Depression

CME credit available from Harvard Medical School through December 2021.

Published Materials

The goal of this program is to update prescribers on the most recent evidence and guidelines regarding the treatment of depression among older adults.

Depression occurs in up to one in ten older adults seen in primary care, with much higher rates in medical and institutional settings. 13 Patients with depression in late life have worse health outcomes than patients without depression, including a higher risk of mortality in patients with underlying coronary heart disease and an elevated risk of suicide. 4,5

Although the U.S. Preventative Services Task Force recommends screening all adults with depression, only 1 in 3 adults who screen positive for depression receive treatment.6 Effective treatment can reduce disability and improve quality of life.

SCREEN FOR, EVALUATE, AND TREAT DEPRESSION SYMPTOMS

PSYCHOTHERAPY IS AN EFFECTIVE TREATMENT

In older adults, cognitive behavioral therapy improved the likelihood of treatment response nearly three-fold and remission seven-fold compared to patients randomized to usual care or wait-list controls.7 Other forms of psychotherapy such as interpersonal therapy, problem solving therapy, and supportive therapy may also be effective. Referral to a psychotherapist is more important than finding one specializing in one treatment over another.

ANTIDEPRESSANT TREATMENT FOR MODERATE TO SEVERE DEPRESSION

Findings of a large multi-year NIH-funded STAR*D trial can guide initial treatment choices.8

In older adults, it may be prudent to follow these general treatment principles

  • Start low, go slow, but don’t stall.
    • Increase to a therapeutic dose.
  • Provide adequate time for effect, as older adults may take up to 10-12 weeks to respond.9
  • While antidepressants are still effective in older adults, response rates may be lower for those 55 and over.10
  • Switching medications may be preferable in frail older adults to avoid polypharmacy resulting from augmentation.
  • Monitor for side effects of antidepressant treatment, such as hyponatremia, bleeding, falls, fractures, and prolonged QTc.

For patients who do not respond to several medications from at least two different classes, additional approaches may be recommended by a specialist, such as lithium, antipsychotic medications, electroconvulsive therapy or transcranial magnetic stimulation.

Older adults have the highest rate of completed suicide.5 Evaluate patients who express thoughts of self-harm or that they would be better off dead.

Suicide assessment framework:11

  1. Identify risk factors (e.g., untreated mood, anxiety, psychotic or substance use disorders, access to lethal means)
  2. Identify protective factors (e.g., ability to cope with stress, positive family or social relationships, responsibility to children or beloved pets)
  3. Ask about suicidal ideation, plan, behaviors, and intent
  4. Determine risk level and select one or more interventions
  5. Provide patients and loved ones with a safety plan and document

 


Information current at time of publication, December 2018.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.


Additional Resources

National Suicide Prevention Lifeline

Senior Suicide Prevention


References
  1. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry. 1999;174:307-311.
  2. Taylor WD. Clinical practice. Depression in the elderly. N Engl J Med. 2014;371(13):1228-1236.
  3. Meeks TW, Vahia IV, Lavretsky H, Kulkarni G, Jeste DV. A tune in “a minor” can “b major”: a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults. J Affect Disord. 2011;129(1-3):126-142.
  4. Barth J, Schumacher M, Herrmann-Lingen C. Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosom Med. 2004;66(6):802-813.
  5. Conejero I, Olie E, Courtet P, Calati R. Suicide in older adults: current perspectives. Clin Interv Aging. 2018;13:691-699.
  6. Olfson M, Blanco C, Marcus SC. Treatment of Adult Depression in the United States. JAMA Intern Med. 2016;176(10):1482-1491.
  7. Gould RL, Coulson MC, Howard RJ. Cognitive behavioral therapy for depression in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc. 2012;60(10):1817-1830.
  8. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917.
  9. Nelson JC, Delucchi K, Schneider LS. Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence. Am J Geriatr Psychiatry. 2008;16(7):558-567.
  10. Tedeschini E, Levkovitz Y, Iovieno N, Ameral VE, Nelson JC, Papakostas GI. Efficacy of antidepressants for late-life depression: a meta-analysis and meta-regression of placebo-controlled randomized trials. J Clin Psychiatry. 2011;72(12):1660-1668.
  11. Jacobs D. Assessment Five-Step Evaluation and Triage for Mental Health Professionals (SAFE-T). 2009.
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