Use of Antidepressants in Older Patients with Co-Morbid Medical Conditions

Abstract

Advanced age and medical complexity are characteristics not often associated with participation in randomised, placebo-controlled trials of antidepressants. Thus, evidence for the efficacy of antidepressant treatment among typical seniors with somatic illness and advanced age is scant. Furthermore, there appears to be no clear empirically based delineation between depressive symptoms and depressive disorders among very old, physically ill adults. The increasing numbers of antidepressants and adjunctive medications add to the practitioner's perplexity when confronted with a very old, very depressed patient. Nonetheless, a growing body of evidence from antidepressant studies in the context of age-related somatic illnesses allows reasonable inferences to guide diagnosis and treatment. Once the practitioner and patient agree upon an antidepressant trial, the benefits of prescribed medication should be assessed within the first days rather than first weeks of treatment. The patient and practitioner should expect to escalate the antidepressant to the established therapeutic range rather than seek the lowest dose that is effective. Patients who experience no benefit whatsoever within the first weeks of treatment despite being within the therapeutic range should be offered an alternative promptly. With the results of studies of depression in co-morbid disorders and analyses of treatment response trajectory, the practitioner can be assured that advanced age, physical illness and depression need not go hand in hand.

Under-treatment of depression in older persons

“…Despite the growth of dedicated geriatric centers in academic medical institutions across the U.S.(Warshaw et al, 2006), most older persons in this country receive treatment for depression from primary care physicians in more traditional practices (Crystal et al, 2003; Harman et al, 2006) who often lack specialty training in geriatric assessment and care (Nutting et al, 2000). Without expertise in geriatric medicine, physicians may be more likely to misdiagnose depression as dementia (Wright and Persad, 2007), may mistakenly attribute depressive symptoms as an acceptable response to aging-related illnesses or conditions (Kennedy and Marcus, 2005), or may interpret depressive symptoms as an inevitable response to loss of social support and socialization (Oxman and Hull, 2001). Other factors contributing to the under-diagnosis of depression in this population include limited time for physicians to discuss mental health during office visits (Tai-Seale et al, 2007) and older patients’ general reluctance to report psychological symptoms (Lebowitz et al, 1997; Lyness et al, 1995).…”

Clinical Effectiveness of Integrating Depression Care Management Into Medicare Home Health

“…In this context, active symptoms suggest the current antidepressant regime is ineffective and patients may benefit from change (e.g., dose, switching, augmentation and/or the non-specific benefit of care management). 59 …”

The Use of Antidepressants in Belgian Nursing Homes

“…The MED does not really consider these particular changes in determining the threshold. In literature, there is not much guidance on dosing of antidepressants in frail older adults; slow upwards titration and close monitoring of side-effects is recommended [41] .…”