Challenges of Treating Depression in the Elderly

Dr Helen Lavretsky discusses some of the challenges of working with elderly patients, which include the following:
 
• Older patients suffer from higher rates of depressive disorders and symptoms than younger patients
• Comorbid medical symptoms, polypharmacy, and cognitive decline are hallmarks of geriatric depression
• Treatment resistance and suicidal ideations are common
• Low remission rates (approximately 30-35%)^* to the standard antidepressants are common

In a recent study in the American Journal of Psychiatry,Lavretsky and colleagues evaluated the potential of methylphenidate to improve antidepressant response to citalopram, as assessed by clinical and cognitive outcomes, in elderly depressed patients in a 16-week randomized double-blind placebo-controlled trial for geriatric depression.

Results: Daily doses ranged from 20 mg to 60 mg for citalopram (mean=32 mg) and from 5 mg to 40 mg for methylphenidate (mean =16 mg). All groups showed significant improvement in depression severity and in cognitive performance. However, the improvement in depression severity and the Clinical Global Impressions improvement score was more prominent in the citalopram plus methylphenidate group compared with the other two groups. Additionally, the rate of improvement in the citalopram plus methylphenidate group was significantly higher than that in the citalopram plus placebo group in the first 4 weeks of the trial. The groups did not differ in cognitive improvement or number of side effects.

Conclusions: Combined treatment with citalopram and methylphenidate demonstrated an enhanced clinical response profile in mood and well-being, as well as a higher rate of remission, compared with either drug alone. All treatments led to an improvement in cognitive functioning, although augmentation with methylphenidate did not offer additional benefits. Summary from Pubmed:

Further reading:
*Lavretsky H, Reinlieb M, St Cyr N, et al. Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry. 2015;172:561-569. http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2014.14070889.

Reynolds CF 3rd, Butters MA, Lopez O, et al. Maintenance treatment of depression in old age: a randomized, double-blind, placebo-controlled evaluation of the efficacy and safety of donepezil combined with antidepressant pharmacotherapy. Arch Gen Psychiatry. 2011;68:51-60. http://archpsyc.jamanetwork.com/article.aspx?articleid=210973.

2010 Census Shows 65 and Older Population Growing Faster Than Total U.S. Population. November 30, 2011. https://www.census.gov/newsroom/releases/archives/2010_census/cb11-cn192.html.

The Myths of Aging. http://transgenerational.org/aging/myths-of-aging.htm.

Disclosures:

Dr Lavretsky is Professor of Psychiatry at UCLA. She also directs the Late Life Mood, Stress, and Wellness Research Program at the Semel Institute at UCLA. She is an editorial board member of Psychiatric Times.