Jeannie Kim Lee, Pharm D, BCPS, College of Pharmacy, University of Arizona

January 2020

Depression in older adults is a common but frequently underdiagnosed and undertreated condition. Depression extends beyond the personal suffering of an older patient,  and may also result in family disruption, increased use of healthcare services, a decline in functional abilities, and increased risk of death from suicide.

A previous edition of Elder Care entitled "Depression in Older Adults" reviewed the epidemiology, risk factors, and diagnosis of depression. This edition focuses on depression pharmacotherapy.

There has been limited research on the use of antidepressant medication in geriatric populations, as the majority of clinical trials of antidepressants have been conducted in younger individuals. Therefore, clinicians need to extrapolate from studies conducted in younger patients who may not have co-morbidities and/or polypharmacy use that often complicate treatment decisions for older patients.  Available research does, however, show that older adults benefit most from aggressive treatment - meaning treatment that is started early (within 2 weeks) and continued longer than in younger adults.

Management Goals

The goals for treating geriatric depression include symptom resolution, relapse prevention, enhanced functional capacity, lower risk of suicide, and reduced use and costs of health services. Treatment should be individualized based on: (1) history of depression, (2) past treatment response, (3) severity of illness, (4) concurrent conditions and medications. For example, if a patient has a history of depression and reports past response to a particular agent, consider prescribing that same medication again. Similarly, if there is a family history of depression, the antidepressant response of family members should be considered in selecting a medication for the patient. Severity of disease is also a consideration. Although combination therapy with multiple antidepressants should generally be avoided to reduce the risk of adverse drug effects, combination therapy may be needed for severe episodes of depression. 

Finally, concurrent disease, such as chronic pain, should be managed effectively, and if the patient is taking medications that can cause depression (Table 1), the need for such medication should be frequently reassessed and the drug discontinued, when possible.

Nonpharmcologic approaches should be considered along with medications and used in combination when indicated: cognitive behavioral therapy (CBT), mindfulness-based CBT, interpersonal therapy, problem adaptive therapy (PATH), repetitive transcranial magnetic stimulation (rTMS), and bright light therapy in morning for seasonal depression. For cognitively impaired, use expression of affect, understanding and empathy.

Pharmacotherapy

Up to 75% of depressed older patients respond to pharmacotherapy. A guideline for treatment of late-life depression and toolkit were developed by the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) group. The recommended first-line antidepressant is a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor - start with half the usual adult dose, titrate slowly to the target dose, if tolerated.  Improved energy may be seen around 2 weeks, but full response may require 6 weeks of consistent use.

If an adequate response to a first agent is not seen after at least 6-8 weeks of therapy at target dose, then switch to a different first-line agent or to a second-line agent (see Table 2). Third-line drugs, such as aripiprazole, quetiapine, buspirone, bupropion and lithium, are reserved for augmentation of first- or second-line antidepressant response.

Medications to avoid in older adults are listed in Table 3. Consider co-management with a psychiatrist, behavioral expert, pharmacist, and social worker on pharmacotherapy, counseling, self-care, behavioral changes, support systems.

To prevent relapse, continue therapy for 6-12 months after the remission, of first episode, 2 years after 2nd episode, and at least 3 years for ≥3 episodes. When discontinuing, gradual taper over 1 month is recommended.

References and Resources

• PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) Toolkit: https://www.sprc.org/settings/primary-care/toolkit

  National Institutes on Aging, Depression and Older Adults: https://www.nia.nih.gov/health/depression-and-older-adults

  Carter J. BMJ Clinical Review: Depression in older adults. BMJ 2011;343:d5219 doi: https://doi.org/10.1136/bmj.d5219

   

Interprofessional care improves the outcomes of older adults with complex health problems

Elder Care Editors: Editor-in-Chief: Barry D Weiss, MD;  Deputy Editors: Mindy Fain, MD; Shaun Chatelain, DO
 
 National Editorial Board:  Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA;  Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania
 
 Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD;  Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD;  Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O'Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES

Published by: The University of Arizona, PO Box 245027, Tucson, AZ 85724-5027  |  (520) 626-5800  | https://uofazcenteronaging.com

 This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28721, Arizona Geriatrics Workforce Enhancement Program.   This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.