Depression

Three methods of treatment have been demonstrated to be effective among elderly persons: antidepressant medications, psychosocial interventions, and electroconvulsive therapy (ECT). Antidepressant medications can be divided into four classes. The first class, heterocyclic antidepressants (HCAs), includes medications such as nortriptyline (Pamelor, Aventyl), desipramine (Norpramin), bupropion (Wellbutrin), and trazedone (Desyrel). HCAs tend to produce unpleasant side effects such as dry mouth, constipation, and mild cognitive impairments. Moreover, they sometimes lead to orthostatic hypotension (low blood pressure that occurs when an individual stands upright) and cardiotoxic affects, which may be especially problematic among individuals with existing heart or blood pressure conditions. In general, bupropion and trazedone produce fewer adverse side effects than other HCAs.

Monoamine oxidase inhibitors (MAOIs) are the second class of antidepressant medications. Similar to HCAs, these medications often produce a number of unpleasant side effects. Moreover, they have potentially lethal interactions with other medications and foods, which may make treatment more difficult among persons who take other medications or who have trouble maintaining dietary restrictions. As a result, MAOIs are rarely used among elderly individuals. Examples of MAOIs include moclobemide (Aurorix), phenelzine (Nardil), and selegiline (Eldepryl).

The third class of antidepressants, serotonin reuptake inhibitors (SRIs), include medications such as paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). SRIs typically produce fewer side effects than HCAs and MAOIs, are less reactive with other medicines, and are less lethal in overdose. Consequently, they may be preferable to the other classes. Evidence suggests that HCAs, SRIs, and MAOIs are comparably effective, producing improvement in 50 to 80 percent of depressed, elderly persons.

The fourth group of antidepressant medications is referred to as atypical because their chemical properties do not fit into any of the other classes. These medications have not yet been adequately studied among depressed, elderly persons. Thus, it is not currently known how effective they may be for this population. Examples of atypical antidepressants include nefazodone (Serzone) and venlafaxine (Effexor).

The duration of antidepressant treatment must be considered when treating depressed, elderly persons. Elderly persons typically respond to antidepressant medications more slowly than younger persons; twelve weeks of treatment may be required to achieve maximum response. Furthermore, treatment should be continued at the same dosage for a minimum of six months after remission to prevent relapse.

In addition to antidepressant medications, five psychosocial interventions have demonstrated efficacy for treating depressed, elderly persons: cognitive-behavioral therapy (CBT), brief psychodynamic therapy, interpersonal psychotherapy (IPT), reminiscence therapy, and psychoeducational approaches. A brief description of these therapies is presented in Table 2. CBT, IPT, and brief psychodynamic therapy all appear to be comparably effective to antidepressant medications, with improvement rates near 70 percent. Reminiscence therapy has been shown to be effective for mild and moderate cases of depression, but does not appear to be as effective as CBT for more severe cases of depression. Psychoeducational interventions are effective in reducing depressive symptoms among elderly persons with subsyndromal depression. Psychosocial interventions may be superior to antidepressants and electroconvulsive therapy at reducing the risk of future depression.

Electroconvulsive therapy (ECT) is a third form of treatment for depressed, elderly individuals. ECT involves passing electrical current through an individual's brain, and is typically used only in severe cases of depression that have not responded to other treatments. ECT appears to be as effective (and perhaps more effective) than antidepressant medications for the short-term treatment of MDD, particularly in severe and psychotic cases of depression. It typically produces a more rapid response than either antidepressants or psychosocial interventions. Nevertheless, the majority of individuals who receive ECT relapse into depression if they do not receive additional treatment. In addition, roughly one-third of elderly persons who receive ECT experience complications such as memory impairment, delirium, and arrythmias.

Although combinations of the three forms of treatment have not been researched thoroughly, a limited amount of data and common clinical practice indicate that antidepressant treatment combined with psychosocial interventions may be superior to either form of treatment administered alone. If the increased cost associated with a second form of treatment is feasible, and if combined treatment is not contraindicated for medical reasons, combined antidepressant and psychosocial interventions may provide the optimal treatment for depression among older adults.