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Drug Treatment of Depression in Frail Elderly Nursing Home Residents

Received April 2, 1999; revised July 7, 1999; accepted September 8, 1999. From the Section on Geriatric Psychiatry, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Department of Psychiatry, Philadelphia VA Medical Center, Philadelphia, PA; and The Nathan Kline Institute for Psychiatric Research, Orangeburg, NY. Address correspondence to Dr. Streim, Department of Psychiatry, Ralston-Penn Center, 3615 Chestnut Street, Room 237, Philadelphia, PA 19104-2676. e-mail: jstreim{at}mail.med.upenn.edu

The authors conducted a randomized, double-blind, 10-week clinical trial of two doses of nortriptyline in eight nursing homes. Sixty-nine patients, average age 79.5 years, were randomized to receive regular doses (60 mg–80 mg/day) vs. low doses (10 mg–13 mg/day) of nortriptyline. Among the more cognitively intact patients, there was a significant quadratic relationship defining a "therapeutic window" for nortriptyline plasma levels and clinical improvement. There were also significant differences in plasma level–response relationships between depressed patients who were cognitively impaired and those who were more cognitively intact. Depression remains a syndrome that responds to specific treatment, even in frail nursing home patients, and those depressions that occur in patients with significant dementia may represent a treatment-relevant condition with a different plasma level–response relationship than in depression alone.

Key Words: Depression • Antidepressants • Long-Term Care