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Antidepressant Tapering: Avoiding Adverse Consequences of Gradual Dose Reduction
PHARMACY COLUMN Barbara J. Zarowitz
ANTIDEPRESSANT TAPERING: AVOIDING ADVERSE CONSEQUENCES OF GRADUAL DOSE REDUCTION Barbara J. Zarowitz, PharmD, FCCP, BCPS, CGP, FASCP
On September 15, 2006, the Centers for Medicare and Medicaid Services released the revised State Operations Manual (SOM) that summarizes guidance for surveyors of long-term care facilities and took effect December 18, 2006. There were major changes to the sections pertaining to the use of medications and pharmacy services in Appendix PP: F329 (Unnecessary Drugs), F425 Pharmacy Services, F428 (Drug [Medication] Regimen Review), and F431 (Labeling and Storage of Medications).1 The American Society of Consultant Pharmacists prepared a short summary of the Ftag changes that can be digested quickly.2 Under the new SOM guidance in F329: Unnecessary Drugs, any drug can be considered unnecessary if used in an excessive dose, for an excessive duration, without adequate monitoring, without adequate indications, in the presence of adverse consequences, or any combination thereof. Previously, antipsychotic, anxiolytic and sedative hypnotic medications required tapering of doses or gradual dose reduction (GDR). The new SOM guidance now requires GDR for psychopharmacologic medications that include any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders such as anxiolytics, anticonvulsants, and antidepressants. The SOM guidance emphasizes “the importance of seeking an appropriate dose and duration for all medications if the resident’s clinical condition has improved or stabilized, whether the underlying causes of the symptoms have resolved and whether non-pharmacological interventions have been tried and were effective.”2 A holistic, multidisciplinary approach to care is required to ensure that appropriate evaluation, monitoring, intervention, and documentation is in place to optimize patient care and satisfy the new requirements.
As psychopharmacologic medications, antidepressants are subject to GDR unless continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or if the resident’s target symptoms returned or worsened after the most recent GDR, and the physician has documented the clinical rationale for why any additional attempted GDR would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.1 Therefore, although not all nursing home residents receiving antidepressant medications will have to undergo GDR, surveyors and health care practitioners may have difficulty distinguishing those receiving antidepressants to manage behavioral symptoms from those with a diagnosis of depression because the clinical presentations can overlap.3 Depression can present as a temporary alteration in mood due to a recent illness or injury or loss of a loved one that may resolve if the older person is supported in a loving environment. In these cases, short-term antidepressant therapy, if warranted, can be tapered and discontinued within a few months of initiation without adverse consequences. Loneliness and boredom can be characterized as depression or a psychiatric disorder leading to pharmacologic treatment when perhaps nonpharmacologic behavioral interventions could suffice.4 Nonpharmacological interventions should be initiated and maintained even if medication therapy is initiated (Figure 1). Examples of nonpharmacologic interventions include music therapy and
Geriatric Nursing, Volume 28, Number 2
75
Treatment of underlying medical conditions should always be the first treatment strategy.
Types of Non-medication treatment include:
Examples of Non-medication Treatment Categories and Strategies Sensory
Environmental
Music therapy, white noise tapes, massage, light therapy, physical touch (with caution in some)
Increase in personal space, reduction in disruptive stimuli, special care units, lighting
Behavioral Reinforcement of alternative behaviors, positive reinforcement, behavior modeling, validation therapy, redirection, psychotherapy
Family Support and Education
Communication Awareness of caregiver’s nonverbal, verbal, and written communication skills
Offer caregiving classes, provide written materials, refer families and caregivers to local support groups
Reprinted with permission from Insight Therapeutics, Inc., 2005.
Figure 1. Nonpharmacological behavioral interventions.
group activities, reinforcement of self-efficacy, health promotion, modeling of roles, and acknowledgment of fear, anxiety, and life stressors leading to the transient state of depression. When antidepressant medication is needed, it should be started at a low appropriate starting dose and maintained for 2-4 weeks, monitoring for response and side effects. Older patients likely respond to antidepressant therapy will do so with a 30% or greater reduction in their depression score (i.e., Hamilton Rating Score for Depression) by week 4.5 If a partial response is observed and reported by the resident, dose escalation to the minimally effective dose is indicated while maintaining nonpharmacological therapy. For a transient episode of depression, medication can be maintained for 2-6 months and then tapered by no more than 25% every 1-2 weeks. Maintenance antidepressant therapy may be unneeded once clinical recovery has occurred. For patients with a diagnosis of major depression disorder, maintenance antidepressant therapy is clinically indicated, following initial response, to prevent relapse.3,6-9 Effective treatment of depression may reduce mortality or improve outcomes in patients with diabetes, ep-
76
ilepsy, ischemic heart disease, myocardial infarction, and stroke.6,10 Patients older than 70 years are less likely to experience a recurrence in depression with medication therapy (paroxetine) than monthly psychotherapy.7 A recently published Cochrane review of rigorously conducted, randomized, controlled trials, clearly establishes the value of treating late-life depression with antidepressant medications.8 Controversy surrounding the value of antidepressant medications in older persons has resulted from clinical trials that have not consistently defined the burden of depression, employed rigorous trial design, or assessed the many moderators affecting treatment outcomes in late-life depression.9 However, in the 32 well-conducted trials reviewed by the Cochrane Foundation tricyclic and selective serotonin reuptake inhibitor antidepressants conferred comparable effectiveness in depressed elderly while analysis of withdrawal due to side effects favored treatment with selective serotonin reuptake inhibitors.8 In residents with a diagnosis of major depressive disorder, maintenance treatment for 12-36 months reduces the risk of recurrence by two thirds.6 Fifty to eighty-five percent of persons
Geriatric Nursing, Volume 28, Number 2
Assess therapy for safety/ toxicity and titrate dosage as appropriate based on acuity, tolerance, and response to therapy at 2-4 weeks.
Assess response to therapy at 4 weeks
Patient Clearly Improved
Patient Somewhat Improved
Patient Not at all Improved
Reconsider Medical Cause
Change treatment, add a drug, or change to a new drug
Continue treatment / adjust dosage Continue treatment for 4 more weeks Assess treatment at 2 weeks
Continued satisfactory response
Yes Continue medication for 2-6 months, then attempt taper at a rate appropriate for the condition and response of the resident but no faster than 25% every 1-2 wks
Clearly Improved? No
Change treatment or adjust dosage
Psychiatry consultation
Reprinted with permission from Insight Therapeutics, Inc. 2005
Figure 2. Monitoring response to short-term antidepressant therapy and tapering. with a single episode of depression will have a recurrence.11 The duration of maintenance treatment will depend on the natural history of the illness and may be prolonged or indefinite, particularly in those with a history of recurrent or long-term illness.6,11 Tolerability issues such as weight gain, sleep disturbances, fatigue, apathy, and cognitive impairment may preclude long-term maintenance therapy or justify changing the daily drug schedule or the selection of antidepressant.12 Drug holidays and dose tapering are strongly discouraged on the basis of concerns that patients’ depressive symptoms may return.12 If tapering becomes necessary, it should occur over several weeks during which
time extensive monitoring is required to detect returning symptoms. Antidepressant discontinuation syndrome consists of symptoms of imbalance, gastrointestinal and influenza-like symptoms, and sensory and sleep disturbances, as well as psychological symptoms such as anxiety agitation, crying spells, and irritability.6 Reinstitution of antidepressant therapy is indicated if discontinuation symptoms appear.6 A slower dosage taper can be reattempted. The prevailing standards of relevant psychiatric practice support appropriate evaluation, monitoring, and treatment of persons with depressive disorders and outline the risks of antidepressant discontinuation, even when dosage
Geriatric Nursing, Volume 28, Number 2
77
tapering occurs slowly over several weeks. However, given that the revised guidance asks surveyors to consider antidepressants as potentially unnecessary medications and subject to GDR, 2 diametrically opposing paradigms emerge. Psychiatrists and geropsychiatric practitioners have strived to ensure that appropriate medication and nonpharmacological treatments are employed in the treatment of older persons with symptoms of depression. Long-term care surveyors have been instructed to ensure that residents’ drug therapy is free of unnecessary medications. The onus falls on the multidisciplinary long-term care team to ensure that appropriately detailed evaluation and assessment has occurred, that other causes of depressive symptoms have been ruled out or corrected, and that depressive signs and symptoms are persistent or clinically significant enough to warrant medication use. Surveyors will be looking to see that the facility has attempted nonpharmacological interventions whenever possible.2 Documentation that GDR is clinically contraindicated is imperative to prevent unnecessary antidepressant discontinuation syndrome in instances when attempts at dosage tapering are inappropriate and can result in adverse consequences. Recurrence of underlying medical conditions and suicide, although infrequent, are more serious adverse consequences of inappropriate antidepressant GDR and discontinuation.11
Summary Judicious evaluation and monitoring of longterm care residents receiving antidepressant therapy is important to avoid adverse consequences. 1. Residents receiving antidepressants for management of behavioral symptoms should undergo behavioral monitoring and reassessment of the ongoing benefit of and potential for side effects associated with antidepressant treatment. When appropriate, emergence of tolerability issues or lack of therapeutic benefit should lead to tapering of antidepressant dosages over several weeks and then discontinuation. When tapering or GDR is clinically contraindicated, it must be documented carefully. Practitioners should become familiar with the federal require-
78
ments pertaining to psychopharmacologic medications. 2. Residents receiving antidepressants for short-term management of depressive symptoms (i.e., those accompanying an injury or illness) may be subject to GDR and should undergo monitoring of behavioral symptoms. Dosages can be tapered as outlined in Figure 2 and antidepressant therapy discontinued after 2-6 months of therapy. 3. Residents receiving antidepressants for major depressive disorders, particularly those at risk of recurrence, are unlikely candidates for GDR and may suffer adverse consequences if subject to GDR. Documentation that GDR is clinically contraindicated is required to ensure that none of the health care team or surveyors suggests GDR for individuals in whom the risk of drug dosage tapering and discontinuation outweighs the potential benefit.
References 1. CMS Manual System. State operations manual: Appendix P. Survey protocol for long term care facilities—Part I. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Available at www.cms.hhs.gov/transmittals/ downloads/R22SOMA.pdf. Cited December 29, 2006. 2. McHenry Martin C, McSpadden CS. Changes in the state operations manual: implications for consultant pharmacy practice. Consul Pharm 2006;21:948-61. 3. American Psychiatric Association. Mood disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Publishing; 2000. p. 345-428. 4. Lantz MS. Loneliness and boredom: a psychiatric disorder of late-life challenge? Clin Geriatr 2006; 14:12-4. 5. Sackeim HA, Roose SP, Burt T. Optimal length of antidepressant trials in late-life depression. J Clin Psychopharm 2005;25:S34-7. 6. Mann JJ. The medical management of depression. N Engl J Med 2005;353:1819-34. 7. Reynolds CF, Dew AM, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med 2006;354:1130-8. 8. The Cochrane Collaborative. Antidepressants for depressed elderly [review]. Cochrane Library 2006; 4:1-54. 9. Roose ST, Schatzberg AF. The efficacy of antidepressants in the treatment of late-life depression. J Clin Psychopharm 2005;25:S1-7. 10. Katon W, Unützer J, Fan MY, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006;29:265-70.
Geriatric Nursing, Volume 28, Number 2
11. Workgroup on Major Depressive Disorder. Practice guideline for the treatment of patients with major depressive disorder. 2nd ed. Washington, DC: American Psychiatric Association; 2005. Available at www.psych.org/psych_pract/treatg/pg/prac_guide.cfm. Cited December 25, 2006. 12. Cassano P, Fava M. Tolerability issues during long-
term treatment with antidepressants. Ann Clin Psych 2004;16:15-25. 0197-4572/07/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2006.12.004
NEW Edition!
For over 100 years, Dorland’s Illustrated Medical Dictionary has been the world's most highly respected reference on the language of medicine. The new, 30th Edition sets an even higher standard for defining the vocabulary that health professionals use every day! • A new, full-color design and over 1,500 full-color illustrations make definitions come alive. • More than 123,000 meticulously revised definitions incorporate all of the very latest terminology in health care. • Over 800 new complementary and alternative medicine terms reflect the growing popularity of these approaches. • New appendices cover Medical Etymology, Symbols, Chemical Elements, Selected Surgical Equipment, and Cancer Staging. • A new, bonus CD-ROM adds hundreds of thousands of medical terms to any computer’s spell- Sp ecial checker...and makes it possible to look up more than 35,000 words and their definitions on value! any handheld device. • Complimentary access to Dorlands.com offers convenient online reference to the dictionary's content, interactive vocabulary-building exercises, and much more. For the first and last word in medicine, turn to Dorland’s! Order your copy today! May 2003 • Over 2,140 pages • Over 1,080 illustrations (over 1,075 in full color) • Includes bonus CD-ROM for Windows® and Macintosh® • $49.95 • 0-7216-0146-4
3 EASY WAYS TO ORDER!
R Phone:
Call toll-free 1-800-545-2522 Mention DM#73165
C Mail: Order Fulfillment Dept. 11830 Westline Industrial Drive Saint Louis, MO 63146-3318
SAUNDERS Web:
Order securely at www.us.elsevierhealth.com and receive free shipping!
An Imprint of Elsevier Science © Elsevier Science 2003. Professional references may be tax-deductible. Offer valid in USA only. Prices subject to change without notice. DM#73165
Geriatric Nursing, Volume 28, Number 2
79
ANTIDEPRESSANT TAPERING: AVOIDING ADVERSE CONSEQUENCES OF GRADUAL DOSE REDUCTION Barbara J. Zarowitz, PharmD, FCCP, BCPS, CGP, FASCP
On September 15, 2006, the Centers for Medicare and Medicaid Services released the revised State Operations Manual (SOM) that summarizes guidance for surveyors of long-term care facilities and took effect December 18, 2006. There were major changes to the sections pertaining to the use of medications and pharmacy services in Appendix PP: F329 (Unnecessary Drugs), F425 Pharmacy Services, F428 (Drug [Medication] Regimen Review), and F431 (Labeling and Storage of Medications).1 The American Society of Consultant Pharmacists prepared a short summary of the Ftag changes that can be digested quickly.2 Under the new SOM guidance in F329: Unnecessary Drugs, any drug can be considered unnecessary if used in an excessive dose, for an excessive duration, without adequate monitoring, without adequate indications, in the presence of adverse consequences, or any combination thereof. Previously, antipsychotic, anxiolytic and sedative hypnotic medications required tapering of doses or gradual dose reduction (GDR). The new SOM guidance now requires GDR for psychopharmacologic medications that include any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders such as anxiolytics, anticonvulsants, and antidepressants. The SOM guidance emphasizes “the importance of seeking an appropriate dose and duration for all medications if the resident’s clinical condition has improved or stabilized, whether the underlying causes of the symptoms have resolved and whether non-pharmacological interventions have been tried and were effective.”2 A holistic, multidisciplinary approach to care is required to ensure that appropriate evaluation, monitoring, intervention, and documentation is in place to optimize patient care and satisfy the new requirements.
As psychopharmacologic medications, antidepressants are subject to GDR unless continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or if the resident’s target symptoms returned or worsened after the most recent GDR, and the physician has documented the clinical rationale for why any additional attempted GDR would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.1 Therefore, although not all nursing home residents receiving antidepressant medications will have to undergo GDR, surveyors and health care practitioners may have difficulty distinguishing those receiving antidepressants to manage behavioral symptoms from those with a diagnosis of depression because the clinical presentations can overlap.3 Depression can present as a temporary alteration in mood due to a recent illness or injury or loss of a loved one that may resolve if the older person is supported in a loving environment. In these cases, short-term antidepressant therapy, if warranted, can be tapered and discontinued within a few months of initiation without adverse consequences. Loneliness and boredom can be characterized as depression or a psychiatric disorder leading to pharmacologic treatment when perhaps nonpharmacologic behavioral interventions could suffice.4 Nonpharmacological interventions should be initiated and maintained even if medication therapy is initiated (Figure 1). Examples of nonpharmacologic interventions include music therapy and
Geriatric Nursing, Volume 28, Number 2
75
Treatment of underlying medical conditions should always be the first treatment strategy.
Types of Non-medication treatment include:
Examples of Non-medication Treatment Categories and Strategies Sensory
Environmental
Music therapy, white noise tapes, massage, light therapy, physical touch (with caution in some)
Increase in personal space, reduction in disruptive stimuli, special care units, lighting
Behavioral Reinforcement of alternative behaviors, positive reinforcement, behavior modeling, validation therapy, redirection, psychotherapy
Family Support and Education
Communication Awareness of caregiver’s nonverbal, verbal, and written communication skills
Offer caregiving classes, provide written materials, refer families and caregivers to local support groups
Reprinted with permission from Insight Therapeutics, Inc., 2005.
Figure 1. Nonpharmacological behavioral interventions.
group activities, reinforcement of self-efficacy, health promotion, modeling of roles, and acknowledgment of fear, anxiety, and life stressors leading to the transient state of depression. When antidepressant medication is needed, it should be started at a low appropriate starting dose and maintained for 2-4 weeks, monitoring for response and side effects. Older patients likely respond to antidepressant therapy will do so with a 30% or greater reduction in their depression score (i.e., Hamilton Rating Score for Depression) by week 4.5 If a partial response is observed and reported by the resident, dose escalation to the minimally effective dose is indicated while maintaining nonpharmacological therapy. For a transient episode of depression, medication can be maintained for 2-6 months and then tapered by no more than 25% every 1-2 weeks. Maintenance antidepressant therapy may be unneeded once clinical recovery has occurred. For patients with a diagnosis of major depression disorder, maintenance antidepressant therapy is clinically indicated, following initial response, to prevent relapse.3,6-9 Effective treatment of depression may reduce mortality or improve outcomes in patients with diabetes, ep-
76
ilepsy, ischemic heart disease, myocardial infarction, and stroke.6,10 Patients older than 70 years are less likely to experience a recurrence in depression with medication therapy (paroxetine) than monthly psychotherapy.7 A recently published Cochrane review of rigorously conducted, randomized, controlled trials, clearly establishes the value of treating late-life depression with antidepressant medications.8 Controversy surrounding the value of antidepressant medications in older persons has resulted from clinical trials that have not consistently defined the burden of depression, employed rigorous trial design, or assessed the many moderators affecting treatment outcomes in late-life depression.9 However, in the 32 well-conducted trials reviewed by the Cochrane Foundation tricyclic and selective serotonin reuptake inhibitor antidepressants conferred comparable effectiveness in depressed elderly while analysis of withdrawal due to side effects favored treatment with selective serotonin reuptake inhibitors.8 In residents with a diagnosis of major depressive disorder, maintenance treatment for 12-36 months reduces the risk of recurrence by two thirds.6 Fifty to eighty-five percent of persons
Geriatric Nursing, Volume 28, Number 2
Assess therapy for safety/ toxicity and titrate dosage as appropriate based on acuity, tolerance, and response to therapy at 2-4 weeks.
Assess response to therapy at 4 weeks
Patient Clearly Improved
Patient Somewhat Improved
Patient Not at all Improved
Reconsider Medical Cause
Change treatment, add a drug, or change to a new drug
Continue treatment / adjust dosage Continue treatment for 4 more weeks Assess treatment at 2 weeks
Continued satisfactory response
Yes Continue medication for 2-6 months, then attempt taper at a rate appropriate for the condition and response of the resident but no faster than 25% every 1-2 wks
Clearly Improved? No
Change treatment or adjust dosage
Psychiatry consultation
Reprinted with permission from Insight Therapeutics, Inc. 2005
Figure 2. Monitoring response to short-term antidepressant therapy and tapering. with a single episode of depression will have a recurrence.11 The duration of maintenance treatment will depend on the natural history of the illness and may be prolonged or indefinite, particularly in those with a history of recurrent or long-term illness.6,11 Tolerability issues such as weight gain, sleep disturbances, fatigue, apathy, and cognitive impairment may preclude long-term maintenance therapy or justify changing the daily drug schedule or the selection of antidepressant.12 Drug holidays and dose tapering are strongly discouraged on the basis of concerns that patients’ depressive symptoms may return.12 If tapering becomes necessary, it should occur over several weeks during which
time extensive monitoring is required to detect returning symptoms. Antidepressant discontinuation syndrome consists of symptoms of imbalance, gastrointestinal and influenza-like symptoms, and sensory and sleep disturbances, as well as psychological symptoms such as anxiety agitation, crying spells, and irritability.6 Reinstitution of antidepressant therapy is indicated if discontinuation symptoms appear.6 A slower dosage taper can be reattempted. The prevailing standards of relevant psychiatric practice support appropriate evaluation, monitoring, and treatment of persons with depressive disorders and outline the risks of antidepressant discontinuation, even when dosage
Geriatric Nursing, Volume 28, Number 2
77
tapering occurs slowly over several weeks. However, given that the revised guidance asks surveyors to consider antidepressants as potentially unnecessary medications and subject to GDR, 2 diametrically opposing paradigms emerge. Psychiatrists and geropsychiatric practitioners have strived to ensure that appropriate medication and nonpharmacological treatments are employed in the treatment of older persons with symptoms of depression. Long-term care surveyors have been instructed to ensure that residents’ drug therapy is free of unnecessary medications. The onus falls on the multidisciplinary long-term care team to ensure that appropriately detailed evaluation and assessment has occurred, that other causes of depressive symptoms have been ruled out or corrected, and that depressive signs and symptoms are persistent or clinically significant enough to warrant medication use. Surveyors will be looking to see that the facility has attempted nonpharmacological interventions whenever possible.2 Documentation that GDR is clinically contraindicated is imperative to prevent unnecessary antidepressant discontinuation syndrome in instances when attempts at dosage tapering are inappropriate and can result in adverse consequences. Recurrence of underlying medical conditions and suicide, although infrequent, are more serious adverse consequences of inappropriate antidepressant GDR and discontinuation.11
Summary Judicious evaluation and monitoring of longterm care residents receiving antidepressant therapy is important to avoid adverse consequences. 1. Residents receiving antidepressants for management of behavioral symptoms should undergo behavioral monitoring and reassessment of the ongoing benefit of and potential for side effects associated with antidepressant treatment. When appropriate, emergence of tolerability issues or lack of therapeutic benefit should lead to tapering of antidepressant dosages over several weeks and then discontinuation. When tapering or GDR is clinically contraindicated, it must be documented carefully. Practitioners should become familiar with the federal require-
78
ments pertaining to psychopharmacologic medications. 2. Residents receiving antidepressants for short-term management of depressive symptoms (i.e., those accompanying an injury or illness) may be subject to GDR and should undergo monitoring of behavioral symptoms. Dosages can be tapered as outlined in Figure 2 and antidepressant therapy discontinued after 2-6 months of therapy. 3. Residents receiving antidepressants for major depressive disorders, particularly those at risk of recurrence, are unlikely candidates for GDR and may suffer adverse consequences if subject to GDR. Documentation that GDR is clinically contraindicated is required to ensure that none of the health care team or surveyors suggests GDR for individuals in whom the risk of drug dosage tapering and discontinuation outweighs the potential benefit.
References 1. CMS Manual System. State operations manual: Appendix P. Survey protocol for long term care facilities—Part I. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Available at www.cms.hhs.gov/transmittals/ downloads/R22SOMA.pdf. Cited December 29, 2006. 2. McHenry Martin C, McSpadden CS. Changes in the state operations manual: implications for consultant pharmacy practice. Consul Pharm 2006;21:948-61. 3. American Psychiatric Association. Mood disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Publishing; 2000. p. 345-428. 4. Lantz MS. Loneliness and boredom: a psychiatric disorder of late-life challenge? Clin Geriatr 2006; 14:12-4. 5. Sackeim HA, Roose SP, Burt T. Optimal length of antidepressant trials in late-life depression. J Clin Psychopharm 2005;25:S34-7. 6. Mann JJ. The medical management of depression. N Engl J Med 2005;353:1819-34. 7. Reynolds CF, Dew AM, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med 2006;354:1130-8. 8. The Cochrane Collaborative. Antidepressants for depressed elderly [review]. Cochrane Library 2006; 4:1-54. 9. Roose ST, Schatzberg AF. The efficacy of antidepressants in the treatment of late-life depression. J Clin Psychopharm 2005;25:S1-7. 10. Katon W, Unützer J, Fan MY, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006;29:265-70.
Geriatric Nursing, Volume 28, Number 2
11. Workgroup on Major Depressive Disorder. Practice guideline for the treatment of patients with major depressive disorder. 2nd ed. Washington, DC: American Psychiatric Association; 2005. Available at www.psych.org/psych_pract/treatg/pg/prac_guide.cfm. Cited December 25, 2006. 12. Cassano P, Fava M. Tolerability issues during long-
term treatment with antidepressants. Ann Clin Psych 2004;16:15-25. 0197-4572/07/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2006.12.004
NEW Edition!
For over 100 years, Dorland’s Illustrated Medical Dictionary has been the world's most highly respected reference on the language of medicine. The new, 30th Edition sets an even higher standard for defining the vocabulary that health professionals use every day! • A new, full-color design and over 1,500 full-color illustrations make definitions come alive. • More than 123,000 meticulously revised definitions incorporate all of the very latest terminology in health care. • Over 800 new complementary and alternative medicine terms reflect the growing popularity of these approaches. • New appendices cover Medical Etymology, Symbols, Chemical Elements, Selected Surgical Equipment, and Cancer Staging. • A new, bonus CD-ROM adds hundreds of thousands of medical terms to any computer’s spell- Sp ecial checker...and makes it possible to look up more than 35,000 words and their definitions on value! any handheld device. • Complimentary access to Dorlands.com offers convenient online reference to the dictionary's content, interactive vocabulary-building exercises, and much more. For the first and last word in medicine, turn to Dorland’s! Order your copy today! May 2003 • Over 2,140 pages • Over 1,080 illustrations (over 1,075 in full color) • Includes bonus CD-ROM for Windows® and Macintosh® • $49.95 • 0-7216-0146-4
3 EASY WAYS TO ORDER!
R Phone:
Call toll-free 1-800-545-2522 Mention DM#73165
C Mail: Order Fulfillment Dept. 11830 Westline Industrial Drive Saint Louis, MO 63146-3318
SAUNDERS Web:
Order securely at www.us.elsevierhealth.com and receive free shipping!
An Imprint of Elsevier Science © Elsevier Science 2003. Professional references may be tax-deductible. Offer valid in USA only. Prices subject to change without notice. DM#73165
Geriatric Nursing, Volume 28, Number 2
79