Prescribing for Older Adults

Sertraline is FDA-approved for the treatment of major depression in older adults (Gilliam et al., 2019). In this population, providers should be conservative in dosing since older adults are highly likely to have declined cardiac, renal, or hepatic function that affects the clearance of the drug. The presence of other drug therapies and concomitant drugs also strengthens the need to use a lower dosage. It is beneficial in preventing the onset of bipolar depression.

lamotrigine is prescribed off-label for the treatment of major depression (Matsuzaka et al., 2022). My preceptor uses it frequently for patients with major depression. The medication is approved by the FDA for bipolar I disorder maintenance treatment to delay the onset of mood issues including hypomania, depression, and mic episodes. It is beneficial in preventing the onset of bipolar depression.

Cognitive-behavioral therapy is an effective non-pharmacological approach for the management of major depression in older adults. It explores the stressors in the patients’ lives and helps in developing effective coping mechanisms to address the feelings of depression (Avasth & Grover, 2018). CBT also helps patients develop behavioral strategies for preventing depression. A key advantage of CBT over pharmacology is that its effects last long after the end of therapy while in the latter, the benefits wear off after the medication is tapered off thereby increasing the risk for relapse.

Risk Assessment

Risk assessment for treatment decision-making in older adults should include the patient’s medication history and current drug use (Avasthi & Grover, 2018). This evaluation is important in lowering the risk for adverse drug interactions likely to lower the effectiveness of depression management of affect cause adverse outcomes.  For example, the use of Zoloft in patients taking other serotonergic drugs may significantly increase the risk for serotonin syndrome which can be life-threatening (Hasani et al., 2021). When used appropriately, Zoloft is effective in the management of depression. Common side effects include headaches, dry mouth, nausea, nervousness, and insomnia. Further assessment is required on current healthcare issues as well as the hepatic and renal function of the patients. For example, lamotrigine may cause elevated serum aminotransferase levels when used extensively. Hepatotoxicity occurs in up to 20% of the patients (Thompson et al., 2017).

Clinical Practice Guidelines

The American Psychological Association’s (APA) clinical guideline for the management of major depressive disorder in older adults recommends CBT or group life review for the initial management of the disorder (APA, 2019). These interventions can be used alone or in combination with usual care interventions. As a second option, APA recommends the combination of interpersonal therapy with pharmacotherapy as compared to interpersonal therapy alone. While the medication strengthens and quickens symptom management, psychotherapy enables patients to adopt cognitive and functional approaches to prevent and address depressive symptoms in the long run. In the selection of a pharmacotherapy option, the APA panel recommends a second-generation antidepressant to minimize the risk for adverse effects. 

Clinical practice guidelines by the Indian Psychiatric Society recommend comprehensive patient assessment in older adults to determine current risk factors, the risk for self-harm, the severity of the depression, and the associated etiological factors (Avasthi & Grover, 2018). The guidelines recommend the combination of a second-generation antidepressant (such as sertraline) with CBT to optimize treatment outcomes as at least 30% of older adults respond poorly to pharmacological management. 

References

American Psychological Association (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for the management of depression in the elderly. Indian Journal of Psychiatry, 60(Suppl 3), S341-S362. https://dx.doi.org/10.4103%2F0019-5545.224474

Gilliam, F. G., Black, K. J., Carter, J., Freedland, K. E., Sheline, Y. I., Tsai, W. Y., & Lustman, P. J. (2019). A trial of sertraline or cognitive behavior therapy for depression in epilepsy. Annals of Neurology, 86(4), 552-560. https://doi.org/10.1002/ana.25561

Hasani, R., Sarma, J., & Kansal, S. (2019). Serotonin syndrome induced by combined use of sertraline and linezolid. Anesthesia, Essays, and Researches, 13(1), 188-190. https://dx.doi.org/10.4103%2Faer.AER_173_18

Matsuzaka, Y., Urashima, K., Sakai, S., Morimoto, Y., Kanegae, S., Kinoshita, H., … & Ozawa, H. (2022). The effectiveness of lamotrigine for persistent depressive disorder: A case report. Neuropsychopharmacology Reports. https://doi.org/10.1002/npr2.12228

Thompson, M., Jaiswal, Y., Wang, I., & Williams, L. (2017). Hepatotoxicity: Treatment, causes, and applications of medicinal plants as therapeutic agents. The Journal of Phytopharmacology, 6(3), 186-193.