Preferred Antidepressant for Elderly Patients
Sertraline is the preferred first-line antidepressant for elderly patients, with citalopram and escitalopram as equally appropriate alternatives. 1, 2, 3
Primary Recommendations
The American Academy of Family Physicians specifically identifies sertraline, citalopram, escitalopram, mirtazapine, venlafaxine, and bupropion as preferred agents for older adults due to their favorable adverse effect profiles. 1, 2
Why Sertraline Stands Out
- Sertraline has a particularly low potential for drug interactions compared to other SSRIs, which is critically important in elderly patients who typically take multiple medications 4, 5, 6
- No dosage adjustment is required based on age alone for sertraline, simplifying prescribing 4, 5
- Sertraline demonstrates superior cognitive functioning outcomes compared to nortriptyline and fluoxetine in elderly patients 4, 5
- Quality of life improvements are significantly better with sertraline versus tricyclic antidepressants 4, 5
Critical Dosing Approach
Start at 50% of standard adult doses due to elderly patients' significantly greater risk of adverse drug reactions 1, 2
- Sertraline: Start 25-50 mg daily, maximum 200 mg daily 3
- Citalopram: Start 10 mg daily, MAXIMUM 20 mg daily in patients >60 years due to FDA boxed warning for QT prolongation 2, 3
- Escitalopram: Start 5-10 mg daily, maximum 10-20 mg daily 1, 3
Antidepressants to Absolutely Avoid
Paroxetine must be avoided due to significantly higher anticholinergic effects that are particularly problematic in elderly patients 1, 2, 3
Fluoxetine must be avoided due to its long half-life, greater risk of drug interactions, and potential for agitation and overstimulation 1, 2, 3
Tertiary-amine tricyclic antidepressants (amitriptyline, imipramine) are considered potentially inappropriate medications according to the American Geriatric Society's Beers Criteria due to significant anticholinergic effects 1
Essential Safety Monitoring
Monitor for hyponatremia, especially within the first month of treatment, as SSRIs are associated with clinically significant hyponatremia in 0.5-12% of elderly patients 2, 7
Watch for increased GI bleeding risk (OR 1.2-1.5), particularly when SSRIs are combined with NSAIDs or antiplatelet drugs 2
Reassuring safety note: Antidepressants are actually protective against suicidality in adults ≥65 years (OR 0.06), unlike in younger populations 2
Treatment Duration
Continue treatment for 4-12 months after first episode remission 1, 2, 3
For recurrent depression (≥3 episodes), consider indefinite maintenance therapy, as recurrence risk escalates dramatically: 50% after first episode, 70% after second episode, 90% after third episode 1, 2
Timeline for Response
Allow 4-8 weeks for full therapeutic trial before determining effectiveness 3
Consider dose increases only after 5-7 days at each dose level if no significant improvement 3
Common Pitfall to Avoid
Never exceed citalopram 20 mg/day in patients >60 years due to dose-dependent QT prolongation risk per 2012 FDA boxed warning 2, 3