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Residents in government-subsidised
places are not eligible for Medicare
rebates, under programs such as
Better Access, to see a psychologist.
Also, psychologists and other mental
healthcare professionals are rarely
employed within residential aged
Most classes of antidepressants that are
effective in young adult patients are also
effective in the elderly and, in general,
the somewhat limited data have shown
comparable efficacy in terms of response
1,2,15,19 Tolerability and the risk of
drug interactions in the elderly are
generally more important considerations,
with antidepressants being among the
most common medications associated
with preventable adverse drug events
in the elderly.20 Tricyclic antidepressants
are avoided as first-line agents because
of the risk of adverse effects related
to their ability to block muscarinic
receptors (e.g. cognitive impairment,
dry mouth, constipation, dizziness,
blurred vision, and urinary retentio
- adrenergic receptors (postural
hypotension and falls). These effects are
most pronounced with the tertiary amine
tricyclics (e.g. amitriptyline, imipramine,
clomipramine, and doxepin) and less
Selective serotonin reuptake inhibitors
(SSRIs) and serotonin-norepinephrine
reuptake inhibitors (SNRIs) are the
antidepressants of choice, followed by
15 Using combinations of
antidepressants is not evidence -based
and increases the risk of serotonin toxicity.
Amongst the SSRIs, citalopram and
escitalopram have the least potential for
Late-life depression is common
(major depression affects up to 20%
of people older than 65) and is often
associated with coexisting medical
illness, cognitive dysfunction, or both.
Depressed older adults are at
increased risk for suicide.
The initial treatment and ongoing
management of moderate and severe
depressive disorders in later life
should usually consist of combined
therapy with antidepressant
medication and some form of
Currently available antidepressants
show efficacy in depressed older
populations, but older adults may be
at increased risk for side effects.
inhibitors (SSRIs) are considered
1. taylor wd. Clinical practice. depression in the elderly. n
engl J med 2014;371:1228–36 .
2. frank C. pharmacologic treatment of depression in the
elderly. Can fam physician 2014;60:121–6 .
3. byrne gJ, pachana na. anxiety and depression in the
elderly: do we know any more? Curr opin psychiatry
4. barca ml, engedal K, laks J, selbaek g. a 12 months follow-
up study of depression among nursing-home patients in
norway. J affect disord 2010;120:141–8 .
5. bhar s. reducing depression in nursing homes requires
more than just antidepressants. the Conversation,
July 28, 2015. http://theconversation.com/reducing-
6. australian institute of health and welfare 2013. depression
in residential aged care 2008–2012. aged care statistics
series no. 39 . Cat. no. age 73. Canberra: aihw.
7. raj a. depression in the elderly. tailoring medical therapy to
their special needs. postgrad med 2004; 115:26-8,37-42.
8. small gw. differential diagnoses and assessment of
depression in elderly patients. J Clin psychiatry 2009;70:e47.
9. mecocci p, Cherubini a, mariani e, ruggiero C, senin u.
depression in the elderly: new concepts and therapeutic
approaches. aging Clin exp res 2004;16:176–89 .
10. Vanitallie tb. subsyndromal depression in the elderly:
underdiagnosed and undertreated. metabolism
11. hattori h. depression in the elderly. nippon ronen igakkai
12. saczynski Js, beiser a, seshadri s, auerbach s, wolf pa,
au r. depressive symptoms and risk of dementia: the
framingham heart study. neurology 2010;75:35–41.
13. bennett s, thomas aJ. depression and dementia: cause,
consequence or coincidence? maturitas 2014;79:184–90 .
14. Kohler s, buntinx f, palmer K, van den akker m. depression,
vascular factors, and risk of dementia in primary care: a
retrospective cohort study. J am geriatr soc 2015;63:692–8 .
15. alexopoulos gs. depression in the elderly. lancet
16. medical care of older persons in residential aged care
facilities, 4th ed. prepared by the royal australian
College of general practitioners - ‘silver book’ national
taskforce, 2006. funded by the australian government
department of health and ageing. at: www.racgp.org.au/
17. lafay-Chebassier C, Chavant f, favreliere s, pizzoglio V,
perault-pochat mC. drug-induced depression: a Case/non
Case study in the french pharmacovigilance database.
18. bridle C, spanjers K, patel s, atherton nm, lamb se. effect of
exercise on depression severity in older people: systematic
review and meta-analysis of randomised controlled trials. br
J psychiatry 2012;201:180–5.
19. mcdonald wm, salzman C, schatzberg af. depression in
the elderly. psychopharmacol bull 2002;36 suppl 2:112–22.
20. gurwitz Jh, field ts, avorn J, mcCormick d, Jain s, eckler
m, benser m, edmondson aC, bates dw. incidence and
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am J med 2000;109:87–94.
21. depression. in: australian medicines handbook. australian
medicines handbook drug Choice Companion: aged Care,
3rd ed., 2010:16–20.
Box 2. Depression in older individuals:
metabolic drug interactions mediated
by inhibition of liver enzymes, while the
long half-life of fluoxetine and its active
metabolite make it a less attractive choice
for the elderly.
Choices can also be
guided by the patient’s other symptoms
(e.g. duloxetine for concurrent neuralgic
pain and mirtazapine with anxiety).
Approximately 8% of people starting
SSRIs or venlafaxine will develop
hyponatraemia related to syndrome of
inappropriate secretion of antidiuretic
hormone. This is reversible but should be
monitored by checking blood levels at
about one month after starting therapy.
Treatment in older patients should usually
start at low doses of antidepressants
and increase slowly. Although the initial
doses of SSRIs and SNRIs given to elderly
individuals should be low (e.g. sertraline
at a daily dose of 25mg, citalopram at
10mg, or escitalopram at 5mg1,2), the final
dosages should be similar to those used in
Change in medication (e.g. from a SSRI
to SNRI) should be considered if patients
have no response after four weeks on
the maximum dose or have only partial
response after eight weeks of treatment.
Approximately 25–30% of patients fail
to respond to initial therapy, and there
is no clarity on the optimal approach to
switching or augmenting treatment.2
Cognitive impairment is predictive of a
poor response to antidepressants.
Older patients should generally be
treated for at least a year from when
clinical improvement is noted, and those
with recurrent depression or severe
symptoms should continue treatment
indefinitely.2,16,21 Treatment should be
tapered gradually to reduce the risk of
Pharmacists can assist in recognising
elderly patients who might have
depression, educating patients about
their antidepressant therapy (e.g. delayed
response after starting therapy, need for
good adherence and the importance
of not suddenly stopping therapy)
and monitoring for potential adverse
reactions and drug interactions.
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