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 The leading web portal for pharmacy resources, news, education and careers April 30, 2017
Pharmacy Choice - Depression Disease State Management - April 30, 2017

Depression Disease State Management


Drug Pearls for the Treatment of Depression and Anxiety in Older Adults
by Joseph P. Vande Griend, Pharm.D., BCPS, CGP
Assistant Professor
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences


Depression and anxiety are common in older adults. Depression is characterized by a loss of interest or pleasure in life activities or by a depressed mood. Generalized anxiety disorder (GAD) is the most common anxiety disorder in older adults and is characterized by excessive and persistent worrying that is hard to control. Overlapping symptoms include irritability and physical symptoms such as increased fatigue and muscular tension. Anxiety and depression affect both men and women, with women twice as likely to be affected. Additionally, both occur at a much higher rate in patients with chronic illness or multiple co-morbidities. Antidepressants and benzodiazepines are used to treat these diseases in older adults, but these drugs have unique features that require important consideration in older adults.

Drug Therapy Pearls for Treating Depression
  1. Selective Serotonin Reuptake Inhibitors (SSRI's) are first-line therapy
    These medications are all available generic, are well tolerated in older adults, and have similar efficacy to all other antidepressants. It is important to start these at the lowest available dose to minimize side effects that occur more frequently in older adults. Citalopram is the only SSRI with specific dosing recommendations in older adults. The maximum dose is 20mg daily for patients > 60 years old because of increased risk of QTc prolongation. A patient's co-morbidities may affect the initial choice of antidepressant therapy. Using one drug to treat multiple conditions can help reduce the number of medications prescribed, which is especially important in older adults who are often at risk for polypharmacy. As an example, duloxetine and venlafaxine can provide benefit for peripheral neuropathy, mirtazapine and paroxetine are more sedating and may provide benefit for insomnia, and bupropion, mirtazapine, and duloxetine are least likely to cause or worsen erectile dysfunction.
  2. Older adults can be more difficult to treat
    Older adults often have challenging life situations, such as the death of a loved one or multiple medical co-morbidity. Additionally, antidepressants can take much longer to work in older adults, sometimes requiring up to 4-8 weeks to start working and up to 16-20 weeks to see optimal benefit. This is an extremely important counseling point for any older adult starting an antidepressant as these patients often stop taking their medication because they think it isn't working.
  3. Treating depression effectively will most often require a drug change
    The real-world treatment of depression was evaluated in the STAR-D trial. In this study, all patients were treated with citalopram over 12 weeks. Only one-third no longer had depression symptoms, and two-thirds of patients required a change in their depression regimen. For patients who do not respond to or tolerate a first-line SSRI, stopping initial therapy and switching to a different first-line SSRI is reasonable. Alternatively, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), or bupropion can be utilized. For those patients who do respond to their first therapy, but do not get entirely back to normal, an antidepressant with a different mechanism of action (Bupropion or buspirone) can be added to the initial antidepressant regimen. Some patients will require further change to resolve their depression, and some patients will have unresolved depression despite multiple drug therapy changes.
Drug Therapy Pearls for Treating Anxiety
  1. SSRI's are also first-line therapy for generalized anxiety disorder
    Similar to depression, GAD is thought to be related to a deficiency in serotonin and/or norepinephrine. Antidepressants work by treating this underlying problem. It is especially important to start antidepressants at the lowest available dose and titrate them slowly for the treatment of GAD. Patients should be counseled that antidepressants can increase anxiety symptoms when first started, but that this should go away over a period of several weeks.
  2. Benzodiazepines should be considered a bridge
    Benzodiazepines work very quickly and effectively to treat the symptoms of GAD. However, these medications have serious side effects in older adults including cognitive impairment, delirium, falls, fractures, and increased risk of motor vehicle accidents. Lorazepam has an intermediate half-life, no active metabolites, and its elimination is much less affected by age, so it is a preferred agent for older adults. Diazepam has a very long half-life and active metabolites with long half-lives, and it is lipophilic, so it can last in the body for a long time. This makes it the least preferred therapy for treating anxiety. If a benzodiazepine is going to be used for GAD, the goal should be to use the lowest dose for the least amount of time. In a perfect scenario, a benzodiazepine would only be used until the antidepressant is working optimally.
  3. Community pharmacists are on the front-line and are uniquely positioned to impact the care of depression and anxiety treatment in older adults. They play an important role in the detection and appropriate pharmacologic treatment of both depression and anxiety. Providing optimal education and counseling regarding these medications can ensure that older adults get the most benefit and highest likelihood of getting better.

    References

    Espinoza RT, Unutzer J. Diagnosis and Management of Late-life Depression. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA. (Accessed on February 3, 2014.)

    Bystritsky A. Pharmacotherapy for generalized anxiety disorder. In: UpToDate, Basow DS (ED), UpToDate, Waltham, MA. (Accessed on February 3, 2014.)

    Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. Am J Psychiatry 2006; 163:1905-1917.

    American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60: 616-31.


    Links - Depression
    National Alliance for Research on Schizophrenia and Depression is the largest donor-supported organization in the world devoted exclusively to supporting scientific research on brain and behavior disorders.

    Depression Alliance is a UK charity offering help to people with depression, run by sufferers themselves.

    depression-screening.org is sponsored by the National Mental Health Association (NMHA) as part of NMHA's Campaign for America's Mental Health.

    Dr. Ivan's Depression Central Internet's central clearinghouse for information on all types of depressive disorders and on the most effective treatments for individuals suffering from Major Depression, Manic-Depression (Bipolar Disorder), Cyclothymia, Dysthymia and other mood disorders.

    If you would like to contact us please go to our Contact Page.

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