determinations, as the other medications and/or disorders can alter antidepressant absorption or metabolism. Because of the natural metabolic slowing that accompanies aging, blood level monitoring may be advisable in otherwise healthy elderly patients, particularly where therapeutic ranges are better established. Table 15. Confounds in the diagnosis and treatment of depression in the elderly A. Concurrent nonpsychotropic medications may: (1) Cause depression. (2) Change antidepressant blood levels. (3) Increase antidepressant side effects. (4) Biochemically block antidepressant effects. B. Concurrent medical illnesses may: (2) Reduce the efficacy of antidepressant medication or psychotherapy. (4) Impair ability to participate in psychotherapy. (5) Create disability contributing to both chronicity and reduced treatment efficacy. (6) Increase the need for simplified medication dosing schedules (e.g., once daily). C. Concurrent nonmood psychiatric conditions may: (1) Cause depression (e.g., early Alzheimer's). (2) Call for different medications. (3) Impair participation in psychotherapy. (4) Reduce response to antidepressant medications (e.g., personality (5) Worsen prognosis of the depression (e.g., alcoholism). D. Other issues: (1) Slower metabolism with age often requires lower dosages. (2) Transportation difficulties may restrict access to care. (3) Increased interview time needed. (4) Fixed income may limit availability of therapy and nongeneric Psychosocial difficulties that may interfere with optimal treatment response include: ■ Negative intercurrent life events. ■ Ongoing severe interpersonal conflicts about dependency and role transitions. ■ Prolonged or unresolved grief. Social isolation. General clinical management or a formal psychotherapy may be equally helpful in addressing these psychosocial obstacles. Social casework, particularly during acute treatment, to remove or modify “real life" obstacles to recovery may be helpful. However, the efficacy of social casework in those with major depressive disorder has not been formally tested. Regular contacts with family members during periods of individual crisis may also be useful. The use of stimulant medications in the elderly was recently reviewed by an NIMH Consensus Development Conference (1991). While no randomized controlled trials were available, 8 to 12 open trials conducted over the last 3 decades, as well as clinical experience of psychopharmacologists who are expert in the treatment of the depressed elderly, suggest some efficacy and a low abuse potential for stimulant medications (NIMH, 1991). The panel does not recommend the routine use of stimulants in depressed elderly patients, given the availability of antidepressants with more predictable and established efficacy and sideeffect profiles. However, stimulants may be an option for highly selected elderly patients who have not responded to adequate trials of other treatments. A psychopharmacologic consultation is mandated before selection of this treatment. Seasonal Depression Guideline: Light therapy is a treatment consideration only for Light therapy is a relatively new treatment that has been tested in randomized trials for up to 2 weeks in patients with seasonal mood disorders, nearly always those with winter depressions (Depression Guideline Panel, forthcoming). Its longer term efficacy has not been formally evaluated, though case reports and clinical experience suggest efficacy throughout the winter and in subsequent episodes. In addition, light therapy has not been tested against other potentially active treatments, such as medication, psychotherapy, or the combination, so whether seasonal depressions respond to these alternative treatments is unknown. Case reports suggest some efficacy for selected antidepressants. Since many patients with major depressive episodes occurring in a seasonal pattern have bipolar II or recurrent major depressive disorder, it is logical to believe that medication will be effective. Given the current modest knowledge about light therapy and continuing research into the optimal method of administration, long-term safety, and other practical issues, the panel suggests the following principles: Light therapy is a logical consideration only for well documented seasonal, nonpsychotic, winter depressive episodes in patients with recurrent major depressive or bipolar II disorders or milder seasonal episodes. ■ It should be administered by a professional with experience and training in its use who deems it suitable for the particular patient. It may be a second-line treatment option after the patient has failed to respond to an adequate medication trial. It may be a first-line treatment for these patients if they are not severely suicidal and if there are medical reasons to avoid antidepressants, if the patient has a history of a positive response to light therapy and no negative effects, if the patient requests it, or if an experienced practitioner deems it indicated. Since the underlying mechanisms implicated in the seasonal pattern are not likely to be remedied by psychotherapy alone and there is no evidence to date for its efficacy, formal psychotherapy is not recommended as a first-line approach for truly seasonal depressions. Logically, light therapy should not be used as an adjunct to medication until either one alone has been optimally used. Light therapy can be useful to augment the response (if partial) to antidepressant medication and vice versa. As with any treatment, the patient's response should be closely monitored. Response to light therapy can be rapid (4 to 7 days), but for some, response may be delayed to 2 weeks. However, the placebo response rate may be significant as well. Therefore, one or several "extended evaluation" visits may be useful in identifying those in whom symptoms persist. Caution is urged in the use of light therapy with patients with specific ophthalmologic or other conditions (Depression Guideline Panel, forthcoming). Since safety and efficacy have not been fully established beyond 2 weeks, consultation with a specialist may be helpful in determining specific risks and benefits for particular patients. Further information is available for interested practitioners (see Oren and Rosenthal, 1992; Terman, Williams, and Terman, 1991). Depression and Other Nonpsychiatric Medical Guideline: If a patient has a depressive episode thought to be As noted in Volume 1 of Depression in Primary Care, Detection and Diagnosis, the incidence of a major depressive episode at some time in the course of several other medical conditions (e.g., myocardial infarction, stroke, cancer, diabetes) is around 25 percent. Similar percentages may be expected for other nonpsychiatric medical conditions. The general strategy in such cases is to treat the medical condition first, since depression can be an unwanted direct effect of either the illness or its treatment, to reevaluate the patient's condition for continued depression, and to treat the major depression as an independent disorder if it is still present (Hall, Popkin, Devaul, et al., 1978) (Figure 9). However, in some cases, the major depression is sufficiently severe or disabling that treatment for it is indicated while the general medical condition is being treated. There are insufficient studies to recommend one medication over another solely on the basis of efficacy data. The side-effect and pharmacologic profiles of the antidepressant, patient age, prior response to specific antidepressants, family history of response to an antidepressant, and drug-drug interactions are among the many factors that must be weighed by a clinician when choosing a particular medication. The efficacy of psychotherapy is suggested by some open studies (see Watson, 1983, for a review) and by 20 randomized controlled trials for patients with cancer and depression (Depression Guideline Panel, forthcoming), but predictors of response are not well defined. Those with low emotional support and pessimism who are widowed or divorced may particularly benefit from psychotherapy (Weisman and Worden, 1976-77). An empirical treatment trial with careful assessment of outcome (just as with major depressive disorder not associated with a general medical illness) is recommended. Further research in this area is sorely needed to determine which patients should be treated with which therapy and to establish with greater certainty the efficacy of various treatments. Figure 9. Relationship between major depressive and other current general medical disorders Note: In some clinical situations, treatment of the depression (e.g., if severe, incapacitating, or life-threatening) cannot be delayed until treatment for the general medical disorder has been optimized. Depression and Other Psychiatric Disorders Guideline: When major depressive disorder co-occurs with another psychiatric disorder, the practitioner has three options: (1) to treat the major depressive disorder as the primary target and reevaluate the patient's condition once he or she has responded to determine whether additional treatment is needed for the associated condition (e.g., as in major depressive disorder with personality disorder or generalized anxiety disorder), (2) to treat the associated condition as the initial treatment focus (e.g., as in concurrent major depression and anorexia |