November 1, 2008
Psychiatric Times.
No. 13
CATEGORY 1
Late-Life Depression
Abebaw Mengistu Yohannes, PhD
and Robert C Baldwin, MD
Dr Yohannes is reader in physiotherapy in the department of physiotherapy at Manchester Metropolitan University, United Kingdom. He is a member of the International Psychogeriatric Association and British Geriatric Society. Prof Baldwin is psychiatric consultant on old age at the Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, and honorary professor of psychiatry at the University of Manchester. He is a Fellow of the Royal College of Psychiatrists, past executive member of the International Psychogeriatric Association, and member of the American Association of Geriatric Psychiatry.
The authors report no conflicts of interest concerning the subject matter of this article.
Pharmacological therapy Antidepressants are as effective in older patients as in younger patients. There is no evidence that one class is more effective than another. However, tolerance and susceptibility to adverse effects may increase both with age and comorbidity. Vigilance over potential interactions with other drugs used to treat comorbidity is vital. Also, there is much more variability among older adults in pharmacodynamic responses to antidepressants. The same dose may have quite different effects on older persons of roughly the same age. Therefore, the adage “start low and go slow” is sensible when considering treatment options for older adults. It is also important to remember that antidepressants help in pain management.35 More than 20 antidepressants have been FDA-approved for the treatment of depression in older people (Table 4).7 SSRIs are the usual first-line choice of pharmacotherapy in older patients who are depressed because of lower serious adverse effect and toxicity profiles compared with older antidepressants.7 However, a risk of GI bleeding has to be considered in geriatric patients particularly if aspirin or NSAIDs are prescribed and/or there is a history of peptic ulcer; in such patients GI protection is advised. SSRIs are sometimes associated with a low sodium syndrome secondary to inappropriate secretion of antidiuretic hormone which, in extreme cases, leads to lethargy and confusion. In medically unwell patients, tricyclics increase the risk of delirium. Mirtazapine is useful when insomnia is problematic, and bupropion can be used for lethargic patients. The chances of recovery are small if a patient has made no or minimal improvement after 4 weeks of treatment at optimal dose, in which case a change to another antidepressant is recommended.36 If the patient is improving, then augmentation strategies or antidepressant combinations are appropriate. Lithium and triiodo-thyronine may be used, and psychotherapy may also be effective. Conclusion The causes of depression are multifactorial. Several factors may contribute to depression, including sensory impairment, overall handicap, social deprivation, and individual coping strategies. There is every reason to be optimistic about treating depression in older adults. There are effective psychological and antidepressant drug treatments, for both the immediate management and to keep the patient well after recovery from depression. First, however, depression must be detected. Earn CME Credit
Evidence-Based References
Cuijpers P, van Straten A, Smit F. Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. Int J Geriatr Psychiatry. 2006;21:1139-1149.
Unutzer J, Katon WJ, Fan MY, et al. Long-term effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
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