Treatment

Treatment requires the following to be borne in mind:

• remember interactions in multiply medicated patients
• there may be increased memory loss in some patients on antidepressants
• patients have less functional reserve, thus might experience side effects sooner than younger patients
• behavioural methods can be effective if the indications exist, and psychotherapy in the form of cognitive behaviour therapy and interpersonal therapy is the first-line treatment of mild depression (1)

NICE have stated that (2):

• for older adults with depression, antidepressant treatment should be given at an age-appropriate dose for a minimum of 6 weeks before treatment is considered to be ineffective. If there has been a partial response within this period, treatment should be continued for a further 6 weeks
• SSRIs are, in general, the antidepressant treatment of first choice in management of depression in the elderly. In the long term, they reduce the risk of suicide. (3)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are considered as the second-line treatment and include venlafaxine and duloxetine. This group of medication is thought to be safe in the elderly population. This class of the drug has a dual-action and found to be useful in patients with comorbid pain.(4)
• tricyclic antidepressants can be efficacious, though these are no longer considered first or second-line agents. These agents may be useful in cases of treatment failure with other antidepressants. They are dangerous in overdose, although lofepramine has the best safety profile of this class of drugs.
• when prescribing antidepressants - in particular tricyclics - for older adults with depression, careful monitoring for side effects should be undertaken
• note that there is an increased frequency of drug interactions when prescribing an antidepressant to older adults who are taking other medications

For more detailed guidance then consult the full guideline (2)

Reference

1. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry. 2006 Sep;163(9):1493-501.
2. NICE. Depression in adults: treatment and management. NICE guideline NG222. Published June 2022
3. Bruce ML et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004 Mar 03;291(9):1081-91
4. Mukai Y, Tampi RR. Treatment of depression in the elderly: a review of the recent literature on the efficacy of single- versus dual-action antidepressants. Clin Ther. 2009 May;31(5):945-61