• Recognize depression in the elderly, its clinical manifestations, risk factors and prevalence.
• Understand the importance of developing systematic approaches to monitor patient responses, side effects and progress.
• Discuss the latest research on treatment-resistant depression.
• Summarize recent findings on non-pharmacologic therapies for treatment-resistant depression.
• Recognize electrolyte imbalances due to antidepressants.
• Recognize the signs and symptoms of withdrawal.

Angela R. Curtis, PhD
Managing Editor
Assistant Professor, Geriatric Education Manager

Richard V. Sims, MD
Associate Professor of Medicine

Samina Uddin , MD
Geriatric Medicine Fellow

Division of Gerontology, Geriatrics and Palliative Care
University of Alabama at Birmingham
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Depression currently ranks as the fourth leading global disease burden. It is projected to rise to number two by the year 2020, second only to ischemic heart disease.[1] Community studies have shown that 25% of elderly persons report depressive symptoms, but only 1% to 9% meet the criteria for major depression. However, prevalence varies according to the population being sampled. For example, higher prevalence rates are reported in the hospitalized elderly (36-46%) and those in long-term care facilities (10-22%)[2]

Often depressed patients report unexplained physical symptoms as their chief complaints. Symptoms are more somatic than typical. For example, frequent office visits or use of medical services and persistent reports of pain, fatigue, insomnia, changes in appetite and unexplained gastrointestinal symptoms are characteristic of depression in older adults.[3] Signs of social isolation and increased dependency are also common. Suicide rates are nearly twice as high in this group compared to younger patients. Sixty three percent of persons who commit suicide are white, elderly men, and eighty-five percent of them have an associated psychiatric or physical illness.[3]

Diagnostic criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition revised, (DSM-IV) should be able to identify most cases of depression. When a medical disorder or event is identified as causative, a diagnosis of mood disorder due to medical condition or event is made.[2]

Several neurotransmitters regulate mood; dysregulation of serotonin (5HT) and norepinephrine (NE) in the brain are strongly associated with depression.  Increased pain perception among depressed patients is probably due to this dysregulation in the brain and spinal cord. In fact, the imbalance of 5HT and NE probably explains the presence of both emotional and physical symptoms of depression in affected patients.

As of 2007, the evidence base for treatment of minor depression in the elderly is limited.  The few randomized controlled trials focusing on the elderly patient suggest that antidepressant medication or depression-specific counseling methods have a relatively modest benefit.  However, interpersonal psychotherapy and cognitive behavioral therapy have well-documented efficacy in randomized controlled trials, compared to medications, for elderly patients with mild to moderate depression.  The combination of pharmacotherapy and psychotherapy has been shown to be the most efficacious treatment for severe depression, though results are mixed.[5] 

Approximately 2 million individuals in the United States will experience an inadequate response to treatment for depression during their lifetimes.[1] The choice of antidepressant depends on symptoms, potential drug interactions and underlying medical illnesses. SSRIs are the first-line drugs of choice rather than the tricyclic antidepressants and MAOIs, due to better tolerance, lower incidence of sedation, little effect on cognition and fewer anticholinergic effects. Gastrointestinal symptoms in particular can be minimized by starting at lower dosages and taking the medicine with food. Sexual dysfunction is less frequent with fluvoxamine and non-SSRI agents like bupropion (Wellbutrin), mirtazapine (Remeron) and trazodone.

Mr. AB, a 69-year-old Caucasian male, comes to your office accompanied by his daughter. His chief complaints are “no energy”, memory problems, and worsening back pain for the past 6 months. He thinks that he is feeling fatigue due to his “poor back”.

His last visit with you was 10 months ago; since that time, he was admitted twice to the hospital. The first admission was with chest pain and the other with severe arthritic back pain following an automobile accident. His recent exercise MIBI was negative, and an MRI of the lumbosacral spine revealed osteoarthritis.

Mr. AB offers that his daughter has something that she wants to say. She reported that Mr. AB moved in with his younger brother after the death of his wife in 1996. Together they enjoyed dining out and socializing. Since his brother died 8 months ago, “Dad aged fast” the daughter added. She confides that for the past 6 months, Mr. AB has been exhibiting outbursts of anger and significant withdrawal from his usually active social life. He has always been a very independent and active person; the recent changes are atypical for him. He gradually began “to depend on others” and expects family members to do all his daily chores, including cooking and cleaning. He often forgets to eat meals prepared by the family, stating, “my back is too bad to warm up the food.” He has lost several pounds and begun to nap throughout the day.

Mr. AB has a history of hypertension controlled with lisinopril and is on a statin for hypercholesteremia. Two years ago, he underwent a diagnostic work-up, including a stress test and angiography, which revealed a lesion in the right coronary artery. A stent was placed.

Mr. AB never smoked or drank alcohol. His exercise routine has never been regular, and his intake of caffeine is moderate. Current medications include lisinopril 10 mg/d, atorvastatin 20 mg/d, Tylenol as needed and a baby aspirin. He never tolerated beta blockers because of symptomatic bradycardia.

On physical exam, you noted his blood pressure as 140/80 with otherwise normal vital signs. He lost 12 pounds since the last visit. There are no significant findings on the rest of the physical exam, including the neurological. On psychiatric exam, a flat affect was observed. His answers were limited to “yes” and “no” with very poor eye contact. On cognitive testing, he was only able to recall two out of three objects. Serial 7’s and orientation were normal.

You reviewed a recent comprehensive metabolic panel, PSA, TSH, and colonoscopy, all of which were essentially normal. A head CT scan at the time of the automobile accident was interpreted as “cerebral atrophy, consistent with age”.