Running Head: COMBINATION THERAPY AND HAM-D

How Combination Therapy Effects Hamilton Depression Rating Scale Scores

Ruth Vasquez

SUNY Upstate Medical University

COMBINATION THERAPY AND HAM-D 2

How Combination Therapy Effects HAM-D Scores

Depression is considered a mental health illness that contributes to a worldwide

debilitating disease, where women are more likely than men to suffer of such disease

(Sassarini, 2016). Depression further constitutes of massive distinctions in etiologies that

can lead to detrimental consequences including death, if left untreated (HealthyPeople

2020, 2019). In 2007, there were a 69.9% of adult women whom received some sort of

treatment for depression and for the year 2020 the target is to increase the number of

women that receive treatment by 10% (HealthyPeople 2020, 2019). Particularly in

middle-aged women, there are some indications that point out their higher state of

susceptibility of depression, for example their sex hormones and neurotransmitters can

solicit brain imbalances that could potentially be the culprit of depression (Sassarini,

2016).

A class of antidepressant medications that is widely used and prescribed is

selective serotonin reuptake inhibitors (SSRIs) (Mayo Clinic, 2018). Serotonin is a brain

chemical or neurotransmitter that has many responsibilities in the body, one of which is

mood control (Mayo Clinic, 2018). Furthermore, another method of depression treatment

is that of psychotherapy, a means in which the patient diagnosed with depression has a

communication outlet to discuss with a therapist their concerns and set goals towards

improving moods (Society of Clinical Psychology, 2017). A scale that is widely used in

the primary care setting for depression severity scoring is the Hamilton Depression

Rating Scale (HAM-D), scores range from 17 to 28, where scores that are below seven

are indicative of no depression while scores that are above 24 are indicative of severe

depression (Lichtenberg, 2010).

COMBINATION THERAPY AND HAM-D 3

It is important to focus on what therapeutic processes are effectual in decreasing

depressive moods in women. Implementing methods that are supported by scientific

research can be life altering and even life saving. The purpose of this paper is to provide a

synthesis of studies that may answer, if the combination of SSRI’s and psychotherapy

improve HAM-D scores compared to the use of SSRI’s alone in women over the age of

40 with major depression disorder.

Search methods

A literature search was conducted using Psychiatric Online, CINAHL, Pubmed,

and Upstate Health Sciences Library databases. Filters that were applied to the search

included: years from 2010 to 2019, article type were clinical trials, peer-reviewed

journals, and English language. The key search words used in combination for

Psychiatric Online literature search were: “depression,” “monotherapy,” and

“combination therapy.” The key search words used in combination for CINAHL

literature search are as follows: “depression,” “SSRI,” and “psychotherapy.” The key

search words used in combination for Pubmed (MeSH) were: “cognitive behavioral

therapy,” “SSRI,” and “depression.” Finally, the combination of key search words used

for Upstate Health Sciences Library databases were: “major depression,” “SSRI,” and

“psychotherapy.”

Search results summary

A total of 110 articles were generated after the literature search methods

previously portrayed were implemented. Of these articles, six were selected for further

review and synthesis, all of which fall under level two category of evidence, given that

that they are research articles of randomized controlled trials and the articles excluded
COMBINATION THERAPY AND HAM-D 4

were those that did not have any means of psychotherapy and pharmacological

interventions of SSRI’s, depicted in Appendix A. The studies by Dunlop et al. (2019),

Nakagawa et al. (2017), Menchetti et al. (2014), Lackamp, Schlachet, & Sajatovic

(2016), Rucci et al. (2011), Frank et al. (2011) were chosen because they portrayed the

highest level of evidence utilizing HAM-D depression scale along with the combination

therapy including pharmacotherapy and psychotherapy on adults diagnosed with

depression.

Study Number One

Dunlop et al. (2019) conducted a RCT quantitative study to configure the

effectiveness of combination therapy of either pharmacological or psychotherapy

augmentation intervention for depressed adults between the ages of 18 -65 with long-term

follow-up. The study took place in Atlanta, Georgia, in a two-phase clinical process. The

first phase consisted 344 adults diagnosed with major depressive disorder with HAM-D

scores ≥18 at screening or ≥ 15 at baseline and they were randomly assigned a treatment

group of either pharmacological or psychotherapy intervention (Dunlop et al., 2019).

After 12 weeks of acute treatment with either SSRI’s or cognitive behavioral therapy

(CBT) the clinical participants were reassessed and those that did not reach remission

from depression would continue onto the second phase of the study, where their HAM-D

scores were >7 (Dunlop et al., 2019). The second phase consisted of 112 participants that

received a combination treatment of either CBT with medication or medication with

CBT, 37 and 75 participants respectively (Dunlop et al., 2019). The results were

significant given that the overall HAM-D scores improved from baseline, 8.2 (SD=2.0,

t=8.28, p<0.0001) for the group that had CBT with medication and 5.3 (SD=1.2, t=8.85,
COMBINATION THERAPY AND HAM-D 5

p<0.0001) for the group that had medication with CBT (Dunlop et al., 2019). The

strength of the study was its large sample and its limitation was the lack of

generalizability due to the fact that the patients enrolled in the study did not have any

prior treatment for depression.

Study Number Two

Nakagawa et al. (2017) conducted a RCT quantitative clinical study making a

comparative analysis of the effectiveness of supplementing psychotherapy as treatment

for those whom are depressed and are on a pharmacological treatment to those that are on

a pharmacological treatment plan alone. The study took place in Tokyo, Japan and

consisted of 80 patients from a university hospital and a psychiatric hospital from ages

between 20-65 years (Nakagawa et al., 2017). The patients that were considered for the

study have a major depressive disorder diagnosis and had a HAM-D score of ≥16 despite

taking antidepressant medications (Nakagawa et al., 2017). The study covered over a 16

weeks timeframe, taking on a parallel model of 2 groups that were randomly assigned to

receive either CBT along with their respective medication treatment or their treatment as

usual (TAU) without any augmentations (Nakagawa et al., 2017). The results from this

study reflect the effectiveness of beneficial effects for supplementing CBT with

medication regimen to treat depressive symptoms versus TAU by an improvement of

HAM-D scores of -12.7 versus -7.4 respectively, where the mean difference between the

groups was also significant indicated by a -5.4 (CI=95%, p<0.001) (Nakagawa et al.,

2017). The strength of the study is the implementation of follow-up regimen on the

patients being study and the limitation of the study was the considerably small sample

size.
COMBINATION THERAPY AND HAM-D 6

Study Number Three

Menchetti et al. (2014) conducted a RCT quantitative study with the goal of

comparing treatments between SSRI’s and interpersonal counseling (psychotherapy) for

primary care patients with depression. This study took place in nine academic centers of

Italy where a total 287 adults of 18 years of age or older with a diagnosis of major

depression and had a HAM-D score of ≥13, were randomly placed in either the clinical

group that received an SSRI or interpersonal counseling treatment for 8 weeks (Menchetti

et al., 2014). The results were indicative that those whom received interpersonal

counseling achieved remission of depressive symptoms considerably higher than those

that were in the SSRI treatment group (58.7% versus 45.1%, χ 2 =5.3, d.f.=1, p=0.021)

(Menchetti et al., 2014). The strength of this study was the large sample size that was

utilized and its limitation was the targeted group of patients that had only one to two

treated depressive episodes in their history making the results not generalizable across all

mood disorders.

Study Number Four

Frank et al. (2011) conducted a RCT quantitative study to examine the

implementation of the psychotherapy, psychopharmacotherapy, or a combination of both

in the treatment of those that suffer depression and the incidence in which the participants

will also suffer emergent suicidal ideation (ESI). The study took place at two outpatient

psychiatric clinics over a five year time period, involving patients that were between the

ages 18 and 66 year of age that presented with nonpsychotic depression and with a HAM-

D score of ≥15, where 456 patients were assessed eligible for the study and 291 patient

were randomly allocated intervention (Frank et al., 2011). Of the 291 patients that
COMBINATION THERAPY AND HAM-D 7

participated in the study, 210 were females and a mean age of 39.3 years, where 149 were

randomly assigned psychotherapy and 142 to SSRI (Frank et al., 2011). There were a

total of 231 participants that had a pretreatment baseline of no suicidal ideation and it was

present in 60 participants, of the 231 with no suicidal ideation at baseline, 32 exhibited

ESI on one post treatment visit where 22 were initially received randomized

psychotherapy and 10 received randomized SSRI augmentation of treatment related to

adding psychotherapy or SSRI and increasing the frequency of the clinical visits (Frank

et al., 2011). The onset of ESI was longer on the assigned group of SSRI compared to

psychotherapy (HR=2.22, 95% CI 1.00-4.94, P=0.05) with no greater incidence of

combination therapy of either psychotherapy with SSRI or SSRI with psychotherapy

(Frank et al., 2011). Implicating that the means of treatment of combination therapy at an

early onset of ESI was found during the first month of treatment was successfully

managed (Frank et al., 2011). The strength of this study was the large amount of

participants and the treatment methods that were utilized to further implement

combination therapy on those participants that were at high risk and its limitation

revolved around the exclusion of patients that have previous severe mental health

disorders.

Study Number Five

Rucci et al. (2011) conducted a RCT quantitative study to investigate the relapse

of major depressive disorder after treatment of psychotherapy, SSRI, or the combination

of the two when there was no response to the use of monotherapy. The study took place

at two outpatient psychiatric clinics where 291 outpatients between the ages 18-66 years

of age with HAM-D score of ≥15 were recruited and were randomly allocated into
COMBINATION THERAPY AND HAM-D 8

psychotherapy or SSRI treatment or if initial treatment did not achieve stable remission

the other treatment was added, once stabilized the groups entered a 6-month continuation

phase (Rucci et al., 2011). The focal point of the study was on the continuation phase that

consisted of 225 participants that achieved stabilization of depressive episode with HAM-

D score ≤7, where 161 participants were women (Rucci et al., 2011). It was found that

the risk factors that increased the likelihood of relapse included higher age, higher

baseline HAM-D scores, residual depressive mood, and requiring combination therapy in

order to achieve remission (OR5 1.05, 95% CI: 1.01–1.10; OR5 1.15, 95% CI: 1.02–1.28;

OR5 1.11, 95% CI: 1.01–1.23; OR5 3.30, 95% CI:1.27–8.86, respectively) (Rucci et al.,

2011). The strength of the study was the large number of participants and the length of

the continuation therapy with follow-up; its limitation was the exclusion of participants

with multitude of psychiatric disorders.

Study Number Six

Lackamp, Schlachet, and Sajatovic (2016) conducted a mini review meta-analysis

study of means in which the elderly (age 65 and older) with major depression disorder

(MDD) should be approached and treated. Particularly the elderly that live in long-term

facilities suffer one of the most prevalent mental health disorders accounting for 14.4 %,

where all those that are 65 years of age or older estimates 1-5% suffer MDD (Lackamp,

Schlachet, & Sajatovic, 2016). Geropsychiatrists have concluded that the serious

complication of MDD amongst the elderly is that of suicide, rates have significantly

increased with age (Lackamp, Schlachet, & Sajatovic, 2016). Studies have indicated that

the female gender including sleep disturbances and other disabilities in older age are

considerable risk factors (Lackamp, Schlachet, & Sajatovic, 2016). HAM-D depression
COMBINATION THERAPY AND HAM-D 9

screening is amongst the useful screenings that can be utilized with older adults and it is

important to take time alone with the patient when screening to allow for them to open up

(Lackamp, Schlachet, & Sajatovic, 2016). Research has implicated that the first line of

medication treatment for MDD in the elderly population are SSRI and SNRI given their

properties that have a least effect in drug interaction (Lackamp, Schlachet, & Sajatovic,

2016). Psychotherapy is another recommended approach in treatment method for the

elderly that can be helpful but there are many constraints that may not facilitate the

intervention given the limitation of transportation to and from appointments (Lackamp,

Schlachet, & Sajatovic, 2016).

Discussion and Synthesis of Literature Review

It was found throughout three studies that implementing treatment of

psychotherapy for those with depression resulted in improved HAM-D scores for

depressive symptoms remission (Dunlop et al., 2019; Nakagawa et al., 2017; Menchetti et

al., 2014). Where the earlier the implementation of combination therapy was more

beneficial than later (Frank et al., 2011). There were many similarities and limitations

that may have influenced the results of these studies. Themes that seemed to be

prominent in the studies were factors that may play a role in making depressive

symptoms exacerbate, preference to psychotherapy, and insufficient studies of this realm.

The following will further iterate the findings amongst the three studies that correlate to

the treatment plan of patients with depression.

Factors that exacerbate depression

There are many contributing factors that can make depressive symptoms worse in

some patients versus others that can potentially interfere with the efficacy of treatment.
COMBINATION THERAPY AND HAM-D 10

When a patient has the desire to recuperate from depressive symptoms this could be their

drive to pursue treatment as offered. Factors that need to be taken into consideration are

those of comorbid anxiety disorders (Dunlop et al., 2019; Nakagawa et al., 2017;

Menchetti et al., 2014). It has been found that patients that have higher levels of anxiety

have a tendency to have no remission of depression with pharmacotherapy but yet it

remains to be uncertain for its reasoning, these patients are also at a higher risk of relapse

compared to patients that reported not having anxiety at baseline (Dunlop et al., 2019).

The greater incidence of relapse also involved that of patients that of older age and those

that had to add combination treatment to reach remission (Frank et. al., 2011; Rucci et al.,

2011). Other factors that hinder the effects of treatment include whether or not the

patient is married, employed, are a smoker, or have other physical illness (Dunlop et al.,

2019; Menchetti et al., 2014). It has been found, patients have a better response to

treatment of psychotherapy if they are nonsmokers, to SSRI if they are smokers along

with other illnesses (Menchetti et al., 2014).

Psychotherapy preference

Throughout the studies, psychotherapy was used as a treatment method to either

augment or use as sole treatment plan for patients with depression (Dunlop et al., 2019;

Nakagawa et al., 2017; Menchetti et al., 2014; Frank et al., 2011; Rucci et al., 2011). This

method of treatment demonstrated to be a means of treatment in which patients accepted

given the high retention rate of patients completing the study (Dunlop et al., 2019;

Nakagawa et al., 2017; Menchetti et al., 2014). All the studies resulted with improved

HAM-D scores where patients remained in remission when psychotherapy was the

treatment choice (Dunlop et al., 2019; Nakagawa et al., 2017; Menchetti et al., 2014).
COMBINATION THERAPY AND HAM-D 11

Limited studies

A repeated theme throughout the studies was the very limited amount of research

that have been developed that consider to make a comparison between combination

therapy of psychotherapy and medication for the goal of depression remission (Dunlop et

al., 2019; Nakagawa et al., 2017; Menchetti et al., 2014). Nakagawa et al. (2017) points

out the plenteous amount of evidence that connotes the efficacy of either CBT or

pharmacotherapy alone but is limited on evidence of treatment efficacy in patients with

major depression that is resistant to medication. Menchetti et al. (2014) denote the limited

clinical trials that have investigated combination of treatment for depression in the

primary care setting. Dunlop et al. (2019) conveyed the limited research finding in the

sequence in which treatment is given and its effects with achieving remission, which all

suggested the combination treatment were the most effective treatment.

Clinical Implications

The review of these studies overwhelmingly direct the efficacy of implementing

psychotherapy into the treatment plan of patients with depression. Although these studies

did not particularly target women, adults in general can benefit in incorporating CBT as

an option to reduce depressive symptoms and remain in remission. Primary care

providers need to keep in prospects the options that patients with depression have when it

comes to creating a treatment plan. Dependent on the severity of the depression,

psychotherapy alone was found to be effectual in mild to moderate depression (Menchetti

et al., 2014). Patients that do not respond to a single method of treatment significantly

benefit from a combination therapy of both psychotherapy and pharmacotherapy (Dunlop

et al., 2019; Nakagawa et al., 2017; Menchetti et al., 2014). Overall, these studies may be
COMBINATION THERAPY AND HAM-D 12

preliminary findings due to the lack of extensive investigation of pharmacological versus

psychotherapy interventions, but are of strong evidential support given the improvement

in HAM-D scores and the length of remission in which the patients that participated

sustained.
COMBINATION THERAPY AND HAM-D 13

References

Dunlop, B. W., Loparo, D., Kinkead, B., Mletzko-Crowe, T., Cole, S. P., Nemeroff, C.

B., . . . Craighead, W. E. (2019). Benefits of Sequentially Adding Cognitive-

Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting

Depression. American Journal of Psychiatry.

doi:10.1176/appi.ajp.2018.18091075

Frank, E., Scocco, P., Miniati, M., Fagiolini, A., Cassano, G., & Cassano, G. (2011).

Treatment-emergent suicidal ideation during 4 months of acute management of

unipolar major depression with SSRI pharmacotherapy or interpersonal

psychotherapy in a randomized clinical trial. Depression and Anxiety (Hoboken),

28(4), 303–309. https://doi.org/10.1002/da.20758

HealthyPeople 2020. (2019, March 11). Mental Health and Mental Disorders. Retrieved

March 11, 2019, from https://www.healthypeople.gov/2020/topics-

objectives/topic/mental-health-and-mental-disorders

Lackamp, J., Schlachet, R., & Sajatovic, M. (2016). Assessment and management of

major depressive disorder in older adults. Psychiatria Danubina, 28(Suppl-1), 95–

98.

Lichtenberg, P. A. (2010). Handbook of assessment in clinical gerontology. London:

Academic.

Mayo Clinic. (2018, May 17). Selective serotonin reuptake inhibitors (SSRIs). Retrieved

March 11, 2019, from https://www.mayoclinic.org/diseases-

conditions/depression/in-depth/ssris/art-20044825
COMBINATION THERAPY AND HAM-D 14

Menchetti, M., Rucci, P., Bortolotti, B., Bombi, A., Scocco, P., Kraemer, H. C., &

Berardi, D. (2014). Moderators of remission with interpersonal counselling or

drug treatment in primary care patients with depression: Randomised controlled

trial. British Journal of Psychiatry, 204(02), 144-150.

doi:10.1192/bjp.bp.112.122663

Nakagawa, A., Mitsuda, D., Sado, M., Abe, T., Fujisawa, D., Kikuchi, T., . . . Ono, Y.

(2017). Effectiveness of Supplementary Cognitive-Behavioral Therapy for

Pharmacotherapy-Resistant Depression. The Journal of Clinical Psychiatry,

78(8), 1126-1135. doi:10.4088/jcp.15m10511

Rucci, P., Frank, E., Calugi, S., Miniati, M., Benvenuti, A., Wallace, M., … Cassano, G. B.

(2011). Incidence and predictors of relapse during continuation treatment of

major depression with SSRI, interpersonal psychotherapy, or their

combination. Depression And Anxiety, 28(11), 955–962.

https://doi.org/10.1002/da.20894

Sassarini, D. J. (2016). Depression in midlife women. Maturitas, 94, 149-154.

doi:10.1016/j.maturitas.2016.09.004

Society of Clinical Psychology. (2017, July 31). What Is Psychotherapy? Retrieved

March 11, 2019, from https://www.apa.org/ptsd-guideline/patients-and-

families/psychotherapy
COMBINATION THERAPY AND HAM-D 15

Database Key words & Search filters / Number Number Number Comments
linkages inclusion criteria retrieved excluded retained for
& retained based on selection -
based on abstract or Potential
title &/or brief scan of (used)
abstract article
Psychiatr (“depression”) English, 42 37 5 (1) Many articles
y Online AND 2013-2019 had different
(“monotherapy”) mental illnesses
AND other than
(“combination depression and
therapy”) pharmacotherapy
that did not
include SSRI’s
CINAHL (“depression”) Peer-reviewed, 25 16 9 (1) Many of the
AND (“SSRI”) English, articles were
AND 2013-2019 more based on
(“psychotherapy” adolescents
)
Pubmed (“depression”) Clinical trials, 7 2 5 (1) Many of the
AND (“cognitive published in the articles were
behavioral last 5 years, specific to PDD
therapy”) AND Humans, English and PTSD
(“SSRI”)
(MeSH)
Upstate (“major English, Peer- 36 30 6 (3) Many articles
Health depression”) reviewed journals, had a different
Sciences AND (“SSRI”) 2010-2019 treatment
Library AND approach,
(“psychotherapy” implicated
) pregnant women
and adolescents

Appendix A

Search history table related to the effect of combination therapy on depression.

Note. SSRI= selective serotonin reuptake inhibitors; PDD= Post Partum Depression;
PTSD= Post Traumatic Stress Disorder.
 COMBINATION THERAPY AND HAM-D 16

Appendix B

Synthesis of literature related to SSRI, psychotherapy, HAM-D scores

Source Study goal Sample, Variables Study Data Conclusions Strength of

setting & design analysis evidence &
sampling   limitations
Dunlop et Effectiveness Depressed Mean HAM-D Quantitative Chi- Improved Strong
al. (2019) of combination adults 18-65 scores per week, , cross- square HAM-D evidence
therapy of years old CBT with sectional scores, 8.2
either Phase 1: medication and descriptive, (SD=2.0, Limitations:
pharmacologic n=344 medication with RCT t=8.28, patients did
al or Phase 2: CBT p<0.0001) not have
psychotherapy n=112 for the group previous
augmentation Outpatient that had CBT treatment
intervention setting in with
Atlanta, medication
Georgia and 5.3
Phase 1 (SD=1.2,
HAM-D t=8.85,
scores ≥18 p<0.0001)
Phase 2 for the group
HAM-D that had
scores >7 medication
with CBT

 Nakagaw Effectiveness Depressed Mean HAM-D  Quantitativ  Repeated Improved Strong

a et al. of adults 20-65 scores per week, e, cross- -measures HAM-D evidence
(2017) supplementing years old, supplementing sectional analysis scores, mean
psychotherapy n=80 CBT with descriptive, difference Limitations:
for those on a University medication RCT between the small
pharmacologic and regimen to treat groups sample size
al treatment psychiatric depressive significant
compared to hospitals of symptoms indicated by
those that are Tokyo, Japan versus TAU  a -5.4
on a HAM-D (CI=95%,
pharmacologic score of ≥16 p<0.001)
al treatment despite
plan alone taking
antidepressa
nt
medications
Menchetti Compare the Depressed Mean HAM-D  Quantitativ Chi- Interpersonal Strong
et al. efficacy of adults 18 scores per week, e, cross- square counseling evidence
(2014) treatment years and allocated sectional significantly
between older, n=287 intervention of descriptive, higher than Limitations:
SSRI’s and Primary care either RCT SSRI in not
interpersonal of Italy interpersonal remission generalizabl
counseling HAM-D counseling or (58.7% e across all
score of ≥13 SSRI versus mood
45.1%, χ 2 disorders
=5.3, d.f.=1,
p=0.021)
 COMBINATION THERAPY AND HAM-D 17

Frank et Examine the Depressed Mean HAM-D Quantitative Chi- Onset of ESI Strong
al. (2011 suicidal adults scores with , cross- square was longer evidence
ideation between 18 weekly sectional and t-test on the
tendency of and 66 years treatment visits descriptive, assigned Limitations:
those under of age, and RCT group of exclusion of
treatment of n=291 Two assessments, SSRI other mental
SSRI or outpatient three triage compared to health
psychotherapy psychiatric points at 6, 12, psychotherap disorders
clinics, and 20 weeks, y (HR=2.22, and those
HAM-D and suicidality 95% CI 1.00- with active
score of ≥15 evaluated 4.94, P=0.05) suicidal
weekly using ideation
the Quick
Inventory of
Depressive
symptomatolog
y- Self-report
(QUIDS)
Rucci et Investigate the Depressed Participants that Quantitative Logistic The Strong
al. (2011) relapse of adults relapsed entered , cross- regressio likelihood of evidence
major between 18 continuation sectional n relapse
depressive and 66 years phase, weekly descriptive, analyses included Limitations:
disorder after of age, HAM-D score RCT higher age, sample
treatment of n=225 Two during the acute higher included
psychotherapy, outpatient phase and at baseline patient
SSRI, or the psychiatric eight points HAM-D without
combination of clinics, during the scores, significant
the two when HAM-D continuation residual risk of
there was no score of ≥15 phase (at entry, depressive suicide with
response to the and 15 days, 1, 2, 3, mood, and nonpsychoti
use of diagnosed 4, 5, 6 months) requiring c depression
monotherapy with MDD and completed combination and the
for baseline therapy in results
purposes the order to cannot be
Lifetime Mood achieve generalized
Spectrum Self- remission to other
Report (OR5 1.05, forms of the
Questionnaire 95% CI: depression
(MOODS-SR), 1.01–1.10;
and the Lifetime OR5 1.15,
Panic– 95% CI:
Agoraphobic 1.02–1.28;
Spectrum Self- OR5 1.11,
Report 95% CI:
questionnaire 1.01–1.23;
(PAS-SR), OR5 3.30,
95%
CI:1.27–8.86,
respectively)
Lackamp, Methods in Elderly (age Mini review Treating the Small
Schlachet, which the 65 and older) meta- elderly with review of
and elderly (age 65 with MDD analysis MDD is a research
Sajatovic and older) with complex
(2016) MDD should approach due Limitation:
be approached to not
and treated. comorbidity,
COMBINATION THERAPY AND HAM-D 18

where SSRI
and SNRI in inclusive of
combination different
with treatment
psychotherap avenues for
y are shown those with
to be helpful. medical
complexitie
s and MDD