***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The authors conducted a r and omized , double-blind , 10-week clinical trial of two doses of nortriptyline in eight nursing homes . Sixty-nine patients , average age 79.5 years , were r and omized to receive regular doses ( 60 mg-80 mg/day ) vs. low doses ( 10 mg-13 mg/day ) of nortriptyline . Among the more cognitively intact patients , there was a significant quadratic relationship defining a " therapeutic window " for  nortriptyline plasma levels and clinical improvement . There were also significant differences in plasma level-response relationships between depressed patients who were cognitively impaired and those who were more cognitively intact . Depression remains a syndrome that responds to specific treatment , even in frail nursing home patients , and those depressions that occur in patients with significant dementia may represent a treatment-relevant condition with a different plasma level-response relationship than in depression alone A significant drug-placebo difference was found in a double-blind , placebo-controlled study of nortriptyline for treatment of major depression among frail elderly patients living in an institutional setting . This finding confirms the validity of the DSM-III-R diagnosis of major depression and establishes the need for specific psychiatric services for the chronically ill elderly living in nursing homes and congregate housing facilities . The incidence of adverse events requiring early termination of treatment was 34 % , demonstrating the vulnerability of these patients and their need for careful monitoring during treatment . High levels of self-care disability and low levels of serum albumin were both associated with decreased therapeutic responses , demonstrating the need for further research on psychopathology in these setting There has been limited research into defining what constitutes an adequate first-line antidepressant trial in elderly patients . The authors report the outcome of extended , high-dosage sertraline treatment in a sample of nursing home residents experiencing residual significant depressive symptoms after 10 weeks of treatment with sertraline at a final dosage of 100 mg/day . Subjects who had a Hamilton Depression Rating Scale score ≥ 12 after 10 weeks of treatment with sertraline were eligible for the 8-week open-label extension phase , which involved titrating the sertraline dosage to 200 mg/day . The cumulative response rate was 52 % for the extension phase , compared with 37 % for the acute phase . Examining acute phase nonresponders , 39 % responded during the extension phase . Rates of discontinuation due to adverse events were comparable in the 2 phases . Our findings suggest that an extended trial or high dosages of sertraline may benefit some depressed elderly patients with persistent depression after acute treatment . ( J Geriatr Psychiatry Neurol 2003 ; 16:109 - 111 SUMMARY Objective : To evaluate the efficacy and tolerability of mirtazapine orally disintegrating tablets in depressed , elderly nursing home residents , under naturalistic study conditions . Methods : In this open-label 12-week study , mirtazapine orally disintegrating tablets ( 15–45 mg day−1 ) were administered to patients > 70 years old with physician-diagnosed depression and a Mini-Mental State Examination ( MMSE ) score > 10 . Patients with medical comorbidities , cognitive impairment and /or concomitant medications were enrolled if they met study inclusion criteria and had illnesses and /or medication dosages that were considered stable . Assessment s were performed at baseline by physicians and at days 14 , 28 , 56 , and 84 ( or early termination ) by physicians or nurse coordinators using the Clinical Global Impression ( CGI ) scale , the 16-item Hamilton Rating Scale for depression ( Ham-D-16 ( the st and ard 17-item scale minus item 14 ) ) , and the Cornell Scale for Depression in Dementia ( CSDD ) . Tolerability was evaluated based on treatment-emergent adverse events . Results : A total of 119 patients in the intent-to-treat ( ITT ) group were treated with mirtazapine orally disintegrating tablets ( mean daily dose : 19.4 mg ) and evaluated for efficacy . At endpoint , 54 % of patients in the ITT group showed CGI-I response ( defined as a CGI-I score of 1 or 2 ( ' very much ' or ' much ' improved ) and 47 % were Ham-D-16 responders ( defined as decrease from baseline of at least 50 % in Ham-D-16 total score ) . CSDD mean scores and Ham-D-16 mean total scores demonstrated a progressive decrease from baseline to trial completion . The decrease in Ham-D scores from baseline to day 84 was statistically significant ( p < 0.0001 ) . Mean changes from baseline to day 84 were −6.6 ± 6.9 ( CSDD score ) and −7.9 ± 7.4 ( Ham-D-16 total score ) . Ham-D Factor I , Factor VI and item 1 scores also decreased . Fourteen of 124 patients in the all-subjects-treated ( AST ) group ( 11.3 % ) discontinued prematurely due to adverse events . The most frequently occurring adverse events were urinary tract infection ( 19 % ) , accidental injury ( 18 % ) , fall ( 18 % ) , somnolence ( 12 % ) , and upper respiratory infection ( 12 % ) . Mean body weight increased by 0.7 ± 2.25 kg ( 1.54 ± 5 lb ) from baseline to day 28 , and by 1.3 ± 3.36 kg ( 2.86 ± 7.4 lb ) from baseline to day 84 . Conclusions : The results suggest that mirtazapine orally disintegrating tablets provide antidepressant efficacy and are a relatively well-tolerated treatment for depression in this patient population of elderly nursing home residents with medical and cognitive comorbidities Studies have demonstrated that the selective serotonin reuptake inhibitor antidepressants have similar efficacy to other agents , such as tricyclic antidepressants . However , data are limited for direct comparisons with other antidepressants . The authors conducted a contemporaneous comparison of nursing home residents treated with open-label sertraline in doses up to 100 mg/day with nursing home residents treated in a double-blind r and omized study of low vs. regular doses of nortriptyline . There were 97 patients enrolled in the study ( 28 treated with sertraline ) , with an average treatment duration of 55 days . There were no differences in the tolerability of sertraline vs. nortriptyline . However , in this group of frail older adults , sertraline was not as effective as  nortriptyline for the treatment of depression Depression is common across a broad spectrum of severity among nursing home residents . Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression , but it is not known whether antidepressants are helpful in residents with less severe forms of depression . We conducted a r and omized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression . The main outcome measure was the primary nurse 's Clinical Impression of Change ( CGI-C ) . Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale ( HDRS ) and Cornell Scale for Depression ( CS ) scores .  Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial .  Placebo response was high , and when all subjects were considered , there were no differences in improvement between the paroxetine and placebo groups . Two subjects that received paroxetine developed delirium , and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores ( P = .03 ) . There were no differences in serum anticholinergic activity between groups . In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores  , there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures ( P = .06 ) . Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression , and there is a risk of adverse cognitive effects . Because of the high placebo response and the trend towards improvement in the more severely ill patients , it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo . The study also illustrates the discordance between patient and caregiver ratings , and the difficulties in study ing very elderly patients with mood disorders The authors examined 50 patients , with a mean age of 89 years ( range : 80–98 ) , placed in a prospect i ve , open-label trial of either fluoxetine , sertraline , or paroxetine . At 12-week follow-up , there was a significant overall decline ( 36 % ) in Ham-D scores ; 42 % had at least a 50 % decline in their scores . There were no significant differences in responses to the three antidepressants , and all drugs were well tolerated . However , there were significant differences between diagnostic subgroups in the percentage of persons showing at least a 50 % decrease in their Ham-D scores : major depressive disorder ( MDD ; 93 % ) , Alzheimer 's disease with MDD ( 8 % ) , vascular dementia with MDD ( 6 % ) , and other CNS-related disorders with MDD ( 83 % ) . The findings confirm earlier accounts that antidepressants may be substantially less effective with MDD secondary to dementia in very old patients A sample of 31 female nursing home patients with late-stage Alzheimer 's disease participated in a double-blind clinical trial of the antidepressant medication sertraline . Measures of depression included various objective scales and two measures of facial expressions of emotion coded during a semistructured interview using a facial affect coding system . Repeated- measures ANOVAs at baseline and at the 8-week endpoint indicated that on all measures , both the treatment and placebo groups improved over time , with three of six measures showing a significant time effect . The " knit-brow " facial measure approached significance for a Treatment x Time effect . Thus , sertraline had no significant benefits over placebo . However , if , as we hypothesize , the knit-brow response is more sensitive to signs of depression in advanced dementia , our study justifies the further investigation of the use of sertraline in this population OBJECTIVES Depression in older patients contributes to personal suffering and family disruption and increases disability , medical morbidity , mortality , suicide risk , and healthcare utilization . The majority of clinical trials of antidepressant treatments are conducted in younger patients . For this reason , clinicians often have to extrapolate from studies in population s that do not present the same problems as older patients . For example , older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment . Older patients as a rule need to be on many medications , some of which may contribute to depression and /or interact with antidepressants . Finally , older adults metabolize medications slowly and are more sensitive to side effects than younger patients . Because of these complexities , we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature . METHOD After review ing the literature and convening a work group of experts , we prepared a written survey with 64 questions that asked about 857 options . 618 of the options were scored using a modified version of the R AND 9-point scale for rating appropriateness of medical decisions . For the other options , the experts were asked to write in answers ( e.g. , average doses ) or to check a box to indicate their preferred answer . We sent the survey to 50 national experts on geriatric depression , all of whom completed it . Consensus on each option was defined as a nonr and om distribution of scores by chi-square " goodness-of-fit " test . We assigned a categorical rank ( first line/preferred choice , second line/alternate choice , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean rating . Guideline tables indicating preferred treatment strategies were then developed for key clinical situations . RESULTS The expert panel reached consensus on 89 % of the options rated on the 9-point scale . The experts stress the importance of identifying coexisting medical conditions that may be contributing to the depression or complicate treatment . For unipolar nonpsychotic major depression , the preferred strategy is an antidepressant ( selective serotonin reuptake inhibitor [ SSRI ] or venlafaxine XR preferred ) plus psychotherapy . For unipolar psychotic major depression , the treatment of choice is an antidepressant ( SSRI or venlafaxine XR ) plus one of the newer atypical antipsychotics . Electroconvulsive therapy is also first line . For dysthymic disorder or persistent milder depression , the experts recommend combining an antidepressant ( SSRIs preferred ) and psychotherapy . If the patient has a comorbid medical condition ( e.g. , hypothyroidism ) that is contributing to the depression , the experts recommend treating both the depression and the medical condition from the outset . The SSRIs were the top-rated antidepressants for all types of depression . Among them , the experts gave the highest ratings for efficacy and tolerability to citalopram and sertraline . Paroxetine was another first-line option , and fluoxetine was rated high second line . The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy , supportive psychotherapy , problem-solving psychotherapy , and interpersonal psychotherapy . The experts also give strong support to including 
    Output:
    
The limited amount of evidence from r and omized and non-r and omized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications .