Medical Monitor: Medical Treatment of Depression
Clinicians must keep the special needs of geriatric patients in mind.
Depression is one of the most commonly encountered psychiatric disorders in the United States, affecting approximately 8% of Americans and contributing to more than $210 billion in health care costs annually. In 2015, roughly 16.1 million adults experienced at least one major depressive episode in the previous year.1
While not all depressive symptoms can contribute to significant impairment in functioning, it’s typically those that lead to disability and associated health care costs that are presented to the public. Approximately 1% to 5 % of older adults live with depression, and this incidence may be higher among home health care or hospital patients. As the older adult population continues to grow and people live longer, the responsibility of understanding and managing concerns of aging increases.2 Older adults can face challenges such as loss of independence, loss of spouse, or health problems that can lead to depression, but depression isn’t a normal part of the aging process.3 While depression stems from a variety of psychological, environmental, and physical factors—including genetics, personality characteristics, and medication use—there are common and standard treatment approaches to management.
General Management Approach for Depression
If these approaches don’t produce the desired effects, another option is vagus nerve stimulation, which utilizes an implanted generator, wires, and electrodes to provide electricity to the vagus nerve to alleviate or eradicate the signs of depression.7 Another nonpharmacological intervention that can be considered on a case-by-case basis is deep brain stimulation, which is designed to provide stimulation of the neurons in the brain by means of an implanted generator and electrodes, as with vagus nerve stimulation.8
The strongest evidence for the effectiveness of nonpharmacological interventions has been established for cognitive behavioral therapy, problem solving therapy, and interpersonal therapy. Ultimately, the decision to take a nonmedical approach to depression treatment must be guided by an extensive review of the risks vs benefit of the applied interventions.
With any antidepressant that’s initiated for late-life depression, the dose should begin at one-half that of the normal adult dose and then increased with tolerability and clinical response. Since there are specific neurotransmitters that have been correlated with depression—notably serotonin, norepinephrine, and dopamine—many antidepressants have been developed to target one or more of these neurotransmitters as a means of achieving symptom control.11
Monoamine Oxidase Inhibitors
TCAs, such as imipramine, nortriptyline, desipramine, and protriptyline, work by inhibiting the reuptake of serotonin and norepinephrine and blocking alpha-1-adrenergic , histamine-H1, and muscarinic acetylcholine receptors to different degrees.13 If the decision is made to utilize a TCA in a geriatric patient, an electrocardiogram, assessment of blood pressure, and blood level monitoring should be performed at baseline and during the course of treatment.14 Nortriptyline and desipramine are noted to be less likely to have anticholinergic side effects.
When initiating treatment with TCAs, clinicians should take a slow and gradual approach and ensure that the patient knows not to abruptly discontinue medication due to the risk of developing cholinergic rebound effect.14
The Effects of SSRIs and SNRIs
Selective and norepinephrine inhibitors (SNRIs) include duloxetine, venlafaxine, and desvenlafaxine, which are considered to be potent inhibitors of serotonin and norepinephrine reuptake and weak inhibitor of dopamine uptake.16 SNRIs possess virtually no affinity for cholinergic, histaminergic, and alpha-1 adrenergic receptors. They are also well tolerated in geriatric patients and have been recommended along with SSRIs for long term care residents diagnosed with depression.14,17,18
Norepinephrine and Dopamine Reuptake Inhibitors
Other Antidepressant Agents
Serotonin-2 antagonist reuptake inhibitors such as trazodone and nefazodone work by inhibiting the reuptake of serotonin, but also potentially block the serotonin receptors. Mirtazapine can serve as an alternative agent if SSRIs or SNRIs don’t produce a desired effect. Trazodone has the ability to block histaminergic and alpha-adrenergic receptors while nefazodone also has weak norepinephrine inhibition and weak alpha adrenergic blocking properties.20,21 Trazodone has been relegated to a sleep agent, but there are instances in which it can be used for depression as well. Nefazodone isn’t used in the United States at this time.
Last, one of the newer classes of antidepressants is the serotonin reuptake inhibitor/5-HT1A receptor partial agonist. Vilazodone, a drug in this class, inhibits presynaptic serotonin reuptake and has partial agonist activity at the 5-HT1A receptor.21 It’s known to cause nausea and diarrhea but is thought to have a lower risk of sexual side effects when compared with the majority of the other antidepressants.
— Abimbola Farinde, PharmD, is a clinical pharmacy specialist with experience in the field and practice of psychopharmacology/mental health and geriatric pharmacy. A professor at Columbia Southern University, she has worked with active-duty soldiers with dual diagnoses of traumatic brain injury and a psychiatric disorder providing medication therapy management and disease state management. She’s also worked with mentally impaired and developmentally disabled individuals.
2. Tkatch R, Musich S, MacLeod S, Alsgaard K, Hawkins K, Yeh CS. Population health management for older adults: review of interventions for promoting successful aging across the health continuum. Gerontol Geriatr Med. 2016;2:2333721416667877.
3. Depression is not a normal part of growing older. Centers for Disease Control and Prevention website. https://www.cdc.gov/aging/depression/index.html. Updated January 6, 2021.
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14. Canadian Coalition for Seniors’ Mental Health. National guidelines for seniors’ mental health: the assessment and treatment of mental health issues in long term care homes (focus on mood and behaviour symptoms). https://brainxchange.ca/Public/Files/Long-Term-Care/NatlGuideline_LTC.aspx. Published May 2006. Accessed January 5, 2021.
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17. Brown MN, Lapane KL, Luisi AF. The management of depression in older nursing home residents. J Am Geriatr Soc. 2002;50(1):69-76.
18. Fink J. Serotonin-norepinephrine reuptake inhibitors (SNRIs). Healthline website. http://www.healthline.com/health/depression/serotonin-norepinephrine-reuptake-inhibitors-snris. Updated June 9, 2020. Accessed January 4, 2021.
19. Major depression. U.S. National Library of Medicine website. https://medlineplus.gov/ency/article/000945.htm. Reviewed May 2020. Accessed January 5, 2021.
20. Hirsh M, Birnhaum R. Serotonin modulators: pharmacology, administration, and side effects. UpToDate website. https://www.uptodate.com/contents/serotonin-modulators-pharmacology-administration-and-side-effects?search=serotonin-modulators-pharmacology-administration-and-side-effects.&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Updated December 3, 2020. Accessed January 5, 2021.
21. Cruz MP. Vilazodone HCl (Viibryd): a serotonin partial agonist and reuptake inhibitor for the treatment of major depressive disorder. P T. 2012;37(1):28-31.
22. Health Canada endorsed important safety information on atypical antipsychotic drugs and dementia. Health Canada website. https://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2005/14307a-eng.php. Published June 22, 2005. Accessed January 4, 2021.