Evidence-Based Reviews

Depression in older adults: How to treat its distinct clinical manifestations

Current Psychiatry. 2010 August;9(8):39-46

References

1. Lyketsos CG, Lee HB. Diagnosis and treatment of depression in Alzheimer’s disease. A practical update for the clinician. Dement Geriatr Cogn Disord. 2004;17(1-2):55-64.

2. Alexopoulos G. Late-life mood disorders. In: Sadavoy J, Jarvik LF, Grossberg GT, et al, eds. Comprehensive textbook of geriatric psychiatry. 3^rd ed. New York, NY: W.W. Norton and Company; 2004:609-653.

3. Shanmugham B, Karp J, Drayer R, et al. Evidence-based pharmacologic interventions of geriatric depression. Psychiatr Clin North Am. 2005;28(4):821-835,viii.

4. Alexopoulos GS, Katz IR, Reynolds CF, III, et al. The expert consensus guidelines series. Pharmacotherapy of depressive disorders in older patients. Postgrad Med. 2001; Spect No Pharmacolotherapy:1–86.

5. American Psychiatric Association practice guidelines for the treatment of psychiatric disorders. Arlington, VA: American Psychiatric Association; 2006:793–794.

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7. Bartels SJ, Dums AR, Oxman TE, et al. Evidence-based practices in geriatric mental health care: an overview of systematic reviews and meta-analyses. Psychiatr Clin North Am. 2003;26(4):971-990,x–xi.

8. Raskin J, Wiltse CG, Siegal A, et al. Efficacy of duloxetine on cognition, depression, and pain in elderly patients with major depressive disorder: an 8-week, double-blind, placebo-controlled trial. Am J Psychiatry. 2007;164(6):900-909.

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Algorithm 5: Treatment-resistant geriatric depression: Partial vs no response

SNRI: selective serotonin-norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressant

Nonpharmacologic treatments

ECT is an important therapeutic intervention because of its safety, efficacy, and faster clinical response.^6,7,9,21 Consider ECT for older adults with severe or psychotic major depression, acute suicidality, catatonia, or severe malnutrition caused by refusal to eat. Patients who remain significantly symptomatic after multiple medication trials, do not tolerate medications well, or have comorbid medical conditions that preclude antidepressant use also are potential candidates for ECT.^5,22

ECT can be administered to many older depressed adults with relatively low complication rates. Pretreatment clinical and laboratory evaluations and consultation with medical colleagues may minimize the risk of adverse effects, including cardiovascular instability, delirium, and falls.⁹ Anterograde memory loss—a common concern for clinicians and patients—usually is temporary and can be reduced by modifying the ECT administration parameters, such as switching from bilateral to unilateral stimulus and spacing treatments.⁹ Use caution when considering ECT for patients with cardiovascular or neurologic conditions—such as myocardial infarction or cerebrovascular accident within 6 months of treatment—that may increase the risk of adverse effects. Some pharmacologic agents, such as benzodiazepines and anticonvulsant mood stabilizers, may decrease ECT’s efficacy by inhibiting seizure.²²

Clinical Point

ECT can be administered to many older depressed adults with relatively low complication rates

Depressive relapse after ECT is a major clinical concern.²¹ Continuation ECT— within the first 6 months of remission— aims to prevent relapse of the same episode, whereas maintenance ECT—beyond the first 6 months—helps avert occurrence of new episodes.^4,21 Relapse and recurrence also can be prevented with continuation or maintenance pharmacotherapy,^4,21 which should be initiated immediately after the index course of ECT.²¹ Typically, ECT continuation/maintenance treatments are provided weekly, then gradually spaced out to once a month based on the minimum frequency that is effective for an individual patient.²¹

Psychotherapy for geriatric depression generally is effective.²³ One-half of older patients prefer psychotherapy over pharmacotherapy.²⁴ Efficacious psychotherapies include behavioral therapy, cognitive-behavioral therapy (CBT), PST, brief dynamic therapy, interpersonal therapy, supportive therapy, and reminiscence therapy.²³ CBT has the most empiric support for treating geriatric depression.^5,6

Clinical Point

Among psychotherapies, cognitive-behavioral therapy has the most empiric support for treating geriatric depression

Psychotherapy alone is appropriate for mild-to-moderate depression, although severe depression requires adding medication.²⁵ The combination of pharmacotherapy and psychotherapy appears to be more effective than either intervention alone in preventing recurrent major depression, especially when a specific psychosocial stressor has been identified.^5,6 CBT, interpersonal therapy, and family-focused therapy enhance pharmacotherapy outcomes in bipolar disorder.¹³

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study found that in mixed-age patients, pharmacotherapy plus psychotherapy is more beneficial than medication alone in stabilizing bipolar depression.²⁶ For older adults with executive dysfunction, research suggests that PST is more effective than other psychotherapies.²⁷ Psychosocial interventions—such as psychoeducation for the family and caregivers, family counseling, and participation in senior citizen centers and services—are strongly recommended for many patients.⁴

Clinical Point

For older adults with executive dysfunction, problem-solving therapy is more effective than other psychotherapies

Related Resources

Blazer DG, Steffens DC, Koenig HG. Mood disorders. In: Blazer DG, Steffens DC, eds. The American Psychiatric Publishing textbook of geriatric psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2009:275-300.
American Association for Geriatric Psychiatry. www.aagponline.org.

Drug Brand Names

Aripiprazole • Abilify
Bupropion • Wellbutrin, Zyban
Buspirone • Buspar
Citalopram • Celexa
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluoxetine-olanzapine • Symbyax
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Mirtazapine • Remeron
Nortriptyline • Aventyl, Pamelor
Olanzapine • Zyprexa
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Tranylcypromine • Parnate
Trazodone • Desyrel
Valproate • Depakote
Venlafaxine • Effexor
Ziprasidone • Geodon

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.