Recognizing and Treating Depression in the Elderly

Mark D. Miller, MD

Medscape Psychiatry & Mental Health eJournal. 1997;2(2) 

In This Article

Treatment -- Antidepressant Medication

Antidepressant medication is the most common therapy for geriatric depression. The newer SSRIs are effective and generally well tolerated by elderly patients. These drugs have largely supplanted the tricyclic antidepressants (TCAs) as first-line agents due to their comparative cardiac safety, ease of use, tolerability, minimal anticholinergic effects, and low lethality in overdose.[45,46,47]

Not all patients can tolerate SSRI medications, however, because of gastrointestinal side effects (eg, nausea, bloating, or diarrhea); headaches; and, less frequently, sexual dysfunction. Caution is required when coadministering SSRIs with certain other medications. For example, the SSRIs are powerful inhibitors of the cytochrome P-450 enzyme system. If they are combined with medications such as phenytoin, tricyclics, neuroleptics, theophylline, or warfarin, the blood levels of these concomitant drugs can rise precipitously.[45]

The TCAs are effective agents in depression in the geriatric population with a long record of success. Nortriptyline is the best tolerated and most studied TCA in this patient group.[47] Electrocardiograms must be obtained prior to beginning TCA therapy in the elderly, and anticholinergic effects such as dry mouth, urinary retention, constipation, and orthostatic hypotension must be monitored.

Measuring serum levels of nortriptyline can be an important guide to an adequate dosage. A serum level at the midpoint of the recommended range of 50-150ng/mL achieves more stable antidepressant response, in our experience, than levels at the lower end of the range (Perel J, 1994. Verbal communication.). Blood levels should be measured also because approximately 5% of the population are slow metabolizers of nortriptyline. These patients may achieve an adequate serum level of nortriptyline on a dosage as low as 20mg per day and may show toxic levels at regularly prescribed doses.[46]

First-line antidepressant therapy with SSRIs or TCAs is effective in relieving depression in 60% to 70% of geriatric patients.[47] For patients who are unresponsive or intolerant to this first-line therapy, bupropion, venlafaxine, or an MAO inhibitor can be tried alone or, alternatively, with augmentation strategies that include the combined use of TCAs and SSRIs (reducing the dose of TCA is imperative to avoid toxic levels), or as augmentation with lithium, methylphenidate, or thyroid hormone.[48,49,50] Anxiety symptoms are managed with concomitant benzodiazepines or buspirone, while psychotic symptoms require combined treatment with antipsychotic medication.[47]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.