Rescue Pharmacotherapy With Duloxetine for Selective Serotonin Reuptake Inhibitor Nonresponders in Late-Life Depression: Outcome and Tolerability
J Clin Psychiatry 2008;69(3):457-463
© Copyright 2017 Physicians Postgraduate Press, Inc.
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Background: Up to 50% of depressed older adults either do not
adequately respond to or are unable to tolerate treatment with a
serotonin-specific reuptake inhibitor. On the basis of previous experience with
serotonin-norepinephrine reuptake inhibitors, we predicted at least a 50%
response rate to open-label treatment with duloxetine in subjects who were
resistant to treatment with the selective serotonin reuptake inhibitor (SSRI)
Method: Community-dwelling subjects aged 65 years or older
with current nonpsychotic major depressive disorder as established by the
Structured Clinical Interview for DSM-IV received escitalopram under
protocolized conditions between April 2004 and September 2006. Subjects who
failed to meet response criteria or relapsed after achieving an initial
response were subsequently switched to open treatment with duloxetine up to 120
mg/day. Side effects were assessed at every visit.
Results: Subjects (N = 40) switched to duloxetine had a mean
(SD) age of 74.4 (7.0) years and a baseline (before escitalopram) 17-item
Hamilton Rating Scale for Depression (HAM-D-17) score of 20.0 (3.5) and were
predominantly female (65.0%) and white (82.5%). The mean (SD) maximum dose of duloxetine was 93.0 (27.8) mg/day. Subjects received this maximum dose for a
median duration of 6.9 weeks. Fifty percent of subjects (N = 20) met criteria
for full response, 17.5% (N = 7) were partial responders, and 32.5% (N = 13)
did not respond. The median time to response was 12.0 weeks (95% CI = 8.4 to
14.6). Five of the subjects (12.5%) discontinued duloxetine because of
intolerable side effects.
Discussion: These open-label data suggest that duloxetine at
doses up to 120 mg/day is a well-tolerated and potentially effective treatment
for older adults who fail to respond to an adequate trial of an SSRI. These
results are preliminary, and future controlled studies are required to test the
efficacy of rescue pharmacotherapy with duloxetine.