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

July 2016

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.

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.

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.

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

Elder Care Editors: Editor-in-Chief: Barry D Weiss, MD;  Deputy Editor: Mindy Fain, MD
 
 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; Marilyn Gilbert, MS, CHES; 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.