Nortriptyline and interpersonal psychotherapy as maintenance therapies forrecurrent major depression - A randomized controlled trial in patients older than 59 years

Context Elderly patients with major depression are at high risk for recurre nce, increased mortality, and chronic disability. Objective To determine the efficacy of maintenance nortriptyline hydrochlor ide and interpersonal psychotherapy (IPT) in preventing recurrence of major depressive episodes in patients older than 59 years. Design A 2 x 2 randomized, double-blind, placebo-controlled clinical trial, stratified by therapist. Setting University-based psychiatric research clinic. Patients Of atotalof 187 patients with recurrent nonpsychotic unipolar majo r depression (average age, 67 years; one third aged greater than or equal t o 70 years) recruited through clinical referral and media announcements, 10 7 were fully recovered after open acute and treatment continuation with nor triptyline and IPT. These patients were randomly assigned to 1 of 4 mainten ance therapy conditions, Interventions Monthly medication clinic with nortriptyline hydrochloride (8 0-120 ng/mL steady-state levels) (n = 24); medication clinic with placebo ( n = 29); monthly maintenance IPT with placebo (n = 21), and monthly mainten ance IPT with nortriptyline (n = 22). Main Outcome Measure Recurrence of major depressive episode. Results The time to recurrence of a major depressive episode for all 3 acti ve treatments was significantly better than for placebo. Recurrence rates o ver 3 years were as follows: nortriptyline and IPT, 20% (95% confidence int erval [CI], 4%-36%); nortriptyline and medication clinic visits, 43% (95% C I, 25%-61%); IPT and placebo, 64% (95% CI, 45%-83%); and placebo and medica tion clinic visits, 90% (95% CI, 79% 100%), Combined treatment with nortrip tyline and IPT was superior to IPT and placebo and showed a trend to superi or efficacy over nortriptyline monotherapy (Wald chi(2) = 3.56; P = .06), S ubjects aged 70 years and older had a higher and more rapid rate of recurre nce than those aged 60 to 69 years. Conclusion In geriatric patients with recurrent major depression, maintenan ce treatment with nortriptyline or IPT is superior to placebo in preventing or delaying recurrence. Combined treatment using both appears to be the op timal clinical strategy in preserving recovery.