Late-life depression: Managing mood in patients with vascular disease
Initiate preventive strategies to protect your patient’s brain and reduce the risk of stroke
Antihypertensives and statins. Patients with vascular depression may benefit from calcium channel blockers or angiotensin-converting enzyme (ACE) inhibitors for hypertension and HMG-CoA reductase inhibitors (statins) for hyperlipidemia. Statins seem to decrease the generation of amyloid precursor protein, the neuronal secretion of β-amyloid, and cholesterol synthesis.39 Some epidemiologic studies suggest an association between statin use for cholesterol reduction and reduced prevalence of Alzheimer’s disease and vascular dementia.40
Potential preventive strategies are not without controversy, however:
- Beta blockers and ACE inhibitors have been linked to depression, although the evidence has been conflicting.
- Lipid-lowering therapies and calcium-channel blockers have been linked to an increased risk of suicide.41
- A more recent population-based study did not support an association between an increased risk of suicide and cardiovascular drugs (except perhaps for angiotensin-receptor antagonists).42
Table 4
Preventing vascular causes of late-life depression
| Decision point | Assessment/intervention | Comment |
|---|---|---|
| Primary, secondary prevention of stroke, vascular depression, and cognitive impairment | Identify and treat modifiable risk factors (hypertension, alcohol use, smoking, hyperlipidemia, diabetes mellitus), especially in high-risk patients | Consider as high-risk patients having ≥1 of these features: age >50; male gender; Asian, Hispanic, or African-American heritage; low educational achievement; concurrent vascular risk factors |
| Tertiary prevention of worsened illness in patients with established vascular disease | Intensively treat vascular risk factors | Collaborate with primary care physician to manage arterial hypertension, myocardial infarction, atrial fibrillation, coronary heart disease, diabetes, atherosclerosis, hyperlipidemia, obesity, and smoking |
| Rapidly identify and treat acute stroke to limit ischemic brain changes and promote recovery | ||
| Prevent stroke recurrence by aggressively treating vascular risk factors | Let CVD etiology guide treatment | |
| CVD: cerebrovascular disease | ||
| Source: Adapted from Lavretsky H. Diagnosis and treatment of vascular dementia. Directions in Psychiatry. 2006;26(1):49-68 | ||
Related resources
- Lavretsky H, Chui H. Vascular dementia. In: Agronin ME, Maletta GJ, eds. Principles and practice of geriatric psychiatry. New York, NY: Lippincott, Williams, and Wilkins; 2005: 301-310.
- Baldwin RC, O’Brien J. Vascular basis of late-onset depressive disorder. Br J Psychiatry. 2002;180:157-160.
- Kendler KS, Gardner CO, Fiske A, et al. Major depression and coronary heart disease in the Swedish twin registry. Arch Gen Psychiatry. 2008;66(8):857-863.
Drug brand names
- Bupropion • Wellbutrin
- Duloxetine • Cymbalta
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Methylphenidate • Ritalin, Concerta, others
- Mirtazapine • Remeron
- Nortriptyline • Aventyl, Pamelor
- Paroxetine • Paxil
- Sertraline • Zoloft
- Venlafaxine • Effexor
Disclosures
Dr. Lavretsky receives grant/research support from Forest Research Institute and is a consultant to Forest Laboratories, Myriad Pharmaceuticals, and Accera, Inc.
Dr. Meeks reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgments
This work was supported by National Institute of Health grants R01 MH077650 and R-21 AT003480 (Dr. Lavretsky), the U.S. Department of Health and Human Services, Health Resources and Services Administration (Geriatric Academic Career Award), and the Sam and Rose Stein Institute for Research on Aging (Dr. Meeks).
