Pharmacologic treatment of depression
in the elderly
- Christopher Frank, MD FCFP⇑
+ Author Affiliations
- Correspondence: Dr Christopher Frank, St Mary’s of the Lake Hospital, 340 Union St, Kingston, ON K7L 5A2; telephone 613 548-7222, extension 2208; fax 613 544-4017; e-mail frankc@pccchealth.org
Abstract
Objective
To discuss pharmacologic treatment of depression in the elderly, including choice of antidepressants, titration of dose,
monitoring of response and side effects, and treatment of unresponsive cases.
Sources of information
The 2006 Canadian Coalition for Seniors’ Mental Health guideline on the
assessment and treatment of depression was used as
a primary source. To identify articles published
since the guideline, MEDLINE was searched from 2007 to 2012 using the
terms
depression, treatment, drug therapy, and elderly.
Main message
The goal
of treatment should be remission of symptoms. Improvement of symptoms
can be monitored by identifying patient goals
or by use of a clinical tool such as the Patient
Health Questionnaire–9.
Treatment should be considered in 3 phases:
an
acute
treatment phase to achieve remission of
symptoms, a continuation phase to prevent recurrence of the same episode
of illness
(relapse),
and a maintenance (prophylaxis) phase
to prevent future episodes (recurrence).
Initial dosing should be half
of
the usual adult starting dose and be titrated
regularly until the patient responds, until the maximum dose is reached,
or
until side effects limit further increases.
Common side effects of medications include falls, nausea, dizziness,
headaches,
and, less commonly, hyponatremia and QT interval
changes.
Strategies for switching or augmenting antidepressants are
discussed.
Older patients should be treated for at least a
year from when clinical improvement is noted, and those with recurrent
depression
or severe symptoms should continue treatment
indefinitely.
Treatment of specific situations such as severe depression
or depression
with psychosis is discussed, including the use
of electroconvulsive therapy.
Criteria for referral to geriatric
psychiatry
are provided; however, many family physicians do
not have easy access to this resource or to other nonpharmacologic
clinical
strategies.
Conclusion
The
effectiveness of pharmacologic treatment of depression is not
substantially affected by age. Identification of depression,
choice of appropriate treatment, titration of
medications, monitoring of side effects, and adequate duration of
treatment
will improve outcomes for older patients.
- Copyright© the College of Family Physicians of Canada
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