SSRIs Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline SNRIs

1. Depression in Older Adults Depression is common in older adults, and especially prevalent in older adults with chronic illnesses TREATMENT OF NON-PSYCHOTIC MAJOR DEPRESSIVE DISORDER IN PRIMARY CARE • EPIDEMIOLOGY OF DEPRESSION • A diagnosis of depression is associated with increased length of hospitalization, increased medical costs, and a higher rate of readmission. • Risk factors of depression include specific diagnoses of MI, CVA, or malignancy. • 50% of patients who commit suicide were seen by a provider in the preceding 30 days. • Risk factors for suicide: living alone, male, alcoholism, comorbid physical illnesses. • Suicide is a significant risk in older adults, men more than women. • Older men are at highest risk for completed suicide (15% of population, 25% of suicides). • Older individuals are more susceptible to medication toxicity such as serotonin syndrome. • Early dementia may co-occur with late onset depression. Pearls of Wisdom • Pearls for SSRIs: • Sertraline is the preferred SSRI in patients with CAD/CVD. • Fluoxetine has a very long half-life; avoid in patients who have had ADRs to previous SSRIs. • Hyponatremia – Risk with SSRIs, SNRIs; increased risk in elderly, women and patients on thiazides. • Sexual Dysfunction – Sexual dysfunction can be seen when treating depression with pharmacologic therapies. Of the treatment options, mirtazapine and buproprionhave the lowest incidence of sexual dysfunction. • Pearls for SNRIs and Other: • Mirtazapine – Good in patients with decreased appetite and insomnia. • Avoid SNRIs and Buproprionin patients with uncontrolled hypertension (or those on >2 antihypertensives). • Duloxetine – Potential complications include abnormal bleeding and hepatic failure. Partial Response No response Partial Response No response Key: BUP = bupropion SR/XL BUS = buspirone CBT = cognitive behavior therapy MRT = mirtazapine SNRI = serotonin-noreprinephrine reuptake inhibitor SSRI = selective serontonin reuptake inhibitor Medications Associated with Depression No response SSRIs Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline SNRIs Duloxetine Venlafaxine Other Mirtazapine Buproprion Varenacline Benzodiazepines & other sedative hypnotics Opiates Isotretinoin Finasteride (high dose) Leukotriene antagonists Anti-hypertensives – (Weak Association) CBT (Cognitive Behavioral therapy) is an option before starting or in combination with pharmacotherapy at any stage in the algorithm. Reference: Espinoza, RT and J Unutzer. Diagnosis and management of late-life depression. In: UpToDate, Solomon, D. (Ed), UpToDate, Waltham, MA, 2013UpToDate Funded by D.W. Reynolds Foundation