From the Guidelines
For a 70-year-old female who experienced depression and side effects with Zoloft (an SSRI), I would recommend trying a medication from a different antidepressant class, specifically mirtazapine (Remeron), as it has a more favorable side effect profile for older adults, according to the American College of Physicians 1. Starting at a low dose of 7.5-15mg taken at bedtime would be appropriate for an elderly patient, with potential to increase gradually to 30mg if needed and tolerated. Mirtazapine works differently than SSRIs by affecting both serotonin and norepinephrine systems, which can help with sleep and appetite issues common in depression. It tends to cause less nausea, sexual dysfunction, and agitation than SSRIs. For elderly patients, this medication is often well-tolerated, though it may cause some sedation and weight gain. Some key points to consider when selecting an alternative antidepressant include:
- The patient's preferences and adverse effect profiles, as recommended by the American College of Physicians 1
- The cost and dosing frequency of the medication, as these can impact patient adherence and overall treatment outcomes
- The potential for drug interactions and side effects, particularly in older adults who may be taking multiple medications Other reasonable alternatives include:
- Bupropion (Wellbutrin), which is activating rather than sedating, and has a lower rate of sexual adverse events than fluoxetine or sertraline, as noted in the American College of Physicians guideline 1
- Venlafaxine (Effexor), a serotonin-norepinephrine reuptake inhibitor, which may be slightly more effective than SSRIs but is associated with higher rates of adverse effects, according to the American Family Physician journal 1 Given her age, medication changes should be made gradually with close monitoring for side effects, and she should continue any therapy or lifestyle interventions that support her mental health alongside medication treatment. Regular assessment of patient status, therapeutic response, and adverse effects of antidepressant therapy is crucial, beginning within 1 to 2 weeks of initiation of therapy, as recommended by the American College of Physicians 1.
From the FDA Drug Label
1 Suicidal Thoughts and Behaviors in Adolescents and Young Adults In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and 4,500 pediatric patients, the incidence of suicidal thoughts and behaviors in antidepressant-treated patients age 24 years and younger was greater than in placebo-treated patients.
2 Agranulocytosis In premarketing clinical trials, 2 (1 with Sjögren’s Syndrome) out of 2796 patients treated with mirtazapine tablets developed agranulocytosis [absolute neutrophil count (ANC) <500/mm3 with associated signs and symptoms, e.g., fever, infection, etc.]
3 Serotonin Syndrome Serotonergic antidepressants, including mirtazapine tablets, can precipitate serotonin syndrome, a potentially life-threatening condition.
The next safest thing to try for depression if the patient failed the SSRI is mirtazapine. However, it is crucial to monitor the patient for:
- Suicidal thoughts and behaviors, especially during the initial few months of drug therapy
- Agranulocytosis, by checking for signs of infection and monitoring white blood cell count
- Serotonin syndrome, by watching for mental status changes, autonomic instability, and neuromuscular symptoms Considering the patient's age (70 years), the risk of suicidal thoughts and behaviors is lower compared to younger patients, as shown in Table 1, with 6 fewer patients per 1000 patients treated experiencing suicidality compared to placebo 2.
From the Research
Alternatives to SSRIs for Depression
If a 70-year-old female patient has failed to respond to SSRIs like Zoloft or experienced bad side effects, there are other options to consider:
- Venlafaxine: A serotonin-norepinephrine reuptake inhibitor (SNRI) that has been shown to be effective in treating depression, especially in patients who have not responded to SSRIs 3, 4, 5.
- Mirtazapine: An antidepressant that works by increasing the levels of certain neurotransmitters in the brain, which can help improve mood and reduce symptoms of depression 3, 6, 5.
- Bupropion: An antidepressant that works by increasing the levels of certain neurotransmitters in the brain, which can help improve mood and reduce symptoms of depression, but may require careful monitoring due to potential interactions with other medications 4, 7.
- Desvenlafaxine: An SNRI that has been shown to be effective in treating depression, especially in patients who have not responded to SSRIs 4, 5.
Considerations for Older Adults
When prescribing antidepressants to older adults, it's essential to consider the potential risks and benefits, including:
- Hyponatraemia: A condition that can occur when taking certain antidepressants, especially in elderly patients, and can lead to confusion and other symptoms 7.
- Polypharmacy: The use of multiple medications, which can increase the risk of adverse interactions and side effects 7.
- Monitoring: Regular monitoring of serum sodium levels and other potential side effects is crucial when prescribing antidepressants to older adults 7, 5.
Treatment Options
The choice of antidepressant will depend on the individual patient's medical history, symptoms, and preferences. A thorough evaluation and discussion with a healthcare professional can help determine the best course of treatment. Some studies suggest that:
- Combination therapy: Using a combination of antidepressants and psychotherapy may be effective in treating depression, especially in patients who have not responded to single antidepressant therapy 4.
- Network meta-analysis: A systematic review and network meta-analysis can help compare the efficacy, acceptability, tolerability, and safety of different antidepressants 5.