Pharmacotherapy of Depression in Older Patients: A Summary of the Expert Consensus Guidelines

Cornell Institute of Geriatric Psychiatry, White Plains, NY 10605, USA.
Journal of Psychiatric Practice (Impact Factor: 1.34). 12/2001; 7(6):361-76. DOI: 10.1097/00131746-200111000-00003
Source: PubMed


Depression in older adults increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. Most studies of antidepressants are conducted in younger adults, and clinicians often have to extrapolate from findings in populations that do not present the same problems as older patients. Older patients often have serious coexisting medical conditions that may contribute to or complicate treatment of depression; they tend to take multiple medications, some of which may contribute to depression or interact with antidepressants; and they metabolize medications slowly and are more sensitive to side effects than younger patients. To address clinical questions not definitively answered in the research literature, the authors surveyed 50 experts on the pharmacotherapy of depressive disorders in older patients. The survey contained 64 questions with 857 options: 618 of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions; for the other 239 options, the experts were asked to write in answers or check a box. The experts reached consensus on 89% of the options rated on the 9-point scale. Categorical rankings (first line/preferred, second line/alternate, third line/usually inappropriate) were assigned to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for common and important clinical scenarios. The authors summarize the expert consensus methodology and the experts' recommendations and discuss how they relate to research findings. The experts recommend including both antidepressant medication and psychotherapy in treatment plans for nonpsychotic unipolar major depressive disorder of any severity, as well as for dysthymic disorder or persistent minor depressive disorder. They would also consider using either medication or psychotherapy alone for milder depression. For unipolar psychotic major depression, the treatment of choice is an antidepressant plus one of the newer atypical antipsychotics, with electroconvulsive therapy another first-line option. If the patient has a comorbid medical condition that is contributing to the depression, the experts recommend treating both the depression and the medical condition from the outset. The SSRIs were the top-rated antidepressants for all types of depression, with highest ratings for efficacy and tolerability given to citalopram and sertraline. Paroxetine was another first-line option, and fluoxetine was rated high second line. The preferred psychotherapy techniques for treating depression in older patients are cognitive-behavioral therapy, supportive psychotherapy, problem-solving psychotherapy, and interpersonal psychotherapy. The experts also recommended use of psychosocial interventions (e.g., psychoeducation, family counseling, visiting nurse services) in addition to pharmacotherapy and psychotherapy. Within limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction concerning common clinical dilemmas in older patients. They cannot address the complexities of each individual patient's care and can be most helpful in the hands of experienced clinicians.

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    • "Diagnostic issues are of critical importance in geriatric depression, a condition that is underdiagnosed and undertreated (Alexopoulos, 2005). Whereas effective treatment of depression among older adults has been linked to improved quality of life and reduced cost of health care (Alexopoulos et al., 2001), untreated depression has been associated with poorer cognitive and physical functioning, and increased suicide rate (Blazer, "
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    ABSTRACT: Objective Previous studies have identified differential item function (DIF) in depressive symptoms measures, but the impact of DIF has been rarely reported. Given the critical importance of depressive symptoms assessment among older adults, we examined whether DIF due to demographic characteristics resulted in salient score changes in commonly used measures.Methods Four longitudinal studies of cognitive aging provided a sample size of 3754 older adults and included individuals both with and without a clinical diagnosis of major depression. Each study administered at least one of the following measures: the Center for Epidemiologic Studies Depression scale (20-item ordinal response or 10-item dichotomous response versions), the Geriatric Depression Scale, and the Montgomery–Åsberg Depression Rating Scale. Hybrid logistic regression-item response theory methods were used to examine the presence and impact of DIF due to age, sex, race/ethnicity, and years of education on the depressive symptoms items.ResultsAlthough statistically significant DIF due to demographic factors was present on several items, its cumulative impact on depressive symptoms scores was practically negligible.Conclusions The findings support substantive meaningfulness of previously reported demographic differences in depressive symptoms among older adults, showing that these individual differences were unlikely to have resulted from item bias attributable to demographic characteristics we examined. Copyright © 2014 John Wiley & Sons, Ltd.
    Full-text · Article · Jan 2015 · International Journal of Geriatric Psychiatry
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    • "Both major depression and depressive symptoms are associated with increased healthcare costs (Katon et al., 2003) and adverse outcomes, including exacerbation of coexisting medical illness, disability in activities of daily living, and mortality (Carnethon et al., 2007; Penninx et al., 1999; Unutzer et al., 2002). Because many antidepressant medications are safe and well-tolerated in older persons (Mamdani et al., 2000; Sonnenberg et al., 2008), they are considered a first-line treatment for a spectrum of depressive disorders in this population, including clinically significant depressive symptoms (Alexopoulos et al., 2001). "
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    ABSTRACT: Due to the cross-sectional design of most existing studies, longitudinal characterization of treatment for depression in older persons is largely unknown. Seven hundred fifty-four men and women (aged 70+ years) underwent monthly assessments of mental health professional use and 18-month assessments of antidepressant medication use and depressive symptoms over 9 years. Scores of ≥20 on the Center for Epidemiological Studies-Depression (CES-D) scale denoted depression. We evaluated trends in depression treatment over time in the entire sample and among the depressed participants. Using generalized linear models, we determined characteristics associated with receiving treatment for depression in these groups and among those with persistent depression. During the 9-year follow-up period (1998-2007), 339 (45.0%) of the participants reported depression treatment. Over time, antidepressant use alone decreased (p trend<0.001) while treatment with both antidepressants and a mental health professional increased (p trend=0.002). Of the 286 (27.9%) depressed participants, between 43% and 69% did not receive depression treatment during any 18-month interval. 30.5% of the 121 participants with persistent depression did not receive treatment during the study period. Increasing number of years of education, decreasing cognitive status score, and being physically frail were associated with a higher likelihood of receiving treatment in all models. Pre-baseline depression, pre-baseline treatment, and indication for treatment were unavailable. Our findings indicate that the profile of treatment for depression in older persons has changed over time, that depressed older persons, including those with persistent depression, are under-treated, and that patient characteristics influence receipt of treatment.
    Full-text · Article · Feb 2012 · Journal of Affective Disorders
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    • "Older adults can also benefit from supportive counseling and assistance with problem solving for day-to-day stressors. The preferred kinds of psychotherapies for treatment of depression in older adults include cognitive-behavioral therapy, problem solving psychotherapy, interpersonal therapy, and supportive psychotherapy (Alexopoulos et al., 2001). Complementary or alternative therapies such as prayer, massage, and aromatherapy can also help reduce depressive symptoms (Simpson, 2003). "
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    ABSTRACT: Psychotropic medications are commonly administered to elderly clients to manage behavior and psychiatric symptoms. These drugs are known to have potentially serious side effects, to which older adults are more vulnerable. Nurses care for older adults in many different practice settings but have varying degrees of knowledge about these kinds of medications. The purposes of this article are to (a) provide information to geriatric nurses in all settings about how the most commonly prescribed psychotropic medications (i.e., anxiolytic, antidepressant, and antipsychotic drugs) differentially affect older adults; (b) examine recent concerns about the use of psychotropic medications with older adults; and (c) discuss nursing implications for those administering psychotropic medications to older adults.
    Preview · Article · Sep 2009 · Journal of Gerontological Nursing
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