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A Guide to Mental Wellness in Older Age: Recognizing and Overcoming Depression

Treatment Options for Late-Life Depression

Depression is treatable. Treatment will reduce your pain and suffering caused by the symptoms of depression. The first treatment may not work—you may have to try one or two different methods before finding the best one for you. Try not to get discouraged—it may take some time to recover.

The most prescribed treatments for late-life depression are medication and psychotherapy (talk therapy). Medication is often necessary to balance the chemicals in your brain, but psychotherapy can help you cope with your feelings and help change some of the patterns in your life that may have contributed to the illness. In some cases, the physician will suggest medication as a necessary first step until your symptoms have lessened enough to benefit from psychotherapy. In many instances, psychotherapy is as effective as medications for depression.

Medications

Great progress in the treatment of depression has occurred in the past ten years with the development of new, safer, and easier to use medications for depression. Although some people don’t understand why they need to take medication for what they may consider to be a weakness, depression should be thought of as any other illness. Depression is no different than other illnesses like diabetes or high blood pressure—it can be successfully treated.

Antidepressants are the types of drugs normally prescribed for people diagnosed with depression. Antidepressant medications are not habit forming. There are more than 20 antidepressants available, however, not all antidepressants are as effective for people over 60 years of age as they are for younger persons. In addition, it is important for your physician to know all of the medications you are currently taking—including vitamins, herbal supplements, alcohol and tobacco, and recreational drugs—because the combination of medications can impact the effectiveness of your treatment. You should also be honest with your physician about your consumption of alcohol and tobacco. Antidepressants may take longer to start working in older adults than in younger adults.

All medication treatments have some side effects. Side effects can include drowsiness, dry mouth, muscle aches, light-headedness, diarrhea or constipation. Your physician will want to work with you to see which medicine you can tolerate the best because it is very important to keep to your treatment plan. No two people respond the same way to the same medicine—while one person can have total improvement with one medication, another person with similar symptoms may not benefit or may experience different side effects. Never stop your medication or adjust the dosage on your own. If you and your doctor decide it is time to stop medication, you may agree on a schedule to decrease the dosage over time.

You should start to feel some relief from your depression two to eight weeks after you start taking antidepressants, although it may take up to three to four months for substantial improvement. Continue taking your medicine even if you begin to feel better. Sometimes physicians prescribe lower loses of antidepressants for persons over 65 years because of their increased sensitivity to medications. This may make the recovery period a bit longer. Depression can reoccur if medications are stopped too soon or stopped without gradually tapering off. Antidepressants are usually prescribed for three to six months to provide initial relief from depression and then continued for a minimum of an additional six months for maintenance of care.

There are different classes or types of drugs that can be prescribed for depression. Each class of medicines or drugs acts a little differently on the brain and may have different side effects. Side effects usually happen early in treatment or after a dosage increase—and they may disappear over time. The following table shows which drugs are grouped in a class and their possible side effects. The drug’s scientific or common name is listed first and the brand name is in parentheses.

Classes of Medications Used in Treating Depression in Older Adults
Examples of the medications used to treat depression are listed. This is not a complete list.

Classes of Medications Examples: Scientific Name and Brand Name of Drugs Included in the Class Possible Side Effects
SSRIs (selective serotonin reuptake inhibitors)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Paroxeltine (Paxil)
  • Sertraline (Zoloft)
  • Trazodone (Desyrel)
  • Upset stomach and other gastrointestinal (GI) problems
  • Nausea
  • Restlessness
  • Headache
  • Insomina
  • Sexual dysfunction
  • Possible sedation—Trazodone
TCA (tricyclic antidepressants)
  • Desipramine (Norpramin)
  • Nortriptyline (Pamelor)
  • Sedation
  • Dry mouth or eyes
  • Constipation
  • Urinary retention
  • Rapid heart beat
Other Agents
  • Buproprion (Wellbutrin)
  • Restlessness
  • Insomnia
Other Agents
  • Mitrazapine (Remeron)
  • Sedation
  • Low blood pressure
Other Agents
  • Nefazodone (Serzone)
  • Sedation
  • Low blood pressure
  • Liver disease or liver toxicity–Do not use

 

Managing Side Effects of Medications Used in Treating Depression in Older Adults Side Effects What You Can Do

Side Effects What You Can Do
Sedation (sleepiness)
  • Take medication at bedtime.
  • Try caffeine (coffee, cola, etc.). Check with your physician first.
Dry mouth or eyes; urinary retention; rapid heartbeat
  • Drink more fluids.
  • Chew sugarless gum.
  • Use artificial tears, eye drops.
  • Increase fiber in diet.
  • Talk to your doctor about switching to another medication.
Gastrointestinal distress Nausea
  • Symptoms should improve in 1-2 weeks.
  • Take medication with meals.
  • Ask your doctor about taking antacids.
Restlessness Jitters or tremors
  • Ask your physician to start with small dose.
  • Ask your doctor about reducing the dose for a temporary period of time.
  • Talk to your doctor about the symptoms—he/she may add a mild sedative for a short time.
Headache
  • Ask your doctor if you should decrease the dose.
  • Talk to your doctor about taking acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).
Insomnia
  • Take the medication in the morning.
Sexual dysfunction
  • This side effect may be part of the depression or caused by another medical disorder. Talk to your doctor.
  • Ask your doctor if you should decrease the dose.
  • Ask your doctor about a trial of Viagra or Levitra.
Weight Gain
  • Exercise.
  • Diet.
  • Ask your doctor if you should consider changing medication.



Questions to Ask Your Doctor About Your Medications

  1. What are the common name, product/brand name and suggested level of dosage for this medicine? Is there a generic form and is it appropriate?
  2. What dosage of medicine should I start with? Is there a preferred method and time to take the medicine (e.g., first thing in the morning, before bed at night, with or without food)?
  3. What does the physician expect the medicine to do and how long will it take to do it?
  4. How well has this medicine worked for other older adult patients?
  5. What are the possible side effects for taking this medicine; are they usually short-term or long-term side effects?
  6. Is there any way to minimize the side effects?
  7. What restrictions need to be considered when taking this medicine? Is it okay to drink alcohol?
  8. Are there any tests that need to be taken before I begin taking this medicine and during the time I am taking this medicine?
  9. How do I know when the dose may need to be changed or the medicine stopped?
  10. How much does the medicine cost? Are there any programs that may help to cover the costs of the prescriptions?
  11. How do I reach the doctor if the side effects get very bad—bad enough not to be able to take the prescription?
  12. How often do I see the doctor—when is my next appointment?
  13. Are there other things I can do in addition to taking the medicine to help improve my mental health?

Use medicines exactly as the doctor has instructed. If you miss a dose—do not double the next dosage. Get back on schedule and follow the prescription as written. Do not stop taking the medication without talking with your physician.

Psychotherapy and Counseling

Psychotherapy or talk therapy can help you develop the skills and behaviors that make it easier to cope with troubling events and ease the feelings of depression. If your physician suggests psychotherapy as part of your treatment, it may be with the physician or he or she may refer you to another health provider such as a psychologist.

Support and education are an important part of depression treatment. There are several different types of therapy. Psychotherapy can involve yourself and your family, who may join you for part of the sessions. Group therapy involves a group of unrelated individuals with a common experience. Group therapy for patients with depression provides a communal experience of guidance and education that can assist with treatment. One approach is not necessarily better than another one—you should find the one that works best for you.

Psychotherapy and counseling are important in the treatment of depression for older adults. As older adults retire and alter their life roles, individuals may experience significant life crises, may lack social support systems, and may not have the coping skills needed to deal with these new situations. The goal of psychotherapy is to discuss issues and problems in order to eliminate or control troubling and painful symptoms. Sessions usually last 45-50 minutes and focus on identifying the possible triggers of depression and how to manage them.

Electroconvulsive Therapy

ECT or electroconvulsive therapy is used as a valid treatment option today, but the actual procedure is quite different than what has been portrayed in the movies as a harmful experience.

The use of ECT in treating older adults with depression can be very useful as it is faster and safer than medications. Older adults who have had ECT report that there are few side effects. ECT is normally prescribed for an older adult who has tried several medications with little success or has symptoms that are severe. As with any course of treatment, the use of ECT and its impact may depend on other health problems you may have.

If your physician recommends ECT as a course of treatment, it is important to discuss what to expect, how long the treatment will last, and possible side effects. You should feel comfortable with the process. ECT is usually administered in the morning. The patient is given a general anesthetic and is unconscious and does not suffer from any pain or physical convulsions. ECT is usually given in a series of short treatments—several times per week over a period of time. Some patients report that their thinking is fuzzy, and some experience headaches, nausea and short-term memory loss—particularly shortly after the treatment is administered. As with medication treatments, these side effects are usually temporary and go away after a short period of time. ECT has been shown to be very effective, but the relapse rate is also very high if there is no ongoing treatment for depression. If your physician suggests ECT as a treatment from which you may benefit, make sure that you will be monitored throughout and after the procedures.

Herbal Remedies

Some herbal remedies, such as St. John’s Wort, have received a lot of attention in recent years as being effective for the treatment of depression. The National Institute of Mental Health undertook a research study to determine whether there was any scientific evidence to support the use of St. John’s Wort for depression. Although no elderly patients were included in the study, results showed no difference between St. John’s Wort and a placebo. Despite this research, many people still promote the use of herbal remedies as safe for treating depression. The most important factor to consider if you are thinking of taking St. John’s Wort or any other herbal mixture is that natural substances are not necessarily safe. In fact, there are studies to show that taking large quantifies of some herbals can have very dangerous side effects. Natural does not mean safe! Talk to your doctor if you are taking or considering herbal remedies.

A Guide to Mental Wellness in Older Age: Recognizing and Overcoming Depression

© Geriatric Mental Health Foundation 2004
7910 Woodmont Avenue, Suite 1050
Bethesda, Maryland 20814
301.654.7850
info@GMHFonline.org
www.GMHFonline.org

Expert assistance was provided by Lissy F. Jarvik, M.D., Professor Emerita of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, School of Medicine; Susan Lieff, M.D., M.Ed., Assistant Professor, Department of Psychiatry, University of Toronto; and Stephen J. Bartels, M.D., M.S., Associate Professor of Psychiatry, Dartmouth Medical School.

The Geriatric Mental Health Foundation grants permission to print, photocopy, and distribute this material. Please cite the Foundation, including the address, phone and website.