Psychiatric Times.
No. 13
CATEGORY 1
Late-Life Depression
By Abebaw Mengistu Yohannes, PhD
and Robert C Baldwin, MD |
November 1, 2008
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(Drug information on 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(Drug information on 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(Drug information on 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.
References
1. Lopez AD, Mathers DC, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367:1747-1757.
2. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry. 2003;64:1465-1475.
3. MacHale S. Managing depression in physical illness. Adv Psych Treat. 2002;8:297-306.
4. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58:249-265.
5. Evans DL, Charney DS, Lewis L, et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry. 2003;58: 175-189.
6. Sirey JA, Bruce ML, Alexopoulos GS, et al. Stigma as a barrier to recovery: perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatr Serv. 2001;52: 1615-1620.
7. Unutzer J. Clinical practice. Late-life depression. N Engl J Med. 2007;357:2269-2276.
8. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54:216-226.
9. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000; 160:2101-2107.
10. Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide Life Threat Behav. 2001;31(suppl):32-47.
11. Lyness JM. Depression and comorbidity: objects in the mirror are more complex than they appear. Am J Geriatr Psychiatry. 2008;16:181-185.
12. Rovner BV, Casten RJ. Preventing late-life depression in age-related macular degeneration. Am J Geriatr Psychiatry. 2008;16:454-459.
13. Dhondt TD, Beekman AT, Deeg DJ, Van Tilburg W. Iatrogenic depression in the elderly: results from a community-based study in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2002;37:393-398.
14. Lyness JM, Kim J, Tang W, et al. The clinical significance of subsyndromal depression in older primary care patients. Am J Geriatr Psychiatry. 2007;15:214-223.
15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association: 1994.
16. Kramer-Ginsberg E, Greenwald BS, Aisen PS, Brod-Miller C. Hypochondriasis in the elderly depressed. J Am Geriatr Soc. 1989;37: 507-510.
17. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17:37-49.
18. Kroenke K, Spitzer RL, Williams JB. The PHQ-9 validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.
19. Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, et al. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? J Gen Intern Med. 2005;20:738-742.
20. Baldwin RC, Anderson D, Black S, et al. Guideline for the management of late-life depression in primary care. Int J Geriatr Psychiatry. 2003;18:829-838.
21. Krishnan KR, Doraiswamy PM, Clary CM. Clinical and treatment response characteristics of late-life depression associated with vascular disease: a pooled analysis of two multicenter trials with sertraline. Prog Neuropsychopharmacol Biol Psychiatry. 2001;25:347-361.
22. Unutzer J, Tang L, Oishi S, et al. Reducing suicidal ideation in depressed older primary care patients. J Am Geriatr Soc. 2006;54:1550-1556.
23. Bruce ML, Ten Have TR, Reynolds CF 3rd, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291:1081-1091.
24. 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.
25. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry. 2006;163:1493-1501.
26. Yohannes A, Connolly MJ, Baldwin RC. A feasibility study of antidepressant drug therapy in depressed elderly patients with chronic obstructive pulmonary disease. Int J Geriatr Psychiatry. 2001;16:451-454.
27. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression. A cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321.
28. Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
29. Sjösten N, Kivelä SL. The effects of physical exercise on depressive symptoms among the aged: a systematic review. Int J Geriatr Psychiatry. 2006;21:410-418.
30. Tew JD Jr, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry. 1999; 156:1865-1870.
31. Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry. 1994;151:1657-1661.
32. Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001;285:1299-1307.
33. Dumitriu D, Collins K, Alterman R, Mathew SJ. Neurostimulatory therapeutics in management of treatment-resistant depression with focus on deep brain stimulation. Mt Sinai J Med. 2008;75:263-275.
34. Fabre I, Galinowski A, Oppenheim C, et al. Antidepressant efficacy and cognitive effects of repetitive transcranial magnetic stimulation in vascular depression: an open trial. Int J Geriatr Psychiatry. 2004;19: 833-842.
35. Lin EH, Katon W, Von Korff M, et al; IMPACT Investigators. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003; 290:2428-2439.
36. Sackeim HA, Roose SP, Burt T. Optimal length of antidepressant trials in late-life depression. J Clin Psychopharmacol. 2005;25(suppl 1): S34-S37.
37. Arthur A, Jagger C, Lindesay J, et al. Using an annual over-75 health check to screen for depression: validation of the short Geriatric Depression Scale (GDS-15) within general practice. Int J Geriatr Psychiatry. 1999;14:431-439.
38. Rinaldi P, Mecocci P, Benedetti C, et al. Validation of the five-item geriatric depression scale in elderly subjects in three different settings. J Am Geriatr Soc. 2003;51:694-698.
39. Wallbridge HR, Furer P, Lionberg C. Behavioral activation and rehabilitation. J Psychosoc Nurs Ment Health Serv. 2008;46:36-44.
41. Dunitz M. Guideline on Depression in Older People: Practicing the Evidence. London: Taylor and Francis; 2002.
42. Fabian TJ, Amico JA, Kroboth P, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study. Arch Intern Med. 2004;164:327-332.
42. Boyer EW, Shannon W. Serotonin syndrome. N Engl J Med. 2007;352:1112-1120.
