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Less than 40% of depressed older adults treated with an antidepressant achieve remission. Incomplete response to treatment is common. Current augmentation strategies have limited efficacy, and many have side effects that restrict their utilization in older adults. We conducted the first open pilot trial of minocycline augmentation in older adults who had failed to achieve remission after adequate psychopharmacologic treatment. Subjects older than 55 years of age with major depression and failure to achieve substantial improvement of depressive symptoms after at least 6 weeks of antidepressant treatment were given augmentation with minocycline 100 mg twice daily over an 8-week period. At the end of 8 weeks of augmentation with minocycline, 31% (4/13) patients achieved remission. Remitters had higher baseline ratings of hopelessness and apathy. Minocycline was well tolerated with no reported adverse events or discontinuation due to intolerance. Larger placebo-controlled studies are needed to evaluate the effects of minocycline augmentation in older adults who had failed to achieve remission after adequate treatment with antidepressants.
Multiple studies have demonstrated that psychotic major depression (MDpsy) occurs more frequently in bipolar than in unipolar depression. Most MDpsy patients receive acute treatment on inpatient services. Management begins with establishing the diagnosis. DSM-IV recognizes that depression may occur during the prodromal, active, and residual phases of schizophrenia, and limits MDpsy to patients whose episodes of psychosis occur exclusively during episodes of major depressive disorder (MDD). An appropriate goal of acute treatment is to achieve both the remission of major depression and the resolution of delusional ideas. Remarkably little systematic data is available to guide continuation treatment to prevent relapses in the 4-6 months following remission and no studies are available on the prevention of recurrences after 6 months. The outcomes of untreated or inadequately treated MDpsy are poor, with high rates of suicide attempts, recurrences, and residual disability.