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
When drug-related interventions fail, therapy ought to be more psychologically focused.37 Psychotherapy is usually helpful and is particularly indicated when recovery is suboptimal. Counseling might come from the treating physician or referral to a psychotherapist.
Nasal esketamine can be efficacious when supplementing antidepressant pharmacotherapy among older patients with treatment-resistant depression.38 Elderly individuals responding to antidepressants do not benefit from adjunctive donepezil to correct mild cognitive impairment.39 There is no advantage to off-label cholinesterase inhibitor prescribing for patients with both depression and dementia.
Other options. Electroconvulsive therapy (ECT) does not cause long-term cognitive problems and is reserved for treatment-resistant cases.40 Patients with depression who also have had previous cognitive impairment often improve in mental ability following ECT.41
A promising new option. Transcranial magnetic stimulation (TMS) is a promising, relatively new therapeutic option for treating refractory cases of depressive mood disorders. In TMS, an electromagnetic coil that creates a magnetic field is placed over the left dorsolateral prefrontal cortex (which is responsible for mood regulation). Referral for TMS administration may offer new hope for older patients with treatment-resistant depression.42
Keep comorbidities in mind as you address depression
Coexisting psychiatric illnesses worsen emotions. Geriatric patients are susceptible to psychiatric comorbidities that include substance abuse, obsessive-compulsive characteristics, dysfunctional eating, and panic disorder.19 Myocardial and cerebral infarctions are detrimental to mental health, especially soon after such events.43 Poststroke depression magnifies the risk for disability and mortality,16,17 yet antidepressant pharmacotherapy often enhances prognoses. Along with early intervention algorithm-based plans and inclusion of a depression care manager, antidepressants often diminish poststroke depression severity.44 Even when cancer is present, depression care reduces mortality.44 So with this in mind, persist with antidepressant treatment, which will often benefit an elderly individual with depression.
Continue to: When possible, get ahead of depression before it sets in
