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The paper focuses on the problem of the efficacy of major depression treatment in the elderly. Depression is a widespread issue of the present time. It is twice as common in women as in men. According to the data provided by the World Health Organization, depression affects 121 million people all over the world. It has been estimated that by the year 2020, depression will take the second place after the heart disease as the largest killer of mankind (WHO, 2007). Depression has a complex causal structure; most frequently, an accumulation of different risk factors leads to depression. There are two main principle forms of treatment for depression in the elderly patients: antidepressant medication and electroconvulsive therapy (ECT).
The aim of the paper is to compare and discuss how electroconvulsive therapy and antidepressant medication effect major depression after 8 weeks of treatment.
A comprehensive review of the English language literature was performed using electronic databases Medline (2005-2015), CINAHL (2005-2015), ProQuest (2005-2015). The author researched “Major depression”, “the elderly”, “antidepressants”, and “electroconvulsive therapy” expressions in various combination. The sources of the selected articles have been reviewed as well.
Determinants of Health
According to the WHO (2007), the determinants of health include the following elements: the social and economic environment, the physical environment, and the person’s individual characteristics (Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.)
Health is a multifactorial phenomenon that reflects a person’s well-being in the given conditions. Health does not simply entail the absence of diseases as the traditional medicine defines it. Moreover, all the symptoms of a disease, if it is not a traumatic injury, reflect a deeper biopsychosocial imbalance of a person. Thus, the perfect valid treatment of the “disease” has to focus the inner causes and not the superficial symptoms. The physical and psychological signs of a disease like depression have to be treated as a whole in any area of medical practice.
Major Depression in the Elderly
The problem of depression is a significant issue of the present time which health care providers have to solve nowadays. Major depression appears to be one of the most ordinary and essential disorders in the elderly. It affects nearly 10-15% of the community, 5 million out of the 31 million Americans over the age of 65; in senior persons over the age of 80, depressive symptoms emerge among the 13% of the population (Blazer, 2009). Major depression is usually diagnosed in patients with cardio-vascular illnesses, such as chronic ischemic heart disease, post stroke patients, etc.
The currency, signs, treatment and results of depression in the aged patients greatly differ from depression in children, adolescents, and adults; as a result, it may be a severe continuation of this mood disorder. Biological and psychosocial factors play a principle role in the pathogenesis of the major depression disorder in the elderly. The increased concentration of IL-6 and hyperactivity of the hypothalamic-hypophysis-adrenocortical system turn to be key biological risk factors of depression progression. In the anamnesis of elderly persons with depression one can find lacunar and/or cortical infarcts; MRI scans typical for elderly patients suffering from major depression contain focuses of white matter hyperintensivity (Stek, Wurff, Hoogendijk, & Beekman, 2009).
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Depression does not always emerge with aging; if healthcare providers reveal it at the early stages, adequate and apropos treatment may reverse the process of its development. Vice versa, an unrecognized depression in the elderly may cause all sorts of individual impairment followed by the decreased quality of life, resulting even in suicide.
Antidepressant Medication in the Treatment of Major Depression in the Elderly
The medical treatment of major depression in the elderly is a significant problem of the modern society. The fact that this disorder is so widespread challenges the contemporary industrial countries. Mottram, Wilson, and Strobl (2006) conducted a profound analysis of the effects of antidepressant medication in the elderly and presented it in their systematic review. Practitioners define antidepressants as a group of remedies used in the medical ordinal treatment of depression. Numerous antidepressants possess different pharmacological characteristics, including side effects and antidepressant mechanisms. According to the British National Formulary, all antidepressants are divided into the following pharmacological groups: tricyclic antidepressants (TCAs), the selective serotonin reuptake inhibitors class of drugs (SSRIs), the mono-amine oxidase inhibitors group (MAOIs), and “atypical” antidepressants (Mottram, Wilson, & Strobl, 2006).
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Senior citizens are prone to all the side effects of antidepressant medication, especially to the cardio-vascular and cognitive dysfunction side effects on the background of physical illnesses caused by aging (Mottram, Wilson, & Strobl, 2006). Many of the antidepressant drugs provide severe anticholinergic side effects that may limit the effect of the therapy. Because of the co-morbid cerebrovascular, cardiovascular, pulmonary, and respiratory pathology in the elderly, there is a serious problem of drugs interaction with the simultaneous antidepressant treatment. The issue predominantly concerns interactions of these drugs with the adrenergic stimulating effects found in cold medicines and cough suppressants; stimulants, such as amphetamines and methylphenidate; antidepressants with norepinephrine reuptake inhibition; appetite suppressants and analgesics with NERI and the drugs which inhibit 5-hydrotriptophane (serotonin) uptake. The simultaneous administration of MAO with the drugs producing adrenergic stimulating effects may cause hypertensive crisis. Besides, the concurrent consumption of MAO with the drugs that inhibit 5-hydroxytryptophan uptake may give rise to serotonin crisis because of the increase in the synaptic availability of 5-hydroxytryptophan both by MAOIs and agents that block 5-hydroxytryptophan (serotonin) reuptake. Such a condition may lead to malignant hyperthermia due to the impairment of thermoregulation. The signs of serotonin syndrome vary from myoclonus, agitation, migraines at the beginning of treatment to seizures, cardiovascular collapse, malignant hyperthermia, hyperthermic brain impairment and death in the final stages (Stahl & Felker, 2008).
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Most frequently, there is a delay in 4-8 weeks between the start of the antidepressant medication treatment and the appearance of therapeutic effects (Cohen, 2003).
Electroconvulsive Therapy of Major Depression in the Elderly
Ugo Cerletti and Lucio Bini used EST in the treatment of patients with mental disorders in 1930s in Italy. These physicians tried to provoke seizures in order to treat schizophrenia. An American psychiatrist Walter Freeman conducted his first lobotomy with electroconvulsive treatment qua anesthesia in 1936. It was the dawn of the Electroconvulsive Therapy era. Ever after, practitioners broadly applied ETC in the treatment of different psychiatric illnesses and mood disorders. Nearly one million people in the world and 100,000 people in the USA undergo ECT every year. It can be conducted either for inpatients or outpatients in special apartments equipped with oxygen, suction, and CPR equipment for the urgent improvement of casual side effects.
ECT creates an electric field in the tissue of the brain; it varies in strength, modulates neural activity, and provokes seizures (Peterchev, Rosa, Deng, Prudic, & Lisanby, 2010). ECT aims at provoking controlled clinical seizers caused by the application of the electrical stimulus to the head. During ECT, certain parts of the brain are injured by electricity, which remolds chemical processes in the brain tissue, raises the rate of oxygen demand by the brain and causes flash-burn. The electric field impairs the activity of the brain by the depolarization and hyperpolarization of the axon membranes (Peterchev et al., 2010). Health care providers perform electroconvulsive therapy under general anesthesia, including muscle relaxants, in order to prevent fractures of the vertebral bodies. A variety of articles provide extended explanations of ETC methods, indications, and contradictions (Peterchev, Rosa, Deng, Prudic, & Lisanby, 2010; Lisanby, 2007). Patients undergo ECT at intervals of a couple of days in the acute or primary period, and then they undergo supportive ECT once a week. The effect of ECT mostly depends on the character of cerebral seizure activity; the duration of seizers has to constitute more than 15 seconds (Shah, Wadoo, & Latoo, 2013).
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In the elderly, ECT causes impairment of the brain, which may lead to a serious and irreversible amnesia, fainting fit, loss of orientation in time and place. In their review, Stek, Wurff, Hoogendijk, and Beekman (2009) pointed out that ECT did not cause any kind of physical damage to the brain tissue. However, they observed some cognitive maladies, such as reversible memory problems, as complications of ECT (Stek, Wurff, Hoogendijk, & Beekman, 2009).
Nowadays, in some countries, ECT treatment is an illicit issue (Stek, Wurff, Hoogendijk, & Beekman, 2009). However, the majority of reports insist on the particular efficacy of ECT in the elderly who suffer from major depression, in the therapy of patients with medication-refractory disease, and in the cases when patients cannot tolerate antidepressant drugs (Cohen, 2003; Stek, Wurff, Hoogendijk, & Beekman, 2009). When the antidepressant medication treatment and/or psychotherapy measures do not show positive results, ECT demonstrates efficacy in the 80-90% of cases (Cohen, 2003). ECT may be followed by or combined with psychotherapy measures or antidepressants in severe cases; benzodiazepines are forbidden as a concurrent medication due to its anticonvulsant properties.
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According to the data of numerous researches, ECT is a rather harmless and safe manipulation that can be conducted even in the aged patients with the co-morbid heart, lungs, cerebrovascular diseases, and Parkinson’s disease. Researchers believe ECT is a less harmful, remarkably safe, and more effective method than antidepressant medications in older patients because of the absence of general toxic side effects caused by antidepressants (Stek, Wurff, Hoogendijk, & Beekman, 2009). The delay between the start of ECT and the appearance of therapeutic effects is twice as shorter (2-4 weeks) than in the case of antidepressant medication treatment (4-8 weeks); that is, the therapeutic effect of ECT reveals itself earlier (Cohen, 2003).
According to the above information, the positive clinical effect of ECT was determined by numerous researches; however, there are certain contradictions concerning its use for the major depression treatment. For example, Ernest Hemingway committed suicide after undergoing electroconvulsive therapy treatment. Electrical shock causes euphoria which erases the memory of depression, but it does not cure the real cause of the disorder.
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ECT remains the “gold standard” of the major depression treatment in the elderly nowadays because of the sensitivity of geriatric patients with co-morbid diseases to the side effects of drugs.
Even though mood disorders, including depression, are frequent in the society (approximately 150 million patients all over the globe), there are no reliable methods of treading the condition. Depression likewise aggression demonstrates a sort of psychological strong drug that tries to affect as many personalities as possible. It is easy to be in depression, to pity oneself, to receive satisfaction from one’s fecklessness, and to relish the indifference of the world to one’s person. It is actually necessary to find the source of depression and to acknowledge it.