Major Depressive Disorder – Older Adults

One FDA-approved drug, sertraline, is approved for persons ≥ 18 years of age. SSRIs are considered first-line drugs for depression. Sertraline has minimal drug-drug interactions (Avasthi & Grover, 2018). Benefits include improved mood and well-being, and renewed interest in activities. Risks include suicides, suicidal ideation, suicidal attempts, and serotonin syndrome. Be aware of pharmacokinetic changes in the elderly. Liver and kidney function diminish with age. Metabolism and excretion of the drug decrease, therefore increasing serum levels of the drug. There may be other physical and psychological comorbidities, hence, taper slowly and monitor.

One off-label drug is tramadol. While FDA approved as an analgesic, it is not approved for depression but there are studies that demonstrate its efficacy as an antidepressant at low doses (25-150 mg/day). Tramadol at low doses for depression was well tolerated by most but some patients experienced adverse effects or idiosyncratic responses (Bumpus, 2020). However, the authors concluded that tramadol was effective, safe, and “fast-acting” for decreasing depression symptoms. Risks include addiction, tolerance, and withdrawal if stopped. Tramadol binds to mu-opioid receptors and inhibits the reuptake of serotonin and norepinephrine. Risks include seizures, serotonin syndrome, misuse, overdose, and suicide. Assess renal and hepatic function, review all medications the patient is taking. Concurrent use with CNS depressants, penicillin, MAO inhibitors, SSRIs, SNRIs, TCAs, CYP2D6, and CYP3A4 inhibitors increase adverse effects.  

One nonpharmacological intervention is Art Therapy. In a randomized controlled trial, elderly women that participated in 20 weekly, 90-minute art therapy sessions had reductions in depressive and anxiety symptoms compared to those that were assigned to no therapies (Ciasca, 2018).

Treatment of depression is tailored to the person. The APA provides guidelines and is available on their website. They recommend second-generation antidepressants which include sertraline 100-200 mg daily. Choice of medications and other treatment options is a shared decision-making process between patient and provider. Treatment for depression will vary among individuals. The APA recommends the following 3 psychotherapy interventions: Group Cognitive Behavior Therapy, Interpersonal Psychotherapy, and Group Life Review/Reminiscence Therapy while electroconvulsive therapy (ECT) is reserved for treatment-resistant depression (APA, 2019).

References

APA. (2019). Depression treatment for older adults. Retrieved from https://www.apa.org/depression-guideline/older-adults

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian journal of psychiatry60(Suppl 3), S341.

Bumpus J. A. (2020). Low-Dose Tramadol as an Off-Label Antidepressant: A Data Mining Analysis from the Patients’ Perspective. ACS pharmacology & translational science3(6), 1293–1303. https://doi.org/10.1021/acsptsci.0c00132

Ciasca, E. C., Ferreira, R. C., Santana, C. L. A., Forlenza, O. V., Dos Santos, G. D., Brum, P. S., & Nunes, P. V. (2018). Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial. Revista Brasileira de Psiquiatria (Sao Paulo, Brazil : 1999)40(3), 256–263. https://doi.org/10.1590/1516-4446-2017-2250

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