Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 4-04: Management of Common Geriatric Problems + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Some depressed elders may not admit to depressed mood Depression screening in elders should include a question about anhedonia +++ General Considerations ++ Depressive symptoms are often related to loss, illness, or bereavement Depression rate rises as illness burden increases Depression is more common among hospitalized and institutionalized elders Older single men have the highest rate of completed suicides of any demographic group New onset of depressive symptoms may be an early sign of a dementing illness +++ Demographics ++ Major depressive disorder Most studies report an overall prevalence rate of < 3% Appears to be less common in older adults than younger adults However, clinically significant depressive symptoms and subclinical depression are present in up to 50% of older adults compared to 16% of younger adults Depression is more common in hospitalized and institutionalized elders Older single men have the highest rate of completed suicides of any demographic group + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ A simple two-question screen is at least 96% sensitive for detecting major depression: "Over the last month, have you often been bothered by feeling sad, depressed or hopeless?" "During the last month, have you often been bothered by little interest or pleasure in doing things?" Positive responses can be followed up with more comprehensive interviews such as the PHQ-9 (https://patient.info/doctor/patient-health-questionnaire-phq-9) DSM-5 diagnosis requires at least 5 of the following symptoms for diagnosis of major depression Low mood (required for diagnosis) Diminished interest or pleasure (anhedonia) in most activities (required) Significant weight loss (or weight gain) Insomnia or hypersomnia Fatigue Feelings of worthlessness or guilt Diminished ability to think or concentrate Ask patients and their family members about alcohol and medication use (eg, benzodiazepines) +++ Differential Diagnosis ++ Substance-induced mood disorder (alcoholism) Bipolar disorder Grief reaction + Treatment Download Section PDF Listen +++ +++ Medications ++ Choice of antidepressant agent in elders is usually based on side effect profile, cost, and patient-specific factors such as presenting symptoms and comorbidities SSRIs are often used as first-line agent because of their relatively benign side-effect profile (Table 25–7) Adding methylphenidate to an SSRI appears to enhance clinical response rates Mirtazapine is often used for patients with weight loss, anorexia, or insomnia Duloxetine is useful in patients who have neuropathic pain Esketamine is approved for treatment-resistant depression, but there is little evidence regarding its safety and efficacy for older adults Regardless of the drug chosen, many experts recommend starting elders at a relatively low dose, titrating to full dose slowly, and continuing for a longer trial (at least 8 weeks) before trying a different medication Augmentation therapy (eg, with lithium, methylphenidate, or aripiprazole) can enhance clinical response in treatment-resistant depression Electroconvulsive therapy should be considered for patients with severe or catatonic depression Duration of drug treatment should be for at least 6 months after remission of the patient's first episode Problem-solving therapy and cognitive behavioral therapy can improve outcomes alone or in combination with medication therapy See Depression (Table 25–7) for more detailed description of individual classes of antidepressants ++Table Graphic Jump LocationTable 25–7.Commonly used antidepressant medications (listed in alphabetical order within classes).View Table||Download (.pdf) Table 25–7. Commonly used antidepressant medications (listed in alphabetical order within classes). Medication Usual Daily Oral Dose (mg) Usual Daily Maximum Dose (mg) Sedative Effects1 Anticholinergic Effects1 Cost per Unit Cost for 30 Days of Treatment Based on Maximum Dosage2 SSRIs Citalopram (Celexa) 20 40 < 1 1 $0.14/40 mg $4.20 Escitalopram (Lexapro) 10 20 < 1 1 $0.13/20 mg $3.90 Fluoxetine (Prozac, Sarafem) 5–40 80 < 1 < 1 $4.20/20 mg $504.00 Fluvoxamine (Luvox) 100–300 300 1 < 1 $2.63/100 mg $236.70 Paroxetine (Paxil) 20–30 50 1 1 $2.64/20 mg $161.10 Sertraline (Zoloft) 50–150 200 < 1 < 1 $2.70/100 mg $162.00 SNRIs Desvenlafaxine (Pristiq) 50 100 1 < 1 $5.80/100 mg $179.00 Duloxetine (Cymbalta) 40 60 2 3 $1.92/60 mg $57.60 Levomilnacipran (Fetzima) 40 120 1 1 $16.50/80 mg $495.00 Milnacipran (Savella) 100 200 1 1 $8.02/100 mg $481.20 Venlafaxine XR (Effexor) 150–225 225 1 < 1 $0.63/75 mg $56.70 Tricyclic and Clinically Similar Compounds Amitriptyline (Elavil) 150–250 300 4 4 $2.14/150 mg $128.40 Amoxapine (Asendin) 150–200 400 2 2 $1.98/100 mg $237.60 Clomipramine (Anafranil) 100 250 3 3 $9.70/75 mg $1164.00 Desipramine (Norpramin) 100–250 300 1 1 $4.48/100 mg $403.20 Doxepin (Sinequan) 150–200 300 4 3 $1.97/100 mg $177.30 Imipramine (Tofranil) 150–200 300 3 3 $1.16/50 mg $219.60 Maprotiline (Ludiomil) 100–200 300 4 2 $2.34/75 mg $280.80 Nortriptyline (Aventyl, Pamelor) 100–150 150 2 2 $0.29/75 mg $17.40 Protriptyline (Vivactil) 15–40 60 1 3 $3.30/10 mg $594.00 Trimipramine (Surmontil) 75–200 200 4 4 $9.44/100 mg $566.40 Monoamine Oxidase Inhibitors Phenelzine (Nardil) 45–60 90 … … $0.84/15 mg $151.20 Selegiline transdermal (Emsam) 6 (skin patch) 12 … … $70.27/6 mg patch $2018.10 Tranylcypromine (Parnate) 20–30 50 … … $3.60/10 mg $540.00 Other Compounds Bupropion SR (Wellbutrin SR) 300 4003 < 1 < 1 $3.38/200 mg $202.80 Bupropion XL (Wellbutrin XL) 3004 4504 < 1 < 1 $0.55/300 mg $32.10 Mirtazapine (Remeron) 15–45 45 4 2 $2.77/30 mg $84.90 Nefazodone (Serzone) 150–600 600 3 1 $4.98/200 mg $448.20 Trazodone (Desyrel) 100–300 400 4 < 1 $0.21/100 mg $25.60 Vilazodone (Viibryd) 10–40 40 1 1 $11.43/40 mg $342,90 Vortioxetine (Brintellix) 10 20 < 1 < 1 $16.11/20 mg $483.30 11, weak effect; 4, strong effect.2Average wholesale price (AWP, for AB-rated generic when available) for quantity listed. Source: IBM Micromedex Red Book (electronic version) IBM Watson Health, Greenwood, CO, USA. Available at https://www.micromedexsolutions.com (cited April 10, 2020). AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions.3200 mg twice daily.4Wellbutrin XL is a once-daily form of bupropion. Bupropion is still available as immediate release, and, if used, no single dose should exceed 150 mg.SNRIs, serotonin norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors. + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Depressed patients who have comorbidities, such as heart failure, are at higher risk for hospitalization, tend to have longer hospital stays, and have worse outcomes than their nondepressed counterparts +++ When to Refer ++ Consider referral for psychiatric evaluation patients who have mania, psychosis, catatonia, or treatment-resistant depression Consider referral for any patient who might be considered for electroconvulsive therapy +++ When to Admit ++ Admit as an acute psychiatric emergency, patients who are psychotic, suicidal, homicidal, catatonic, or gravely disabled + References Download Section PDF Listen +++ + +Dham P et al. Collaborative care for psychiatric disorders in older adults: a systematic review. Can J Psychiatry. 2017 Nov;62(11):761–71. [PubMed: 28718325] + +Haigh EAP et al. Depression among older adults: a 20-year update on five common myths and misconceptions. Am J Geriatr Psychiatry. 2018 Jan;26(1):107–22. [PubMed: 28735658] + +Kok RM et al. Management of depression in older adults: a review. JAMA. 2017 May 23;317(20):2114–22. [PubMed: 28535241]