Pharmacotherapy of Depression in Older Adults

Subtypes of Depression

Major Depression With Psychotic Features

The recommended treatment for this condition is a combination of antidepressants and either antipsychotic medication or ECT. As for treatment of nonpsychotic depressed patients, SSRIs and venlafaxine are the first-line agents, and tricyclics are a high second-line alternative. The preferred antipsychotics are the atypical agents: risperidone, olanzapine, and quetiapine. Like antidepressants, the antipsychotics should be used conservatively, starting with low doses and titrating the doses very slowly upwards. There is little information on maintenance treatment of this combination, and the impression (from the adult population's perspective) is that the antipsychotics should be tapered off first (after a year of remission) and slowly.[5]

For severely depressed patients who have received and responded to ECT, the following are suggested as maintenance treatment:[16]For nonpsychotic depression, but no previous adequate antidepressant trial, use SSRIs or venlafaxine.

For nonpsychotic depression with failed antidepressant trials, an antidepressant not previously used–preferably broad spectrum (e.g., venlafaxine, mirtazapine, or a TCA)–is recommended. Alternatively, a combination of mood stabilizers (e.g., lithium or lamotrigine) and broad-spectrum antidepressants is likely to be helpful in maintenance.

For psychotic depression, use a combination of antidepressants and antipsychotics.

TCAs are the preferred choice of antidepressants in psychotic depression.Dysthymia and Minor Depression

Depending on the severity, duration, and presence of psychosocial stressors, either psychotherapy, medication, or a combination is used to treat these conditions.[17,18] Pharmacotherapy is likely to benefit patients with good premorbid personality and recent onset, when neurovegetative symptoms are present, and where there is a history of major depression with good recovery or a family history of major depression and response to antidepressants.

As with major depression, SSRIs and venlafaxine are the first-line medications, with bupropion and mirtazapine as second-line agents. The dose range is the same as for major depression, but these patients often need lifelong maintenance treatment. With chronic psychosocial stressors and maladaptive personality traits, the focus should remain on psychosocial interventions.Anxious Depression

Significant concurrent anxiety symptoms are seen in up to two-thirds of older adults with depression.[19] The presence of anxiety signifies a more severe depressive illness and is also associated with increased suicidality in this age group. It also has implications for treatment and outcome since concurrent anxiety often indicates intolerance to medications, poor response, and worse outcome. In older adults with anxious depression, some key strategies19,20 include the following:Start at very low doses and titrate up slowly.

Emphasize psychoeducation, provide reassurance, and do frequent follow-up in the early stages of treatment.

Use SSRIs and venlafaxine as the preferred first-line agents (avoid TCAs, bupropion, and fluoxetine).

Consider small doses of benzodiazepines short-term to alleviate symptoms, using shorter acting agents such as lorazepam or oxazepam. Keep in mind that benzodiazepines can exacerbate confusion and contribute to risk of falls.

Consider low doses of atypical antipsychotics as a temporary adjunct (e.g., quetiapine) to alleviate anxiety and agitation if the symptoms are severe.Depression With Medical Comorbidity and Medication-Induced Depression

In patients where the onset of depression occurs in the context of a medical comorbidity, it is recommended that the comorbid condition be treated first, followed by antidepressants if symptoms persist.[5,21] SSRIs and venlafaxine are the first-line agents in depression with medical comorbidity. For individuals on several medications, consider SSRIs with the least effect on the cytochrome P450 system (e.g., citalopram or sertraline). For specific subgroups of patients, mirtazapine (e.g., for patients with severe weight loss associated with malignancy) or bupropion (e.g., for patients with extreme fatigue) may also be considered first-line agents. Nortriptyline may be useful in the presence of pain syndromes.[22] For individuals with medication-induced depression, replace the offending agent if possible. If this is not possible, treat concurrently with antidepressant agents. Patients with comorbid depression and dementia should be treated with SSRIs and venlafaxine as first-line agents. TCAs should generally be avoided because of their anticholinergic effects.[23]  Printer- Friendly Email This

Geriatrics Aging.  2005;8(8):20-27.  ©2005 1453987 Ontario, Ltd.
This is a part of article Pharmacotherapy of Depression in Older Adults Taken from "Fluoxetine Generic Prozac" Information Blog