Depression is a common and treatable disorder that affects up to 50% of our residents in the long term care facility. It is important that we recognize the signs and symptoms of depression so that proper psychotherapy and pharmacotherapy can be initiated.
Depression can be caused by psychological, psychosocial, medical and pharmacological factors. Long term care residents often experience a sense of loss or low self worth. Isolation and lack of social activity can contribute to depressed feelings. Diseases that can contribute include Alzheimers, arthritis, hypertension, cardiovascular disease, hypothyroidism, Parkinsons, stroke and anxiety among others. Medications that can induce depression include Opioids, steroids, benzodiazepines (Xanax, Valium), barbiturates, Metoclopramide (Reglan), Levodopa (Sinemet), Ranitidine (Zantac), and cardiovascular agents such as Digoxin, Clonidine & Calcium Channel blockers.
Two criteria that must be met for diagnosis of depression, according to the Diagnostic & Standards Manuel for Mental Disorders, are that a depressed mood must be present for most of the day for at least 2 weeks and a loss of pleasure & interest in most all activities. Other signs of depression include loss of weight & appetite, fatigue, insomnia or hypersomnia, feelings of worthlessness & agitation. The treatment of depression in the elderly should include pharmacotherapy, psychotherapy and social programs.
There are several classes of antidepressant medications with various mechanisms of action and side effects. Tricyclic antidepressants are an older class that include Amitriptyline (Elavil) and Nortrityline (Pamelor) among others. These work well with depression but are usually contraindicated in the elderly due to anticholinergic side effects: Dry mouth, constipation, urinary retention, blurry vision and confusion. They are occasionally used in low doses for neuropathic pain.
Serotonin Selective Reuptake inhibitors (SSRIs) are more recent class of antidepressants with fewer side effects more suitable for the elderly population. Fluoxetine (Prozac), Paroxetine (Paxil), and Sertraline (Zoloft) are among the SSRI class. Although these medications lack strong anticholinergic side effects, insomnia, GI distress, nausea, vomiting and sedation can occur. SSRIs have been shown to also be useful with other psychiatric disorders such as anxiety, agitation, obsessive-compulsive disorders and panic.
Trazodone (Desyrel) is another antidepressant that is rarely used alone for depression in the elderly but is utilized as a relatively safe hypnotic or augmenting agent. Buproipion (Welbutrin) is a noradrenergic dopaminergic reuptake inhibitor that is used alone or with an SSRI. Possible side effects are agitation, anxiety, insomnia & restlessness. Mirtazapine (Remeron) is a noradrenergic serotonin antagonist that has side effects of drowsiness and increased appetite. This is often beneficial for the depressed resident with insomnia and/or anorexia.
Conservative dosing and slow titration of antidepressants is recommended with frequent monitoring of depression and side effects. The resident should be treated for at least six months after response is noted.
Recognition of the signs and symptoms of depression with our residents is vital for proper psychological and pharmacological care can be initiated. It is helpful to be aware of the possible benefits and risks of antidepressant medications for optimal selection and monitoring. Please do not hesitate to call your Gayco pharmacist or consultant pharmacist for any questions.