II. Epidemiology

  1. Prevalence: One third of hospitalized elderly

III. Screening

IV. Signs

  1. May present with many physical complaints

V. Labs

  1. Serum Sodium
    1. Consider monitoring while on SSRI, SNRI (SIADH)

VI. Risk Factors: Suicide

  1. Grief
  2. Living alone and other social isolation
  3. Male gender
  4. Comorbidity and secondary Disability
  5. Poor sleep quality
  6. Substance Abuse (e.g. Alcohol Abuse)
  7. White race
  8. Turvey (2002) Am J Geriatr Psychiatry 10(4): 398-406 [PubMed]

VII. Differential Diagnosis

  1. See Medication Causes of Depression
  2. See Organic Causes of Major Depression
  3. Dementia (contrast with depression with sudden onset, rapid progression)
    1. Insidious onset and long duration
    2. Progressive worsening
    3. Often associated with neurologic deficits
    4. Patient tries to conceal Disability
    5. Memory impaired without benefit of cuing

VIII. Management

  1. See Depression Management
  2. See Depression Medical Management
  3. Non-medication management
    1. Psychotherapy
    2. Encourage socialization and daily Exercise
  4. SSRI Agents (Highly responsive: 60-80% of cases)
    1. Preferred agents due to low side effect profiles, fewer Drug Interactions, less adverse effect on cognition
      1. Escitalopram (Lexapro)
      2. Citalopram (Celexa)
      3. Sertraline (Zoloft)
    2. Agents that improve appetite, maintenance of weight
      1. Mirtazapine (Remeron) promotes weight gain
    3. Agents to consider in concurrent neuropathic path (with caution, as SNRIs may be more Anticholinergic)
      1. Duloxetine
      2. Venlafaxine
    4. Agents to avoid
      1. Avoid Fluoxetine (due to Drug Interactions)
      2. Avoid Paroxetine (due to Anticholinergic effects)
    5. Monitoring
      1. Observe for Hyponatremia while on SSRI (SIADH) with periodic Serum Sodium
      2. Observe for seroronin syndrome
      3. Observe for increased fall risk, sedation, Blurred Vision on SSRI
      4. Start dosing low (half dose)
        1. Increasing slowly every 2-4 weeks
        2. Advance until effective dose reached or maximum based on Renal Function, age
        3. Expect full effect by 12 weeks
  5. Adjunctive agents
    1. Methylphenidate (Ritalin)
      1. Consider short-term use (e.g. 3 months) while starting and titrating SSRI in severe Major Depression
      2. Avoid in severe anxiety, unstable or recent Coronary Artery Disease or Arrhythmia
      3. Example dose: Start Methylphenidate immediate release 2.5 mg in morning and afternoon
        1. Limit dose to <20 mg daily
      4. References
        1. (2016) Presc Lett 23(5):28
        2. Lavretsky (2015) Am J Psychiatry 172(6):561-9 +PMID:25677354 [PubMed]

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