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By Karen Gershman

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Clearly some of the factors lend themselves to intervention, for example ongoing physical ill health or social difficulties. It seems obvious that interventions to improve these will probably lead to an improved quality of life for the patient even if the prognosis of the depressive episode is not altered in the long run. As for the factors that cannot be altered by interventions then their presence may suggest a more aggressive treatment approach at an earlier stage. However, in the absence of conclusive evidence about their role the clinician should be aware that over-treatment may burden the patient with unnecessary side-effects from medication.

A significant proportion of elderly depressed patients does not achieve a full remission. At least a third will not respond to treatment with a single antidepressant. Which treatment strategy should follow this is open to debate but the limited evidence does suggest that vigorous treatment with antidepressants and/or ECT is associated with a better outcome. Although a persistent and aggressive treatment strategy seems obvious the community-based studies of outcome suggest that under-treatment is so prevalent that no treatment at all is the norm.

Nevertheless, the reader could reasonably conclude that a treatment protocol covering a broad range of different physical treatment strategies could result in the improvement of the majority of patients with major late life 32 THE PROGNOSIS OF DEPRESSION IN LATER LIFE depression. This view is supported by Simpson et al. (1998) who, in a study investigating the relationship between subtle brain changes and outcome, treated patients for 24 weeks using a broad protocol. The protocol comprised 6-12 weeks of treatment with a single antidepressant, this was followed by lithium augmentation or ECT.

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