INTRODUCTION
Depressive disorders are one of the common psychiatric ailments seen in elderly population.
As per the World Health Organization (WHO) prevalence of depressive disorders among
elderly is 10 to 20%. Data from India reveals a wide variation in the prevalence rate
of depression. Prevalence in community-based studies have varied from 8.9% to 62.16%
and clinic based studies have estimated the prevalence of depression to range from
42.4 to 72%. Unfortunately, depression among elderly is often considered as part and
parcel of life and is under-recognised and under-diagnosed. Depression in elderly
has been shown to be associated with significant negative consequences ranging from
poor quality of life, difficulties with activities of daily living, physical comorbidities,
premature mortality and cognitive impairments. Although the incidence of depression
among elderly is similar to that reported in adult population, depression in elderly
is associated with higher risk of suicide, more frequent hospitalization, higher number
of consultations with the treatment agencies and family burden. Hence, it is very
important to recognise depression among elderly and manage the same.
Timely recognition and adequate management of depression among elderly can lead to
improvement in quality of life, maintaining optimal levels of function and independence,
reduction in morbidity, reduction in mortality due to suicide, development of medical
illnesses and treatment costs.
Indian Psychiatric Society (IPS) published Clinical Practice Guidelines (CPGs) for
management of depression among elderly, for the first time in the year 2007. IPS also
published revised CPGs for management of depression in adult patients in the year
2017. Current version of the CPGs is an update of the earlier version of CPGs for
management of depression in elderly. The current version of the CPGs for depression
in elderly must be read in conjunction with the previous version of CPGs for depression
in elderly and revised CPGs for management of depression in adult population.
These guidelines provide a broad framework for assessment, management and follow-up
of elderly patients presenting with depression. Most of the recommendations made as
part of the guidelines are evidence based. However, these guidelines should not be
considered as a sustitute for professional knowledge and clinical judgment. The recommendations
made as part of these guidelines have to be tailored to address the clinical needs
of the individual patient and treatment setting.
DIAGNOSTIC COMPLEXITIES OF DIAGNOSING DEPRESSIVE DISORDERS IN ELDERLY
Depressive disorders in elderly can include a spectrum of disorders (Table-1). Depression
in elderly is also known as late life depression, which is further understood as late
onset depression and early onset depression. There is lack of consensus on the age
cut-off used to define late onset depression, with some of the authors considering
the age cut-off of 60 years, whereas others define it as experiencing first episode
of depression ≥ 65 years of age). While assessing depression among elderly, it is
important to remember that although many elderly have depressive symptoms, they do
not fulfil the criteria of major depression. Presence of physical illness and atypical
presentations further complicate the clinical picture. Hence it is postulated that
although the presence of standard diagnostic criteria is a necessary for of depression
in elderly, this is not sufficient condition for diagnosis of depression in elderly.
Due to these intricacies, the concept of 'subthreshold’ depression, 'subclinical’
depression, ‘minor’ depression, ‘milder’ depression etc have been described. Accordingly,
depression in elderly is often broadly classified as Major and Non-major Depression.
The nonmajor category includes minor depression, dysthymia, adjustment disorder with
depressed mood and mixed anxiety and depressive disorder.
Table 1
Spectrum of Depressive Disorders in Elderly
In general it is suggested that prevalence of minor depression is more than that of
major depression. Some of the studies suggest that with increasing age prevalence
of major depression decreases and that of minor or sub-threshold depression increases.
Minor depression in elderly is associated with significant number of disability days
and concomitant anxiety disorder. Proper recognition of minor depression is of paramount
importance because it is often the forerunner of the major depression among elderly
subjects. The spectrum of depressive disorders among elderly also includes dysthymic
disorder and adjustment disorder with depressed mood, which are also seen in 2% and
4% of the population respectively.
Minor depression is defined as presence of clinically significant depressive symptoms
which do not meet the threshold duration criterion or the number of symptoms necessary
for the diagnosis of Major depressive disorder (MDD) as per the current nosology.
Some of the authors have further characterised minor or subsyndromal depression among
elderly into 2 subtypes. According to some authors the first subtype of minor depression
consists of syndromes qualitatively similar to major depression and dysthymia but
it is characterised by presence of fewer symptoms or with less symptom continuity.
The second type of subsyndromal depression is considered to be qualitatively different
from MDD and is associated with lower suicidal thoughts and feelings of worthlessness
or guilt but similar levels of worries about health and “weariness of living”. Judd
et al described 2 subtypes of subsyndromal symptomatic depression (SDD) for minor
depression as SDD with mood disturbance (minor depression) and SDD without mood disturbance.
Minor depression was described in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) as a condition requiring further research to determine both diagnostic
utility and criteria refinement. In DSM-5, minor depression can be subsumed under
the category of “Other specified depressive disorder, depressive episode with insufficient
symptoms”, which is characterised by presence of depressed affect and at least one
of the other eight symptoms of MDD, which is associated with clinically significant
distress or impairment that persists for a duration of at least 2 weeks. It further
requires that the person should never have met the criteria of any other depressive
or bipolar disorder, does not currently meet active or residual criteria for any psychotic
disorders and as well as does not meet the criteria for mixed anxiety and depressive
disorder.
DSM-5 has a separate category for the depressive disorder due to another medical condition
and describes it as medical disorder with depressive features (i.e., full criteria
of MDD is not met), major depressive like and mixed-mood features.
Many elderly patients also present with late-onset dysthymia. Patients with late onset
dysthymia are considered to differ from those with young onset dysthymia, in terms
of absence of personality disorders and if present, these consist of obsessive–compulsive
personality disorder and avoidant personality disorder. There is some evidence to
suggest that clinical features of dysthymia in elderly differ from young onset in
terms of higher prevalence of comorbid medical illness, presence of cognitive deterioration,
and presence of frequent adverse life events and fewer “depressive cognitions” symptoms
but similar neurovegetative and other somatic symptoms.
ASSESSMENT AND EVALUATION
A comprehensive assessment of depression in elderly is of paramount importance to
evaluate the risk factors, comorbidity and associated etiological factors, severity
of depression, risk of self-harm and level of dysfunction. Additionally, assessment
also involves establishing a good therapeutic alliance, deciding about treatment setting
and patient's safety. It is important to remember that assessment is a continuous
process and patient should be assessed regularly, as per the need and phase of the
treatment.
Comprehensive assessment requires elicitation of detailed history including assessment
for presence of physical comorbidity, physical examination and mental state examination.
All efforts must be made to collect the history from multiple sources, especially
from the family members.
The complete psychiatric evaluation involves reviewing history of the present episode
and current symptoms, a psychiatric history including evaluation of symptoms of mania
to rule out bipolar disorder, evaluation of treatment history in terms of current
treatments and responses to previous treatments, history of medical illnesses, history
of substance use disorders, personal history (e.g., psychological development, response
to life transitions, and major life events), psychosocial history, review of current
medications, thorough physical examination with review of all the systems, mental
status examination and diagnostic tests as indicated (Table-2).
Table 2
Components of assessment and evaluation
While assessing elderly for depression, it is important to remember that elderly patients
often under-report their depressive symptoms and they may not acknowledge being sad,
down or depressed. Common depressive symptoms (such as lack of enjoyment in normal
activities, loss of interest in life, apprehension about future, poor sleep, recurrent
thoughts of death, persistent unexplained pain, poor concentration or impaired memory)
are often misattributed to old age, dementia or poor health. Due to this depression
among elderly is often under-detected and untreated for a long time. Many elderly
patients with depression often tend to report more somatic and cognitive symptoms
than affective symptoms. It has been reported that women more often report mood-related
symptoms when compared to men. Patients who do not acknowledge having depressed mood
may report a lack of feeling or emotion or acknowledge a loss of interest and pleasure
in activities. In view of the reporting of fewer depressive symptoms by elderly patients
with depression, some of the authors have suggested the use of the term “depression
without sadness”, which is considered as a variant of depression, which is specifically
seen in primary care populations and comprises of symptoms of apathy, loss of interest,
fatigue, difficulty sleeping, and other somatic symptoms, but not sad mood. However,
it is unclear whether “depression without sadness” is an idiopathic depression, a
depression secondary to medical illness, or a non-affective syndrome related to chronic
medical disease.
Other barriers to accurate diagnosis of depression among elderly include prevalent
stigma and confounding effect of medical co-morbidity. Stigma often prevents effective
health care seeking behavior and the accurate reporting of symptoms. Medical comorbidity
among elderly patients with depression is a rule rather than an exception. Psychological
stress of having an illness, ensuing functional disability, and life changes necessitated
by chronic illness may precipitate depression in susceptible individuals. Many physical
illnesses have been shown to have high prevalence of depression (Table-3). Accordingly,
any elderly individual presenting with first episode depression in the late age must
be properly evaluated for underlying physical illnesses. There is significant overlap
of symptoms of depression and various medical illnesses and it is often difficult
to segregate the attribution of symptoms. Symptoms such as weight loss, fatigue and
insomnia may overlap with patients suffering from various physical illnesses. At times,
evolution of depression may be indicated by appearance of new onset somatic symptoms,
when the physical health was static. Efforts must be made to evaluate anhedonia and
depressive ideations like self-deprecation, guilt, etc. The diagnosis of “depression
due to a general medical condition” can be used for medical illnesses with a known
etiologic link to depression. However, some of the authors consider this terminology
to be irrelevant to significant proportion of the elderly patients in whom overall
medical burden contributes to their depression. Various approaches have been used
for diagnosing depression in medically ill subjects. These include exclusive approach,
substitutive approach, best estimate approach and inclusive approach. The “exclusive
approach” does not consider neurovegetative symptoms (e.g., changes in sleep, energy,
appetite, and weight) to make a diagnosis of depression, whereas the “substitutive
approach”, replaces the neurovegetative symptoms included in the nosological system
by non-somatic cognitive symptoms (e.g., hopelessness) when defining a major depressive
episode (MDD). The “best estimate approach” involves use of clinical judgment to consider
whether the symptom is caused by a physical disorder or is part of a depressive syndrome.
The “inclusive approach” presumes that all the symptoms contribute to the depressive
episode, irrespective of the cause. In general it is suggested that, to overcome the
under-recognition of depressive disorders among elderly, an inclusive approach to
diagnosis may be preferable in older medically ill patients. However, it is also important
to consider all the contributing factors towards the depressive symptoms (e.g., medical
causes) to avoid use of unnecessary medications.
Table 3
Some of the physical illnesses commonly associated with depression
In terms of physical illnesses, it is important to remember that depression among
elderly is often associated with presence of hypertension and accordingly vascular
risk factors have received considerable attention in the research. This is known as
“vascular depression” and newer studies based on magnetic resonance imaging (MRI)
suggest that vascular depression accounts for upto 50% of depression in elderly. Patients
with vascular depression are considered to have a distinct clinical and neuropsychological
profile, which is linked to the presence of hypertension. The MRI findings in such
patients include loss of brain volume and loss of white matter integrity. In general
vascular depression has been shown to be associated with poor treatment outcomes,
higher risk of development of cognitive impairments. Relationship of vascular depression
with development of Alzheimer's disease is non-conclusive, with some reports suggesting
that these patients have higher risk of progressing to Alzheimer's disease. A review
provided the updated information on features of vascular depression and this include:
onset of depression at ≥ 65 years of age, absence of family history of depression,
presence of executive dysfunctions, loss of energy, subjective feeling of sadness,
anhedonia, psychomotor retardation, motivational problems, reduced processing speed
and visuospatial skills, deficits in self initiation and lack of insight; and may
not meet the criteria for any mood disorder as per the DSM-5, presence of high cardiac
illness burden, presence of increased rates of vascular risk factors (hypertension,
etc.), fluctuating course of cognitive impairment due to progression of white matter
hyperintensities, greater treatment resistance and poorer outcome, higher risk for
cognitive decline and association with increased mortality (Table-4). However, it
is important to remember that DSM-5 has not incorporated this entity in its classificatory
system. Another entity related to vascular depression is depression-dysexecutive syndrome
(DES) which is seen in patients with vascular risk factors and is associated with
executive dysfunction due to dysfunction in the frontal-subcortical circuit.
Table 4
Features of Vascular Depression in Elderly
Depression is elderly is also often associated with use of certain medications (Table-5).
Accordingly obtaining a detailed treatment history is of paramount importance. The
treatment history may not be limited only to the prescription drugs, but should extend
to evaluation of over the counter drugs and use of medicines from alternative schools
of medicine. It is important to evaluate the temporal correlation of use of medications
(starting of medications, escalation of dose of medication) and emergence of depressive
symptoms to make any conclusion about the association. However, it is important to
note that except for few drugs (e.g. corticosteroids, interferon), evidence for risk
of development of depression with specific medications is inadequate and perhaps overstated.
Table 5
Medications known to cause depression
While assessing depression among elderly it is important to remember that many elderly
have atypical presentation of their depression. They may present with chronic unexplained
physical symptoms, cognitive symptoms, change in behaviour, anxiety and worries, irritability
and dysphoria, etc. However, development of a therapeutic alliance and proper assessment
often reveals presence of depressive symptoms in these patients. While evaluating
elderly patients, it must be remembered that when neurotic symptoms like hypochondriasis,
obsessive compulsive features emerge for the first time in life in old age, than more
often than not, these are associated with depression. Accordingly, in all such cases,
depression must be ruled out properly. Elderly patients presenting with depression
should also be properly evaluated for substance use disorders. At times, elderly patients
with depression may present with alcohol dependence arising for the first time in
the later life. A thorough history from the patient and an informant often provides
clarity. Whenever required, appropriate tests like, urine or blood screens (with prior
consent) may be used to confirm the existence of comorbid substance abuse/dependence.
Elderly patients with depression are at higher risk for self-harm and completed suicide
when compared to young adults. Depression is the most common risk factor for suicide
in elderly. Hence, every patient must be properly evaluated for suicidal behaviours.
The risk factor for suicide among elderly and those with depression include older
age, male gender, severe anxiety, panic attacks, living alone, severe depression,
bereavement (especially in men) and presence of comorbid alcohol misuse, physical
pain and history of suicide attempts in the past. Clinicians should directly enquire
about the presence of suicidal ideations, planning and availability of means of suicide.
If the patient has means to suicide then a judgment may be made concerning the lethality
of those means. Family history of suicide also must be inquired into and taken into
account while assessing the risk of future self-harm. Patients found to have suicidal
or homicidal ideation, intention or plans need to be monitored closely and hospitalization
should be considered for those at high risk of self-harm/suicide.
At times depression among elderly is often confused with dementia. Symptoms like apathy,
loss of initiative, social withdrawal and cognitive dysfunction (poor attention and
concentration) are present in both the disorders. Compared to dementia, depression
often have more rapid onset, have evidence of mood change, diurnal variation with
morning worsening of symptoms, intact orientation, fluctuating and inconsistent cognitive
deficits, may give more ‘don't know’ answers, significant personal distress, disturbed
sleep and appetite and suicidal ideations. However, it is important to remember that
many patients with dementia also develop depression and it is often missed in such
a scenario. Certain symptoms like psychomotor slowing, emotional lability, crying
spells, insomnia, weight loss, inability to verbalize affective state and pessimism
are seen in both depressed and non-depressed patients with dementia. Some of the studies
suggest that patient's with Alzheimer's disease with depression display more self-pity,
rejection sensitivity, anhedonia and fewer neurovegetative signs than non-demented
depressed older patients. Specific scales like Cornell Scale for depression in dementia,
which is considered to be the gold standard for assessing depressive symptoms among
patients with dementia, may be used. Combining data from the patient interview, information
obtained by caregivers and use of specific scale have been suggested to provide a
reliable and valid assessment. The National Institute of Mental Health has developed
criteria for diagnosis of depression in patients with Alzheimer's dementia. This includes
a list of 10 symptoms, out of which 3 or more must be present during the same 2 week
period and represent a change from previous functioning. Out of the 3 criteria fulfilled,
at least one of these must be depressed mood or decreased positive affect or pleasure.
Other features of the criteria include social isolation or withdrawal, disruption
in appetite which is not related to another medical condition, disruption in sleep,
psychomotor changes (agitation or slowed behavior), irritability, fatigue or loss
of energy, feelings of worthlessness or hopelessness, or inappropriate or excessive
guilt and recurrent thoughts of death, suicide plans or a suicide attempt. These symptoms
must be present for at least 2 weeks for considering the diagnosis of depression among
patients with definite diagnosis of Alzheimer's disease as per the DSM-IV criteria.
The symptoms must be associated with clinically significant distress or disruption
in function; symptoms are not part of delirium, are not related to physiological effect
of substance and are not accounted by other psychiatric conditions (Table-6).
Table 6
NIMH Provisional Diagnostic Criteria for Depression in Alzheimer Disease
An important aspect for evaluation of depression in elderly also involves evaluation
for nutritional deficiencies which may be responsible for the depressive symptoms
and correction of these may be sufficient to manage depressive symptoms.
Due attention must be given to psychosocial factors which may be associated with onset,
continuation/maintenance of depression among elderly. Various psychosocial factors
associated with depression among elderly include loneliness, poor social/family support,
isolation/no social interaction, dependency, lack of family care and affection/lack
of caregivers, insufficient time spent with children, stressful life events, perceived
poor health status, lifestyle and dietary factors, lack of hobby, irregular dietary
habits, substance use/smoking, lower spirituality and emotion-based coping.
Before considering the diagnosis of unipolar depressive disorders, it is important
to ascertain that patient does not have bipolar disorder as use of antidepressants
in patients with bipolar disorder can lead to antidepressant induced switch. Elderly
patients presenting with depressive disorders often do not come up with history of
previous hypomanic or manic episodes. Meticulous history from the patient, family
members, review of treatment records often provide important clues and aid in confirming
the diagnosis of bipolar disorder. At times use of standardized scales like mood disorder
questionnaire can help in detecting bipolarity. Some of the clinical features which
should alert a clinician about the possibility of bipolar disorder include presence
of psychotic features, marked psychomotor retardation, reverse neurovegetative symptoms
(excessive sleep and appetite), irritability of mood, anger and family history of
bipolar disorder.
Evaluation of history should also take the longitudinal life course perspective to
evaluate for previous episodes and presence of symptoms of depression amounting to
dysthymia. History taking should look at the relationship of onset of depression with
change in season (seasonal affective disorder) and relationship with menopause etc.
Response to previous treatment should also be reviewed and whether the patient achieved
full remission, partial remission and did not respond to treatment should be evaluated.
Elderly patients are at higher risk of completed suicide when compared with the young
patients.
Depression is associated with marked dysfunction in the domains of interpersonal relationships,
work, living conditions, activities of daily living, instrumental activities of daily
living, and other medical or health-related needs. At baseline, these need to be noted
and subsequently monitored. If feasible, standard scales may be used to record these
dysfunctions. The areas of dysfunction must be addressed by encouraging the patient
to set realistic, attainable goals for themselves in terms of desirable levels of
functioning.
All the elderly subjects with depressive disorders need to be investigated. The list
of investigations is generally guided by the physical evaluation and history of medical
illnesses. However, it is important to remember that if at all there is no historical
evidence of medical illness and nothing significant is found in physical examination
to warrant laboratory investigation then also the elderly patients should be subjected
to a minimum battery comprising of haemogram, liver function tests, renal function
tests, urine analysis, electrocardiography (ECG) and serum electrolytes. Some authors
also advise to consider thyroid function tests, vitamin B12 and folate levels and
serum levels of drugs received by the patient. Neuroimaging may be considered in those
with in late or very late onset first episode depression, those having associated
neurological signs and those experiencing treatment resistant depression.
Besides, obtaining information from the patients and caregivers, it is also important
to evaluate their knowledge and understanding about the symptoms and the disorder,
their attitudes and beliefs about the symptoms and treatment, the impact of the illness
on them and their personal and social resources.
Many a times, elderly patients with depression present to the primary care to the
physicians, who may require assistance of screening questionnaires to diagnose depression
in elderly. The available questionnaires include Geriatric Depression Scale (GDS),
Evans Liverpool Depression Rating Scale (ELDRS), Brief Assessment Schedule (BASDEC)
and Patient Health Questionnaire (PHQ-9). However, it is important to note that these
are screening questionnaires/scales, and detailed interview will be required for confirming
the diagnosis. It also important to remember that level of cognitive impairment and
visual deficits must be taken into account while asking the patients to complete these
questionnaires or while administrating these questionnaires. Out of these 3 questionnaires,
GDS is available in Hindi.
Scales can also be used to rate the severity of depression among elderly. The various
scales which can be used include Hamilton Rating Scale for Depression (HAM-D), Zung
Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Beck Depression
Inventgory (BDI), Montgomery-Asberg Depression Rating Scale (MADRS) and Cornell Scale
for Depression in Dementia (CSDD). Among the various scales, GDS is the most well
validated scale for use in elderly with intact cognitive functions.
Formulating a treatment plan
Formulation of treatment plan involves deciding about treatment setting, medications
to be prescribed and psychological interventions to be used (
Figure-1
). Wherever possible, the patients may be involved in preparing the treatment plan.
Caregivers must also be consulted in formulating a treatment plan. The role of caregivers
becomes more important when the patient is not in a condition to participate in treatment
decisions due to severity of the depression, lack of insight or marked cognitive impairment.
The treatment plan needs to be practical, feasible and flexible to attend to the needs
of the patients and caregivers. The treatment plan initially formulated need to be
continuously re-evaluated and updated as per the clinical and psychosocial needs.
Figure 1
Initial evaluation and management plan for Depression
DETERMINE A TREATMENT SETTING
Patients with depression can be managed on the outpatient basis. However, it is recommended
that patients be managed in a setting which is most safe and effective. The decision
about treatment setting must take into account symptom severity, comorbid physical
and psychiatric conditions, suicidality, homicidal behaviour, level of functioning
and available support system. It should also take into consideration the ability of
a patient to adequately care for themselves, provide information about the health
status to the clinician and cooperate with treatment. Further, this should be an ongoing
process throughout the course of treatment. Some of the indications for inpatient
care are given in Table-7.
Table 7
Indications for admission in elderly patients with depression
All inpatients should have accompanying family caregivers. In case inpatient care
facilities are not available, then the patient and/or family must be informed about
such a need and admission in nearest available inpatient facility can be facilitated.
ESTABLISH AND MAINTAIN A THERAPEUTIC ALLIANCE
Irrespective of the use of various treatment modalities, it is important for the clinicians
to establish a therapeutic alliance with the patient. Depression often runs a chronic
course and requires patients to actively participate and adhere to treatment for long
periods. Another important aspect of successful treatment is tolerating the side effects
of various treatment modalities. For these reasons, a strong treatment alliance is
crucial. For clinicians, it is important to understand that paying attention to the
concerns of patients and their families as well as their wishes for treatment enhances
the therapeutic alliance.
MONITOR THE PATIENT'S PSYCHIATRIC STATUS AND SAFETY
Management of depression is an ongoing process, which requires continuous assessment
of course of symptoms and acceptability of treatment. Accordingly, it is important
to be on surveillance for emergence of destructive impulses towards self or others
and hospitalization or more intensive treatment need to be considered for patients
at higher risk. At times, patients may present with significant changes in psychiatric
status or emergence of new symptoms, which may warrant a diagnostic re-evaluation
of the patient.
PROVIDE EDUCATION TO THE PATIENT AND, WHEN APPROPRIATE, TO THE FAMILY
All patients and their caregivers need to be educated about symptoms of depression,
available treatment modality, course of disorder and time to response to treatment.
Specific educational elements may be helpful in some circumstances, e.g. that depression
is a real illness and that effective treatments are both necessary and available may
be crucial for patients who attribute their illness to a moral defect, witch craft
or harbour other supernatural causation for their depressive disorder. Education regarding
available treatment options will help patients make informed decisions, anticipate
side effects and adhere to treatments. Another important aspect of providing education
is informing the patient and especially family about the lag period of onset of action
of antidepressants.
ENHANCE TREATMENT ADHERENCE
Adequate management of depression requires adherence to treatment plans. Many elderly
patients may attach stigma to depression and disagree with clinicians when informed
about their diagnosis. Patients also often fear of becoming addicted to antidepressants
and the impact of psychotropics on their medical disorders. Sometimes, patients who
are overtly symptomatic may be poorly motivated and unduly pessimistic about their
chances of improvement with treatment. On the other hand, many patients, who achieve
clinical remission with treatment may underestimate the need for continued treatment
and consider it as a burden. Some patients may not be able to take care of themselves
due to cognitive deficits. Side effects are also well known to contribute to treatment
non-adherence.
Accordingly, treatment adherence can be improved by informing the patients about when
and how often to take medicine, lag period of onset of action (at least 3-4 weeks
will be required for the beneficial effects to emerge), the need to take medication
even after feeling better, the need to consultation prior to discontinuing medication,
what is to be done in the face of side effects and what is to be done, in case of
a problem. Medication adherence among elderly can also be improved by simplifying
the treatment regimen and reducing the cost of treatment. If the patient has severe,
persistent or recurrent non-adherence with treatment, than there may be a need to
evaluate the psychological conflicts or psychopathology which may be contributing
to the non-adherence. Appropriate measures must be taken to address these issues.
Family members must be involved in all stages of treatment and all form of psychoeducation,
as they can play an important role in enhancing treatment adherence.
ADDRESS THE ISSUE OF EARLY SIGNS OF RELAPSE
Patient and family members need to be informed about the chances of relapse after
improvement. Information need to be provided in terms of recognising early signs and
symptoms of new episodes, need for seeking treatment at the earliest to reduce the
chance of development of full-blown relapse.
TREATMENT OPTIONS FOR MANAGEMENT FOR DEPRESSION
The available treatment options for management of depression can be broadly categorised
into antidepressants, somatic treatments and psychosocial interventions. The various
somatic treatments include electro-convulsive therapy (ECT) repetitive transcranial
magnetic stimulation (rTMS), transcranial direct stimulation, vagal nerve stimulation
and deep brain stimulation. Other some of the less commonly recommended treatments
include light therapy and sleep deprivation. Besides these, benzodiazepines are often
prescribed as adjunctive treatment during the initial phase of treatment. Patients
who do not respond to the first line treatments may require use of lithium and thyroid
supplements as augmenting agents.
Depression can be managed with a whole range of antidepressant medications (Table-8).
Antidepressants are the usually preferred modality of treatment for mild, moderate,
or severe depressive episode. Psychotherapeutic treatments are usually indicated for
management of patients with minor depression and mild to moderate major depression.
Clinical features that may guide the choice of use of psychotherapeutic treatments
include the presence of significant psychosocial stressors, intrapsychic conflict,
interpersonal difficulties, or axis II comorbidity. Many times, patients themselves
may be averse to use of antidepressants and express desire for psychotherapeutic treatments
as the initial treatment modality. In such a scenario, patient's preference must be
respected. Combination of antidepressants and psychotherapeutic interventions may
be useful initial treatment choice for patients with psychosocial stressors, intrapsychic
conflict, interpersonal problems, or a comorbid axis II disorder together with moderate
to severe major depressive disorder. Other indications for combined treatment with
antidepressants and psychotherapy include partial response to adequate trials of antidepressants
or psychotherapeutic interventions and patients who are poorly adherent to pharmacotherapy.
Presence of psychotic symptoms may suggest combined use of antidepressant and antipsychotic
medications or ECT. Other indications for ECT include presence of catatonic features
not responding to benzodiazepines (e.g. lorazepam), high risk of suicidality, presence
of comorbid general medical conditions precluding the use of antidepressant medications,
patients refusing food and are nutritionally compromised and those who have a past
history of positive response to ECT. The patient preference is another important consideration
that may influence the decision to select ECT as a treatment modality. However, it
is to be remembered that ECT is relatively contraindicated in patients with recent
myocardial infarction, brain tumor, cerebral aneurysm, and uncontrolled heart failure.
Table 8
Antidepressants Armamentarium
Selecting specific antidepressant: In general, there is no difference in the efficacy
of various antidepressants in management of depression. A metanalysis, which included
51 randomised controlled trials (RCTs) comparing various antidepressants medications
showed lack of significant difference in the efficacy of various antidepressant classes.
Studies which have compared various antidepressants head-to-head show that there is
lack of difference in the efficacy of escitalopram, citalopram, sertraline and paroxetine.
Another meta-regression analysis, which included 34 RCTs showed lower response rate
to various antidepressants in patients of male gender, older age and those having
longer duration of current episode. Better response rate was seen in patients with
higher baseline severity of depression and those experiencing first episode of depression.
Hence selection of antidepressant is guided by other features which can be broadly
divided into patient specific and drug specific factors. The patient specific factors
include patient preference, past history of response/tolerability to medication, family
history of response to a particular antidepressant, comorbid medical illness, comorbid
psychiatric disorder/symptoms, other medication being taken and intellectual and psychological
capacities. The drug specific factors include the anticipated side effects, the safety
or tolerability of these side effects for individual patients, cost, dosing schedule,
type of formulations available and safety in overdose. Elderly people are generally
more susceptible to anticholinergic effects, and the newer antidepressants should
therefore be preferred. If a tricyclic antidepressant has to be used, drugs with pronounced
anticholinergic effects, such as amitriptyline, should be avoided. Antidepressants
associated with side effects like hypotension, and those with highly sedating properties
must be avoided.
Among the cyclic compounds, desipramine is less sedating and can be taken during the
day, and nortriptyline is less likely to cause orthostatic hypotension than amitriptyline
or imipramine. Although MAOIs are thought to be dangerous and difficult to use, drugs
such as phenelzine are relatively safe and effective in older patients. However, it
is important to remember that MAO inhibitors are associated with development of hypotension,
hypertension, and food-drug interactions. Moclobemide is well tolerated by older people.
Although a special diet is not required, patients should be aware of the drug interactions
with painkillers and other antidepressants. Blood pressure monitoring is necessary
with venlafaxine in patients with pre-existing cardiovascular disease and patients
taking relatively high dosages. Nefazodone works well in patients with anxiety and
depression. Gastrointestinal symptoms side effects with SSRIs are well known. Among
the SSRIs sertraline and citalopram have the least potential for drug interactions.
For clinicians it is important to remember that the antidepressant effect may be more
delayed in elderly people than in younger subjects, and treatment may need to be continued
for longer than six months. A small proportion of elderly patients who are prescribed
antidepressants may go on to develop hyponatremia. Hyponatremia is usually seen during
the initial phase of treament. The various risk factors for development of hyponatremia
include older age, female gender, low body weight, presence of comorbid physical illnesses
(i.e., diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary
disease, cardiac failure, head Injury, stroke, cirrhosis of liver and presence of
malignancies), concomitant use of other medications (i.e., diuretics, antihypertensives,
antidepressants, cytochrome P450 inhibitors), past history of hyponatremia, low baseline
serum sodium levels, summer season and initial phase of antidepressant therapy. Accordingly,
some of the authors suggest evaluating the baseline serum sodium levels in all elderly
patients prior to initiation of antidepressants and monitoring the same during the
initial phase of treatment. Other rare but life-threatening side effects of antidepressants
include upper gastro-intestinal (GI) bleeding. It is in general suggested to be more
common in elderly compared to young adult patients. Antidepressants, specifically
those which act on serotonergic system, decrease platelet aggregation and increase
the risk of bleeding. Risk of serotonergic antidepressants associated GI bleed is
high in elderly, those with history of peptic ulcers, gastritis, oesophageal varices,
gastric or colorectal cancers, chronic alcohol use, liver disease, coagulopathies
and concomitant use of other medications (i.e., corticosteroids, warfarin, clopidogrel,
aspirin and other non-steroidal anti-inflammatory agents, calcium channel blockers,
concomitant use of more than one antidepressant). Accordingly, if required antidepressants
are to be used, these must be used under the cover of proton pump blockers, to reduce
the risk of GI bleeding. Possibility of drug interactions must always be kept in mind
while selecting an antidepressant and certain combinations must be avoided (Table-9).
The most clinically significant drug interactions usually involve inhibition or induction
of CYP450 enzymes. Accordingly, the clinicians can use ready reckoner or online drug
interaction calculators to evaluate for the possible drug interactions.
Table 9
Monitor or avoid following combinations in elderly
In general, SSRIs are considered to be the first line antidepressants because of the
side effect and safety profile. Other alternatives include tricyclic antidepressants,
mirtazapine, bupropion, and venlafaxine.
Institution of antidepressant therapy: While using antidepressants among elderly,
it is important to take age related pharmacokinetic and pharmacodynamic changes into
consideration (Table-10). Accordingly, it is suggested that antidepressants must be
started in lower doses and the general principle of “start low and go slow” need to
be followed. Usually the medication must be started in the lower doses and the doses
must be titrated upwards, depending on the response and the side effects experienced.
Patients started on antidepressants need to be monitored carefully to assess the response
to pharmacotherapy as well as the emergence of side effects and safety. Factors which
influence the frequency of monitoring include severity of illness, patient's co-operation
with treatment, the availability of social support and the presence of comorbid general
medical problems. The dose of antidepressants can be titrated to the full therapeutic
doses over the initial weeks of treatment, but it is usually guided by the development
of side effects and the presence of comorbid conditions. Patients need to be monitored
closely for response to pharmacotherapy as well as the emergence of side effects,
clinical condition, and safety. Visits should be frequent enough to monitor and address
suicidality and to promote treatment adherence. The frequency of monitoring during
the acute phase of pharmacotherapy can vary from once a week in routine cases to multiple
times per week in more complex cases. Clinicians should also reassure patients that
they may feel worse before they start to feel better.
Table 10
Points to remember for prescription of antidepressants in elderly
The dose of antidepressants can be increased if patient compliance is good and there
is no response during the initial 3 weeks of treatment. If partial response to treatment
is noted that, clinician can wait for another 2 weeks before escalating the dose.
Improvement with pharmacotherapy can be observed after 4-6 weeks of treatment. If
at least a moderate improvement is not observed in 4-6 weeks, reappraisal and adjustment
of the pharmacotherapy should be considered.
Although there is lack of consensus, but most experts agree that elderly patients
require longer time than young adults to perceive any improvement and moderate improvement
with pharmacotherapy is seen after 4–8 weeks of treatment, but 2 to 3 months of therapy
are necessary to achieve the full benefit of treatment. The delayed clinical response
to antidepressants makes it difficult to establish the optimal dose quickly. The individual
dose is usually decided by trial and error. The patient is usually the last to notice
a change, and others often will tell the person that he/she looks better than before.
At least 30% of elderly patients with depression do not respond to first-line treatment
with an antidepressant. If at least moderate improvement is not observed following
4–8 weeks of pharmacotherapy, a thorough review must be done for re-evaluation of
diagnosis, treatment adherence and pharmacokinetic/pharmacodynamic factors which may
be affecting treatment. Treatment plan must be revised by implementing one of several
therapeutic options, including maximizing the initial medication treatment, switching
to another antidepressant medication, augmenting antidepressant medications with other
agents, psychotherapy, or ECT. Maximizing the initial treatment regimen is perhaps
the most conservative strategy. Patients who show partial response, particularly those
with features of personality disorders, antidepressant medication trial should be
extended as it may allow some patients to respond more fully. Use of higher antidepressant
doses may be helpful for patients who have received only modest doses. Patients who
have had their dose increased, should be monitored for an increase in the severity
of side effects or emergence of newer side effects.
Switching to a different antidepressant medication is a common strategy for treatment-refractory
patients, especially those who have not shown at least partial response to the initial
medication regimen. There is no consensus about switching and patients can be switched
to an antidepressant medication from the same pharmacologic class (e.g., from an SSRI
to another SSRI) or to one from a different pharmacologic class (e.g., from an SSRI
to a tricyclic antidepressant). Some expert suggests that while switching, a drug
with a different or broader mechanism of action should preferably be chosen. While
switching to a second antidepressant, clinicians should remember that there is some
evidence to suggest that venlafaxine may be useful in patients, who don't respond
to initial pharmacotherapy.
Augmentation of antidepressant may be considered in patients who show partial response
to initial antidepressant monotherapy. Options include adding a second antidepressant
medication from a different pharmacologic class, or adding another adjunctive medication
such as lithium, psychostimulants, modafinil, thyroid hormone, an anticonvulsant etc.
Adding, changing, or increasing the intensity of psychotherapy should be considered
for patients with MDD who do not respond to medication treatment. Following any change
in treatment, the patient needs to be closely monitored. If at least moderate level
of improvement is not seen after an additional 4–8 weeks of treatment, the psychiatrist
another thorough review need to be carried out. This reappraisal should include verifying
the patient's diagnosis and adherence; uncovering and addressing clinical factors
that may be preventing improvement, such as the presence of comorbid general medical
conditions or psychiatric conditions (e.g., alcohol or substance abuse); and uncovering
and addressing psychosocial issues that may be impeding recovery. If no new information
is uncovered to explain the patient's lack of adequate response, ECT should be considered.
Psychotherapeutic interventions
Out of the various psychotherapeutic models used in elderly, cognitive behavior therapy
(CBT)/Problem solving techniques, interpersonal psychotherapy (IPT), Brief dynamic
therapy and reminiscence therapy have been found to have some evidence (Table-11).
Use of psychotherapy is often guided by the patient preference and the availability
of clinicians with appropriate training and expertise in specific psychotherapeutic
approaches.
Table 11
Psychotherapeutic interventions for elderly patients with depression
Medications plus psychotherapy
As in adults, there is some data to suggest that combination of pharmacotherapy and
psychotherapy is better than monotherapies in the treatment of late-life depression.
Psychoeducation to the patient and, when appropriate, to the family
Psychoeducation of patients and family members must be integral part of all treatment
packages. Psychoeducation need to address the issues of knowledge about the illness,
available treatment options, time to response, side effects with medications, need
for medication and treatment adherence, providing information about the course and
outcome, impact of stressors on the course of illness, improving adaptive coping skills,
risk of relapse and identification of early signs of relapse, address stigma and encourage
maintenance of healthy life style. Important components of psychoeducation are given
in table-12.
Table 12
Basic components of Psychoeducation
ECT in Elderly:
Available data suggests that ECT is as effective in management of depression in elderly
as in adults. Data also suggest that ECT is well tolerated in patients of old age
depression even by subject aged more than 80 years of age. Studies which have compared
ECT with antidepressants suggest that it is more effective than antidepressants. Over
the years it is increasingly understood that there is no absolute contraindication
for ECT. The potential risk and benefit should be weighed on case to case basis and
where ever warranted the medical treatment should be optimized before ECT. Data suggests
that the risk of complications in elderly is more among those receiving more number
of medications, especially those who are on more number of cardiovascular medications.
However, studies have shown that cardiovascular complications arising during ECT are
transient and don't prevent successful completion of treatment course. The commonly
reported side effects of ECT include an increased risk of falls, post-ECT delirium
or dementia. Data suggests that elderly patients with compromised medical status are
at highest risk for prolonged confusion. Occasional study has also evaluated the effectiveness
of ECT in the continuation/maintenance phase of treatment and this suggests that the
risk of relapse/recurrence with ECT plus nortriptyline is significantly lower than
nortriptyline alone. However, while using ECT among elderly, certain facts, which
can influence the seizure threshold and seizure duration must be kept in mind (Table-13).
In general, it is important to remember that seizure threshold increases with age.
Elderly patients also require modifications of doses of anticholinergic, anesthetic,
and relaxant agents in view of the physiological changes associated with aging. Patients
receiving ECT should be closely monitored for emergence of cognitive side effects.
Patients with pre-existing cognitive deficits are more vulnerable to the development
of cognitive side-effects during the course of ECT and are at risk of having longer
lasting cognitive side-effects. Cognitive side effects can be minimized by use of
high-dose right unilateral ECT in place of the bilateral ECT.
Table 13
Factors influencing seizure threshold and/or seizure duration
Repetitive Transcranial Magnetic Stimulation (rTMS):
rTMS has been used in the management of depression. It is usually not the first line
treatment. Repetitive TMS applied to the left dorsolateral prefrontal cortex (DLPFC)
has been shown to have beneficial effect. However, still there is lack of consensus
about the exact brain localization for individual coil placement. RCTs which have
evaluated the role of rTMS in management of depression in elderly, suggest that rTMS
does not have any beneficial effect at 2 weeks. However, few RCT reported positive
outcome in patients with refractory depression /treatment resistant depression. Recent
data from RCTs suggest that rTMS is equally effective in young and older (>60years)
patients.
PHASES OF ILLNESS/TREATMENT
Management of depression is divided into three phases, i.e., acute phase, continuation
phase and maintenance phase. Maintenance phase of treatment is usually considered
when patient has recurrent depressive disorder (RDD).
ACUTE PHASE TREATMENT
Acute phase treatment must aim to achieve remission. The various components of acute
phase treatment are shown in Table-14. Selection of initial treatment depends on severity
of depression and patients preferences. The first and foremost thing for starting
treatment is thorough evaluation (Figure 2 and 3) and deciding about treatment strategies
after considering the severity of the symptoms.
Table 14
Management in the Acute Phase
Figure 2
Treatment algorithm of mild to moderate Depression in elderly
Figure 3
Treatment algorithm of Severe Depression in elderly
Antidepressant medications may be used as initial treatment modality for patients
with any level of severity (mild, moderate, or severe). Features that suggest that
medications may be the preferred treatment modality include history of previous response
to antidepressants, severity of symptoms, presence of marked sleep and appetite disturbances
or agitation, or anticipation of the need for maintenance therapy. Combination of
antidepressant and antipsychotic medication and/or ECT may be preferred for patients
with severe depression with psychotic features. Selection of specific antidepressant
is usually guided by the comorbid physical illnesses, possible side effects, the tolerability
of these side effects for individual patients, patient preference, and concomitant
pharmacotherapy. Usually, SSRIs are considered as the first line treatment of choice.
Among the various SSRIs, escitalopram and sertraline are considered to have minimal
drug interactions and are considered to be safe in presence of wide range of physical
illnesses. In addition to the use of antidepressants, depending on the symptom severity
and type of symptoms, such as presence of insomnia or anxiety, benzodiazepines or
other hypnotics may be used for short duration. When used, these must be used for
shortest possible duration and the patients and the caregivers must be informed about
the anticipated side effects and risks of over-sedation. Improvement with pharmacotherapy
can be observed after 4-6 weeks of treatment. Additionally, depending on the concomitant
medications, proton pump blockers may be used to minimize the GI side effects and
to reduce the risk of GI bleeding. During the initial phase of treatment serum sodium
levels may also be monitored, depending upon the presence of risk factors. The principle
of “start low and go slow”, must be adhered to and it must be remembered that elderly
usually require lower doses of antidepressants than the adults. The usual starting
dose which is recommended is half of the adult dose. In presence of comorbid physical
illnesses, the usual starting dose in an elderly may be one-fourth of the adult dose.
If some improvement (>25%) is not apparent after continuing antidepressants for 6
weeks, the treatment should be reviewed and a change of antidepressant needs to be
considered. When patient shows 25-50% improvement after the initial 4-6 weeks of antidepressant
trial, the dose must be increased to the maximum tolerable dose. If there is less
than 50% improvement with 6-8 weeks of maximum tolerable dose and the medication compliance
is good, a change in antidepressant may be considered.
If moderate improvement is not evident even after 4-8 weeks of pharmacotherapy, then
a thorough review with review of the diagnosis, complicating conditions and issues,
and treatment plan need to be carried out (Figure-4). Reappraisal of the treatment
regimen also includes evaluation of patient adherence and pharmacokinetic/pharmacodynamic
factors. After the review, the treatment plan can be redesigned by implementing one
of several therapeutic options, including maximizing the initial medication treatment,
switching to another antidepressant medication and augmenting antidepressant medications
with other agents/psychotherapy/ECT. Maximizing the initial treatment regimen is possibly
the most conservative strategy. It is important to note that, while using the higher
therapeutic doses, it is important to closely monitor the patient for an increase
in the severity of side effects or emergence of newer side effects.
Figure 4
Treatment algorithm for inadequate response to first antidepressant therapy in elderly
For treatment-refractory patients, switching to a different antidepressant medication,
especially those who have not shown at least partial response to the initial medication
regimen is a common strategy. There is lack of consensus about switching and a patient
can be switched to an antidepressant medication from the same pharmacologic class
(e.g., from an SSRI to another SSRI) or a different pharmacologic class (e.g., from
an SSRI to a tricyclic antidepressant). In general it is suggested that while switching,
a drug with a different or broader mechanism of action may be chosen.
Among patients who show partial response to initial antidepressant monotherapy, augmentation
with another agent may be considered. Augmentation can be done with a second antidepressant
medication from a different pharmacologic class, or adding agents like lithium, psychostimulants,
modafinil, thyroid hormone, an anticonvulsant etc. Adding, changing, or increasing
the intensity of psychotherapy may be considered for patients who do not respond to
medication treatment. Close monitoring of patient need to be done at the time of change
and after the change. If change of treatment strategy do not yield at least a moderate
level of improvement after an additional 4–8 weeks of treatment, than another thorough
review need to be carried out. This reappraisal may include reviewing the diagnosis
and patient's medication adherence; looking for and addressing clinical factors that
may be impeding improvement, such as the presence of comorbid general medical conditions
or psychiatric conditions (e.g., alcohol or substance abuse); and identifying and
addressing psychosocial issues that may be preventing recovery. If no new information
emerges which can explain the patient's inadequate response, depending on the severity
of depression, ECT may be considered.
Psychotherapeutic interventions: The importance of psychotherapeutic interventions
does not diminish with increasing age. Available data suggest that in elderly patients
with mild to moderate depression, psychotherapeutic interventions are as effective
as antidepressants. Some of the studies also suggest that elderly often have better
treatment compliance, lower dropout rates, and more positive responses to psychotherapy
than younger patients. Cognitive behavior therapy (CBT) and interpersonal psychotherapy
(IPT) have been found to have sufficient evidence for management of depression in
elderly. However, it is important to note that studies which have evaluated the effectiveness
of psychotherapy in elderly with depression have done so in cognitively intact and
medically stable patients and effectiveness outside this patient group is not fully
established. Small studies and case reports suggest that CBT can be adapted for physically
frail patients and those with mild cognitive impairment, but further research is needed.
Use of psychotherapy is often guided by the patient preference and the availability
of clinicians with appropriate training and expertise in specific psychotherapeutic
approaches. In terms of clinical factors, psychotherapy is usually recommended for
elderly patients with mild to moderate depression who have evidence of stressful life
events, family conflicts, and the reduction or absence of social support. In a country
like India, where there is scarcity of trained psychotherapists, clinicians can also
use psycho-educational approach and supportive psychotherapy. In general the basic
principle which should guide any kind of supportive psychotherapy should involve use
of adaptive strengths that have served the patient well in the past, increasing the
patient's self-esteem, accepting feelings at face value, holding the prospect of hope
and accepting anger and irritability.
While using psychotherapy, the frequency of sessions must be guided by type and goals
of the psychotherapy, the frequency necessary to create and maintain a therapeutic
relationship, the frequency of visits required to ensure treatment adherence, and
the frequency necessary to monitor and address suicidality. Other factors which also
influence the frequency of psychotherapy sessions include severity of illness, the
patient's cooperation with treatment, the availability of social supports, cost, geographic
accessibility, and presence of comorbid general medical problems.
Regardless of the type of psychotherapy selected, the response to treatment should
be carefully monitored and if the patient's condition fails to stabilize or deteriorates,
reassessment needs to be carried out. If after 4–8 weeks of treatment at least a moderate
level of improvement is not observed, then a thorough review and reappraisal of the
diagnosis, complicating conditions and issues, and treatment plan should be conducted.
In many cases, the treatment plan can be revised by the addition or substitution of
pharmacotherapy. Following any revision or refinement of treatment, the patient should
continue to be closely monitored.
Medications plus psychotherapy: Available data supports the superiority of the combined
treatment over the use of monotherapies. Selection of pharmacotherapy and psychotherapy
in patients considered for combined treatment must be guided by the same variables,
which determine the use of these treatments as monotherapies. While using combined
treatment, same doses of antidepressant medication and the same frequency and course
of psychotherapy should be used as is employed for patients receiving these as a monotherapy.
Patients receiving combined antidepressant medication and psychotherapy should also
be monitored closely for treatment effect, side effects, clinical condition, and safety.
If after 4–8 weeks, there is not at least a moderate improvement, a thorough review
should be conducted, including of the patient's adherence and pharmacokinetic/pharmacodynamic
factors affecting treatment. The treatment plan can be revised by using many of the
same therapeutic options described for patients who have not responded to treatment
with either modality alone. Following any change in treatment, the patient should
be monitored, and if at least a moderate improvement is not seen after an additional
4–8 weeks of treatment, another thorough review should be carried out.
Improve Social Support/family support: Addressing the issue of social support in elderly
patients with depression is very important. In many elderly patients psychosocial
issues like social isolation, neglect by the family etc contribute to the onset and
or continuation of depression. Accordingly efforts must be made to improve the social
support of the patient. Family members must be encouraged to provide emotional support
and affection. Family members must be asked to show patience, listen to the patient,
be understanding and encouraging. If patient expresses suicidal ideations, plans or
talks about death, than they should take it seriously and family members should liaise
with the treating agencies. Family members must be informed that they should refrain
from being critical. Family members can also help in supervising the medications.
Life style modifications: Besides pharmacotherapy, psychotherapy and improving social
support, it is important to look at the life style issues and patients must be encouraged
to maintain a regular activity schedule, go for walks depending on the physical health
status, socialize and engage themselves cognitively.
Other interventions: There is some data to suggest that aerobic exercises have a positive
effect on depressive symptoms, executive function and psychological well being. It
has also been shown that Yoga and mindfulness-based exercises can increase sense of
emotional and physical wellbeing. Spirituality, religious beliefs and involvement
with a faith group may be protective against development of mental illness while at
the same time provide avenues for increased social connectedness.
CONTINUATION PHASE
Aim of continuation phase treatment is to prevent relapse of depression and the same
treatment as used during the acute phase need to be continued (Figure-5). During the
continuation phase, patients who have been treated with antidepressant medications
in the acute phase should be maintained on the same agent on the same dose. Although
there is scarcity of data about use of psychotherapy in the continuation phase to
prevent relapse, some experts support the use of a specific effective psychotherapy
during the continuation phase. Use of ECT in the continuation phase has received little
formal study. There is no consensus on the duration of continuation phase in elderly,
but some experts suggest that treatment should be continued for 1 year after remission.
The frequency of visits must be determined by the patient's clinical condition as
well as the specific treatments being provided. For stable patients in whom the visits
are for the purpose of providing psychiatric management, the frequency could be once
every 2 weeks to 2 months. For other patients, such as those in whom active psychotherapy
is being conducted, the frequency required may be as high as multiple times a week.
If maintenance phase treatment is not indicated for patients who remain stable following
the continuation phase, patients may be considered for discontinuation of treatment.
If treatment is discontinued, patients should be carefully monitored for relapse,
and treatment should be promptly reinstituted if relapse occurs.
Figure 5
Treatment algorithm for continuation phase treatment of depression in elderly
MAINTENANCE PHASE
As in young adults, the risk of recurrence is high among elderly, with rates of recurrence
of 50 to 90 percent over a period of two to three years; hence, the goal of treatment
should be not only to treat current episode, but also be prevention of recurrence
in future. There is no consensus regarding the duration and when to give and when
not to give maintenance treatment in elderly. There is agreement to large extent that
patients who have history of three or more relapses or recurrences should be given
long-term treatment, but maintenance treatment after 2 episodes is still debated.
In general, the treatment which was effective during the acute and continuation phases
should be used in the maintenance phase (Figure-6). The same full antidepressant medication
doses should be used. For psychotherapy during maintenance phase, treatments can involve
fewer visits (e.g., once a month). Although the effectiveness of combinations of antidepressant
medication and psychotherapy in the maintenance phase has not been well studied, such
combinations may be an option for some patients. The frequency of clinic visits in
maintenance phase can vary from once every several months for stable patients who
require only psychiatric management and medication monitoring to as high as once or
twice per week in those who are either receiving psychotherapy or severely medically
compromised. The optimal length of maintenance treatment is not known and may also
vary depending on the frequency and severity of recurrences, tolerability of treatments,
and patient preferences. For some patients, maintenance treatment may be required
indefinitely.
Figure 6
Treatment algorithm for continuation phase treatment of depression in elderly
DISCONTINUATION OF ACTIVE TREATMENT
The decision to discontinue maintenance treatment should be based on the probability
of future recurrence, the frequency and severity of previous episodes, the persistence
of depressive symptoms after recovery, presence or absence of comorbid physical illnesses
and psychiatric disorders, and patient preferences. If the decision is made to discontinue
or terminate psychotherapy in the maintenance phase, it needs to be individualized
as per the patient's needs. In case, it is decided to discontinue pharmacotherapy,
it is advisable to taper the medication over the period of at least several weeks
to few months. Such tapering allows for the detection of emerging symptoms or recurrences
when patients are still partially treated and can help in returning to full therapeutic
intensity. In addition, tapering also minimizes the risks of antidepressant medication
discontinuation syndrome. Discontinuation syndrome is more frequently reported after
discontinuation of medications with shorter half-lives. Accordingly, short-acting
agents should be tapered more slowly. Paroxetine, venlafaxine, TCAs, and MAOIs tend
to have higher rates of discontinuation symptoms while bupropion-SR, citalopram, fluoxetine,
mirtazapine, and sertraline have lower rates. The symptoms of antidepressants discontinuation
are given in Table-15. Reassurance may be sufficient for mild discontinuation symptoms.
However, for mild to moderate discontinuation, short-term symptomatic treatment (analgesics,
antiemetics, or anxiolytics) may be beneficial. If the discontinuation syndrome is
severe, antidepressant should be reinstated and tapered off more slowly.
Table 15
The antidepressant discontinuation syndrome
After the discontinuation of active treatment, patients should be informed about the
potential risk of relapse of depression. Early signs of depression should be reviewed,
and a plan for seeking treatment in the event of recurrence of symptoms should be
established. Patients should continue to be monitored over the next several months
to identify those in whom a relapse has occurred. If a patient suffers a relapse upon
discontinuation of medication, treatment should be promptly reinitiated. In general,
the previous treatment regimen to which the patient responded in the acute and continuation
phase should be considered.
MANAGEMENT OF TREATMENT RESISTANT DEPRESSION
The term Treatment resistant depression (TRD) is usually used, when the depression
fails to respond to two adequate trials of antidepressant medications. It is estimated
that only half of the elderly patients respond to first line treatment and <49% achieve
remission. The poor response to treatment is usually attributed to the vascular component
in the etiology of late onset depression. Available evidence has also shown association
of cognitive impairment, especially executive dysfunction with poor treatment response
among elderly. Many other factors also contribute to TRD. However, prior to considering
a person to be having TRD, it is important to evaluate the patient properly. Initial
reassessment need to focus on re-evaluating the diagnosis of depression. Next step
involves evaluation of the fact that patient has received adequate doses of the antidepressant
medications for the adequate duration with good compliance. Underlying organic factors
need to be evaluated and if these are reversible (e.g., nutritional deficiencies),
these must be addressed. Management of TRD involves either change of medication or
augmentation of ongoing antidepressant medication. In term of augmentation strategies,
although it has not been evaluated thoroughly, lithium is usually recommended as the
first choice. When used the target serum levels of lithium for elderly must be in
the range of 0.5 to 0.6 mmol/L and it need to be continued for a period of at least
1 year after achieving remission. There is some data to suggest the efficacy of aripiprazole
in elderly patients with treatment refractory depression, when used as an augmenting
agent with venlafaxine.
TREATMENT IMPLICATIONS OF CONCURRENT GENERAL MEDICAL DISORDERS
Many elderly patients present with physical illnesses which require special attention.
Similarly, certain clinical situations also influence the decision making. Management
in some of these difficult situations is summarized in table-16.
Table 16
Management of Depression in Special Situations