Major Depressive Disorder in Older Adults, Treatment Approaches, Risk Assessment/Screening Tools, and Clinical Practice Guidelines
Major Depressive Disorder (MDD) is one of the most common mental disorders in the US. It is a common and serious mood disorder that causes symptoms that affect how people think, feel, and handle daily activities. The symptoms must be present for at least 2 weeks to be diagnosed with MDD. MDD is common in older adults and can occur with other serious medical conditions like diabetes, cancer, heart diseases, dementia, and Parkinson’s disease. Some medications taken for treating the medical conditions sometimes contribute to depressive episodes (National Institute of Mental Health [NIMH], 2022). MDD in older adults are associated with disability, mortality, and morbidity. Treatments for MDD in older adults often involve the use of pharmacological interventions and/or the addition of nonpharmacological approaches (Robertson et al., 2019).
Recommendation of One FDA-Approved Drug, One off-label drug, and One Nonpharmacological Intervention for Treating MDD in Older Adults
Tricyclic Antidepressants (TCAs) were the first line of pharmacological treatment for MDD, but SSRIs have been developed and used for its better safety profile. SSRIs have fewer side effects, they are rarely fatal in overdose, have less dosage interactions, they are once daily administration, and have greater patient adherence. Sertraline is a common and effective FDA-approved SSRI for treating depression in the elderly. It lacks marked anticholinergic effects seen in TCAs and has a low potential for drug interactions at the cytochrome P450 enzyme system level. No adjustment of sertraline is indicated for the elderly based on age (Hsu et al., 2022).
Olanzapine is a second-generation antipsychotic agent used off-label for treating MDD in the elderly. Olanzapine causes increased serotonergic tone and enhances dopamine activity in the frontal cortex. It has low potential for causing extrapyramidal symptoms, tardive dyskinesia, and prolactin elevation (Flint et al., 2019).
Elderly patients with mild to moderate depression can benefit from psychotherapeutic interventions with results of better treatment compliance, lower dropout rates, and positive responses than younger patients. Cognitive Behavior Treatment (CBT) and Interpersonal Psychotherapy (IPT) have been found to be useful for managing depression in the elderly (Avasthi & Grover, 2018). Patients must be cognitively intact and medically stable to be appropriate for psychotherapeutic intervention. The use of psychotherapy is guided by patient’s preference and the availability of provider with appropriate training/expertise in the chosen approach. With psychotherapy, session frequency must be guided by the goals of psychotherapy and the frequency needed for creating/maintaining therapeutic alliance. The severity of illness, patient’s cooperation with treatment, availability of social support, cost, geographic accessibility, and presence of comorbidity must also be taken into consideration (Avasthi & Grover, 2018).
The Risk Assessment for Choosing Treatment Decision Making and the Risks/Benefits of the FDA-Approved Medicine/Off-label Drug.
The Geriatric Depression Scale (GDS) is a well-validated screening tool for depression in the elderly. It comes in either a short form of 15 items with 7 point cut off or long form of 30 items with 11 point cut off. It is a reliable tool for depression screening in the elderly with minimal cognitive impairment. In severe cognitive impairment, as seen in dementia for instance, the Cornell Scale for Depression in Dementia (CSDD) is the gold standard. It relies on the report/interview from family members/caregivers and the patient. It is validated for use in nondemented as well as demented depressed elderly patients (American Psychological Association, 2020).
Sertraline is recommended due to its reduced risk of side effects and safety in the event of overdose. Like other antidepressants, sertraline carries the risk of falls in the elderly. Depression in itself is associated with fall risk. Patients should be assessed for falls and interventions provided accordingly as evidence does not support cessation of antidepressants in the elderly due to risk for falls. All meds have one risk or the other and the question of whether benefit outweigh risk should be considered in all treatment plans (Sadock et al., 2015).
Olanzapine is effective and helps to treat MDD that is resistant to antidepressant monotherapies, but it is associated with mild to moderate weight gain (Sadock et al., 2015).
Clinical Practice Guidelines (CPG) for MDD and Justification for Recommendation
CPGs exist for MDD in the elderly. The latest 2019 version by American Psychological Association (APA) recommends intervention for depression treatment in older adults with recommendations that treatment should be evidence-based with scientific evidence, weighing of benefits and risks of intervention, consideration for patient values/preferences, and consideration of the applicability of the evidence across demographic groups and settings (American Psychological Association [APA], 2021).
