What is the recommended treatment approach for depression in older adults?

From the Guidelines

The recommended treatment approach for depression in older adults typically involves a combination of psychotherapy and medication, with careful consideration of age-related factors. First-line antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as sertraline (starting at 25-50mg daily) or escitalopram (5-10mg daily), which generally have favorable side effect profiles for older adults 1. Treatment should begin at lower doses than those used for younger adults, with gradual increases as needed, and should continue for at least 6-12 months after symptom resolution to prevent relapse. Cognitive behavioral therapy (CBT) is particularly effective and can be used alone for mild depression or in combination with medication for moderate to severe cases, typically involving 12-16 weekly sessions. Some key points to consider when treating depression in older adults include:

• Regular monitoring is essential, with follow-up within 1-2 weeks of starting medication and then every 2-4 weeks initially 1.
• Special considerations for older adults include being vigilant about drug interactions due to common polypharmacy, watching for increased fall risk with certain medications, and addressing common comorbidities like chronic pain or insomnia that may exacerbate depression 1.
• The evidence suggests that antidepressants are effective in treating depressed older adults, with a systematic review indicating that older adults who received antidepressants were twice as likely to have remission from major or minor depression as older adults who received placebo (odds ratio [OR], 2.03 [95% CI, 1.67 to 2.46]) 1.
• Psychotherapy is also an effective treatment of depression in older adults, with two good-quality systematic reviews on the efficacy of psychotherapy in older adults finding that depressed older adults treated with psychotherapy were more than twice as likely to have remission as those who received no treatment 1.

From the FDA Drug Label

Dosage for Elderly Patients No dose adjustment is recommended for elderly patients on the basis of age As with any antidepressant, however, caution should be exercised in treating the elderly. When individualizing the dosage, extra care should be taken when increasing the dose.

The recommended treatment approach for depression in older adults with venlafaxine is to use caution and no dose adjustment is recommended based on age. However, extra care should be taken when increasing the dose 2.

From the Research

Treatment Approaches for Depression in Older Adults

• Depression in older adults is a common psychiatric disorder that can be effectively treated with various approaches, including antidepressants, psychotherapy, exercise therapy, and electroconvulsive therapy 3.
• The treatment approach for depression in older adults is similar to that for younger populations, but there are additional considerations due to comorbidities and cognitive impairment 4.
• Evidence-based psychotherapies, such as cognitive behavioral therapy, interpersonal psychotherapy, and problem-solving therapy, are recommended for mild-moderate depression in older adults 4.

Pharmacological Treatment

• Antidepressants are the best-studied treatment option for depression in older adults, but they can pose a greater risk for adverse events due to multiple medical comorbidities and drug-drug interactions 3.
• The use of pharmacologic treatment for depression in patients with dementia is not supported by high-quality evidence 3.
• Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages 5.

Non-Pharmacological Treatment

• Psychotherapy is recommended for patients with mild to moderate severity depression, and it can be effective for patients who prefer non-pharmacological treatment or are too frail for drug treatments 3.
• Exercise therapy and electroconvulsive therapy may also be effective for treating depression in older adults 3.
• Neuromodulation treatments, such as transcranial magnetic stimulation, could prove beneficial for specific older adults with depression 4.

Treatment Considerations

• Polypharmacy in older patients can be minimized by using the Screening Tool of Older Persons Prescriptions and Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria 3.
• The order in which cognitive-behavioral therapy and antidepressant medication are sequentially combined does not appear to affect outcomes 6.
• Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with cognitive-behavioral therapy, as is adding cognitive-behavioral therapy after antidepressant monotherapy 6.