Before considering an antidepressant as an elderly person, it is important to evaluate your life. This means evaluating your condition of depression from a logical perspective. Realize that there are plenty of ways to overcome depression without meds. Obviously if your diet isn’t optimal for your mental health, you don’t feel socially connected (or are isolated from family and friends), you aren’t getting sunlight each day, and aren’t getting exercise – you’re going to feel depressed.
While many people want to take the easy way out and blame a chemical imbalance for their depression, this clearly isn’t always the case. It may seem easier to throw chemicals at the problem of depression, but this doesn’t always work well. In many cases, making sure that you have a balanced life (social, spiritual, exercise, health, etc.) will do more for depression than any medication.
However if you insist that you need some sort of treatment, there are medications to consider. Before ever taking a medication though, you should take the time to book an appointment with a quality psychotherapist. Sometimes talking to a professionally trained psychotherapist does more for depression than a medication ever would. Only after you’ve corrected all lifestyle imbalances should you seek to use medication.
Factors to consider when treating depression in elderly patients
Before pursuing any antidepressant for an elderly individual, it is important to analyze the potential risks vs. benefits. It is also important to be aware of any interactions and side effects associated with the medication. Finally the elderly patient should estimate a realistic length of treatment and evaluate their quality of life with each treatment.
- Risk vs. Benefit: Prior to pursuing any treatment, it is important to consider the potential risks and potential benefits. The goal should be to first pursue the treatments that have high upside (potential benefits) and low risk. A couple such treatments include: TMS and psychotherapy – virtually side-effect free and low risk. Pharmaceutical interventions may have greater antidepressant potential, but the risks (e.g. side effects, withdrawals, and potentially making depression worse) may be greater.
- Interactions: With all of these treatments, it is important to consider their potential to interact with other medications that you may be taking. In addition to other medication interactions, it is important to consider that some treatment modalities may not be compatible with preexisting health conditions (e.g. ECT with pulmonary disease). It’s best to avoid treatments that have a high likelihood of producing interaction effects.
- Side effects: Always look at the potential side effects of treatment options on the elderly patient. Things to consider are: balance and coordination, cognitive effects (e.g. memory), onset of action, sexual dysfunction, etc. Always look at the side effect profile of the intervention that you’re pursuing to determine whether you think it would be an ideal fit for the elderly person. If an elderly individual wants to maintain a high sex drive, medications should be tested that are less likely to cause sexual dysfunction.
- Estimated duration of treatment: One elderly person may be 65 years old, while another may be 80 years old. While both may still have a significant number of years left to live, estimations should be made by the patient in terms of how long they’d like to be medicated or undergo treatment for depression. Pharmaceutical options are a double-edged sword in that they may be effective for years, but may stop working and/or have hellacious withdrawal periods. Certain treatments may be better long-term strategies (decades) and others may pack a better short-term punch (several years).
- Quality of life: When pursuing each treatment modality, it is important to consider the person’s quality of life. The goal should be to maximize their quality of life so that they can function cognitively, emotionally, and physically to the best of their ability. Blindly throwing medications at an elderly patient without taking their feedback into consideration is a losing strategy. If an off-label option works really well, it may be preferred over traditional options.
7 Best Antidepressants For the Elderly
Assuming you’ve done your due diligence and experimented with various natural cures for depression, but haven’t found any relief, there are some other good antidepressants that elderly people can consider. The first couple I recommend are NOT medication, but have been shown to be just as effective as medication.
1. TMS (Transcranial Magnetic Stimulation)
If you want to try the treatment with the biggest upside and lowest risk of side effects, transcranial magnetic stimulation is clearly your best bet. While low field-magnetic stimulation (LFMS) may be even more effective, it is currently undergoing clinical trials to validate its preliminary efficacy. Studies evaluating TMS in elderly patients have demonstrated that it is effective.
In fact, one study showed that elderly patients (60 years or older) with refractory depression (a form that won’t respond to medication) significantly improved from 10 sessions of high-frequency TMS that was delivered to the left dorsolateral prefrontal cortex. While many of these patients were already on medications, they clearly weren’t getting relief from them.
Another study with adults that were nearly 70 years old, it was found that when the right dorsolateral prefrontal cortex was stimulated, depression also significantly decreased. Although TMS isn’t going to work for everyone, most medications also don’t work for everyone. There are no serious side effects associated with TMS and it may actually improve connectivity of brain regions.
Although it does require up to 8 weeks of treatment to work, in many cases medications can take this long for a person to experience an effect. If you are an elderly individual, this is one of the top therapies for depression to try. At the very least you won’t notice anything, but your depression and cognitive function may improve.
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656335/
- Source: http://www.ncbi.nlm.nih.gov/pubmed/18665102
- Source: http://www.ncbi.nlm.nih.gov/pubmed/21485753
2. CBT (Cognitive Behavioral Therapy)
This is a form of therapy for depression that involves analyzing the relationship between thoughts, behaviors, and emotions. A therapist will work with a person to help them correct errors in their thinking as a result of feeling depressed and may suggest certain behavioral changes in attempt to improve their mood. Cognitive-behavioral therapy is a proven intervention for treating depression in people of all ages.
Meta-analyses have compared the efficacy of psychotherapy (CBT) versus antidepressant medication for the treatment of major depression and anxiety disorders. The difference in efficacy between the two interventions weren’t statistically significant. Therefore it is relatively safe to conclude that psychotherapy, particularly CBT should be considered equally as effective as an actual medication for depression.
While CBT may require some effort on the part of the patient, having another human to talk with about potential concerns and why an elderly person is depressed can make a huge difference. Especially in a person who became depressed as a result of a lifestyle change or environmental factor. It is important to realize that psychotherapeutic interventions may not be effective for all elderly patients with depression.
That said, psychotherapy is regarded by many as being as effective as pharmacological treatments and should be considered as a first-line treatment for depression in elderly patients. A therapist may be able to get down to the root of what’s causing the person’s depression, and may provide additional human social contact for someone that may have become isolated in old-age. There also aren’t any side effects or interactions to worry about with psychotherapy.
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683266/
- Source: http://www.ncbi.nlm.nih.gov/pubmed/21346483
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/
- Source: http://www.ncbi.nlm.nih.gov/pubmed/22815247
3. Traditional Antidepressant Medications
Assuming you’ve already tried TMS, psychotherapy, and logical lifestyle changes, an antidepressant isn’t a bad option. There are many benefits associated with taking antidepressants, but the downside is that most medications have a brutal withdrawal period, and can actually cause a chemical imbalance over the long-term, particularly with the serotonin system. Some would argue that it is possible to become dependent on antidepressants after several years.
Antidepressant medications may work well for a year or two, but come with significant side effects such as sexual dysfunction and weight gain. Additionally if you can’t find a medication that works, you may end up playing a little game called “antidepressant roulette” – where you’re cycled through drugs that are supposed to work, but don’t – and you feel way worse than before you even tried the drugs.
First line treatment options include: SSRIs and some newer, atypical antidepressants followed by SNRIs, TCAs, and finally MAOIs. If comparing the efficacy of antidepressants for the general population, there appears to be no single “best antidepressant.” However many experts would argue that the newer drugs are preferred for overall safety and side effect profiles compared to older-generation drugs.
- SSRIs/SNRIs/atypicals: The newer generation drugs of SSRIs, SNRIs, and atypical antidepressants seem to be the most preferred options for treating depression in the elderly. These tend to have the least number of side effects and greatest upside. Most work by increasing extracellular levels of serotonin to alleviate depression, but may simultaneously target other neurotransmitters to a lesser extent.
- Tricyclic antidepressants: If an elderly individual is using a tricyclic antidepressant, they need to be used with precaution due to their side effects. Various tricyclics that appear to be effective for old people include: nortriptyline, amitriptyline, clomipramine, and desipramine. These seem to be the best tolerated tricyclics.
- MAOIs: These are some of the oldest antidepressants on the market, but that doesn’t mean they aren’t effective. Many people find that they are a great third-line treatment option. Unfortunately they tend to carry a greater number of side effects as well as a greater risk of interactions with other medications and foods containing tyrosine (e.g. cheese).
If a person tries all of those options and isn’t able to find that anything helps, other options can be pursued. It should also be mentioned that there are many antidepressant augmentation strategies that combine multiple pharmaceuticals in attempt to further reduce depressive symptoms. You could even combine a pharmaceutical antidepressant with both therapy and TMS if you wanted.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/10727780
- Source: http://www.ncbi.nlm.nih.gov/pubmed/19031487
If I knew I didn’t have many years left to live, and was struggling with a crippling, refractory depression, I wouldn’t hesitate to find a doctor to prescribe Suboxone. While using Suboxone for depression may not be a well-accepted option, many consider it to be the single most effective and feasible pharmaceutical drug for the immediate obliteration of depressive symptoms. Additionally there is evidence to suggest that it may work for a long-term just like traditional antidepressants without significant tolerance.
Suboxone is a drug with a “ceiling effect” – meaning when you increase the dose past a certain point, you won’t get any additional mood boost or opioid-based “high.” Suboxone is a drug that targets the mu opioid receptor as a partial agonist. It doesn’t tend to create the same degree of euphoria that a person would experience on an opioid, but still packs enough of a punch to decimate most depressive symptoms.
There is controversy as to whether this is a good long-term option though, particularly for the elderly. Elderly individuals may be more sensitive to the effects of Suboxone and will need to work with their doctor to determine any potential interactions that it may have with their current medication regimen and other health conditions. Fortunately a new medication called ALKS 5461 may work just as well as Suboxone, with less potency – so you may want to consider that experimental drug as another option.
Due to the rise in the number of treatment-resistant cases for depression, Suboxone is clearly the single best off-label option to give the elderly individual a higher quality of life and reduced depression in old age. It works significantly better than traditional antidepressants, has a ceiling effect, and provides immediate relief – what more could someone really want? It may not be the best long-term option, so don’t blindly try to get Suboxone without doing your research.
Should you ever want to discontinue, you may want to read cases of people that have been through Suboxone withdrawal – it’s no joke. That said, withdrawal from most antidepressant medications may prove to be just as difficult.
It has been suggested that psychostimulants (e.g. methylphenidate) should be considered for the treatment of depression in elderly patients. Not only do these medications have the potential to help with depression, they can also improve various aspects of cognitive function including: memory and concentration. There is evidence that many traditional antidepressants take a long time to work (sometimes 6 to 8 weeks).
Waiting can be detrimental to the health of the elderly patient and decrease likelihood of treatment adherence if the patient speculates that the medication isn’t working. Therefore an intervention with a psychostimulant such as methylphenidate can be effective. There is also some evidence suggesting that a drug like Adderall for depression may be a great adjunct to a traditional medication.
Psychostimulants generally work immediately and can provide significant short-term relief from depression. Some people may find that they even provide long-term relief when taken for several years. While they do have potential for abuse, if the dosage and supply is closely regulated, this shouldn’t be as much of a problem. In cases which a person’s depression is tied to a serious physical illness, a trial of low dose methylphenidate is recommended.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/8268747
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181580/
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738590/
- Source: http://www.ncbi.nlm.nih.gov/pubmed/8835049
This is a vigilance-promoting drug (classified as a “eugeroic”) that improves cognitive function. Many people taking Modafinil notice that they have more energy, decreased need for sleep, and an increased level of productivity. Among those in the general population who manage to obtain this medication on an off-label basis for the treatment of depression, it has received a lot of praise.
While it isn’t universally regarded as an effective standalone treatment option for depression, it is something to consider in the elderly. Some studies have suggested that it may reduce apathy in elderly patients. It also isn’t considered nearly as addictive as various amphetamine-based psychostimulants, and thus may be preferred for elderly trying to combat excessive fatigue, hypersomnia, or low arousal.
It is an off-label option to consider and is regarded as pretty safe, with minimal withdrawal symptoms (should a person choose to discontinue treatment). There is even some evidence to suggest that the drug may act as both a nootropic and neuroprotective agent – thus preventing the death of brain cells and loss of neural functions that accompany old age.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/17264158
- Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229333/
7. Electroconvulsive Therapy (ECT)
Electroconvulsive therapy, also known as “electroshock” therapy is somewhat controversial because it can lead to memory loss and other unwanted (permanent) effects. Despite the fact that you are taking a gamble with your memory and potentially certain cognitive functions, it is an effective treatment for depression in the elderly. Obviously prior to trying ECT, it would be recommended to run through most of the options on this list.
Approximately 70% to 90% of all people suffering from major depression that get ECT end up feeling better. That said, there are plenty of risks associated with ECT in elderly patients. Not only is ECT fairly expensive and requires hospitalization, it has the potential to cause retrograde and anterograde amnesia, which may be particularly problematic for the elderly. Additionally, simply going under anesthesia for the procedure can be risky and have long-term effects on the brain.
Not only is ECT associated with a high degree of social stigma, but it may be dangerous if the elderly patient has another medical condition such as: cardiac or pulmonary disease. There is no guarantee that the effects of ECT are going to be long-lasting or permanent either. Therefore this therapy should be considered as a last-line option.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/9060342
- Source: http://www.ncbi.nlm.nih.gov/pubmed/22183009
- Source: http://www.ncbi.nlm.nih.gov/pubmed/14533122
- Source: http://www.ncbi.nlm.nih.gov/pubmed/25220219
What about atypical antipsychotics?
Unless a person has been clinically diagnosed with a severe mental illness like schizophrenia, antipsychotics are one of the worst, and least safe options. Not only are they associated with development of Type 2 diabetes, but they can actually cause a loss of brain volume. Elderly medicated with high doses of antipsychotics are at increased risk of early mortality as well.
These drugs are blatantly overprescribed and will impair both memory function and cognition in elderly patients with depression. While they may certainly help someone fall asleep, they will deplete energy levels, and are a pathetic treatment option. If you want an elderly patient to live in a barely-functional haze until their death, an antipsychotic would be the drug of choice. These are the most potent drugs and should be reserved for only those with severe forms of psychosis – not depression.
Bottom line: There is no universally “best” antidepressant for “elderly”
Those that believe that one antidepressant is better than the field for a specific subset of the population (e.g. the elderly) have been mislead. There are many individual factors to consider whenever selecting an antidepressant such as: its effects on memory, interactions with other drugs that the person is taking, as well as how long the person plans to be medicated. Some medications may increase risk of falling due to the fact that they affect balance, coordination, and equilibrium.
Traditional psychiatry would suggest a person start with a logical, safe, proven option like an SSRI. Psychologists would suggest that a person start with psychotherapy and take things from there. The goal is to assess the risk-benefit ratio of each option for the elderly patient and tailor the treatment to fit the individual needs.
Keep in mind that these treatments are devised for those who are doing everything in their power: dietary, exercise, vitamins, sunlight, socialization, etc. to reduce depressive symptoms. Starting with TMS and psychotherapy has promise, and adding an antidepressant if the person doesn’t get benefit from those practices can make a difference. It’s just a matter of choosing whether you want immediate relief (e.g. Suboxone) or want to test the waters and hope that something works (e.g. traditional antidepressants).