Treatment of dysthymia and minor depression in primary care - A randomizedcontrolled trial in older adults

Context Insufficient evidence exists for recommendation of specific effecti ve treatments for older primary care patients with minor depression or dyst hymia, Objective To compare the effectiveness of pharmacotherapy and psychotherapy in primary care settings among older persons with minor depression or dyst hymia. Design Randomized, placebo-controlled trial (November 1995-August 1998). Setting Four geographically and clinically diverse primary care practices. Participants A total of 415 primary care patients (mean age, 71 years) with minor depression (n=204) or dysthymia(n=211) and a Hamilton Depression Rat ing Scale (HDRS) score of at least 10 were randomized; 311 (74.9%) complete d all study visits. Interventions Patients were randomly assigned to receive paroxetine (n=137) or placebo (n=140), starting at 10 mg/d and titrated to a maximum of 40 mg /d, or problem-solving treatment-primary care (PST-PC; n=138). For the paro xetine and placebo groups, the 6 visits over 11 weeks included general supp ort and symptom and adverse effects monitoring; for the PST-PC group, visit s were for psychotherapy. Main Outcome Measures Depressive symptoms, by the 20-item Hopkins Symptom C hecklist Depression Scale (HSCL-D-20) and the HDRS; and functional status, by the Medical Outcomes Study Short-Form 36 (SF-36) physical and mental com ponents. Results Paroxetine patients showed greater (difference in mean [SE] Ii-week change in HSCL-D-20 scores, 0.21 [0.07]; P=.004) symptom resolution than p lacebo patients. Patients treated with PST-PC did not show more improvement than placebo (difference in mean [SE] change in HSCL-D-20 scores, 0.11 [0. 13]; P=.13), but their symptoms improved more rapidly than those of placebo patients during the latter treatment weeks (P=.01). For dysthymia, paroxet ine improved mental health functioning vs placebo among patients whose base line functioning was high (difference in mean [SE] change in SF-36 mental c omponent scores, 5.8 [2.02]; P=.01) or intermediate (difference in mean [SE ] change in SF-36 mental component scores, 4.4 [1.74]; P=.03). Mental healt h functioning in dysthymia patients was not significantly improved by PST-P C corn pared with placebo (P greater than or equal to.12 for low-, intermed iate; and high-functioning groups). For minor depression, both paroxetine a nd PST-PC improved mental health functioning in patients in the lowest tert ile of baseline functioning (difference vs placebo in mean [SE] change in S F-36 mental component scores, 4.7 [2.03] for those taking paroxetine; 4.7 [ 1.96] for the PST-PC treatment; P=.02 vs placebo). Conclusions Paroxetine showed moderate benefit for depressive symptoms and mental health function in elderly patients with dysthymia and more severely impaired elderly patients with minor depression. The benefits of PST-PC we re smaller, had slower onset, and were more subject to site differences tha n those of paroxetine.