ALBUQUERQUE, N.M. – A survey of 50 psychiatrists from across the country provides insight into treatment of refractory depression in the elderly, Dr. William Apfeldorf said at a psychiatric symposium sponsored by the University of New Mexico, Albuquerque.
“Treatment guidelines can help but can't fully address the complexity of a complicated case,” said Dr. Apfeldorf of the department of psychiatry at the university.
In the survey, psychiatrists were asked to rate the appropriateness of treatments, with 9 being the treatment of choice, 7–8 being a first-line treatment, 4–6 a second-line treatment, 2–3 being a treatment rarely used, and 1 being a treatment that is never used.
For mild, nonpsychotic major depression in the elderly, the first line of treatment chosen by respondents was pharmacotherapy and psychotherapy. Pharmacotherapy alone was a close second, almost ranking as a first-line treatment.
If the first-line antidepressant failed, the psychiatrists would switch to a different antidepressant if there was no response and would augment the initial prescription if there was a partial response.
The experts were inclined to use a selective serotonin reuptake inhibitor (SSRI) initially. If there was no response, they would treat with either extended-release venlafaxine (Effexor XR) or sustained-release bupropion (Wellbutrin SR). Second-line treatment for nonresponders included another SSRI or nortriptyline or mirtazapine (Remeron). “Venlafaxine XR rated the highest in usage if the original SSRI didn't work,” said Dr. Apfeldorf.
If a tricyclic is used and there is no response, the next first-line treatment would be venlafaxine XR or an SSRI, according to the experts in the study.
For bipolar disorder, the first choice would be bupropion SR or lithium, then nortriptyline.
“Nothing was considered first line,” said Dr. Apfeldorf, “but we were surprised that lithium still showed up.”
The psychiatrists chose trazodone (Desyrel) as the first-line treatment of insomnia in the geriatric population, with zolpidem (Ambien) and zaleplon (Sonata) use coming later, Dr. Apfeldorf said.
For residual anxiety, the experts chose to increase the dosage of an antidepressant. If an antidepressant and mood stabilizer were required for the acute phase of anxiety, they would continue treatment with the combination. The first choice of mood stabilizer for the geriatric population was divalproex (Depakote), with lithium the second-line choice.
“The experts did not recommend any complementary medicine agents in late-life depression,” he said.
Some experts recommended light therapy as a second treatment to be added to an antidepressant, but most of the experts weren't located in places without a lot of light, Dr. Apfeldorf said.
After the initial episode and treatment, patients should be followed monthly for the first year, then every 1–3 months. Maintenance treatment should continue for 1 year if there was one episode of depression, 2 years if there were two episodes, and more than 3 years if there were three episodes, according to the respondents.
Electroconvulsive therapy is indicated in the geriatric population only if the patient is severely depressed and suicidal or has medical conditions preventing adequate drug treatment, the experts said.
Often, geriatric patients have comorbidities that contribute to depression, such as heart disease. SSRIs were favored for patients with bundle branch block, coronary artery disease, diabetes, and hypotension.
In patients with dementia who also are depressed, the experts chose citalopram (Celexa) and sertraline (Zoloft) as first-line treatments, along with venlafaxine XR.
Other drug combinations with antidepressant drugs also need to be monitored closely, they said.