Monday, March 6, 2023

Older Adults With Resistant Depression May Benefit From Adding Aripiprazole to Antidepressants

Older adults with treatment-resistant depression may experience greater mood improvements when aripiprazole is added to their current antidepressant regimen compared with being switched to bupropion, suggests a study in the New England Journal of Medicine. Older adults who began taking bupropion in combination with their current antidepressants experienced mood improvements as well, but they also reported more falls.

Eric Lenze, M.D., of Washington University School of Medicine in St. Louis and colleagues enrolled 619 adults aged 60 years or older with treatment-resistant depression for this two-stage trial. Treatment-resistant depression was defined as “a lack of remission of major depression after two or more trial uses of antidepressants of adequate dose and duration within the current [depressive] episode,” Lenze and colleagues wrote.

For the first stage, the participants were assigned to start taking aripiprazole in addition their existing medication, start taking bupropion in addition to their existing medication, or switch from their existing medication to bupropion for 10 weeks. Any participants who did not meet the criteria for depression remission (defined as a score of 10 or less on the Montgomery–├ůsberg Depression Rating Scale) after 10 weeks were eligible to enter the second stage of the study.

For the second stage, participants were assigned to start taking lithium in addition to their existing medication or switch from their existing medication to nortriptyline for 10 weeks. One hundred twenty-five participants from stage 1 entered stage 2, while an additional 123 adults entered stage 2 directly because they were ineligible for stage 1 (most commonly because they had previously taken and failed to respond to aripiprazole and/or bupropion).

The primary outcome was the change from baseline in participants’ psychological well-being (measure of life satisfaction, positive mood, and a sense of purpose).

After the first 10 weeks, psychological well-being scores improved significantly more among adults who were in the aripiprazole-augmentation or bupropion-augmentation groups compared with those who switched to bupropion. Remission rates were 28.9% among patients in the aripiprazole-augmentation group, 28.2% among those in the bupropion-augmentation group, and 19.3% among those who switched to bupropion. In addition, aripiprazole augmentation was associated with a 40% reduced risk of falling compared with bupropion augmentation.

Participants who entered the second stage of the trial experienced similar levels of psychological improvement after 10 weeks of lithium augmentation or nortriptyline alone, with remission rates of 18.9% and 21.5%, respectively. The rates of falling between the two groups were similar.

“The low incidences of remission in both steps of the trial highlight the challenge of treating depression when previous medications have failed,” Lenze and colleagues wrote.

For related information, see the Psychiatric Services article “Predictors of CNS-Active Medication Use and Polypharmacy Among Homebound Older Adults With Depression.”

(Image: iStock/Fly View Productions)

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