Geriatric Depression with Cognitive Impairment: Diagnostic Challenges for DSM V and Novel Treatment Options

Steven P. Roose, MD

Professor of Clinical Psychiatry
College of Physicians & Surgeons
Columbia University
Research Psychiatrist,
New York State Psychiatric Institute
New York, New York

When developing a management plan for late-life depression, clinicians are faced with assessing the challenge of making an evidence-based decision regarding which treatment to select and of presenting a realistic answer to the question patients always ask: “Will I get better?” Accumulating data suggest that both patient and clinician expectations can affect treatment response and, as a result, study design has an important effect on the strength of evidence produced. A meta-analysis of randomized clinical trials assessing the effects of antidepressants found that response and remission rates to treatments were higher in trials that had active comparators compared with those using placebo interventions as control. The hypothesis that study design modulates treatment response was prospectively tested in a subsequent pilot study that enrolled patients with major depressive disorder. Study subjects were randomized to either an 8-week trial comparing escitalopram versus placebo or to an 8-week trial comparing escitalopram versus citalopram. Subjects were asked to estimate the likelihood and magnitude of improvement before and after randomization. Subjects in the active-comparator trial reported greater expectancies than subjects in the placebo-controlled trial. The implications of these data are two-fold. First, expectation may be the mechanism underlying the placebo response. Second, clinicians should take advantage of this phenomenon, not ignore it, since they too can modulate expectation and, hence, treatment response.

References

Rutherford B, Sneed J, Devanand D, Eisenstadt R, Roose S. Antidepressant study design affects patient expectancy: a pilot study. Psychol Med. 2010;40(5):781-8.
Rutherford BR, Sneed JR, Roose SP. Does study design influence outcome?. The effects of placebo control and treatment duration in antidepressant trials. Psychother Psychosom. 2009;78(3):172-81.

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