Antidepressant Treatment of Depression in the Elderly: Efficacy and Safety Considerations

Depression in the elderly is a significant clinical problem which is likely to endure as an ongoing issue as the cohort of individuals aged over 65years continues to increase as a proportion of the total population. While there are a multiplicity of approaches to the treatment of depression, the mainstay for moderate to severe cases is pharmacotherapy. The majority of extant antidepressants have demonstrated efficacy, at least in short term (6-12weeks) clinical evaluations. There is demonstrable efficacy over and above that of placebo in the majority of clinical trials for most agents. Within the classes of antidepressants there is no difference between individual agents, while between classes differences have not been demonstrated consistently. Thus, there appears to be little to choose between the various agents. However, considerations other than efficacy play a role in the choice of an antidepressant for an individual patient. A systematic review of the efficacy of antidepressant agents based on trials in elderly populations is presented. Factors influencing the choice of a medication over and above efficacy are presented along with a brief review of adverse events of particular concern in elderly patients. A considerable proportion of elderly patients have comorbid medical conditions, which may also influence the choice of agent due to drug-drug interaction considerations. A brief overview of interactions likely to influence medication selection is also canvassed. While there is every reason to be optimistic about outcomes in elderly patients, there are still unanswered questions about antidepressant efficacy in this population: effectiveness in long-term treatment and in the population of so-called ‘old-old’ elderly are principal among them.