REVIEW OF: Hsu CW et al, J Affect Disord 2022;296:609–615 

STUDY TYPE: Retrospective cohort

When treating depression in older adults, we look for medications that work the best while posing the fewest risks. To find the best balance between risk and efficacy, Hsu and colleagues looked at data from the Taiwanese National Health Insurance system, analyzing demographics, ICD-9 diagnoses, and claims data. They focused on antidepressant use and three main outcomes—discontinuation, antidepressant augmentation, and psychiatric ­hospitalization. 

The authors analyzed 16 years of records from 280,921 adults aged 60 years and older. They excluded people with comorbid conditions (eg, schizophrenia, bipolar spectrum disorders) and those taking multiple psychiatric medications. They also excluded rarely prescribed antidepressants (taken by <5,000 individuals) and drugs used at very low doses, suggesting adjunctive use instead of depression treatment (particularly trazodone, imipramine, and amitriptyline). 

The study found no single antidepressant that consistently outperformed the others across all three outcomes. In terms of tolerability, however, patients on fluvoxamine and venlafaxine were more likely to require a switch to another medication, to need augmentation, and to require psychiatric hospitalization. Mirtazapine had one of the highest hospitalization risks in younger-old patients (<70 years). Bupropion stood out with a higher risk of hospitalization for those diagnosed with major depressive disorder. In the sub-analysis of adults over 70, fluvoxamine had the highest hospitalization rates. Overall, the impact of antidepressants on the risk of hospitalization was muted in adults over 70 compared to younger participants. 

Distinguishing between effectiveness and tolerability was challenging since switching served as a proxy, and hospitalizations may have resulted from side effects or critical events. Additionally, the study did not provide information on participants’ severity of depression, or other lifestyle and historical factors. 

Carlat Take

There is no one-size-fits-all antidepressant for older adults. However, it might be a good idea to monitor patients on fluvoxamine, venlafaxine, and mirtazapine a bit more closely. If you’re starting these medications for an older patient, remember to weigh the risks and benefits carefully.