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Treating Depressive Disorders: Who Responds, Who Does Not Respond, and Who Do We Need to Study?
Research into the efficacy and effectiveness of treatments for depression has grown exponentially during the past several decades. Numerous studies show that disorders like major depression and dysthymia can be treated successfully with antidepressant medication and/or psychotherapy.1 Therapeutic effect sizes from efficacy trials are 18% for antidepressants compared with placebo and 26% for psychotherapy compared with no treatment.2-4 However, when these interventions are administered in real world settings, much lower response rates have been found.5-8
The evidence from these studies indicates that in controlled settings and with highly selected patients, current methods for treating depression are efficacious. However, there are still many people who do not respond to current guideline-based treatment and many segments of the population that have not been included in clinical studies. We briefly review the research and discuss which populations respond to current treatment, which do not, and which require further study.
Definitions of treatment and treatment response
For the purposes of this paper we defined “treatment” as antidepressant medication or psychotherapy. Because the majority of psychotherapy research has focused on cognitive-behavioral and interpersonal therapies, we use psychotherapy as a generic term for these 2 types of treatment. Most depression treatment studies have defined “response” as no longer meeting Diagnostic and Statistical Manual of Mental Disorders criteria for a disorder and exhibiting a statistically significant change on a symptom severity scale (usually a decrement of at least 50%). For the purpose of this paper, we will consider response to mean a significant change in depression severity.
Who responds to treatment?
The authors of several studies have examined patient traits linked to treatment response.9 For the most part, patients who are educated, are experiencing uncomplicated depression, have had 2 or fewer previous episodes of depression, and have faith in their treatment typically respond to guideline-level treatment.10 Depression experts once believed that only patients of this type were likely to show a treatment response and that those who were older, a member of an ethnic minority, or from lower socioeconomic groups were less likely to respond to guideline treatment. Recent research shows that people from low socioeconomic backgrounds can respond to existing treatment, provided they have access to quality care.11,12 Several studies specifically about treating depression in older adults have found positive effects, both in university and primary care settings.4,6 Although research on ethnic minorities is scarce and focused primarily on Latinos and African Americans, the literature indicates that members of these ethnic groups do respond to psychotherapy. With respect to medication treatment, research on the pharmacokinetics of antidepressants in African Americans, Asians, and certain Latino groups indicates that dosages may need to be altered to reduce side effects.13
Current research also indicates that patients with complicated psychiatric presentations can respond to guideline-level treatment. For example, although patients more severe depressive symptoms may not respond to monotherapies as well as patients with milder symptoms,14 they generally respond well to combination treatments.8 The presence of Axis II features and comorbid anxiety or substance abuse does not necessarily have an impact on treatment outcome, although much of the data focus primarily on acute care of depression.14 Finally, even patients with cognitive impairment can respond to both medication and psychotherapy for depression.15
Who does not respond?
Growing evidence suggests that while effective treatments for depression do exist, they are not helpful for everyone. Treatment nonresponders fall into 2 categories: those who are treatment resistant and those who simply resist treatment.
Patients who are treatment resistant have been given an adequate course of either antidepressant medication or psychotherapy and have either no response or a limited response to treatment. Research investigating predictors of treatment failure indicates that several psychiatric and psychosocial variables are related to treatment resistance. Patients with more psychosocial stressors and less social support are more likely to show a limited response to treatment,9 as are patients with a greater number of previous depressive episodes.16 This may be due in part to increased feelings of hopelessness17 or lack of faith in treatment,18 both found to contribute to treatment resistance. Comorbid Axis II features, such as borderline and dependent personality traits tend to predict a decreased treatment response, in part because of the poor psychologic resources these patients have to cope with their symptoms.15 Such patients may benefit from additional interventions to alleviate their symptoms, such as case management, longer courses of psychotherapy, and multiple medications.
Patients who resist treatment include those who despite being identified as depressed and offered treatment, never follow through with the treatment plan. The primary reasons why patients do not adhere to treatment for depression include stigma concerns19 and the belief that depressive symptoms are not significant enough to treat.20 Other factors, such as cognitive impairment, using multiple medications,21 comorbid medical illnesses, sensitivity to side effects,13 cost of mental health services,22 location of mental health services, and cross-cultural issues23 may also have an impact on patient willingness to accept treatment. Once in treatment, psychologic factors such as self-efficacy24 and readiness for change25 can influence whether a patient will adhere to a treatment plan. There is early evidence that educational interventions or treatment management programs may benefit patients with acceptance or adherence issues.26
Who do we need to study?
Several subgroups of patients have typically been excluded from treatment research. In particular, patients with coexisting Axis I disorders are routinely excluded from many treatment studies because of the complications concerning the management of separate conditions. However, the National Comorbidity Survey27 has shown that depression often co-occurs with many other disorders, including substance abuse, psychosis, and anxiety disorders. Although past studies have included patients with comorbid symptoms of substance use and anxiety, little is known about the impact these interventions have when full-blown comorbid disorders are present.
Samples included in recent studies of depression treatment are becoming more diverse with respect to age and minority representation. However, little is known regarding the specific response to treatment in these populations or how response rates compare with those found with more traditional study populations. This is important work to undertake, given that certain age and minority groups have been found to have varying responses to existing treatments. For example, given the pharmacokinetic complications that have been associated with antidepressant medications in ethnic minority populations, investigating the effectiveness of existing interventions in these populations is also important.13
Along similar lines, preliminary research suggests that older people take longer to respond to antidepressant therapies and require smaller doses to prevent toxic effects.4 Other age groups, such as children and adolescents are rarely studied, though this may change as the result of new National Institutes of Health guidelines on the inclusion of children as research subjects. Also, people seeking treatment in medical organizations other than primary care medicine or psychiatry have not been systematically studied. For example, the rates for depression in women seen in obstetrics/gynecology are quite high, but there are no published treatment studies with this population.28 Finally, patients who live in areas where care is hard to access (ie, rural populations) are currently being studied with promising results, yet to date there are no published outcomes.
Conclusions
The current literature shows that depression can be treated in many patients, but treatment response largely depends on the chronicity of the illness and the level of psychosocial stress faced by the patient. Future research should focus on how to best treat patients who tend not to respond to or accept existing treatment and should also examine the effectiveness of existing interventions for special populations who have not been included in past research. Thus far the evidence regarding the effectiveness of depression treatment is very promising, and the results of previous research will be useful in informing future work.
1. NIH Consensus Development Panel on Depression in Late Life. Diagnosis and treatment of depression in late life. JAMA 1992;268:1018-24.
2. Schneider LS, Olin JT. Efficacy of acute treatment for geriatric depression. Int Psychogeriatr 1997;7(suppl):7-25.
3. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental and social functioning. Arch Intern Med 1997;157:1113-20.
4. Reynolds CF, III, Frank E, et al. Treatment outcome in recurrent major depression: a post hoc comparison of elderly (“young old”) and midlife patients. Am J Psychiatry 1996;153:1288-92.
5. Areán PA, Perri MG, Nezu A, Schein RL, Christopher F, Joseph TX. Comparative effectiveness of social problem solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psychol 1993;61:1003-10.
6. Areán PA, Miranda J. Treatment of depression in elderly medical patients: a naturalistic study. J Clin Geropsychol 1996;2:153-60.
7. Simon GE, Lin EHB, Katon W, et al. Outcomes of “inadequate” antidepressant treatment in primary care. J Gen Intern Med 1995;10:663-70.
8. Schulberg HC, Block MR, Madonia MJ, et al. The “usual care” of major depression in primary care practice. Arch Fam Med 1997;6:334-39.
9. Dew MA, Reynolds CF, III, Houck PR, et al. Temporal profiles of the course of depression during treatment: predictors of pathways toward recovery in the elderly. Arch Gen Psychiatry 1997;54:1016-24.
10. Simons Anne D, Gordon JS, Monroe SM, Thase ME. Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy. J Consult Clin Psychol 1995;63:369-77.
11. RF, Ying YW, Bernal G, et al. Prevention of depression with primary care patients: a randomized controlled trial. Am J Comm Psychol 1995;23:199-222.
12. Katz SJ, Kessler RC, Lin E, Wells KB. Appropriate treatment of depression in the United States and Ontario, Canada. Annual Meeting of International Society of Technology. Assessment in Health Care 1997;13:89.-
13. Smith MW, Mendoza RP. Ethnicity and pharmacogenetics. Mt Sinai J Med 1996;63:285-90.
14. Hirschfeld RMA, Russell JM, Delgado PL, et al. Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine. J Clin Psychiatry 1998;59:669-75.
15. Spangler DL, Simons AD, Monroe SM, Thase ME. Respond to cognitive? behavioral therapy in depression: effects of pretreatment cognitive dysfunction and life stress. J Consult Clin Psychol 1997;65:568-75.
16. Reynolds CF, III, Frank E, Perel JM, et al. High relapse rate after discontinuation of adjunctive medication for elderly patients with recurrent major depression. Am J Psychiatry 1996;153:1418-22.
17. Addis ME, Jacobson NS. Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. J Consult Clin Psychol 1996;64:1417-24.
18. Burns DD, Nolen-Hoeksema S. Coping styles, homework compliance, and the effectiveness of cognitive-behavioral therapy. J Consult Clin Psychol 1991;59:305-11.
19. Stefl ME, Prosperi DC. Barriers to mental health service utilization. Comm Ment Health J 1985;21:167-78.
20. Chubon SJ, Schulz RM, Lingle EW, Jr, Coster-Shulz MA. Too many medications, too little money: how do patients cope? Public Health Nurs 1994;11:412-15.
21. Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1998;56 (suppl):18-22.
22. Ettner SL. Medicaid participation among the eligible elderly. J Policy Analysis Manage 1997;16:237-55.
23. Yeatts DE, Crow T, Folts E. Service use among low-income minority elderly: strategies for overcoming barriers. Gerontologist 1992;32:24-32.
24. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice Hall; 1985.
25. Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183-218.
26. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1998;53:924-32.
27. Kessler RC, Stang PE, Wittchen Hans-Ulrich, Ustun TB, Roy-Burne P, Walters EE. Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 1998;55:801-08.
28. Miranda J, Azocar F, Komaromy M, Golding J. Unmet mental health needs of women in public sector gynecology clinics. Am J Obstet Gynecol 1998;178:212-17.
Research into the efficacy and effectiveness of treatments for depression has grown exponentially during the past several decades. Numerous studies show that disorders like major depression and dysthymia can be treated successfully with antidepressant medication and/or psychotherapy.1 Therapeutic effect sizes from efficacy trials are 18% for antidepressants compared with placebo and 26% for psychotherapy compared with no treatment.2-4 However, when these interventions are administered in real world settings, much lower response rates have been found.5-8
The evidence from these studies indicates that in controlled settings and with highly selected patients, current methods for treating depression are efficacious. However, there are still many people who do not respond to current guideline-based treatment and many segments of the population that have not been included in clinical studies. We briefly review the research and discuss which populations respond to current treatment, which do not, and which require further study.
Definitions of treatment and treatment response
For the purposes of this paper we defined “treatment” as antidepressant medication or psychotherapy. Because the majority of psychotherapy research has focused on cognitive-behavioral and interpersonal therapies, we use psychotherapy as a generic term for these 2 types of treatment. Most depression treatment studies have defined “response” as no longer meeting Diagnostic and Statistical Manual of Mental Disorders criteria for a disorder and exhibiting a statistically significant change on a symptom severity scale (usually a decrement of at least 50%). For the purpose of this paper, we will consider response to mean a significant change in depression severity.
Who responds to treatment?
The authors of several studies have examined patient traits linked to treatment response.9 For the most part, patients who are educated, are experiencing uncomplicated depression, have had 2 or fewer previous episodes of depression, and have faith in their treatment typically respond to guideline-level treatment.10 Depression experts once believed that only patients of this type were likely to show a treatment response and that those who were older, a member of an ethnic minority, or from lower socioeconomic groups were less likely to respond to guideline treatment. Recent research shows that people from low socioeconomic backgrounds can respond to existing treatment, provided they have access to quality care.11,12 Several studies specifically about treating depression in older adults have found positive effects, both in university and primary care settings.4,6 Although research on ethnic minorities is scarce and focused primarily on Latinos and African Americans, the literature indicates that members of these ethnic groups do respond to psychotherapy. With respect to medication treatment, research on the pharmacokinetics of antidepressants in African Americans, Asians, and certain Latino groups indicates that dosages may need to be altered to reduce side effects.13
Current research also indicates that patients with complicated psychiatric presentations can respond to guideline-level treatment. For example, although patients more severe depressive symptoms may not respond to monotherapies as well as patients with milder symptoms,14 they generally respond well to combination treatments.8 The presence of Axis II features and comorbid anxiety or substance abuse does not necessarily have an impact on treatment outcome, although much of the data focus primarily on acute care of depression.14 Finally, even patients with cognitive impairment can respond to both medication and psychotherapy for depression.15
Who does not respond?
Growing evidence suggests that while effective treatments for depression do exist, they are not helpful for everyone. Treatment nonresponders fall into 2 categories: those who are treatment resistant and those who simply resist treatment.
Patients who are treatment resistant have been given an adequate course of either antidepressant medication or psychotherapy and have either no response or a limited response to treatment. Research investigating predictors of treatment failure indicates that several psychiatric and psychosocial variables are related to treatment resistance. Patients with more psychosocial stressors and less social support are more likely to show a limited response to treatment,9 as are patients with a greater number of previous depressive episodes.16 This may be due in part to increased feelings of hopelessness17 or lack of faith in treatment,18 both found to contribute to treatment resistance. Comorbid Axis II features, such as borderline and dependent personality traits tend to predict a decreased treatment response, in part because of the poor psychologic resources these patients have to cope with their symptoms.15 Such patients may benefit from additional interventions to alleviate their symptoms, such as case management, longer courses of psychotherapy, and multiple medications.
Patients who resist treatment include those who despite being identified as depressed and offered treatment, never follow through with the treatment plan. The primary reasons why patients do not adhere to treatment for depression include stigma concerns19 and the belief that depressive symptoms are not significant enough to treat.20 Other factors, such as cognitive impairment, using multiple medications,21 comorbid medical illnesses, sensitivity to side effects,13 cost of mental health services,22 location of mental health services, and cross-cultural issues23 may also have an impact on patient willingness to accept treatment. Once in treatment, psychologic factors such as self-efficacy24 and readiness for change25 can influence whether a patient will adhere to a treatment plan. There is early evidence that educational interventions or treatment management programs may benefit patients with acceptance or adherence issues.26
Who do we need to study?
Several subgroups of patients have typically been excluded from treatment research. In particular, patients with coexisting Axis I disorders are routinely excluded from many treatment studies because of the complications concerning the management of separate conditions. However, the National Comorbidity Survey27 has shown that depression often co-occurs with many other disorders, including substance abuse, psychosis, and anxiety disorders. Although past studies have included patients with comorbid symptoms of substance use and anxiety, little is known about the impact these interventions have when full-blown comorbid disorders are present.
Samples included in recent studies of depression treatment are becoming more diverse with respect to age and minority representation. However, little is known regarding the specific response to treatment in these populations or how response rates compare with those found with more traditional study populations. This is important work to undertake, given that certain age and minority groups have been found to have varying responses to existing treatments. For example, given the pharmacokinetic complications that have been associated with antidepressant medications in ethnic minority populations, investigating the effectiveness of existing interventions in these populations is also important.13
Along similar lines, preliminary research suggests that older people take longer to respond to antidepressant therapies and require smaller doses to prevent toxic effects.4 Other age groups, such as children and adolescents are rarely studied, though this may change as the result of new National Institutes of Health guidelines on the inclusion of children as research subjects. Also, people seeking treatment in medical organizations other than primary care medicine or psychiatry have not been systematically studied. For example, the rates for depression in women seen in obstetrics/gynecology are quite high, but there are no published treatment studies with this population.28 Finally, patients who live in areas where care is hard to access (ie, rural populations) are currently being studied with promising results, yet to date there are no published outcomes.
Conclusions
The current literature shows that depression can be treated in many patients, but treatment response largely depends on the chronicity of the illness and the level of psychosocial stress faced by the patient. Future research should focus on how to best treat patients who tend not to respond to or accept existing treatment and should also examine the effectiveness of existing interventions for special populations who have not been included in past research. Thus far the evidence regarding the effectiveness of depression treatment is very promising, and the results of previous research will be useful in informing future work.
Research into the efficacy and effectiveness of treatments for depression has grown exponentially during the past several decades. Numerous studies show that disorders like major depression and dysthymia can be treated successfully with antidepressant medication and/or psychotherapy.1 Therapeutic effect sizes from efficacy trials are 18% for antidepressants compared with placebo and 26% for psychotherapy compared with no treatment.2-4 However, when these interventions are administered in real world settings, much lower response rates have been found.5-8
The evidence from these studies indicates that in controlled settings and with highly selected patients, current methods for treating depression are efficacious. However, there are still many people who do not respond to current guideline-based treatment and many segments of the population that have not been included in clinical studies. We briefly review the research and discuss which populations respond to current treatment, which do not, and which require further study.
Definitions of treatment and treatment response
For the purposes of this paper we defined “treatment” as antidepressant medication or psychotherapy. Because the majority of psychotherapy research has focused on cognitive-behavioral and interpersonal therapies, we use psychotherapy as a generic term for these 2 types of treatment. Most depression treatment studies have defined “response” as no longer meeting Diagnostic and Statistical Manual of Mental Disorders criteria for a disorder and exhibiting a statistically significant change on a symptom severity scale (usually a decrement of at least 50%). For the purpose of this paper, we will consider response to mean a significant change in depression severity.
Who responds to treatment?
The authors of several studies have examined patient traits linked to treatment response.9 For the most part, patients who are educated, are experiencing uncomplicated depression, have had 2 or fewer previous episodes of depression, and have faith in their treatment typically respond to guideline-level treatment.10 Depression experts once believed that only patients of this type were likely to show a treatment response and that those who were older, a member of an ethnic minority, or from lower socioeconomic groups were less likely to respond to guideline treatment. Recent research shows that people from low socioeconomic backgrounds can respond to existing treatment, provided they have access to quality care.11,12 Several studies specifically about treating depression in older adults have found positive effects, both in university and primary care settings.4,6 Although research on ethnic minorities is scarce and focused primarily on Latinos and African Americans, the literature indicates that members of these ethnic groups do respond to psychotherapy. With respect to medication treatment, research on the pharmacokinetics of antidepressants in African Americans, Asians, and certain Latino groups indicates that dosages may need to be altered to reduce side effects.13
Current research also indicates that patients with complicated psychiatric presentations can respond to guideline-level treatment. For example, although patients more severe depressive symptoms may not respond to monotherapies as well as patients with milder symptoms,14 they generally respond well to combination treatments.8 The presence of Axis II features and comorbid anxiety or substance abuse does not necessarily have an impact on treatment outcome, although much of the data focus primarily on acute care of depression.14 Finally, even patients with cognitive impairment can respond to both medication and psychotherapy for depression.15
Who does not respond?
Growing evidence suggests that while effective treatments for depression do exist, they are not helpful for everyone. Treatment nonresponders fall into 2 categories: those who are treatment resistant and those who simply resist treatment.
Patients who are treatment resistant have been given an adequate course of either antidepressant medication or psychotherapy and have either no response or a limited response to treatment. Research investigating predictors of treatment failure indicates that several psychiatric and psychosocial variables are related to treatment resistance. Patients with more psychosocial stressors and less social support are more likely to show a limited response to treatment,9 as are patients with a greater number of previous depressive episodes.16 This may be due in part to increased feelings of hopelessness17 or lack of faith in treatment,18 both found to contribute to treatment resistance. Comorbid Axis II features, such as borderline and dependent personality traits tend to predict a decreased treatment response, in part because of the poor psychologic resources these patients have to cope with their symptoms.15 Such patients may benefit from additional interventions to alleviate their symptoms, such as case management, longer courses of psychotherapy, and multiple medications.
Patients who resist treatment include those who despite being identified as depressed and offered treatment, never follow through with the treatment plan. The primary reasons why patients do not adhere to treatment for depression include stigma concerns19 and the belief that depressive symptoms are not significant enough to treat.20 Other factors, such as cognitive impairment, using multiple medications,21 comorbid medical illnesses, sensitivity to side effects,13 cost of mental health services,22 location of mental health services, and cross-cultural issues23 may also have an impact on patient willingness to accept treatment. Once in treatment, psychologic factors such as self-efficacy24 and readiness for change25 can influence whether a patient will adhere to a treatment plan. There is early evidence that educational interventions or treatment management programs may benefit patients with acceptance or adherence issues.26
Who do we need to study?
Several subgroups of patients have typically been excluded from treatment research. In particular, patients with coexisting Axis I disorders are routinely excluded from many treatment studies because of the complications concerning the management of separate conditions. However, the National Comorbidity Survey27 has shown that depression often co-occurs with many other disorders, including substance abuse, psychosis, and anxiety disorders. Although past studies have included patients with comorbid symptoms of substance use and anxiety, little is known about the impact these interventions have when full-blown comorbid disorders are present.
Samples included in recent studies of depression treatment are becoming more diverse with respect to age and minority representation. However, little is known regarding the specific response to treatment in these populations or how response rates compare with those found with more traditional study populations. This is important work to undertake, given that certain age and minority groups have been found to have varying responses to existing treatments. For example, given the pharmacokinetic complications that have been associated with antidepressant medications in ethnic minority populations, investigating the effectiveness of existing interventions in these populations is also important.13
Along similar lines, preliminary research suggests that older people take longer to respond to antidepressant therapies and require smaller doses to prevent toxic effects.4 Other age groups, such as children and adolescents are rarely studied, though this may change as the result of new National Institutes of Health guidelines on the inclusion of children as research subjects. Also, people seeking treatment in medical organizations other than primary care medicine or psychiatry have not been systematically studied. For example, the rates for depression in women seen in obstetrics/gynecology are quite high, but there are no published treatment studies with this population.28 Finally, patients who live in areas where care is hard to access (ie, rural populations) are currently being studied with promising results, yet to date there are no published outcomes.
Conclusions
The current literature shows that depression can be treated in many patients, but treatment response largely depends on the chronicity of the illness and the level of psychosocial stress faced by the patient. Future research should focus on how to best treat patients who tend not to respond to or accept existing treatment and should also examine the effectiveness of existing interventions for special populations who have not been included in past research. Thus far the evidence regarding the effectiveness of depression treatment is very promising, and the results of previous research will be useful in informing future work.
1. NIH Consensus Development Panel on Depression in Late Life. Diagnosis and treatment of depression in late life. JAMA 1992;268:1018-24.
2. Schneider LS, Olin JT. Efficacy of acute treatment for geriatric depression. Int Psychogeriatr 1997;7(suppl):7-25.
3. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental and social functioning. Arch Intern Med 1997;157:1113-20.
4. Reynolds CF, III, Frank E, et al. Treatment outcome in recurrent major depression: a post hoc comparison of elderly (“young old”) and midlife patients. Am J Psychiatry 1996;153:1288-92.
5. Areán PA, Perri MG, Nezu A, Schein RL, Christopher F, Joseph TX. Comparative effectiveness of social problem solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psychol 1993;61:1003-10.
6. Areán PA, Miranda J. Treatment of depression in elderly medical patients: a naturalistic study. J Clin Geropsychol 1996;2:153-60.
7. Simon GE, Lin EHB, Katon W, et al. Outcomes of “inadequate” antidepressant treatment in primary care. J Gen Intern Med 1995;10:663-70.
8. Schulberg HC, Block MR, Madonia MJ, et al. The “usual care” of major depression in primary care practice. Arch Fam Med 1997;6:334-39.
9. Dew MA, Reynolds CF, III, Houck PR, et al. Temporal profiles of the course of depression during treatment: predictors of pathways toward recovery in the elderly. Arch Gen Psychiatry 1997;54:1016-24.
10. Simons Anne D, Gordon JS, Monroe SM, Thase ME. Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy. J Consult Clin Psychol 1995;63:369-77.
11. RF, Ying YW, Bernal G, et al. Prevention of depression with primary care patients: a randomized controlled trial. Am J Comm Psychol 1995;23:199-222.
12. Katz SJ, Kessler RC, Lin E, Wells KB. Appropriate treatment of depression in the United States and Ontario, Canada. Annual Meeting of International Society of Technology. Assessment in Health Care 1997;13:89.-
13. Smith MW, Mendoza RP. Ethnicity and pharmacogenetics. Mt Sinai J Med 1996;63:285-90.
14. Hirschfeld RMA, Russell JM, Delgado PL, et al. Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine. J Clin Psychiatry 1998;59:669-75.
15. Spangler DL, Simons AD, Monroe SM, Thase ME. Respond to cognitive? behavioral therapy in depression: effects of pretreatment cognitive dysfunction and life stress. J Consult Clin Psychol 1997;65:568-75.
16. Reynolds CF, III, Frank E, Perel JM, et al. High relapse rate after discontinuation of adjunctive medication for elderly patients with recurrent major depression. Am J Psychiatry 1996;153:1418-22.
17. Addis ME, Jacobson NS. Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. J Consult Clin Psychol 1996;64:1417-24.
18. Burns DD, Nolen-Hoeksema S. Coping styles, homework compliance, and the effectiveness of cognitive-behavioral therapy. J Consult Clin Psychol 1991;59:305-11.
19. Stefl ME, Prosperi DC. Barriers to mental health service utilization. Comm Ment Health J 1985;21:167-78.
20. Chubon SJ, Schulz RM, Lingle EW, Jr, Coster-Shulz MA. Too many medications, too little money: how do patients cope? Public Health Nurs 1994;11:412-15.
21. Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1998;56 (suppl):18-22.
22. Ettner SL. Medicaid participation among the eligible elderly. J Policy Analysis Manage 1997;16:237-55.
23. Yeatts DE, Crow T, Folts E. Service use among low-income minority elderly: strategies for overcoming barriers. Gerontologist 1992;32:24-32.
24. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice Hall; 1985.
25. Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183-218.
26. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1998;53:924-32.
27. Kessler RC, Stang PE, Wittchen Hans-Ulrich, Ustun TB, Roy-Burne P, Walters EE. Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 1998;55:801-08.
28. Miranda J, Azocar F, Komaromy M, Golding J. Unmet mental health needs of women in public sector gynecology clinics. Am J Obstet Gynecol 1998;178:212-17.
1. NIH Consensus Development Panel on Depression in Late Life. Diagnosis and treatment of depression in late life. JAMA 1992;268:1018-24.
2. Schneider LS, Olin JT. Efficacy of acute treatment for geriatric depression. Int Psychogeriatr 1997;7(suppl):7-25.
3. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriguez E. Treating depressed primary care patients improves their physical, mental and social functioning. Arch Intern Med 1997;157:1113-20.
4. Reynolds CF, III, Frank E, et al. Treatment outcome in recurrent major depression: a post hoc comparison of elderly (“young old”) and midlife patients. Am J Psychiatry 1996;153:1288-92.
5. Areán PA, Perri MG, Nezu A, Schein RL, Christopher F, Joseph TX. Comparative effectiveness of social problem solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psychol 1993;61:1003-10.
6. Areán PA, Miranda J. Treatment of depression in elderly medical patients: a naturalistic study. J Clin Geropsychol 1996;2:153-60.
7. Simon GE, Lin EHB, Katon W, et al. Outcomes of “inadequate” antidepressant treatment in primary care. J Gen Intern Med 1995;10:663-70.
8. Schulberg HC, Block MR, Madonia MJ, et al. The “usual care” of major depression in primary care practice. Arch Fam Med 1997;6:334-39.
9. Dew MA, Reynolds CF, III, Houck PR, et al. Temporal profiles of the course of depression during treatment: predictors of pathways toward recovery in the elderly. Arch Gen Psychiatry 1997;54:1016-24.
10. Simons Anne D, Gordon JS, Monroe SM, Thase ME. Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy. J Consult Clin Psychol 1995;63:369-77.
11. RF, Ying YW, Bernal G, et al. Prevention of depression with primary care patients: a randomized controlled trial. Am J Comm Psychol 1995;23:199-222.
12. Katz SJ, Kessler RC, Lin E, Wells KB. Appropriate treatment of depression in the United States and Ontario, Canada. Annual Meeting of International Society of Technology. Assessment in Health Care 1997;13:89.-
13. Smith MW, Mendoza RP. Ethnicity and pharmacogenetics. Mt Sinai J Med 1996;63:285-90.
14. Hirschfeld RMA, Russell JM, Delgado PL, et al. Predictors of response to acute treatment of chronic and double depression with sertraline or imipramine. J Clin Psychiatry 1998;59:669-75.
15. Spangler DL, Simons AD, Monroe SM, Thase ME. Respond to cognitive? behavioral therapy in depression: effects of pretreatment cognitive dysfunction and life stress. J Consult Clin Psychol 1997;65:568-75.
16. Reynolds CF, III, Frank E, Perel JM, et al. High relapse rate after discontinuation of adjunctive medication for elderly patients with recurrent major depression. Am J Psychiatry 1996;153:1418-22.
17. Addis ME, Jacobson NS. Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. J Consult Clin Psychol 1996;64:1417-24.
18. Burns DD, Nolen-Hoeksema S. Coping styles, homework compliance, and the effectiveness of cognitive-behavioral therapy. J Consult Clin Psychol 1991;59:305-11.
19. Stefl ME, Prosperi DC. Barriers to mental health service utilization. Comm Ment Health J 1985;21:167-78.
20. Chubon SJ, Schulz RM, Lingle EW, Jr, Coster-Shulz MA. Too many medications, too little money: how do patients cope? Public Health Nurs 1994;11:412-15.
21. Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1998;56 (suppl):18-22.
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