REVIEW OF: Srifuengfung M et al, Ther Adv Psychopharmacol 2023;13:1–14 

STUDY TYPE: Narrative review

Treating depression in older adults isn’t just about choosing the correct antidepressant, but also about getting the dose and duration right and avoiding harmful drug interactions. This population often deals with multiple health issues, cognitive decline, and the risks of polypharmacy, all of which complicate their treatment. Despite the widespread use of antidepressants, many older patients end up on doses that are too low or don’t continue their treatment long enough to see full benefits. This review highlights strategies to optimize antidepressant use and minimize the risks associated with inappropriate medications, such as anticholinergics and benzodiazepines (BZDs).

Findings were consolidated from a literature search that prioritized studies from the past 10 years, including randomized controlled trials, meta-analyses, and clinical guidelines, to provide a comprehensive approach for treating late-life depression. The search focused on dose optimization, treatment duration, and selecting safer alternatives to anticholinergics and BZDs, which can worsen cognitive function. 

The authors recommended first maximizing the dose within the therapeutic range to achieve remission. They also recommended switching to another class, such as a serotonin/norepinephrine reuptake inhibitor, bupropion, or mirtazapine, if the patient does not achieve remission after eight weeks at the highest tolerated dose. These alternatives are also beneficial for comorbidities like pain (duloxetine) or insomnia (mirtazapine). For patients who do not achieve remission after two trials from different classes, the authors advocated for aripiprazole augmentation, which has shown superior effectiveness compared to switching strategies. Although augmenting with lithium or switching to nortriptyline could be considered for highly resistant cases, these approaches have lower remission rates. 

The authors advocated for the regular use of scales like the Patient Health Questionnaire (PHQ-9) to guide treatment adjustments and improve outcomes. For patients who achieve remission, the authors endorsed continuing antidepressants for at least one year to prevent recurrence, with longer durations recommended for recurrent or severe cases. 

The authors stressed the importance of deprescribing inappropriate medications, particularly those with anticholinergic properties like diphenhydramine, tricyclic antidepressants, and paroxetine, which are tied to cognitive impairment and a higher risk of dementia. They also emphasized the need for careful tapering of BZDs (reducing the dose by 10%–25% every two weeks to prevent withdrawal symptoms) and suggested a shift toward nonpharmacologic approaches for managing insomnia and anxiety (eg, cognitive behavioral therapy, relaxation techniques, improved sleep hygiene).

Carlat Take: Getting antidepressants right in older adults requires being proactive. This review challenges two prevalent practices in geriatric depression care: underdosing and “sticking it out” with ineffective treatments. Don’t settle for low doses, and don’t shy away from switching strategies if the first approach isn’t working. Be vigilant about the medications you keep a patient on; anticholinergics and BZDs can do more harm than good, so taper them carefully and consider nondrug options for issues like insomnia or anxiety. When treating treatment-resistant cases, don’t rule out aripiprazole too quickly. Yes, there’s a strong push to avoid antipsychotics in older adults, but at low doses, aripiprazole has a better safety profile than most alternatives and is worth trying before moving on to options like lithium or nortriptyline.