Management of depression

Practical recommendations for the diagnosis and treatment of depression in the elderly

Depression in the elderly is one of the most common and challenging conditions facing the primary care physician. Symptoms of depression may be incorrectly attributed to "just getting old," or may present with, or be masked by somatic complaints. Failing to make the correct diagnosis can mean losing an opportunity to make a significant improvement in a patient's life, or even saving it. Identifying who does and does not need treatment can limit exposures to unnecessary medications, their side effects, and costs.

 

Accurate diagnosis and appropriate treatment of depression are essential

• Major depression is present in up to one in twenty older patients, with dramatically increased rates in those with other illnesses and functional limitations,¹ causing substantial disability.²
  
• Older people are 33% more likely to commit suicide than the general population.³
• Up to 75% of those who committed suicide had seen their health care providers within the month before their death.⁴

Making the diagnosis

In a busy practice, it can seem daunting to identify and diagnose depression correctly, especially in a patient with multiple chronic illnesses or life-crises such as bereavement.

Simple, practical screening tools can help. One well-validated instrument compresses the initial depression screening to just two questions.⁶ These can be provided to the patient to answer in the waiting room:

• "During the past month, have you been bothered by feeling down, depressed or hopeless?"
• "During the past month, have you been bothered by little interest or pleasure in doing things?"

In all patients with symptoms of depression, a careful history and physical should seek other treatable problems such as hypothyroidism, dementia or parkinsonism, which must be considered before labeling the patient as "depressed".

Patients who screen positive on a depression screen should be queried using the DSM-IV criteria⁵ to establish the diagnosis.

For mild depression

A recent comprehensive review of the clinical trials literature, including studies with negative results that were not published, found that for patients with only mild depression, there is no clear benefit of drug treatment over placebo.⁷ For these patients, drug treatment may bring the risk of side effects without the promise of symptomatic improvement. Other treatment modalities, such as cognitive behavioral therapy, interpersonal therapy, or even careful monitoring without treatment may be appropriate for these patients.

If depression is moderate to severe...

...this constitutes a major medical problem that can cause substantial morbidity and mortality if untreated. In these patients, it is important to rule out a treatable organic condition or medication side effect. Once this is done, antidepressants can be an important component of treatment. Although the trials comparing individual antidepressants to placebo or to each other have methodological limitations, these trials have generally found that all of the commonly used agents are equally effective.^8-10

Older tricyclic antidepressants have been largely replaced by the SSRIs because of differences in their side effect profiles, and because SSRIs present a much lower suicide risk, since an overdose of a tricyclic antidepressant carries a high risk of death.

Initiating drug treatment

Before initiating therapy, patients should always be evaluated for conditions that would require psychiatric referral, including:

• suicidality
• severe features such as psychosis, minimal verbal interaction, or severely restricted food intake
• manic symptoms

Based on their effectiveness and side effect profiles, most older patients requiring an antidepressant can be started on citalopram 10-20 mg/day or sertraline 25-50 mg/day.

Patients should be given the following information with the first prescription:

• Improvement in symptoms may not occur for 4 to 6 weeks. Patients who are not informed about the time required to see a benefit are more likely to abandon therapy if they experience only side effects during this period.
• These drugs may increase feelings of suicidality in the initial weeks of treatment. Patients should be warned about this and told to contact their physician if this occurs. Patients should be carefully reassessed during this period. 

Continuation and monitoring of therapy

Patients should be reassessed after 4 to 6 weeks. A 50% reduction in the original symptoms represents an adequate response, and can be identified with the question:

• "How depressed are you compared to when we first met?"

Research has shown that patients who say they are "much better" are having an adequate response to treatment.¹² If a patient is not having an adequate response, the physician should consider augmenting or changing the initial treatment.

Intensifying therapy

The federally funded STAR*D trial evaluated 4,000 patients with moderate to severe depression, testing several regimens in order to determine the best treatment approach for those who do not respond adequately to citalopram.¹³ This important study provided valuable evidence on the efficacy of several alternative next-step strategies.¹⁴ A management approach based on the STAR*D results is shown below.

Adjunct therapies

Although medications have become the most common treatments for depression, other forms of management can play an important role for patients with moderate to severe depression, and will actually work as well as drugs in patients with mild depression. Cognitive behavioral therapy and interpersonal psychotherapy are two modalities that have been extensively studied and consistently show a beneficial effect, even for patients with more severe depression.^10,15

Rarely, depression can present emergently in an older patient whose symptoms are so severe that they lead to total withdrawal and cessation of food and fluid intake. In these patients, or in carefully selected patients with refractory severe depression, electroconvulsive therapy (ECT) can be strikingly effective and even life-saving. 

Referral to a psychiatrist

Although primary care doctors manage most depression in the elderly, for some patients help from a psychiatrist is needed. Patients should be screened for suicidal ideation both initially and at follow-up visits, and evidence of suicidality should result in immediate referral. Patients with atypical features of depression suggesting schizophrenia or bipolar disease, or those not responding to treatment should also be referred to psychiatric consultation.

Medication costs

Even though the effectiveness of most commonly used antidepressants is nearly identical, the costs of drug regimens can differ dramatically, an important consideration for patients with limited or no health insurance, as well as for those taking multiple drugs who must bear the burden of many co-payments. Unaffordable prescriptions reduce adherence, which can doom the effectiveness of even the most carefully constructed regimen.

References:

1. NIMH. Older adults: depression and suicide facts.Available at http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts.shtml#cdc. 2. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J.The functioning and well-being of depressed patients. Results from the Medical Outcomes Study.JAMA. 1989;262(7):914-919.3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online].(2005)[accessed July 18 2008].Available from URL:www.cdc.gov/ncipc/wisqars. 4. Szanto K, Gildengers A, Muslant BH, Brown G, Alexopoulos GS, Reynolds CF 3rd. Identification of suicidal ideation and prevention of suicidal behavior in the elderly. Drugs Aging. 2002;19(1):11-24. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 6. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003;327(7424):1144-1146. 7. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine. 2008;5(2):e45. 8. Gartlehner G, Hansen R, Kahwati L, Lohr K, Gaynes B, Carey T. Drug class review on second generation antidepressants. Final AHRQ-approved report available at http://www.ohsu.edu/drug effectiveness/reports/draft.cfm; most recent update, May 2006. 9. Mottram P, Wilson K, Stroble J. Antidepressants for depressed elderly. Cochrane Database Syst Rev (online). 2006(1):CD003491. 10. Wilson K, Mottram P, Sivanranthan A, Nightingale A. Antidepressant versus placebo for depressed elderly. Cochrane Database Syst Rev (online). 2001(2):CD000561. 11. Nelson JC, Delucchi K, Schneider LS. Efficacy of second generation antidepressants in late-life depression: a meta-analysis of the evidence. Am J Geriatr Psych. 2008 May 12 [Epub ahead of print]. 12. Datto CJ, Thompson R, Knott K, Katz IR. Older adult report of change in depressive symptoms as a treatment decision tool. J Am Ger Soc. 2006;54(4):627-631. 13. Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ, Rosenbaum JF, Sackeim HA, Kupfer DJ, Luther J, Fava M. Acute and longer-term outcomes in depressed patients requiring one or several treatment steps: a STAR*D report. Am J Psych. 2006;163(11):1905-1917. 14. Rush AJ, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med. 2006;354(12):1231-1242. 15. de Mello MF; de Jesus Mari J, Bacaltchuk J, Verdeli H, Neugebauer R. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Er Arch Psych Clin Neurosci. 2005;255(2):75-82.

This information was created by the Alosa Foundation, a nonprofit organization that is not affiliated in any way with any pharmaceutical company. It is provided through the Independent Drug Information Service and supported by the PACE Program of the Department of Aging of the Commonwealth of This Pennsylvania.

This summary was written by Niteesh K. Choudhry, M.D., Ph.D., Assistant Professor of Medicine, Harvard Medical School (HMS); Michael A. Fischer, M.D., M.S., Assistant Professor of Medicine, HMS; Elizabeth Hoge, M.D., Instructor in Psychiatry, HMS; Aaron Kesselheim, M.D., J.D., M.P.H., Instructor in Medicine, HMS; Seema Parikh, M.B.B.S.(M.D.), ER.C.P., Research Fellow, HMS; Frank May, M.App.Sci. (Pharm), Visiting Clinical Professor, HMS; William H. Shrank, M.D., M.S.H.S., Instructor in Medicine, HMS; Michelle Spetman, M.S., M.P.H. Series editor: Jerry Avorn, M.D., Professor of Medicine, Harvard Medical School.

These are general recommendations only; specific clinical decisions should be made by the treating physician based on an individual patient's clinical condition.