Depression in the elderly — treatment and management in older adults

Principles of treatment. The indications mirror those in younger adults — severity, duration, previous failed treatment, and patient preference. Watchful waiting for mild depression; psychotherapy or medication for mild-to-moderate illness; antidepressants and ECT have the most convincing evidence in major depression. Functional recovery, not just symptom relief, is always part of the goal.

The stepped-care model. Step 1 — recognition, psychoeducation, exercise, activity scheduling, watchful waiting. Step 2 — structured psychotherapy (CBT, problem-solving therapy). Step 3 — antidepressant, with or without psychotherapy. Step 4 — switch, augment, or refer to specialist services. Step 5 — ECT for severe, psychotic, catatonic or resistant illness.

Non-pharmacological treatment. Psychotherapy is as effective in older as in younger adults, and many older adults prefer counselling to drugs; there is currently excessive reliance on drugs and under-use of psychotherapy. Use CBT, problem-solving therapy (best if executive dysfunction is present), interpersonal therapy, and reminiscence/life review. Exercise is effective, including for subthreshold symptoms, and suits a stepped-care programme. Add psychoeducation involving the family.

Pharmacological treatment. SSRIs are first-line; start low — half the usual adult dose — and go slow; assess response at 4 weeks and allow 6–12 weeks for full effect; never declare failure before an adequate dose has been given for an adequate duration. Avoid TCAs, paroxetine and benzodiazepines wherever possible.

Resistant depression and duration of treatment. For non-response to an SSRI — switch antidepressant (within or between classes) or add lithium; after TCA failure, lithium augmentation is probably the best option; ECT for pharmacotherapy resistance. Continue for ≥1 year after a first recurrence, and consider lifelong maintenance after a second or subsequent recurrence.

Service delivery and comorbidity. Depression treatment in the elderly requires a multidisciplinary approach par excellence — multidisciplinary outpatient teams are effective, with nurses central to rehabilitation. Treat coexisting physical illness, pain, sensory loss, alcohol misuse and loneliness, review every drug that could be causing depression, and restore ADL function. Monitor weight, sodium (mEq/L), falls and suicide risk throughout.

OPTIMUM trial (NEJM 2023). In adults over 60 with treatment-resistant depression, aripiprazole augmentation of the existing antidepressant was superior to switching to bupropion (remission approximately 28% versus 19%) and carried a lower fall risk than bupropion, making it the preferred next step after SSRI or SNRI failure in late life. Condensed 6-Mark Version — 5 Textbook Points + 1 Latest Update Textbook Core — 5 Points

Match treatment to severity. Mild — watchful waiting, exercise, activity scheduling. Mild to moderate — psychotherapy (CBT or problem-solving therapy). Moderate to severe — antidepressant, with or without psychotherapy. Severe, psychotic, catatonic, suicidal or not eating — ECT.

Prescribing rules in the elderly. SSRI first-line at half the starting dose, titrated slowly; review at 2 weeks for tolerability and at 4–6 weeks for response; allow up to 12 weeks for full benefit. One drug at a time; an adequate dose for an adequate duration before switching.

Non-response pathway. Switch antidepressant → augment (lithium, or aripiprazole) → ECT. Never conclude "treatment resistance" without first confirming adherence, adequate dose and duration, and the absence of an untreated medical cause.

Special situations. Depression in dementia — use the Cornell Scale, prioritise psychosocial and behavioural measures; drug benefit is modest (the HTA-SADD trial showed no benefit from sertraline or mirtazapine). Post-stroke depression — treat actively, since it impairs rehabilitation. Apathy — this is not depression; SSRIs may worsen it; manage with activity scheduling, music therapy, outdoor activity, and in severe cases a trial of low-dose methylphenidate.

Maintenance and relapse prevention. Continue for ≥1 year after a first recurrence and consider lifelong maintenance after a second. Maintain the same dose that achieved remission; taper slowly if stopping; and continue exercise, social engagement and structured follow-up as relapse-prevention measures.

USPSTF 2023 (JAMA). A Grade B recommendation to screen all adults, including those aged ≥65, for major depressive disorder wherever systems exist for accurate diagnosis, treatment and follow-up — supporting the collaborative and stepped-care model (PHQ-2 → PHQ-9 or GDS-15 → structured treatment → follow-up) now built into India's NPHCE and Ayushman Arogya Mandirs, with referral through Tele-MANAS 14416.