Don't Fear Older Medications and Treatments for Our Senior Patients

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CLINICAL REFLECTIONS

Both recurrent depression and bipolar I and II depression are ordeals both for the patient and psychiatrist. This past year, I have had 3 similarly aged women presenting with difficult to treat depression, challenging my psychiatric skills and decision making. All 3 were women over 70 years of age; only 1 had been hospitalized in the past for depression and all were currently on medication for depression.

It was early in the year when my first patient, aged 77 years, showed a rapid decline in her mood after a small flood in her apartment. She had had 2 episodes of serious depression, usually preceded by insomnia and physical weakness usually quickly relieved with an adjustment in the dose of a selective serotonin reuptake inhibitor (SSRI), short term use of a benzodiazepine, and supportive and behavioral psychotherapy. During the current episode, she regressed in her personal care neglecting to groom in her usual meticulous manner. She was afraid to be left alone and was fully absorbed in the miserableness of her being. Her preoccupation with somatic symptoms and changes in her sleep pattern affected her ability to tolerate new medications. Fortunately, both the patient and spouse were open to the idea of electroconvulsive therapy (ECT) but the logistics of finding a hospital for outpatient ECT after COVID-19 (to mitigate the trauma of inpatient hospitalization) was no easy endeavor. However, once started on a course of 12 ECT sessions, she readily improved. Each session with me notably measured improvement in her physical appearance and a reestablishment of her independence and confidence.

My second patient was a 76-year-old woman who lost her partner to cancer during COVID-19 and came to treatment with me on an SSRI and a benzodiazepine. At the start of treatment, she was very energetic, involved in Zoom learning, and traveling. Over time, despite compliance with medication, she became more and more depressed. Novel antidepressants and atypical antipsychotics both second and third generation were tried to no avail. ECT was suggested but was too frightening a prospect for the patient. Because of adverse effects, a course of transcranial magnetic stimulation (TMS) was encouraged. Halfway through TMS, a relative called to inform me that the patient's mental state had so seriously declined that she was spending all of her time in bed. She was admitted to a nearby hospital for a week without improvement. I advocated for ECT; she was transferred to a hospital out of county for ECT but was unable to tolerate the conditions of the psychiatric unit and signed out. I again took on the role of social worker and found a hospital within traveling distance for her relative; she was admitted for ECT and after a course of 12 ECT she rapidly improved and was discharged home on an SSRI, olanzapine, and a mood stabilizer.

The third patient, who was married and 73 years old, presented to me a few years ago after a hospitalization for serious depression and suicidal ideation. Her depression persisted for over 2 years despite trying newer antidepressants and mood stabilizers. I came to believe that depression was her baseline until almost overnight she had a remarkable improvement in her mental state and became happy, motivated, and purposeful. Despite warnings about noncompliance, she disappeared from treatment and discontinued all her medications until she represented this year with anxiety, depression, insomnia, and anhedonia. It was a difficult course; ECT was too frightening for her and her spouse to consider. However, with lithium and Symbyax (combination fluoxetine and olanzapine) and behavioral and supportive interventions, her depression remitted. (Interestingly, Symbyax was the first medication approved by the US Food and Drug Administration in 2003 for the treatment of bipolar I depression.)

Of course with older patients, medical complications causing mental status changes need to be ruled out. However, do not be swayed by the age of the patient and the possibility of adverse effects. Careful titration of lithium, second generation antipsychotics such as the olanzapine/fluoxetine combination and ECT have proven efficacy. Long term relationships between a psychiatrist and patient are also invaluable to provide support and optimism during serious episodes of depression. Full remission of depressive symptoms in an older patient is the treatment goal.

Dr Varas is a psychiatrist in Westwood, New Jersey.