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Depression in the elderly: A pharmacist’s perspective


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Depression is a disease state that is commonly underdiagnosed and undertreated in patients over the age of 65 years. Elderly patients may differ from younger patients in the presentation of symptoms and in the prevalence of comorbidities. Risk factors for the development of depression are different for elderly patients. Treatment may also be dissimilar, including response and response time to treatment. Treatment should be tailored to the individual patient in the geriatric population to optimize therapeutic outcomes. Pharmacists can be vigilant of comorbidities and medications that potentially increase the risk of depression in the elderly. Pharmacists can play a significant role in advocating for the screening and treatment of this disease state. They are in a unique position to improve patient outcomes in late-life depression.
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388 Formulary December 2013 | Vol. 48 |
Cover Article
P e e r - r e v i e w e d
Depression in the elderly: A pharmacists perspective
he American Psychiatric
Association’s Diagnostic and
Statistical Manual of Mental
Disorders (DSM-IV) denes late-life
depression as depressive symptoms
in adults older than 65 years of age.
This includes elderly patients who
have experienced a mood disorder for
the rst time in later life and t hose
whose symptoms initially presented
earlier in life and are now recurring.
The diagnosis of depression in older
patients utilizes the same criteria as
young adults. The diagnosis may be
more difcult in the elderly due to
coexist ing chronic medical condi-
tions and medication use, disability,
or cognitive decline.1 Depression in
the elderly population is widespread
and is often underdiagnosed and in-
adequately treated. Healthcare per-
sonnel who oversee care of the elderly
may not be equipped to recognize or
treat patients with depression. This
is likely due to the presentation of
depression in the elderly, which is
often atypical—insomnia, anorexia,
and fatigue—as opposed to t he typi-
cal depressed mood reported by the
younger depressed patient. Rather
than reporting feeling sad or de-
pressed, elderly more often have so-
matic complaints such as ch ronic
pain, weight loss, headache, or gas-
trointestinal symptoms.2 The elderly
often dismiss their less-severe de-
pressive symptoms as an acceptable
response to life stress or a normal part
of aging; however, depression is not a
normal consequence of aging. Late-
life depression, when untreated, has a
signicant impact on a patient’s qual-
ity of life, healthcare resources, func-
tional status, morbidity, and mortal-
ity.3,4 Late-life depression should be
treated with antidepressants that are
safe in geriatrics and careful ly chosen
to meet each patient’s needs.
There are over 39 million adults age
65 years and older in the United States
and an estimated 7 million of these
are affected by depression.5 About 5%
of community-dwelling older adults
meet the criteria for a major depres-
sion diagnosis. In institutional set-
tings, the incidence of depression in
the elderly population ranges from
12% to 30% and increases up to 50%
among long-term care residents.6 By
2020, the World Health Organization
predicts that in developed countries,
depression will be t he second leading
cause of disability and untimely death,
after heart disease.2
Risk factors for depression in elderly
persons include a family history of
depression; chronic medical illness;
use of certain medications; female
gender; single, widowed, or divorced
marital status; those with social iso-
lation; lower socioeconomic status;
and, stressful life events. Signicant
life events have been identied that
increase an older adult’s risk for de-
pression. These include death of a
spouse or loved one, disease or injury,
disability and functional impairment,
and loneliness.7
In a meta-analysis, 5 major risk fac-
tors for depression in older adults were
reported. These risk factors included
grief, sleep problems, disability, pre-
vious episodes of depression, and fe-
male gender. Of these, sleep issues,
grief, and disability may be potentially
Depression is a disease state that is commonly underdiagnosed and undertreated in patients over
the age of 65 years. Elderly patients may differ from younger patients in the presentation of symp-
toms and in the prevalence of comorbidities. Risk factors for the development of depression are
different for elderly patients. Treatment may also be dissimilar, including response and response
time to treatment. Treatment should be tailored to the individual patient in the geriatric population
to optimize therapeutic outcomes. Pharmacists can be vigilant of comorbidities and medications
that potentially increase the risk of depression in the elderly. Pharmacists can play a signicant
role in advocating for the screening and treatment of this disease state. They are in a unique
position to improve patient outcomes in late-life depression. (Formulary. 2013;48:388–394).
Dr Castillo is assistant pr ofessor of pharma cy practice, Cre ighton Universi ty School of Pharm acy and Health Profes -
sions, Omaha, Nebr aska. Dr Begley is assistant prof essor of pharmac y practice, Creig hton Universit y School of Phar-
macy and Health Profe ssions. Dr Ryan- Haddad is associa te professor of pharm acy practic e, Creighton Univers ity School
of Pharmacy and Heal th Professions. Ms Sorr entino is a PharmD candid ate, Creighton Univer sity School of Phar macy
and Health Profess ions. Mr Twum-Fening is a Pharm D candidate, Creight on University Sc hool of Pharmacy and He alth
Disclosure info rmation: The autho rs report no nan cial disclosures as relate d to products discus sed in this article.
Shana Casti llo, PharmD, MBA K imberley Begley, PharmD Ann Ryan-Haddad, PharmD
Ellen Sorrentino, Pharm D cand idate Kwasi Twum-Fening, PharmD candidate | December 2013 | Vol. 48 Formulary 389
Cover article
Rates of depression are higher for el-
derly patients with coexisting medical
conditions. Older adults with possible
depression should have a complete
physical examination, medication his-
tory, and necessary laboratory assess-
ment to rule out medical conditions
such as hypothyroidism, alcohol use,
or prescription drug abuse that may
contribute to depression.
Untreated depression may result
in patients developing chronic medi-
cal illnesses such as cardiovascular
disease, and worsening others such as
diabetes mellitus and Alzheimer’s dis-
ease.9-11 Depressed patients with co-
morbid diabetes are at greater risk for
decreased adherence to medications,
poor diet, decreased physical activity,
higher functional impairment, and in-
creased healthcare costs compared to
their nondepressed peers.12,13
A number of medical illnesses have
been reported to have the highest rates
linked to late-life depression. Nearly
25% to 50% of all stroke patients de-
velop depression post stroke.14-16 Ma-
jor depression also may affect 20% to
25% of patients with Alzheimer’s dis-
ease.17 Other medical illnesses include
cancer (18%–39%), Parkinson’s dis-
ease (10%–37%), rheumatoid arthritis
(13%), diabetes (5%–11%), and myo-
cardial infarction (MI) (15%–19%).18
The American College of Cardiol-
ogy and the American Heart Asso-
ciation recommend screening for and
treating depression for secondary pre-
vention in patients with ST-segment
elevation MI. Evaluation is recom-
mended while hospitalized, 1 month
after hospital discharge, and yearly.19
Researchers have reported that de-
pression in the hospital after an MI is a
signicant predictor of 1-year cardiac
mortality for both men and women.
Depressed patients were signicantly
more likely to die of cardiac causes
and to have an arrhythmic episode
than patients without depression.20
Common psychiatric comorbidities
of depression have been reported in
a cohort study of 378 older depressed
patients. Rates of anxiety-related disor-
ders included any anxiety (41%), social
phobia (19.6%), agoraphobia (10.8%),
generalized anxiety disorder (10.6%),
and panic disorder (7.7%).21
A number of medications are be-
lieved to be capable of causing depres-
sion. Although these medications may
be associated with depression, there
have been no stud-
ies assessing the risk
they pose above and
beyond that normally
present in geriatric pa-
tients with comorbid
disease states. Case
reports, post-market-
ing surveillance, and
retrospective studies
have linked the fol-
lowi ng medicat ions
with depression: an-
tipsychotics, digoxin,
hydr alazine, efav i-
renz, antineoplastic
agents, beta blockers,
cort icosteroids, ben-
zodiazepines, anti-Parkinson’s agents,
hormone-altering drugs, stimulants,
triptan antimigraine medications, an-
ticonvulsants, proton-pump inhibi-
tors and H2 blockers, statins and other
lipid-lowering drugs, and ant icho-
linergic drugs.2 2 Table 1 lists some
medications associated with depres-
sion, their reported incidence, and
proposed mechanism of action.22
When treating elderly patients with
depression, it is important to remem-
ber that although they may respond to
therapy as well as younger patients, the
time to full response may require up to
8 to 12 weeks. For a rst-time depres-
sive episode, treatment for up to 2 years
may be required. In patients with 3 or
more episodes, lifelong maintenance
treatment may be considered. Dosage
reduction may lead to relapse; thus dos-
ages to which patients respond should
be maintained.2 Currently available an-
tidepressants are listed in Table 2.23,24
Selective serotonin reuptake inhibitors
(SSRIs) work by enhancing the action
of serotonin by blocking its reuptake at
the presynaptic terminals.23 First-line
treatment of depression in an elderly
patient is generally an SSRI, because
of the drug’s fewer side
effects, ease of use,
and safety (especially
in overdose). Time
to full patient benet
with an SSRI in the
elderly population may
be longer than the
usual 4 to 6 weeks.25
Despite the more fa-
vorable tolerabilit y
of SSRIs, some side
effects such as Par-
kinsonism, akathisia,
anorexia, sinus brady-
cardia, and hypona-
tremia may warrant
caution in the elderly
population.25 A rare but potentially
lethal side effect, serotonin syndrome,
may be seen if the patient is taking
other drugs that enhance the availabil-
ity of serotonin.24 One study reported
a 2-fold increase in the risk of clinical
fragility fracture in patients older than
50 years on a daily SSRI. An increased
risk of falling and lower bone mineral
density at the hip was also reported in
the same group.26 Suicide risk should
be monitored in the elderly patient,
especially during the rst month of
Untreated de-
pression may result
in patients develop-
ing chronic medi-
cal illnesses such
as cardiovascular
disease, and wors-
ening others such
as diabetes mellitus
and Alzheimer’s
Watch Ann Ryan-Haddad
of Creighton Unversity
School of Pharmacy and
Health Professions, talk
about depression in the
390 Formulary December 2013 | Vol. 48 |
Cover article
treatment. One study found the suicide
risk in men older than 66 years of age
in their rst month of antidepressant
therapy to be 5-fold higher with SSRIs
than with other antidepressants. No
difference in risk, however, was ob-
served in the second month or subse-
quent months of treatment.27 There
is no evidence to show that one SSRI
antidepressant is more effective than
another and no evidence to show that
SSRIs are more effective than older
antidepressants.25,28 One SSRI that re-
quires dosage adjustment in the elderly
population is citalopram. Due to the
risk of QT prolongation with citalo-
pram, the maximum recommended
dosage in patients older than 60 years
of age is 20 mg daily.29 Citalopram,
escitalopram, and sertraline may be
preferred due to fewer drug interac-
tions and cognitive effects.30
Serotonin–norepinephrine reuptake
inhibitors (SNRIs) work similarly
to the SSRI class, while additionally
blocking the reuptake of norepineph-
rine.23 Adverse effects are similar to the
SSRIs but also include sweating, tachy-
cardia, and urinary retention.31 SNRIs
should be avoided in patients with
uncontrolled hypertension because
these agents can cause dose-dependent
increases in diastolic blood pressure.32
Similar to SSRIs, SNRIs can cause
serotonin syndrome, usually result-
ing from interactions with monoamine
oxidase inhibitors (MAOIs). Examples
of drugs with MAOI properties in-
clude linezolid, dextromethorphan,
sumatriptan, tramadol, and St. John’s
Wort.31 Both SSRI and SNRI agents
are less lethal in overdose as compared
to tricyclic antidepressants.24 Even
though the SSRIs and SNRIs are not
addictive, it is important to educate
Table 1
Medications that cause depression
Medication Reported incidence Proposed mechanism
Cardiovascular agents
Reduces NE output via alpha-adrenergic receptor agonism
Depletes neuronal NE
Partial agonism of NE receptor
Depletes neuronal NE, serotonin, and dopamine
Retinoic acid derivatives
Isotretinoin 1.5%-5% Alters dopaminergic, serotonin, and possibly NE systems
Reduces plasma unbound tryptophan, which inuences plasma
serotonin concentrations
Increases the amount of GABA available
Increases the amount of GABA available
Hormonal agents
GnRH agonists
Elevates plasma cortisol concentrations
Reduces both estrogen and androgen production
Reduces estrogen function via antagonizing estrogen receptors
Immunologic agents
Increases interleukin-6 production
Abbreviations: GABA, gamma-aminobutyric acid; GnRh, gonadotropin-releasing hormone; NE, norepinephrine
Formulary/Source: Ref 22 | December 2013 | Vol. 48 Formulary 391
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patients to avoid abrupt discontinua-
tion of therapy with both classes due
to the potential for antidepressant dis-
continuation syndrome.24 After abrupt
cessation, symptoms associated with
antidepressant discontinuation usually
appear within 2 to 3 days. The medi-
cations associated with the highest risk
of producing these symptoms are par-
oxetine and venlafaxine. Sertraline,
citalopram, and escitalopram have a
lower risk, but the risk with uoxetine
is the lowest.33 An SSRI is usually the
drug of choice for patients with late-life
depression, but an SNRI is also appro-
priate rst-line treatment.31
Tricyclic antidepressants (TCAs)
work by decreasing reuptake of norepi-
nephrine and serotonin.23 TCAs work
well as antidepressants; however, their
actions at the additional adrenergic,
cholinergic, and histaminic receptors
produce adverse effects that detract
from their overall tolerability in all
patients, especially the elderly. These
adverse effects include orthostasis, dry
mouth, sexual dysfunction, constipa-
tion, urinary retention, blurred vision,
confusion, and weight gain. Patients
often discontinue the medication or
are unable to titrate to the highest ef-
fective dose of the medication due to
the intolerability of the TCAs.24 These
agents should be used with caution in
patients who have urinary retention,
benign prostatic hyperplasia, arrhyth-
mias, cardiac conduction abnormali-
ties, or narrow-angle glaucoma.25 This
class of antidepressants is not recom-
mended for rst- or second-line treat-
ment in any age group.25 The TCAs
still remain an option for patients who
do not respond to or cannot tolerate an
SSRI or SNRI.31 TCAs, however, are
rarely the antidepressant of choice for
elderly patients. They should generally
be avoided in the elderly population.
Monoamine oxidase inhibitors (MAOIs)
work by inhibiting monoamine oxidase
Table 2
Currently available antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin–norepinephrine reuptake inhibitors (SNRIs)
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
Atypical antipsychotics*
Atypical antipsychotic/SSRI combination**
*FDA approved for adjunctive treatment of depression
**FDA approved for treatment-resistant depression
Formulary/Source: Refs 23,24
392 Formulary December 2013 | Vol. 48 |
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enzyme, which increases the availability
of monoamines causing increased con-
centration of neurotransmitters such
as epinephrine, norepinephrine, and
dopamine.23 Adverse effects of this class
(sleep disturbance, orthostatic hypoten-
sion, sexual dysfunction, weight gain)
detract from their use as an antide-
pressant in the elderly population. Not
only are MAOIs associated with a poor
adverse-effect prole,
they also can cause a
potentially fatal interac-
tion with SSRIs, sym-
pathomimetics, and
tyramine-rich foods
that can result in de-
lirium or hypertensive
crisis.24,34 MAOIs are
not recommended as a
rst-line agent for treat-
ing late-life depression.
Generally, this class is
only used when a pa-
tient is treatment re-
sistant to other antide-
pressant agents. Some
studies have shown ef-
cacy superior to other
antidepressant agents in the treatment
of atypical depression, mixed anxiety-
depressive states, and panic disorder;
however, few studies have included an
elderly population of patients.25 Selegi-
line is available as a transdermal patch,
which may provide a convenient dosage
form for some elderly patients. An ad-
ditional benet with this patch is that
when used at its lowest recommended
dose (6 mg/24 hr), there appear to be no
signicant interactions with tyramine-
containing foods, as well as fewer sexual
dysfunction, weight gain, or hypoten-
sive adverse effects. The absence of
these interactions and adverse effects,
however, is not seen with higher dos-
The actions of bupropion with regard
to antidepressant activity are not fully
understood. It does inhibit the neuro-
nal reuptake of dopamine.23 It may be as
effective as the SSRI and TCA classes
when treating major depression.35 Pa-
tients who suffer with lethargy, fatigue,
or daytime sedation may benet from
treatment with bupropion because it
is generally an activating medication.
It should not be used in patients who
have seizure disorders, past or current
diagnosis of bulimia
nervosa, or are under-
going alcohol detoxi-
cation.25 Patients with
hypertension should
have their blood pres-
sure checked regularly
due to the potential for
elevation.23 The com-
bination of an SSRI
plus bupropion is com-
monly used.33
The chemical struc-
ture of mirtazapine is
not related to any other
antidepressants.23 It
has both serotonergic
and noradrenergic properties.25 Mir-
tazapine has an anxiolytic effect and
might be benecial in patients with in-
somnia, agitation, or restlessness due to
its sedating nature. Its sedating effects
do tend to diminish with further treat-
ment that includes titration to higher
doses.23,25 Its appetite-stimulating effect
may prove useful in an anorexic de-
pressed patient.31 Mirtazapine is gener-
ally considered a second-line agent.25
Elderly patients should be initiated at
lower dosages and titrated more slowly.
They are also more susceptible to hypo-
natremia, a rare side effect of mirtazap-
ine.23 Abrupt withdrawal of mirtazap-
ine should be avoided.
Nefazodone’s antidepressant activity is
due to actions on the serotonergic and
noradrenergic systems.23 It is rarely pre-
scribed due to its association with rare,
hepatic failure requiring transplanta-
tion. Nefazodone has been removed
from the market in Canada and Europe
because of this serious adverse effect.31
It might be a choice for patients who
have insomnia, anxiety, or agitation. It
should be used with caution because
it is a potent inhibitor of the CYP-
50-3A4 isoenzyme, which can lead to
signicant drug–drug interactions.25 In
elderly patients, nefazodone should be
initiated at half the normal adult dose.23
Trazodone and nefazodone have simi-
lar structures.35 Trazodone is rarely
prescribed as a sole antidepressant
agent but is commonly prescribed
as an adjunct to an SSRI in patients
with insomnia due to its sedating
properties.25,31 Elderly patients usually
require a lower dose and may be at
increased risk for adverse reactions.
If a patient cannot tolerate an SSRI
or SNRI, however, trazodone may be
preferred over a TCA because it has
fewer cardiac effects.23
FDA has approved both aripiprazole
and quetiapine for the adjunct ive
treatment of depression. A combina-
tion of olanzapine and uoxetine has
been approved for treatment-resistant
depression.31 Atypical antipsychotics
used as adjunctive treatment for de-
pression in the geriatric population
have not been systematically studied.
Of concern is the association between
atypical antipsychotics and increased
mortality in geriatric patients with
dementia; however, it is not clear if
the low doses used in adjunctive treat-
ment of depression will produce the
same association.36
Nonpharmacologic therapy continues
to have an important role in treat-
ing depression. Consensus guidelines
for rst-line treatment of both mild
and severe depression in the elderly
population include not only an anti-
Not only are
MAOIs associated
with a poor adverse-
effect prole, they
also can cause a po-
tentially fatal inter-
action with SSRIs,
and tyramine-rich
foods that can result
in delirium or hy-
pertensive crisis.
Continued on page 393 | December 2013 | Vol. 48 Formulary 393
Cover article
depressant but also psychotherapy.3 6
Psychotherapy may include cognitive-
behavioral therapy, supportive psy-
chotherapy, problem-solving therapy,
or interpersonal therapy.35 Increased
exercise and exposure to bright light
have also shown benet in the de-
pressed elderly population.25 Electro-
convulsive therapy (ECT) can be
effective for severe depression. If two
trials of antidepressants have failed,
ECT may be an option. ECT is also
effective for patients with depression
that exhibits psychotic features, who
have not responded to antipsychotics
and antidepressants.35
The best therapeutic outcome of anti-
depressant therapy is remission. Nev-
ertheless remission rates for geriatric
patients are only approximately 30%.
In the Sequenced Treatment Alterna-
tives to Relieve Depression (STAR*D)
study, only 30% of study participants
attained remission status.37 Similarly,
other researchers noted that 71% of
the 792 geriatric patients with major
depression did not achieve remission.
Factors increasing nonremission in-
cluded comorbid anxiety, female sex,
general medical comorbidity, and in-
creased baseline depressive symptom
Depression may affect older pa-
tients’ use of medical services such as
physician visits and hospital admis-
sion rates. In the KORA-Age study,
participants with depressed mood
had signicantly more physician visits
than those without depressed mood.39
In the Health in Men Study 44.8% of
patients with depressive symptoms
had at least one emergency hospital
admission for nonpsychiatric con-
ditions compared to 22.9% of male
patients wit hout depression. In addi-
tion, those with depression had longer
hospital stays and worse hospital out-
comes.40 Depressed patients’ nonad-
herence to treatment plans are a pos-
sible reason for the increased hospital
admission rates. Because of their non-
adherence, patients may be admitted
to the hospital in a more serious or ad-
vanced stage of their condition, which
can signicantly impact hospital stay
durations and health outcomes.
The frequency of antidepressant
use in US nursing home residents
has increased from 21.9% to 47.5%
(1996 –2006).41 Investigators have
also evaluated antidepressant use
for older patients admitted to Veter-
ans A ffairs (VA) Community Liv-
ing Centers during an 18-month
period. They identied that 25% of
patients potentially underused an-
tidepressants (patients had depres-
sion diagnosis but were not receiving
an antidepressant), 42% potentially
overused antidepressants (patients
without depression were taking an
antidepressant), and nearly 60% of
patients with depression receiving
antidepressant therapy had 1 or more
prescribing problems (eg, drug– dr ug
and dr ug–disease interactions). Pa-
tients with moderate-to-severe pain
and those tak ing anxiolytic/hypnotic
medications were at signicant ly in-
creased risk for inappropriate use of
antidepressants. Patients with mild/
moderate cognit ive impairment,
polypharmacy (>5 medications),
cerebrovascular accidents, other anx-
iety, or tak ing an antipsychotic with-
out diagnosis of schizophrenia were
at greater risk for overuse of antide-
pressants. The only associated risk
factor for ant idepressant underuse
was activities of daily living (ADL)
Pharmacists can provide several im-
portant services to their older patients
with depression. Providing educational
information about depression and anti-
depressant medication could enhance
medication adherence. Additionally,
monitoring patients for medication ef-
fectiveness, side effects, and adherence
could improve treatment outcomes.
For patients who are not aware of or
have not sought medical care for de-
pression, the pharmacist may encour-
age them to make an appointment
with their primary care provider for
assessment.43 Researchers have evalu-
ated pharmacists’ perceived barriers to
providing depression care and found
deciency in psychiatric education,
minimal time for personalized care for
patients, limited patient information
related to treatment, lack of private
spaces in the pharmacy to talk to pa-
tients about mental health issues, and
concerns about effectively communi-
cating with depressed patients were the
most commonly noted barriers.44
In a study evaluating the impact of
pharmacist intervention on outcomes
of depressed primary care patients,
investigators reported signicant im-
provement in antidepressant use rates
for intervention patients (57.5% vs
46.2%) and for patients not on anti-
depressants at enrollment (32.3% vs
10.9%) as compared to non-interven-
tion patients. Pharmacist consultation
was either conducted in person or by
As the most accessible healthcare
provider, pharmacists are in a unique
position to inform patients and as-
sist in recognition of depression, of-
fer screening, provide education, and
offer support to their elderly patients
who may be suffering from depres-
sion. Pharmacists can monitor for pa-
tients’ somatic complaints that might
indicate undiagnosed depression.
Pharmacists should be cognizant and
able to recognize comorbidities and
medications that may contribute to
depression in the elderly patient. They
can also advocate for their patients
to discuss their symptoms with their
primary care providers. For those pa-
tients receiving medication therapy
for depression, pharmacists should be
mindful of potential drug–drug and
drug–disease interactions as well as
side effects, monitor rells to ensure
medication adherence, and coun-
sel patients about the possible need
for continued maintenance therapy.
Continued from page 392
394 Formulary December 2013 | Vol. 48 |
Cover article
Pharmacists may also consider inno-
vative practice or outreach opportu-
nities, such as community presenta-
tions on the signs and symptoms of
depression, developing a call interven-
tion system for elderly patients taking
antidepressants, offering medication
reviews to determine potential medi-
cation causes of depression, offering
educational brochures in the phar-
macy, or collaborating with primary
care providers in the community to
provide free screenings.
Because so many elderly are af-
fected by depression and studies
have shown depressed elderly have a
higher morbidity and mortality with
increased use of healthcare resources
and costs, pharmacists have a profes-
sional duty to ensure they receive opti-
mal pharmacy care in their treatment
of depression.
1. Alexopoulos GS, Buc kwalter K, Ol in J, et al.
Comorbidity of late l ife depression: an oppor -
tunity for research on mechanisms and tr eat-
ment. Biol Psychiat ry. 2002;52:543 –558.
2. Rojas-Fernandez C, Mikha il M. Contempo-
rary concepts in the pharmac otherapy of de-
pression in older people. Can Pharm J (Ott).
3. Frederick J T, Steinma n LE , Prohaska T, et al.
Commun ity-based t reatment of late life de-
pression: an expert panel-informed literatu re
review. Am J Prev Med. 2007;33:222 –249.
4. Snowden M, Steinma n L, Frederick J. Treating
depression in older adults: challen ges to imple-
menting the recom mendations of an exp ert
panel. Prev Chro nic Dis. 200 8;5:A2 6.
5. CDC pr omotes public health approach to ad -
dress depre ssion among older adults. ht tp://
ww ng /pdf/CI B _me ntal_ hea lth .
pdf. Accessed Aug ust 20, 2013.
6. Park M , Unutz er J. Geri atric depression
in prima ry care. Psych iatr Clin North Am.
2011;34:469,487, ix-x.
7. Bruce ML. Psychosocial risk factors for de-
pressive disorders in late l ife. Biol P sychiatry.
8. Cole MG, Denduku ri N. Risk fac tors for de-
pression among elderly community subject s:
A systematic review and meta-analysis. Am J
Psychiatr y. 2003;160:1147–1156.
9. Lustma n PJ, Anderson RJ, Freedland KE , et al.
Depression and poor glycem ic control: a meta-
analy tic review of the lite rature. Diabetes Ca re.
2000;23:934– 942.
10. Jiang W, Kr ishnan RR , O’Connor CM. De-
pression and he art disea se: ev idence of a l ink,
and its t herapeut ic implications. CNS Drugs.
11. A lexopoulos GS, Meyer s BS, Young RC, et al.
The course of geriat ric depression with “re-
versible dementia”: a c ontrolled study. Am J
Psychiatr y. 1993;150:1693–1699.
12. Ciechanowsk i PS, K aton WJ, Russo JE. De-
pression a nd diabe tes: impac t of depressive
symptoms on adherence , funct ion, and costs.
Arch Intern Med. 20 00;160:3278– 3285.
13. L in EH, Katon W, Von Korff M, et al. Rela-
tionship of depression and diabetes self-care ,
medication adherence, and preventive care.
Diabetes Care . 2004;27:2154–2160.
14. Robi nson RG, Kubos K L, Sta rr LB , et al.
Mood disorder s in stroke patients. Impor-
tance of locat ion of lesion. Brain . 1984;107( Pt
15. A strom M, Adolfsson R, Asplund K. Major
depression in stroke patients. A 3-year long itu-
dina l study. Stroke. 1993;24:976 –982.
16. Wade DT, Legh- Smith J, Hewer R A. De-
pressed mood after str oke. A community st udy
of its frequency. Br J Psychiatry. 1987;151:200
17. Lyketsos CG, Olin J. Depression in Alzheim-
er’s disea se: overv iew and treat ment. Biol Psy-
chiatry. 20 02;52:243–252.
18. Sable JA, Dunn LB, Zisook S. Late-l ife depres-
sion. How to identify its symptoms and provide
effective t reatment. Geriatric s. 2002;57:18–26.
19. A ntman EM, Anbe DT, Armstrong PW, et
al. ACC/AHA gu idelines for the ma nagement
of patients with ST-elevation myocardial in-
farction--exec utive summary. A report of the
Americ an Colle ge of Card iology/Amer ican
Heart Asso ciation task force on practice gu ide-
lines (writing com mittee to revise the 1999
guidel ines for the management of patients with
acute myocardial infarction). J Am Coll Car-
diol. 20 04;44:671–719.
20. Fr asure- Smith N, Lesperance F, Ju neau M, et
al. Gender, depression, and one-year prognosis
after myoca rdial i nfarc tion. Psych osom Med.
21. Com ijs HC, van Ma rwijk HW, van der Mast
RC, et al . T he Net herlands Study of De-
pression in Older Persons (N ESDO); a
prospective cohort st udy. BM C Res Notes .
2011;4:524,0500 -4 -524.
22. Bot ts S, Ryan M. Depression. In: Tisdale J,
Mil ler D, eds. D rug-Ind uced Diseases: Pre -
vention, Detectio n, and Management. 2nd ed.
Bethesd a, MD: A merica n Societ y of Healt h-
System Pharmacists; 2010:317–332.
23. Clinical phar macology. Updated 2013. http://
cl in ical phar ma co log y-ip. com /defa ul t. as px .
Accessed July 2, 2013.
24. Fi nley PR, L ee KC. Providi ng pharmaceutica l
care to pat ients wit h depression. Pharmacy To-
day: Topics in Patient Care. 2006:S1.
25. Di agnosis and management of late-life depres-
sion. Updated 2013.
conten ts/d iag nosis-a nd-m ana gemen t-of- late -
life-depres sion#H1. Accessed August 8, 2013.
26. R ichards J B, Papaioa nnou A, Adachi JD, et al.
Effect of selective serotonin reuptake inhibi-
tors on the r isk of frac ture. Arch Intern Med.
27. Juu rlin k DN, Ma mdani MM, Kopp A, Redel-
meier DA. The risk of suicide with selective se-
rotonin reupta ke inh ibitors in the elderly. Am J
Psychiatr y. 2006;163:813–821.
28. G art lehner G, Gaynes BN, Hansen RA , et a l.
Comparative benets and har ms of second-
generation antidepre ssants: B ackground paper
for the American College of Phys icians. Ann
Intern Med. 20 08;149:734–750.
29. F DA drug safety commun ication: Revised rec-
ommendations for celexa (citalopram hydro-
bromide) related to a potential risk of abnor-
mal heart rhythms with high doses. Updated
2012. http://ww rugsa fety/
ucm297391.htm. Acces sed August 12, 2013.
30. Pollock B, Semla T, Forsyt h C. Psychoactive
drug therapy. In: Halter J B, ed. Hazzard’s
Geriatr ic Medicine and Geronto logy. 6th ed.
New York, NY: McG raw-Hi ll Professional;
31. D rugs for depression and bipolar disorder.
Treat Guidel Med Lett. 2010;8:35– 42.
32. Wern icke J, Panga llo B, Wang F, et al. Hepat ic
effects of duloxeti ne-I: Non-cli nical and cl ini-
cal trial data. Cur r Drug Saf. 2008;3:132–142.
33. Fi nley PR, Rens HR, Pont JT, et al. Impact of
a collaborat ive care model on depression i n a
prima ry care set ting: A randomized controlled
tria l. Pharmacotherapy. 2003 Sep;23(9):1175-
34. Transde rmal se legil ine (E msam). Med Lett
Drugs Ther. 20 06;48:41–42.
35. Bi rrer R B, Vemuri SP. Depression i n later li fe:
a diag nostic and t herapeutic challe nge. Am
Fam Physician. 20 04;69:2375–2382.
36. A lexopoulos GS. Pharmacotherapy for late-life
depression. J Clin Psychi atry. 2011;72:e04.
37. Zisook S, Ganadjia n K , Mout ier C, et al. Se-
quenced treatment altern atives to relieve de-
pression (STAR*D): lessons learned . J Clin
Psychiatr y. 2008;69:1184–1185.
38. A zar AR, Chopra MP, Cho LY, e t al. Rem is-
sion in major depression: result s from a geri -
atric pri mary c are populat ion. Int J Geriatr
Psychiatr y. 2011;26:48–55.
39. L acruz ME, Emeny RT, Haefner S, et al. Rela-
tion between depressed mood, somatic comor -
bidities and health service utilisation in older
adults: results from the KOR A-age study. Age
Ageing. 2012;41:183–190.
40. P rina AM, Huisma n M, Yeap BB, et al .
Associat ion between depression and hos-
pital outcomes among older men. CM AJ.
41. H anlon JT, Handler SM, Castle NG. Ant i-
depressant prescribing in US nursing homes
between 1996 and 2006 and its relationship
to s taf ng patter ns and use of other psy-
chotropic medications. J Am Med Dir Assoc.
42. H anlon JT, Wa ng X, Castle NG, et a l. Potential
underuse , overuse, and inappropriate use of
antidepres sants in older veteran nursin g home
residents. J Am Ger iatr S oc. 2 011;59:1412–
43. Wells BG. Underrecog nition and undertreat-
ment of depression: what is the pharmacist’s
culpabil ity? Pharmacotherapy. 1999;19:1237–
44. Scheerder G, De Coster I, Van Audenhove C.
Pharm acists’ role in depression care: a survey
of attitudes, cur rent practice s, and barr iers.
Psychiatr Ser v. 2008;59:1155–1160.
45. Ad ler DA, Bungay K M, Wilson IB, et a l.
The impact of a pharm acist intervent ion on
6-mont h outcome s i n depre ssed prima ry care
patients. Gen Hosp Psychiatr y. 2004. May-
... A study carried out by Aaltonen et al., in 2010 stated that the mental disorder patients have reported their dissatisfaction with the information given by the healthcare provider upon collecting the medication after discharge from the ward or regular follow-up. The complex prescription due to polypharmacy of antipsychotic medication [3] and concurrent diseases [2,6] may be steered to misunderstanding. A clear guidance and enough information from the healthcare provider are required. ...
Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.
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Late-life depression is common in older people. Its incidence increases significantly after age 70 to 85, as well as among those living in long-term care facilities. Depression contributes to excess morbidity and complicates management of comorbid conditions in older people. Diagnosis and management of depression often present clinicians with a challenge. Indeed, symptoms of depression in older people may not always be the same as those associated with depression in younger people. Additionally, age-related changes in pharmacokinetics and pharmacodynamics also impact selection, dosing, and monitoring of psychopharmacologic regimens. Optimizing management of depression and providing sound advice to older patients with depression requires knowledge and understanding of many clinical factors. The purpose of this review is to highlight salient issues in late-life depression, with a focus on the pharmacotherapy of depression.
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Background: Studies that have investigated the relation between depression and the type, nature, extent and outcome of general hospital admissions have been limited by their retrospective designs and focus on specific clinical populations. We explored this relation prospectively in a large, community-based sample of older men. Methods: A cohort of 5411 men aged 69 years and older enrolled in the Health in Men Study was assessed at baseline for depressive symptoms, defined as a score of 7 or higher on the 15-item Geriatric Depression Scale. Participants were followed for 2 years for occurrence and number of hospital admissions, type of hospital admission, length of hospital stay and inpatient death as recorded in the Western Australian Data Linkage System. Results: Of 339 men with depressive symptoms, 152 (44.8%) had at least 1 emergency hospital admission, compared with 1164 of 5072 (22.9%) nondepressed men (p < 0.001). In multivariate analyses, the presence of depressive symptoms was a significant independent predictor of hospital admission (hazard ratio 1.67, 95% confidence interval [CI] 1.38-2.01), number of hospital admissions (incidence rate ratio [IRR] 1.22, 95% CI 1.07-1.39) and total length of hospital stay (IRR 1.65, 95% CI 1.36-2.01). Interpretation: Participants with depressive symptoms were at higher risk of hospital admission for nonpsychiatric conditions and were more likely to have longer hospital stays and worse hospital outcomes, compared with nondepressed participants. These results highlight the potential to target this high-risk group to reduce the burden of health care costs in an aging population.
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prior literature suggests that comorbidity with depression significantly worsens the health state of people with chronic diseases. the present study examines whether depressed mood increased medical care use for patients with a comorbid physical disease. Design, setting and subjects: the study was a population-based study (KORA-Age), with 3,938 participants aged 64-94. we investigated differences in health services use in participants with and without depressed mood (Geriatric Depression Scale). A further adjustment for disease was done and differences were examined with the Mann-Whitney U test. The incidence rate ratios (IRRs) for doctors' appointments or the number of days in hospital were explored with (zero-inflated) negative binomial regression models. there are increased self-neglecting behaviours and medical comorbidities in participants with depressed mood. Depressed mood increased participants' use of medical services (P < 0.0001). Among participants who visited the doctor during the last 3 months, those with depressed mood had more visits than those without depressed mood, irrespective of somatic comorbidities (P < 0.0001 and P < 0.05 for ill and healthy, respectively). Additionally, patients with coexisting depressed mood and physical disease visited the doctor's practice significantly more often. Having depressed mood significantly increases the likelihood for more doctor visits (IRR = 1.5, CI = 1.3-1.7) and longer hospital stays (IRR = 1.9, CI = 1.6-2.3). In participants with somatic comorbidities the risk is even greater (IRR = 1.6, CI = 1.3-2, for the number of doctors visits and IRR = 2, CI = 1.4-2.9, for the number of days in the hospital). results suggest that patients with depressed mood had increased use of health-care services overall, particularly those with somatic comorbidities.
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To study late-life depression and its unfavourable course and co morbidities in The Netherlands. We designed the Netherlands Study of Depression in Older Persons (NESDO), a multi-site naturalistic prospective cohort study which makes it possible to examine the determinants, the course and the consequences of depressive disorders in older persons over a period of six years, and to compare these with those of depression earlier in adulthood. From 2007 until 2010, the NESDO consortium has recruited 510 depressed and non depressed older persons (≥ 60 years) at 5 locations throughout the Netherlands. Depressed persons were recruited from both mental health care institutes and general practices in order to include persons with late-life depression in various developmental and severity stages. Non-depressed persons were recruited from general practices. The baseline assessment included written questionnaires, interviews, a medical examination, cognitive tests and collection of blood and saliva samples. Information was gathered about mental health outcomes and demographic, psychosocial, biological, cognitive and genetic determinants. The baseline NESDO sample consists of 378 depressed (according to DSM-IV criteria) and 132 non-depressed persons aged 60 through 93 years. 95% had a major depression and 26.5% had dysthymia. Mean age of onset of the depressive disorder was around 49 year. For 33.1% of the depressed persons it was their first episode. 41.0% of the depressed persons had a co morbid anxiety disorder. Follow up assessments are currently going on with 6 monthly written questionnaires and face-to-face interviews after 2 and 6 years. The NESDO sample offers the opportunity to study the neurobiological, psychosocial and physical determinants of depression and its long-term course in older persons. Since largely similar measures were used as in the Netherlands Study of Depression and Anxiety (NESDA; age range 18-65 years), data can be pooled thus creating a large longitudinal database of clinically depressed persons with adequate power and a large set of neurobiological, psychosocial and physical variables from both younger and older depressed persons.
Objective: The authors explored the relationship between the initiation of therapy with selective serotonin reuptake inhibitor (SSRI) antidepressants and completed suicide in older patients. Method: The authors linked population-based coroner's records with patient-level prescription data, physician billing claims, and hospitalization data for more than 1.2 million Ontario residents 66 years of age and older from 1992 to 2000. For each suicide case, four closely matched comparison subjects were selected using propensity score methods. The authors determined the odds ratio for suicide with SSRIs versus other antidepressant treatment, calculated at discrete monthly intervals from the start of treatment. Results: Of 1,329 suicide cases, 1,138 (86%) were each fully matched to four comparison subjects using propensity scores. During the first month of therapy, SSRI antidepressants were associated with a nearly fivefold higher risk of completed suicide than other antidepressants (adjusted odds ratio: 4.8, 95% confidence interval=1.9-12.2). The risk was independent of a recent diagnosis of depression or the receipt of psychiatric care, and suicides of a violent nature were distinctly more common during SSRI therapy. Numerous sensitivity analyses revealed consistent results. No disproportionate suicide risk was seen during the second and subsequent months of treatment with SSRI antidepressants, and the absolute risk of suicide with all antidepressants was low. Conclusions: Initiation of SSRI therapy is associated with an increased risk of suicide during the first month of therapy compared with other antidepressants. The absolute risk is low, suggesting that an idiosyncratic response to these agents may provoke suicide in a vulnerable subgroup of patients.
Objective: Review nonclinical and clinical trial data for hepatic effects of duloxetine. Methods: Review studies of toxicology, metabolism, mitochondrial effects, and clinical trials. Results: Nonclinical studies revealed no treatment-related transaminase elevations and no effects of duloxetine on mitochondrial beta-oxidation in rat hepatocytes. In patients with a normal baseline alanine transaminase (ALT), duloxetine was associated with elevated transaminases >3X ULN in about 1% of patients. ALT and aspartate transaminase values peaked at 8 weeks, alkaline phosphatase steadily increased to maximum value at Week 52 and mean total bilirubin values were not increased. Hepatic-related treatment-emergent adverse events were uncommon. Seven of 23,000 duloxetine- and 2/6000 placebo-treated patients met criteria for modified Hy's rule (significant elevation of both ALT and total bilirubin) but were complicated by contributing factors such as excessive alcohol consumption (n=3), gall stones, common bile duct calculus, hepatitis C, and liver adenocarcinoma (n=1 each). Conclusions: Duloxetine has an effect on the liver, manifested by transient, self-limiting transaminase elevations. Rare events characterized as hepatocellular injury, cholestatic injury, or mixed type of hepatic injury have been reported. The pattern of liver effects was different from that in laboratory animals.
To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents. Longitudinal study. One hundred thirty-three VA CLCs. Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥ 90 days). Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale). Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use. Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.
Primary care settings present important opportunities for the detection and management of depression in older adults. In this article, the authors review the common barriers to effective treatment of geriatric depression, identify treatment strategies that can substantially improve the effectiveness of treatment in this setting, and highlight the opportunities for addressing health disparities in geriatric depression care. The importance of engaging and supporting family caregivers of depressed older adults and the 3 strategic areas to improve the treatment of geriatric depression in primary care are also discussed.
The 2001 expert consensus guidelines for treating major depressive disorder (MDD) in geriatric patients recommended antidepressant treatment in combination with psychotherapy. Recent evidence continues to support the use of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors as first-line agents in the elderly, and although the transdermal monoamine oxidase inhibitor selegilene has shown promise in adult patients, it has not been studied in geriatric depression. Augmentation therapy with atypical antipsychotics or other agents may provide benefits for agitated, psychotic, or resistant MDD in the elderly. The few treatment studies that have been conducted in the geriatric population since the publication of the guidelines have had mixed results and high placebo response rates. More large controlled trials are needed.