Treatment of Depression in Elderly: The Challenge to Success

Abstract

Depression in the elderly is a major challenge to current Psychiatry and a major mental health problem for several reasons, including its clinical atypicity (hampering a correct diagnosis), its greater severity and risk of suicide. The success of drug treatment will depend on a suitable assessment of the risk-benefit balance. In this review, we will address the antidepressants with a favorable side effect profile, because the elderly have a higher sensitivity to them. Antidepressant treatment in the elderly has a number of peculiarities: it should start with lower doses than those recommended for adults, it is preferable to the use of antidepressants without anticholinergic and sedative effects, to prevent cognitive impairment and risk of cardiotoxicity; it should evaluate possible interactions with other drugs, since the elderly are usually polymedicated patients with different somatic comorbidities; if antidepressant response is obtained, the drug should be kept for long periods, even for lifetime. There is a wide arsenal of antidepressant drugs with mechanisms of action focused on enhancing monoaminergic transmission. An alternative to these classical mechanisms of action is given by agomelatine, a melatoninergic agonist drug. In this paper, we discuss the pharmacodynamic and pharmacokinetic profiles of these agents that may have an influence on the efficacy, tolerability and safety of treatment in the elderly. The use of antidepressants in the elderly should be performed only when necessary, but age should not deprive the patients of medication to improve their health and quality of life.