Depression

Care & Treatment

Most people respond well to treatment for depression, but some may relapse and have more episodes of depression after an initial episode has been treated.  Treatment for depression typically has three parts:

  1. Immediate treatment.
  2. Continuing treatment to prevent relapse. This includes antidepressant therapy, usually lasting for about six months.
  3. Maintenance therapy (longer-term therapy), if considered necessary.

The following treatments, which may be used in combination, can help treat depression among older adults:

  • Psychotherapy (“talk therapy”)
  • Antidepressant medications
  • Electroconvulsive therapy
  • For people with seasonal affective disorder (SAD), light therapy during the winter months may help restore a normal sleep cycle and reduce depressive symptoms.
  • There are newer treatments that are available in some centers and usually involve some surgery.  These include vagus nerve stimulation (VNS), deep brain stimulation (DBS), and the most recent, transcranial magnetic stimulation (TMS).

If you have severe or suicidal depression, it is best to treat it with a combination of medications and psychotherapy. This combination appears to work quickly and keep depression from recurring. Some depression can be severe enough to require treatment by a mental health specialist.  In that case, your primary healthcare provider may give you a referral. Sometimes depression is so severe that you cannot carry out daily activities, are suicidal, or cannot be safely cared for in the community.  If this is the case, you may need to be treated in a psychiatric hospital.

Therapy should continue as long as your healthcare provider recommends. Remember that depression is a disease, not a sign of weakness. Just as you should continue treatment for a physical health problem as long as needed, you should continue treatment for depression as long as needed.

Psychotherapy

Psychotherapy is a safe and effective way to help you cope with depression. It is often combined with antidepressant drugs (described below). There are several useful psychotherapy techniques:

  • Problem-solving therapy. In this type of psychotherapy, a therapist helps you identify specific life difficulties that are causing problems, and helps you find solutions to these problems.
  • Cognitive behavioral therapy (CBT). Cognitive behavioral therapy helps you understand the role that your thoughts and other factors play in your depression, and how to better deal with them. CBT programs generally run for a specified number of weekly visits.  They may include helpful activities and assignments to perform at home.
  • Interpersonal psychotherapy. This therapy has shown promise in treating minor depression, especially in people who become depressed after the death of a close friend or relative. It has also been shown to help caregivers of older adults who develop depression. This therapy helps people deal with personal relationships, grief, loss and coping with their role in life.

Antidepressant Medications

If your healthcare provider determines that medication will help treat your depression, they will consider several things when choosing a medication. These include what other medical problems you may have, what side effects the antidepressant may produce, and whether it might interact with other medications you are taking.

You will likely start with a low dose of the antidepressant.  Then your healthcare provider may increase the dose slowly and carefully until you get the desired effect. If you have kidney or liver disease, the levels of the medication in your blood may be monitored to make sure these levels aren’t getting too high.  

Antidepressant medications take time to work and must be taken as prescribed for several weeks. About half of adults with major depression respond well to medications within 6 weeks. Another 15% to 25% only begin to respond during the first 6 weeks, but continue to improve if treatment is continued for another 4 to 6 weeks.

If a prescribed medication doesn’t seem to be working, your healthcare provider may increase the dose, prescribe a different medication, or arrange additional therapy such as talk therapy. If the antidepressant you are taking causes side effects, let your provider know right away.

Never stop taking an antidepressant without first consulting your healthcare provider, even if you feel better. Stopping or reducing the dose suddenly can make your symptoms worse.

Many people need to continue taking an antidepressant for at least six to twelve months to get the full benefit and lower the odds that the depression will happen again. If your healthcare provider recommends stopping a medication, they will explain how to do so gradually and under supervision so that you avoid possible withdrawal symptoms.

Common side effects of antidepressants include:

  • Nausea
  • Decreased sexual desire
  • Diarrhea
  • Blood “thinning”
  • Constipation
  • Sleepiness
  • Dry mouth
  • Low blood pressure
  • Vision problems

There are different kinds of antidepressant medications and treatments. The most commonly used ones are the following.

Selective serotonin re-uptake inhibitors (SSRIs)

SSRIs are the most commonly prescribed antidepressants. 

  • fluoxetine (Prozac)
  • fluvoxamine (Luvox)
  • sertraline (Zoloft)
  • citalopram (Celexa)
  • paroxetine (Paxil)
  • escitalopram (Lexapro)

Serotonin norepinephrine reuptake inhibitors (SNRIs)

These medications are also often used. 

  • desvenlafaxine (Pristiq)
  • duloxetine (Cymbalta)
  • venlafaxine (Effexor)

Tricyclic and tetracyclic antidepressants (TCAs)

These are not first- or second-line medications to treat depression due to their many side effects and are not recommended for older adults.  However, they are still very effective in certain situations.

  • amitriptyline (Elavil)
  • doxepin (Sinequan)
  • nortriptyline (Pamelor)
  • trimipramine (Surmontil)
  • desipramine (Norpramin)
  • imipramine (Tofranil, Tofranil-PM)
  • protriptyline (Vivactil)  

Other antidepressants

These include medications that act on different neurotransmitters.

  • bupropion (Wellbutrin)
  • mirtazapine (Remeron)
  • trazodone (Desyrel)

Monoamine oxidase inhibitors (MAOIs)

You need to watch what you eat if you take MAOIs. For example, you may develop life-threatening high blood pressure if you eat foods such as wine or aged cheeses that contain high levels of tyramine. This medication is not recommended for older people.

Always follow your healthcare provider’s instructions regarding dietary restrictions when taking MAOIs.

Lithium

Lithium carbonate is sometimes prescribed for treatment resistant depression.

The body “breaks down” lithium slowly in older people, and lithium can cause side effects such as tremors, diarrhea, and muscle spasms. Many common medications, like ibuprofen and diuretics (“water pills”), can also slow the lithium from leaving the body. This causes the lithium to build up in the blood and may increase the severity of side effects. Side effects of anti-seizure and anti-psychotic medications may include skin rashes or problems with the blood or certain organs.

Antipsychotic medications

These may be needed if you have psychotic symptoms, such as delusions or hallucinations, along with typical symptoms of depression. These must be started by a mental health specialist.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy can be useful if other treatments have not helped. It is the first choice of treatment in life-threatening depression, when a patient is suicidal or at risk of starvation due to depression. Although ECT may bring scary images to mind, it can actually be a very effective and safe treatment for both major depression and mania. Success rates are better than 70% in older adults.

If you are scheduled to receive ECT, you will be given general anesthesia, which makes sure that the procedure is painless. For people with most kinds of heart disease or stroke, ECT is a safe treatment. But if you’ve recently had a heart attack or stroke, the risk of complications is higher. ECT is not appropriate for older people with unstable heart problems or increased pressure in the brain due to a brain tumor or other medical problem.

The most common side effect of ECT is short-term amnesia (forgetting things that happened very recently). For example, you may not remember things that occurred immediately before the therapy. You may also find it harder to learn new things for a little while. However, this problem usually disappears quickly after the treatment stops. ECT doesn’t cause long-term memory loss, and sometimes your memory will actually get better.

Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It may be considered if ECT has already been tried and your depression still has not resolved.

 

Last Updated September 2020