Depression is “the second most common psychiatric disorder” for elderly people. Age is one important variable associated with severity of depression, with studies showing a worse course in elderly patients compared with other adults. Depression in the elderly challenges the available treatment options, as elderly depressive patients commonly suffer from disability, functional decline, diminished quality of life as well as mortality from other medical conditions. Fortunately, there are some good treatment options, including pharmacological, psychological, and nonpharmacological treatment strategies, such as TMS (transcranial magnetic stimulation).
What Is Treatment Resistant Depression?
The treatment for depression usually consists of varying proportions of medication and talk-therapy. These treatments don’t always work, however, and some people might find that they have a form of Treatment Resistant Depression. Treatment Resistant Depression, as outlined by the Psychiatric Times, happens when there is “an inadequate response to at least two antidepressant trials of adequate dose and duration.”
Conditions Specific to Elderly Patients
Ultimately, Treatment Resistant Depression falls under the category of “difficult to treat” depression and when considering the treatment options for the elderly, there are other factors to evaluate. Many often wonder if the kind of treatment needed is covered by Medicare and seek to explore treatment options that are cost effective. Another issue when considering the management of Treatment Resistant Depression is that this kind of depression is heightened by other special concerns that specifically affect the elderly community.
Early-Onset Depression vs. Late-Onset Depression
Early-onset depression refers to a form of depression where the symptoms are diagnosed earlier in life and have affected the patient throughout their lives. Patients were either treated for depression as children, teenagers, or young adults with this type of depression and the disorder is likely to have run in the patient’s family.
Late-onset depression is experienced later on in life for a patient who has had no previous experience with depression. When patients develop late-onset depression, it could be as a result of “medical morbidity,” meaning the patient has incurred other medical conditions and become depressed as a culmination of all their symptoms. Since elderly people tend to have a variety of health concerns, late-onset depression might be difficult to diagnose. A few symptoms of this type of depression are memory loss, loss in weight, or withdrawn behavior.
- Vascular Depression is a form of late-onset depression that results from damage to the blood vessels in the brain or lesions within the subcortical microvascular region.
Understanding the designation between early-onset depression and late-onset depression is clinically important because late-onset depression frequently develops in the context of medical morbidity, such as heart disease/stroke (vascular etiology), dementia (neurodegenerative illness), and/or chronic inflammation.
Management of Treatment Resistant Depression in the Elderly
The management of late‐life depression is challenged by high rates of treatment‐resistance, side effects to medication, and medical comorbidities. When pursuing the best form of treatment in the elderly, here are some tips for finding a solution:
Give Your Current Method Some Time
Patients may feel that their current medications aren’t working. However, it’s possible that they just haven’t been taking the medication long enough. The typical duration for an adequate trial of antidepressants is typically 6 to 8 weeks in adults. However, elderly patients often require a longer duration of treatment to achieve an adequate response, upwards of 8, 10, or 12 weeks.
Switching or Adding Medications
For managing Treatment Resistant Depression, evidence supports switching your medication can be helpful. For example, if a patient is not responding to serotonin reuptake inhibitors, consider beginning a serotonin-norepinephrine reuptake inhibitor instead. Another suggestion is to consider adding another medication, such as Lithium, or an antipsychotic, such as Abilify to augment the antidepressant when relief isn’t adequate from the antidepressant alone.
Patients should pursue a psychological counseling style that best suits them for treatment. Psychotherapy can help find the root of the problem and assist the later in life patients who suffer from depression. For example, CBT (cognitive-behavioral therapy) is based on the assumption that maladaptive patterns of thought and behavior contribute to the onset and the maintenance of a psychological illness such as depression. To remedy the illness, CBT aims to break the patterns of dysfunctional cognitions and behaviors. There is evidence that CBT in combination with an antidepressant leads to superior results in reducing depressive symptoms than treatment with either CBT or the antidepressant alone.
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation (TMS) has been used since 1985 and has been approved since 2008 by the FDA for treatment resistant depression. TMS has an almost 60% improvement rate in elderly patients.
When considering the effectiveness of TMS, it’s important to know the difference between unilateral and bilateral TMS to know which treatment method will work best for you. Unilateral TMS treatment sends a high-frequency magnetic pulse to the left side of a patient’s brain. In turn, this “enhances the functioning in this region of the brain” and patients’ mood symptoms improve.
Bilateral Transcranial Magnetic Stimulation administers a low-frequency stimulation to the right side of the brain in addition to high-frequency pulses to the left side of the brain. One recent study demonstrated that elderly patients who received bilateral TMS “experience especially high remission rates.”