of Blanchard and colleagues (3) that elderly patients with depression responded to simple intervention from a community nurse. A practical point that can be taken from this review is that time spent talking to patients might be as effective as a drug.

Robin Jacoby, DM, FRCP, FRCPsych
University of OxfordOxford, England, UK

Robin Jacoby, DM, FRCP, FRCPsych
University of Oxford
Oxford, England, UK


1. Anstey K, Brodaty H. Antidepressants and the elderly: double-blind trials 1987-1992. Int J Geriatr Psychiatry. 1995;10:265-79.

2. Bonner D, Howard R. Epidemiology of chronic venous ulcers. Int J Geriatr Psychiatry. 1995;10:259-64.

3. Blanchard M, Waterreus A, Mann A. The effect of primary care nurse intervention upon older depressed people screened as depressed. Int J Geriatr Psychiatry. 1995;10:289-98.