The elderly have quite different presentations of depression compared to younger adults. These differences can complicate the diagnosis and treatment of major depressive disorder in the elderly.

Depression is a scary, isolating disease that can be especially consuming when accompanied by older age.

To aid family members and caregivers in understanding depression in the elderly, I have developed a common list of questions and answers and some popular management approaches.

If you or a loved one are an older adult who experiences depression, it is essential to understand how to manage it properly.

This article will discuss the available agents and strategies for treating depression in the elderly.

We’ll discuss what’s known to work and what definitely won’t!

How common is depression in older adults?

An older adult is at roughly the same risk for clinically significant depression as someone younger or middle-aged.

That being said, very old adults are significantly more prone to developing depression, with the incidence and prevalence of depression doubling after 75.

Depression in older people is a prevalent, serious condition that affects patients, families, and caregivers. Roughly 14 to 20 percent of seniors in the community are expected to have depression.

Despite these statistics, late-life depression remains under-recognized and undertreated because older people often don’t communicate the full extent of their symptoms.

Consequently, many individuals are left undiagnosed despite having an underlying depressed mood.

Depression is also more likely to develop with chronic illness, cognitive impairment, and disability.

Common conditions and other risk factors such as infection, cancer, heart attack, and stress have been scientifically linked to the development of depression.

The greater the patient’s medical problems, the higher the risk of depression.

Older adults admitted to the hospital and in long-term care facilities are anticipated to have an even higher incidence of depression, with estimates of up to 45 percent.

Diagnosis and treatment of elderly patients are a bit more complex than in a younger person.

Older patients typically have comorbid conditions and take multiple medications predisposing them to depression and complicating their illness.

Additionally, depression symptoms present differently in older adults.

For example, many will have a flat affect, where they don’t get excited about anything and don’t engage with others.

They are also more likely to experience side effects and sensitivity to antidepressant medications.

Should an elderly person be concerned about depression? Why is it important to treat?

Depression can have troubling effects on one’s mental health and physical well-being if not managed appropriately.

Untreated depression can worsen the outcome of many medical illnesses, such as those living with cardiovascular disease.

It can also increase the risk of loss of independence and interfere with a person’s ability to function.

Conditions such as high blood pressure, heart disease, and diabetes are associated with an increased risk for depression in the elderly, negatively affecting disease outcomes.

One study showed that those with depression were four times more likely to die within months of a heart attack than those without depression.

Suicide is another primary concern with depression. The suicide rate among elderly people is twice as high as that of the general population.

An older person is more likely to die if an attempt is made.

Therefore, individuals and families must look for common signs and symptoms of depressed mood and seek help when it is appropriate.

What are the signs and symptoms of depression in older adults?

Healthcare professionals recognize that when seniors are depressed, they have more pronounced functional loss than their younger peers.

Functional losses include extreme negativity, lessened activity, staying in bed, exaggerated helplessness, and dependency.

Seniors may also be preoccupied with their bodily functions (pain, constipation, etc.) or melancholia.

Symptoms such as these are often overlooked and attributed to normal aging patterns. However, they can be signs of depression.

The anxiety and fear of growing older and realizing that their time on this planet is limited may also contribute to feelings of sadness, and trigger depression.

Major depression is diagnosed when someone has five or more of the warning signs listed below.

Patients exhibiting at least two but fewer than five of these symptoms are classified as having minor depression:

• Depressed mood
• Diminished interest
• Loss of pleasure in activities (Apathy)
• Weight loss or gain (more than 5% of body weight)
• Insomnia or hypersomnia
• Agitation
• Physical complaints such as fatigue
• Feelings of worthlessness or inappropriate guilt
• Reduced ability to concentrate
• Recurrent thoughts of death or suicide

What are the causes of depression in the elderly?

There can be various causes of mood disorder in older people, but common causes are associated with life changes due to aging.

Factors that can contribute to an older person’s development of depression include, but are not limited to:

• Chronic medical conditions
• Cognitive decline/Alzheimer’s Disease
• Grief from losing family or friends
• Transitioning to assisted living
• Decreased functional ability
• Social isolation 

How is depression in older people diagnosed?

Start by making an appointment with your doctor.  A person’s health care provider or a geriatrician can diagnose depression.

An initial assessment will include a comprehensive interview, history, and mental status examination.

Providers can use depression scales such as the Patient Health Questionnaire (PHQ), Geriatric Depression Scale, or Beck Depression Inventory.

The PHQ-2 is usually the first screening tool administered before the PHQ-9.

If a patient responds ‘yes’ to at least one of the questions on the PHQ-2, the PHQ-9 is then administered.

These scales help to diagnose and track depressive symptoms over time.

However, it is important to note that there are steps you can take to find effective treatment.

Treatment for depression in older adults

Before initiating antidepressant medications, your provider will assess underlying conditions contributing to your mood.

Adequate management of comorbidities will ensure that you receive optimal treatment. 

Your physician will carefully assess whether your new antidepressant has interactions with other medicines you are currently taking.

With increased age, you may be more sensitive to certain medications.

This is because you may have certain health conditions, drugs you are on, or altered metabolism that affect how your antidepressant might work.

Therefore, when you start an antidepressant medication as an older adult, your starting dose should typically be one-half of what is prescribed to a younger adult.

This lessens the chance of developing side effects by starting at too large a dose.

When starting an antidepressant in an older adult, the strategy involves starting low and going slow.

However, dose escalation in seniors can be difficult because of potential cognitive impairment and adherence difficulties for independent adults.

Therefore, dose increases must be done carefully and under the supervision of a doctor.

After starting on a low dose, your doctor will likely increase your dose every one to two weeks until you achieve the average therapeutic dose.

When you reach this dose, your doctor will assess how your mood improves after two to four weeks.

If your depression is still not adequately controlled, your doctor will usually increase your dose to the maximum if you tolerate it. Reaching higher doses can also help with symptoms of anxiety.

Your Mental Health is Important! Help is right here! – Click on the image to connect to a trained, licensed mental health professional.

What are the best antidepressant medications for older adults?

There is no single drug to treat depression in older adults, and several different medications can be used.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the gold-standard drug classes for treating depression in older adults. 

Second-line or adjunct agents include bupropion and mirtazapine.

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are also options reserved for treatment-resistant cases because of their negative side-effect profiles.

Starting doses for SSRIs and SNRIs should be low for elderly patients, but the final doses should be similar to those used in younger adults.

Various treatment options are available to safely and effectively manage clinical depression in older adults.

If you are considering starting an antidepressant medication, your choice of drugs should consider side effects and drug-drug interactions.

Selective serotonin reuptake inhibitors (SSRIs), bupropion (Wellbutrin®), and mirtazapine (Remeron®) are all potential options to consider.

These agents have minimal anticholinergic effects (certain dangerous side effects among older adults) and, therefore, are relatively safe in those with heart conditions.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Certain SSRIs are great options for managing depression symptoms. Common side effects of SSRIs may include:

• Nausea
• Diarrhea
• Dry mouth
• Somnolence (sleepiness)
• Agitation
• Insomnia (difficulty falling asleep)
• Sweating
• Low sodium

The best options for older patients include escitalopram and sertraline.

These agents have minimal drug-drug interactions.

SSRIs that you should avoid include fluoxetine, paroxetine, and fluvoxamine. These medications will be discussed in-depth in this article.

Sertraline (Zoloft)

Sertraline is an excellent option to treat depression as it is safe and effective in those over 60. Like other SSRIs, it does not induce anticholinergic effects like tricyclic antidepressants (TCAs).

Some common examples of TCAs are amitriptyline (Elavil), clomipramine (Anafranil), doxepin (Sinequan), and imipramine (Tofranil), desipramine (Norpramin), nortriptyline (Pamelor, Aventyl), etc.

Sertraline has a low potential for drug interactions, which is essential for older patients who may be on various medications.

Dosing

Sertraline requires careful dose escalation (the medical term is called dose titration). Doses should start at 25 mg and then increase to 75-150 mg, depending on tolerance.

Some people may even benefit from going up to 200 mg daily. However, older adults may suffer from cognitive impairment.

This can cause individuals to be forgetful or confused, making medication adherence difficult, especially when titrating doses. In this instance, patients may benefit from a more easily titrated option known as escitalopram.

Side effects

Common side effects of sertraline include:

• GI: diarrhea, nausea, dry mouth
• Nervous system: sexual dysfunction, decreased libido, dizziness, tiredness, insomnia

Escitalopram (Lexapro)

If you have difficulty with the dose adjustments required for sertraline, escitalopram may be a good option.

Dosing

Like sertraline, escitalopram should be started at a low dose. Doses of escitalopram should begin at 5 mg once daily. Doctors can then increase the dose to the maintenance dose of 10 mg daily only after a few weeks.

Side effects

Common side effects of escitalopram include:

• GI: diarrhea, nausea
• Nervous system: tiredness, headache, insomnia
• Other: ejaculatory disorder

Citalopram (Celexa)

Citalopram is an effective SSRI to treat depression. However, use in older adults is limited due to the chance of QTc prolongation (see explanation below).

Dosing

Citalopram doses should start at 10 to 20 mg once daily. The maximum dose of citalopram in older adults at least 60 years is 20 mg daily because of the risk of QT prolongation.

Side effects

While citalopram may be an option in elderly patients, use may be limited by the risk of prolonging the QTc interval. The QTc interval describes the electrical activity in the heart.

If your QTc interval becomes prolonged, it can cause a condition known as Torsade’s de Pointes (TdP). TdP is a dangerous change in heart rate that can increase your risk of hospitalization and death.

A QTc over 500 milliseconds (ms) increases your likelihood of Tdp by two or three times.

Other medications can also cause QT prolongation. When citalopram is taken together with these drugs, the risk of QT prolongation and TdP is increased.

Drugs that may cause this include certain antibiotics, antipsychotics, and other antidepressants.

Since discovering this effect, the FDA issued a safety warning for citalopram in those over 60.

For these individuals, doses greater than 20 mg are not recommended because citalopram may affect the heart (6). 

If your provider decides citalopram is right for you, they should use caution and monitor you for QTc prolongation. Other side effects of citalopram include:

• Dermatological: sweating
• GI: nausea, dry mouth
• Nervous system: tiredness, insomnia

Mirtazapine (Remeron)

Mirtazapine is another medication that can treat depression in the elderly. In addition to its anti-depressive effects, it also has a modest benefit in appetite stimulation.

For patients that struggle with poor appetite and weight loss, mirtazapine may be a good option.

Additionally, mirtazapine can be a great co-treatment to escitalopram or sertraline to maximize antidepressant effects.

Dosing

The clinical effects of mirtazapine vary greatly between doses, and it has an unusual dose-dependent response.

This makes it incredibly important to have proper dosing to achieve optimal safety and effectiveness.

At low doses, mirtazapine demonstrates sedating effects due to its high activity at histamine sites in the body—the lower the dose, the more sedating the effect. Sedating doses are 7.5 mg and 15 mg.

For this reason, it is often used to treat insomnia and dosed at bedtime.

However, low doses may be problematic in older adults who may experience confusion or fatigue with mirtazapine.

Unlike other antidepressants, mirtazapine usually shouldn’t be started at its lowest dose of 7.5 mg.

While still sedating, experts recommend starting at 15 mg as a nice clinical compromise.

From there, mirtazapine can be increased up to 45 mg daily.

However, higher doses of mirtazapine can have an activating effect due to its norepinephrine effects.

Therefore, you should take higher doses of mirtazapine in the morning to avoid insomnia.

Side effects

Common side effects of mirtazapine include:

• Endocrine and metabolic: increased cholesterol, weight gain
• GI: constipation, dry mouth, increased appetite
• Nervous system: tiredness

Trazodone (Desyrel, Oleptro)

Depression can sometimes be accompanied by insomnia, and SSRIs used to treat depression can also cause or worsen insomnia.

Because of this, trazodone may have a place in therapy for certain patients. Trazodone is a sedating antidepressant that can be used to treat insomnia if you have comorbid depression.

Multiple studies exist, establishing trazodone’s efficacy in treating insomnia accompanying depression.

Trazodone effectively increases time spent asleep, improves sleep efficiency, and reduces the number of awakenings throughout the night.

Additionally, it does not demonstrate anticholinergic activity and has a favorable side effect profile, making it a good option for seniors.

However, there is not as much evidence that supports its use in insomnia alone. Therefore, it is often misused as a sleep aid in those who don’t have depression.

Additionally, there is not much data available evaluating trazodone in seniors.

It is a good option, though, compared with other sleep aids like benzodiazepines (e.g., alprazolam, diazepam) and tricyclic antidepressants (e.g., amitriptyline) that have several side effects.

Dosing

In one study, insomnia improved in depressed individuals two weeks after starting trazodone at doses between 50 to 100 mg at bedtime.

Trazodone should be initiated at 25 to 50 mg at bedtime for senior patients. The doses can be increased by 25 to 50 mg daily each week. Usual doses are between 75 to 150 mg daily.

Side effects

Common side effects of trazodone include:

• Gastrointestinal: nausea, vomiting, dry mouth
• Nervous system: dizziness, drowsiness, headache

Trazodone does not have anticholinergic activity or cardiotoxicity, making it a good option for older adults at increased risk of side effects. It also has less abuse potential than benzodiazepines.

In rare cases, trazodone has caused priapism (a prolonged erection of the penis). Should this occur, it must be treated as a medical emergency, and individuals must seek immediate medical care.

Bupropion (Wellbutrin)

Bupropion is a common agent used to treat elderly depression, and it has few stomach and sexual side effects.

It is available as both an immediate-release (IR) and sustained-release (SR) formulation. Bupropion, however, may have a prolonged half-life in elderly patients. This can increase your risk of adverse events such as seizures.

Bupropion’s mechanism involves norepinephrine and dopamine, two neurotransmitters that are important chemical messengers.

This mechanism differs from that of SSRIs, which cause changes to another neurotransmitter, serotonin. Because bupropion and SSRIs utilize different pathways, they can be used together to increase antidepressive effects.

Dosing

Bupropion comes in different formulations. For immediate-release bupropion, doses should start at 100 mg twice daily. 

After three days, the dose can be increased to 100 mg three times daily. The maximum dose is 450 mg daily in three to four divided doses. A single dose should not exceed 150 mg.

For 12-hour extended-release (sustained-release) bupropion, doses can start at 150 mg taken in the morning.

The dose can be increased to 150 mg twice daily after three days. The maximum dose is 200 mg twice a day.

For 24-hour extended-release bupropion hydrochloride, doses can start at 150 mg taken in the morning.

After three days, the dose can be increased to 300 mg daily if tolerated. The maximum dose is 450 mg once a day.

Side effects

Common side effects of bupropion include:

• Cardiovascular: fast heart rate
• Dermatologic: sweating
• Metabolic: weight loss
• Gastrointestinal: constipation, nausea, vomiting, dry mouth
• Nervous system: agitation, dizziness, headache, insomnia, migraine
• Other: Tremor, blurred vision, stuffy nose, common cold, sore throat

Of note, bupropion was found to cause seizures in roughly 0.4% of patients taking doses up to 450 mg daily. Seizure risk is dose-related, increasing tenfold at doses between 450 and 600 mg daily.

The risk of seizures is almost four times greater than other antidepressants. Therefore, bupropion should be dosed with caution in elderly patients.

Here are the medications in table form to help you visualize their doses and side effects:

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin–Norepinephrine Reuptake Inhibitor (SNRIs)

Other Antidepressants

The recommendation is to continue an antidepressant for 4 to 6 weeks before evaluating its efficacy and adjusting the dose or agent.

If the first antidepressant trial is ineffective, the dose should be increased per the titration guidelines above.

If there is still no improvement, a different class of antidepressants should be tried or added.

Providers will use caution when starting more than one drug in an older patient, as the elderly are a very sensitive patient population regarding side effects.

Typically, SSRIs are the best agents for older adults and are well-tolerated.

It is essential to be vigilant of common side effects, as they can still occur.

What are some alternative treatments for depression?

Psychotherapy is an intervention commonly described as “talk therapy.” Patients speak with a counselor and develop techniques and solutions to reduce distress and unproductive behavior.

Cognitive-behavioral therapy (CBT) is an incredibly effective talk therapy for depression.

CBT focuses on identifying and changing depressive thought and behavior patterns with a structured-based approach.

With the help of a therapist, elders can gain important skills to manage their symptoms and reduce their risk of a relapse episode.

If you are depressed, you must seek treatment by talking to your doctor or mental health professional.

Depression may not go away and could progressively worsen, adding to your decreased quality of life and everything necessary to you.

Depression in older adults must never be minimized or attempted to be “rationalized” away….”Oh, I’m just getting old,” “It’s normal,” etc.

Suppose you are uncomfortable approaching your medical provider about this topic because of your familiarity with them.

In that case, it may be worthwhile to talk to a qualified, licensed mental health professional with whom you do not have a personal relationship.

Talking to a professional online may be a better approach for you.

Online-therapy is a trusted and well-known web-based service that provides cognitive behavioral therapy facilitated by licensed professionals.

Registration and appointments are made discreetly and efficiently, and you will be paired with a professional who cares about you.

If you would like to give this service a try, you can click here to be taken to the website. You will get a 20% discount for the first month if you sign up!

Electroconvulsive therapy (ECT) is another medical treatment that patients can consider.

Because of its representation in Hollywood movies and the stigma surrounding mental illness, many patients fear resorting to ECT.

However, it is an incredibly effective method and is most commonly used when depressed seniors have not responded to other treatments.

ECT involves a brief electrical stimulation of the brain while the patient is under anesthesia and is facilitated by an experienced medical team.

Other holistic forms of treatment include things like yoga, acupuncture, hypnosis, and meditation.

Yoga combines mindfulness, meditation, and movement to improve physical and mental health, rather than just mental illness. 

Yoga has been shown to reduce symptoms of depression when compared to regular care alone.

Many other studies have examined acupuncture’s effect on depression symptoms.

Current evidence indicates that with both acupuncture and antidepressants, depression severity and the rate of side effects can be reduced.

These nonpharmacologic methods can be used as an adjunct to conventional treatments, as they can significantly affect one’s health and well-being.

AGENTS TO AVOID

General Approach

The American Geriatric Society (AGS) maintains and updates a list known as the Beers Criteria. Based on scientific evidence, this list includes medications that should be avoided in older adults.

It also contains medications that should be avoided in specific disease states or conditions. If a therapy on the list must be prescribed, providers can initiate the drug at a low dose with strict monitoring.

You must understand which agents may be dangerous in seniors and which are optimal for treating depression.

AGS findings and recommendations in the Beers Criteria are summarized in the tables below. We will delve further into specific agents throughout the rest of the article.

Potentially Dangerous Antidepressants

SSRIs = selective serotonin reuptake inhibitors

SNRIs = serotonin-norepinephrine reuptake inhibitors

TCA = tricyclic antidepressant

Potentially Dangerous Antidepressants in Certain Conditions

UTI = urinary tract infection

SSRIs

Fluoxetine (Prozac)

Fluoxetine should be avoided in older adults because it has a long half-life, which refers to how long the drug stays in our bodies.

It is also an activating agent, so dosing too late in the day or closer to bedtime can cause insomnia.

It should be taken upon waking or in the late morning at the latest to prevent this. Additionally, fluoxetine interacts with several other drugs.

Paroxetine (Paxil)

Paroxetine is also NOT recommended in elderly patients due to its potent anticholinergic properties.

Side Effects

Anticholinergic effects include:

• Dry mouth
• Constipation
• Urinary retention (incomplete bladder emptying)
• Blurred vision
• Increased heart rate
• Confusion
• Feeling hot

Older patients are particularly susceptible to anticholinergic effects.

Therefore, when managing medications in an older adult, you should aim to limit the number of anticholinergic drugs they are on.

Of all the SSRIs, paroxetine imposes the most significant anticholinergic burden.

This is likely why paroxetine tends to be more sedating than other medications. It also has a higher risk of drug-drug interactions compared with other SSRIs.

Paroxetine has a high risk of withdrawal symptoms because of its short half-life. If you stop paroxetine suddenly, you may experience withdrawal that includes insomnia, anxiety, and flu-like symptoms.

If you were to miss just one dose, you might experience these withdrawal symptoms. These effects can be minimized by gradually decreasing the paroxetine dose over 7 to 10 days.

TCAs

TCAs such as amitriptyline (Elavil), nortriptyline (Pamelor), doxepin (Sinequan), imipramine (Tofranil), etc. are also not recommended in older adults because of their potential for side effects.

One of these effects includes postural hypotension, which means having low blood pressure when you stand up.

This effect can cause falls or fractures in seniors. Additionally, tricyclic antidepressants can cause cardiac problems and anticholinergic effects.

Your doctor should monitor your blood levels, heart function, and blood pressure if they must be used.

Tricyclic antidepressants also have several drug-drug interactions of particular concern in seniors who may be on many drugs.

An overdose of tricyclic depressants can also be fatal, making them dangerous and usually avoided.

Other common conditions, such as Parkinson’s disease, dementia, and cardiovascular issues, can be worsened by a tricyclic antidepressant.

A few over-the-counter dietary supplements have mixed evidence regarding their benefit in helping depression.

Supplements such as these are not approved or regulated by the FDA and are not recommended by specialists for self-treatment.

St. John’s Wort

St. John’s Wort is an over-the-counter herbal medication that has been used in a variety of different conditions. It is either a capsule, tablet, tea, or liquid extract.

St. John’s Wort has shown some efficacy in treating depression. However, its use is limited by severe potential drug interactions.

The most concerning adverse effect of St. John’s Wort is a potentially fatal increase in serotonin when used in combination with other antidepressants. This dangerous increase in serotonin is called serotonin syndrome (see below for a description).

St John’s Wort interacts with many medications, causing clinically significant issues. As such, it must be used with the utmost caution. Your medical provider must be informed if you are taking this OTC agent.

DRUG-DRUG INTERACTIONS

When used together, certain combinations of antidepressants can have serious drug interactions. Specific interactions can cause what is known as serotonin syndrome, a life-threatening condition.

Serotonin Syndrome

Some symptoms of serotonin syndrome include:

• High blood pressure
• Fast heart rate
• Pupil dilation
• Sweating
• Fever
• Temperatures exceeding 106 degrees Fahrenheit
• Muscle twitching or rigidity
• Confusion
• Agitation

Serotonin syndrome occurs when you take too many drugs that affect serotonin levels. These drugs include:

• SSRIs
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Tricyclic antidepressants, including amitriptyline and nortriptyline
• Monoamine oxidase inhibitors (MAOIs), including drugs such as isocarboxazid and phenelzine

Summary

Depression in seniors is a serious condition and should be monitored with increasing age. Key takeaways discussed in this article include:

• Depression in older patients is serious and life-threatening
• Presentation is distinct from younger adults with depression
• SSRIs and SNRIs are first-line treatments for depression
• Other methods such as CBT and ECT can be effective in reducing symptom burden
• Dietary supplements can have serious drug interactions with antidepressant medications

There are many agents available to treat depression. However, senior citizens have certain conditions that may predispose them to adverse effects and drug interactions.

Therefore, your choice of antidepressant as an older adult should be carefully selected.

Typically, SSRIs such as sertraline and escitalopram are considered safe and effective in older adults. Bupropion and mirtazapine are non-SSRI agents that are also good options.

You should avoid fluoxetine, paroxetine, TCAs, and St. John’s Wort because of the high risk of adverse effects and drug interactions.

These agents may have anticholinergic effects or run the risk of serotonin syndrome.

Selecting an antidepressant is a personal decision, and you should always consider the efficacy and safety of the medication before starting it. Discuss with your doctor which antidepressant may be the best for you.