The role of aripiprazole. Elderly patients not achieving remission from depression with antidepressant agents alone may benefit from co-prescribing aripiprazole.32 As an adjunct, aripiprazole is effective in achieving and sustaining remission, but it has the potential for less tolerability by inducing akathisia and parkinsonism.32
Minimize risks and maximize benefits of antidepressants by following these recommendations:
Ascertain whether any antidepressant treatments have worked well in the past.
Start with an SSRI if no other antidepressant treatment has worked in the past.
Counsel patients about the need for treatment adherence. Antidepressants may take 2 weeks to 2 months to provide noticeable improvement.
Prescribe up to the maximum drug dose if needed to enhance benefit.
Use a mood measurement tool (eg, the Patient Health Questionnaire-9) to help evaluate treatment response.
Try a different class of drugs for patients who do not respond to treatment. For patients who have a partial response, augment with bupropion XL, mirtazapine, aripiprazole, or quetiapine.33 Sertraline and nortriptyline are similarly effective on a population-wide basis, with sertraline having less-problematic adverse effects.34 Trial-and-error treatments in practice may find one patient responding only to sertraline and another patient only to nortriptyline.
Transcranial magnetic stimulation is a promising, relatively new therapeutic option for treating refractory cases of depressive mood disorders.
Combinations of different drug classes may provide benefit for patients not responding to a single antidepressant. In geriatric patients, combined treatment with methylphenidate and citalopram enhances mood and well-being.35 Compared with either drug alone, the combination yielded an augmented clinical response profile and a higher rate of remission. Cognitive functioning, energy, and mood improve even with methylphenidate alone, especially when fatigue is an issue. However, addictive properties limit its use to cases in which conventional antidepressant medications are not effective or indicated, and only when drug refills are closely monitored.
The challenges of advancing age. Antidepressant treatment needs increase with advanced age.36As mentioned earlier, elderly people often have medical illnesses complicating their depression and frequently are dealing with pain from the medical illness. When dementia coexists with depression, the efficacy of pharmacotherapies is compromised.
