Tips for treating patients with late-life depression
Zeroing in on the right drug regimen requires a look at an agent’s clinical benefits, tolerability profile, and risk of drug interactions, as well as the patient’s comorbidities.
PRACTICE RECOMMENDATIONS
› Begin treatment with a selective serotonin reuptake inhibitor (SSRI) unless another antidepressant has worked well in the past. A
› Consider augmenting therapy with bupropion XL, mirtazapine, aripiprazole, or quetiapine for any patient who responds only partially to an SSRI. C
› Add psychotherapy to antidepressant pharmacotherapy, particularly for patients who have difficulties with executive functions such as planning and organization. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The role of aripiprazole. Elderly patients not achieving remission from depression with antidepressant agents alone may benefit from co-prescribing aripiprazole.32 As an adjunct, aripiprazole is effective in achieving and sustaining remission
Minimize risks and maximize benefits of antidepressants by following these recommendations:
- Ascertain whether any antidepressant treatments have worked well in the past.
- Start with an SSRI if no other antidepressant treatment has worked in the past.
- Counsel patients about the need for treatment adherence. Antidepressants may take 2 weeks to 2 months to provide noticeable improvement.
- Prescribe up to the maximum drug dose if needed to enhance benefit.
- Use a mood measurement tool (eg, the Patient Health Questionnaire-9) to help evaluate treatment response.
Try a different class of drugs for patients who do not respond to treatment. For patients who have a partial response, augment with bupropion XL, mirtazapine, aripiprazole, or quetiapine.33 Sertraline and nortriptyline are similarly effective on a population-wide basis, with sertraline having less-problematic adverse effects.34 Trial-and-error treatments in practice may find one patient responding only to sertraline and another patient only to nortriptyline.
Combinations of different drug classes may provide benefit for patients not responding to a single antidepressant. In geriatric patients, combined treatment with methylphenidate and citalopram enhances mood and well-being.35 Compared with either drug alone, the combination yielded an augmented clinical response profile and a higher rate of remission. Cognitive functioning, energy, and mood improve even with methylphenidate alone, especially when fatigue is an issue. However, addictive properties limit its use to cases in which conventional antidepressant medications are not effective or indicated, and only when drug refills are closely monitored.
The challenges of advancing age. Antidepressant treatment needs increase with advanced age.36 As mentioned earlier, elderly people often have medical illnesses complicating their depression and frequently are dealing with pain from the medical illness. When dementia coexists with depression, the efficacy of pharmacotherapies is compromised.
Continue to: When drug-related interventions fail
