Elder Care Interprofessional Provider Sheets

Depression in Older Adults - Pharmacotherapy

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

July 2016

TIPS FOR ANTIDEPRESSANT THERAPY IN OLDER ADULTS
  • Recognize and treat early to alleviate overuse of health services.
  • Assure an adequate trial (at least 6 weeks) after titrating first-line agent to therapeutic dose.
  • Avoid combination regimen if possible to reduce the risk of adverse effects.
  • Work with psychiatrists, psychologists, counselors, pharmacists, and social workers on pharmacotherapy, counseling, self-care, behavioral changes, support systems, etc.

Depression in older adults is a common, but frequently under diagnosed and under-treated, condition. Depression extends beyond the personal suffering of an older patient, it can 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 pharmacotherapy with antidepressant medications.

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. Thus, clinicians have to extrapolate from studies conducted in younger individuals who do not exhibit the co-morbidities and polypharmacy 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 response, (3) severity of illness, (4) concurrent diseases and medications.

For example, if a patient has a history of depression and reports past response to a particular agent, consideration should be given to 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's current episode of depression.

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 conditions causing chronic pain, should be managed effectively, and if the patient is taking a medication that can cause depression (see Table 1), the need for such medication should be frequently reassessed and the drug discontinued, when possible.

Table 1. Medications That Can Cause Depression
Class Examples
Antibiotics
  • ampicillin
  • dapsone
  • isoniazid
  • metronidazole
  • nitrofurantoin
  • sulfonamides
  • tetracycline

Anticonvulsants

  • carbamazepine
  • ethosuximide
  • phenobarbital
  • phenytoin
  • primidone

Antihypertensives

  • clonidine
  • methyldopa
  • propranolol

Anti-Parkinsons

  • amantadine
  • bromocriptine
  • levodopa

Antipsychotics

  • fluphenazine
  • haloperidol

Cardiac medications

  • digoxin
  • procainamide

Chemotherapies

  • azathioprine
  • bleomycin
  • cisplatin
  • cyclophosphamide
  • doxorubicin
  • vinblastine
  • vincristine

Gastrointestinal agents

  • cimetidine
  • metoclopramide
  • ranitidine

Hormones

  • glucocorticoids
  • estrogen-progestin

Sedatives/anxiolytics

  • barbiturates
  • benzodiazepines

Stimulant withdrawal

  • amphetamines
  • caffeine
  • methylphenidate

Pharmacotherapy

Up to 75% of depressed older patients respond to pharmacotherapy. A guideline for treatment of late-life depression was 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). The initial dose should be half the usual adult dose, with slow titration to the target dose, if tolerated.

If an adequate response to a first-line drug 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 (Abilify) and buspirone (Buspar), are reserved for augmenting the response to a first or second-line therapy. Drugs to be avoided in older adults are listed in Table 3. Consider co-management with a behavioral expert.

To prevent relapse, continue therapy for 6 months after initial remission. Patients at high risk for relapse (those who have had two or more depression episodes, or depression lasting more than two years) need continued therapy for at least two years. Many clinicians would recommend indefinite treatment.

Table 2. Commonly Used Antidepressants: Initial Geriatric Dose, Target Dose, and Geriatric Considerations
First-Line Medications Initial Dose Target Dose Geriatric Considerations
Citalopram (Celexa)
10-20 mg
20-60 mg
Fewer adverse effects compared to other agents; GI distress may limit adherence; may cause weight gain or loss; decreased sexual function possible; generic available.
Escitalopram (Lexapro)
5-10 mg
10-20 mg
Fewer adverse effects compared to other agents; GI distress may limit adherence; may cause weight gain; decreased sexual function possible; more costly, no generic.
Fluoxetine (Prozac)
5-10 mg
20-60 mg
Last-line among SSRIs due to long half-life (parent drug and metabolite); CNS effects, GI
distress, hyponatremia, sexual dysfunction possible; weight gain or loss; generic available.
Paroxetine (Paxil)
5-10 mg
10-40 mg
More adverse effects compared to other SSRIs - CNS effects, ACH side effects, GI distress, tremor, hyponatremia, sexual dysfunction possible; weight gain or loss; generic available.
Sertraline (Zoloft)
25 mg
50-200 mg
Less adverse effects compared to other agents; GI distress, sexual dysfunction and tremor may limit adherence; may cause weight gain or loss; generic available.
Second-Line Medications
Bupropion (Wellbutrin)
50-100   mg
300-450 mg
Mild GI distress possible; no effect on sexual function; effective for smoking cessation; CNS effects, tachycardia and weight loss may limit adherence; generic available.
Duloxetine (Cymbalta)
20 mg
40-60 mg
CNS effects, ACH side effects,GI distress may limit adherence; weight loss and decreased sexual function possible; more costly, no generic.
Mirtazapine (Remeron)
7.5 mg
15-45 mg
Severe sedation (effective in concurrent insomnia), ACH side effects, Hypotension, and large weight gain (effective in concurrent anorexia) can be seen; generic available.
Venlafaxine (Effexor)
25-75 mg
75-225 mg
CNS effects, ACH side effects, GI distress, and dose-related hypertension may limit adherence; weight loss and decreased sexual function possible; generic available.
CNS=central nervous system   ACH=anticholinergic side effects    GI=gastrointestinal

 

Table 3. Antidepressants to Avoid in Older Adults
Medication Problems in Older Adults
Amitriptyline (Elavil) anticholinergic, sedating, hypotensive
Amoxapine anticholinergic, sedating, hypotensive, extra-pyramidalside effects
Doxepin (Prudoxin) anticholinergic, sedating, hypotensive
Imipramine (Tofranil) anticholinergic, sedating, hypotensive
Maprotiline seizure, rash
Protriptyline (Vivactil) anticholinergic, can be stimulating
St. John's Wort multiple drug interactions including SSRIs, photosensitivity at 2-4g/day
Trimipramine (Surmontil) anticholinergic, sedating, hypotensive

References and Resources

  • Alexopoulos GS, et al. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study.  Am J Psychiatry  2009; 166: 882-90.
  • Depression Age Page. National Institutes on Aging
  • Gartlehner G, et al. Comparative benefits and harms of second-generation antidepressants. Ann Intern Med. 2008; 149:734-50. 
  • Khouzam HR. The diagnosis and treatment of depression in the geriatric population. Compr Ther. 2009; 35:103-114. 55: p. S247-S252.