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Optimizing Antidepressant Therapy in Older Adults | Pharmacy QI | Mar 2021

March 2021 | Practical Tips for Quality Improvement | View PDF

Antidepressant therapy in older adults should be guided by a resident-centred approach, including: comorbidities, concurrent medications, clinical features of depression, previous antidepressant history, and renal and hepatic function. To optimize antidepressant therapy in older adults, consider the following:

1. START LOW AND GO SLOW

Start with a low dose (e.g., 50% of the adult starting dose) and slowly titrate to a therapeutic dose.

2. WAIT 12 weeks to assess the response to antidepressant therapy.

3. ASSESS
If a partial response is observed, there are several options:

  1. Increase the antidepressant dose, if possible, to maximum dosing or tolerability;
  2. Switch to another first-line antidepressant from the same or different medication class;
  3. Initiate combination therapy, such as the use of an antidepressant with the addition of mirtazapine or bupropion with different mechanism of action and lower risk combinations for serotonin syndrome;
  4. Combine depression-specific psychotherapy with an antidepressant; or
  5. Initiate antidepressant augmentation strategies – use of lithium as an augmentation antidepressant therapy was associated with a response rate of 42%, and the use of venlafaxine with aripiprazole resulted in remission rates of 44%.

4. CONTINUE TREATMENT for 12 months from the first depressive episode, to prevent relapse.

5. CONTINUE THERAPY for another one to two years in residents with a history of two depressive episodes.

  • Continue for three years, or possibly indefinitely, for those with rapid recurrence or three or more episodes.

Reference:

  1. Marvanova M, McGrane IR. Treatment Approach and Modalities for Management of Depression in Older People. Sr Care Pharm 2021;36:11-21.

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