The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT.

OBJECTIVE

Response to combination pharmacotherapy and to electroconvulsive therapy (ECT) was evaluated in elderly patients with psychotic depression.

METHOD

Twenty-five patients, aged 60 years and older, with DSM-III-R unipolar psychotic major depression, were treated in an open, non-randomized fashion with either 6 weeks of nortriptyline and perphenazine (N = 8) or ECT (N = 17). Response was defined as a Hamilton score of < or = 10 and the absence of delusions and hallucinations. Patients who failed to respond to combined antidepressant-antipsychotic medication underwent 2 weeks of lithium augmentation.

RESULTS

Two (25.0%) patients responded to the first 6 weeks of pharmacotherapy whereas 15 (88.2%) patients responded to ECT (Fisher's exact test, p = 0.004). Even after lithium augmentation, there was a trend for patients to be less responsive to medication than to ECT (50.0% versus 88.2%, Fisher's exact test, p = 0.059). Survival analysis, based on 8 weeks of observation, demonstrated that patients took longer to respond to pharmacotherapy than to ECT (mean (SE) of 7(0) weeks versus 4(0) weeks; log rank chi2 = 10.43, df = 1, p = 0.001).

CONCLUSIONS

We found that elderly patients with psychotic depression had a significantly lower frequency of response to nortriptyline and perphenazine than to ECT. However, patients responded more slowly to pharmacotherapy than to ECT and longer duration of treatment may have improved the outcome of the medication group. These findings suggest the need for a randomized controlled trial comparing the efficacies of drug treatment and ECT in late life psychotic depression.