To discuss pharmacologic treatment of depression in the elderly, including choice of antidepressants, titration of dose, monitoring of response and side effects, and treatment of unresponsive cases.
Sources of information
The 2006 Canadian Coalition for Seniors’ Mental Health guideline on the assessment and treatment of depression was used as a primary source. To identify articles published since the guideline, MEDLINE was searched from 2007 to 2012 using the terms depression, treatment, drug therapy, and elderly.
The goal of treatment should be remission of symptoms. Improvement of symptoms can be monitored by identifying patient goals or by use of a clinical tool such as the Patient Health Questionnaire–9. Treatment should be considered in 3 phases: an acute treatment phase to achieve remission of symptoms, a continuation phase to prevent recurrence of the same episode of illness (relapse), and a maintenance (prophylaxis) phase to prevent future episodes (recurrence). Initial dosing should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases. Common side effects of medications include falls, nausea, dizziness, headaches, and, less commonly, hyponatremia and QT interval changes. Strategies for switching or augmenting antidepressants are discussed. Older patients should be treated for at least a year from when clinical improvement is noted, and those with recurrent depression or severe symptoms should continue treatment indefinitely. Treatment of specific situations such as severe depression or depression with psychosis is discussed, including the use of electroconvulsive therapy. Criteria for referral to geriatric psychiatry are provided; however, many family physicians do not have easy access to this resource or to other nonpharmacologic clinical strategies.
The effectiveness of pharmacologic treatment of depression is not substantially affected by age. Identification of depression, choice of appropriate treatment, titration of medications, monitoring of side effects, and adequate duration of treatment will improve outcomes for older patients.