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September 9, 1988

The Diagnosis and Treatment of Depression in the Old-Reply

Author Affiliations

Maimonides Hospital Montreal

Maimonides Hospital Montreal

JAMA. 1988;260(10):1406. doi:10.1001/jama.1988.03410100095023

In Reply.—  I disagree with Dr. Fink. In geriatric psychiatry, where diagnosis can be uncertain, as when distinguishing depression from dementia, response to treatment is an important diagnostic tool. Used in this context, psychopharmacology offers more flexibility and practicality than does electroconvulsive therapy (ECT). Would it not be a disservice to treat with ECT a cognitively impaired 102-year-old woman with no prior history of depression when only 5% to 10% of elderly patients with cognitive impairment have pseudodementia?1 Moreover, a depressive syndrome can be the presenting feature of degenerative brain pathology, eg, Alzheimer's disease, multi-infarct dementia, and parkinsonian dementia.2 Under such circumstances would it not seem more reasonable to pick up functional depression from a positive response to carefully controlled drug therapy than to confirm dementia from a negative response to ECT?The flexibility of psychopharmacological strategies derives from a range of antidepressants that are serotonergic or noradrenergic,