Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults
2000
ContextInsufficient evidence exists for recommendation of specific effective
treatments for older primary care patients with minor depression or dysthymia.ObjectiveTo compare the effectiveness of pharmacotherapy and psychotherapy in
primary care settings among older persons with minor depression or dysthymia.DesignRandomized, placebo-controlled trial (November 1995–August 1998).SettingFour geographically and clinically diverse primary care practices.ParticipantsA total of 415 primary care patients (mean age, 71 years) with minor
depression (n = 204) or dysthymia (n = 211) and a Hamilton Depression Rating
Scale (HDRS) score of at least 10 were randomized; 311 (74.9%) completed all
study visits.InterventionsPatients 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 paroxetine and placebo
groups, the 6 visits over 11 weeks included general support and symptom and
adverse effects monitoring; for the PST-PC group, visits were for psychotherapy.Main Outcome MeasuresDepressive symptoms, by the 20-item Hopkins Symptom Checklist Depression
Scale (HSCL-D-20) and the HDRS; and functional status, by the Medical Outcomes
Study Short-Form 36 (SF-36) physical and mental components.ResultsParoxetine patients showed greater (difference in mean [SE] 11-week
change in HSCL-D-20 scores, 0.21 [0.07]; P = .004)
symptom resolution than placebo 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, paroxetine
improved mental health functioning vs placebo among patients whose baseline
functioning was high (difference in mean [SE] change in SF-36 mental component
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 health functioning in dysthymia patients was not significantly
improved by PST-PC compared with placebo (P≥.12
for low-, intermediate-, and high-functioning groups). For minor depression,
both paroxetine and PST-PC improved mental health functioning in patients
in the lowest tertile of baseline functioning (difference vs placebo in mean
[SE] change in SF-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).ConclusionsParoxetine 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 were smaller,
had slower onset, and were more subject to site differences than those of
paroxetine.
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