Grades are shown as the source states them. The guideline gives expert recommendations drawn from the evidence it reviews, without a formal grading system, so no grades are shown.
Key recommendations
Look actively for depression. In older people it is under-recognised, often put down to ageing or ill health, and may show as physical or cognitive complaints rather than low mood.
Assessment and evaluation
Assess suicide risk in everyone with depression: ask directly about thoughts, plans and access to means, monitor closely, and consider admission for those at high risk.
Assessment and evaluation
SSRIs are usually the first choice; escitalopram and sertraline have few interactions and are safe across a wide range of physical illness. Follow “start low, go slow”.
Acute phase treatment
Psychotherapy (such as cognitive behavioural therapy or interpersonal therapy) works as well as antidepressants in mild to moderate depression, and medicine plus psychotherapy works better than either alone.
Acute phase: psychotherapeutic interventions; medications plus psychotherapy
After remission, continue the same medicine at the same dose; some experts advise continuing for a year. Offer long-term maintenance treatment to people who have had three or more episodes.
Continuation phase; Maintenance phase
Diagnosis
Late-life depression spans major depression and non-major forms (minor depression, dysthymia, adjustment disorder with depressed mood, mixed anxiety and depression). Minor depression is more common and often comes before major depression.
Diagnostic complexities
Presentations are often atypical: unexplained physical symptoms, memory or concentration problems, behaviour change, anxiety or irritability, sometimes without any reported sadness. Hypochondriacal or obsessional symptoms appearing for the first time in old age usually point to depression.
Assessment and evaluation
In people with physical illness, counting all symptoms towards the diagnosis whatever their cause (the inclusive approach) reduces under-recognition, but still look for medical contributors so that unnecessary medicines are avoided.
Assessment and evaluation
Compared with dementia, depression tends to have a quicker onset, low mood, worse mornings, intact orientation, patchy and inconsistent deficits, “don't know” answers and obvious distress. Depression is also common in dementia and easily missed; the Cornell Scale for Depression in Dementia can help.
Assessment and evaluation
Rule out bipolar disorder before starting an antidepressant. Psychotic features, marked psychomotor slowing, oversleeping and overeating, irritability, anger and a family history of bipolar disorder should raise the possibility.
Assessment and evaluation
Screening questionnaires such as the Geriatric Depression Scale (the best validated in cognitively intact older people, and available in Hindi) and the PHQ-9 need confirming by clinical interview, allowing for cognitive and visual impairment.
Assessment and evaluation
Investigations
Investigate every older person with depression, even with no known medical illness: at minimum a blood count, liver and kidney function, electrolytes, urinalysis and an ECG. Consider thyroid function, vitamin B12, folate and drug levels.
Assessment and evaluation
Consider neuroimaging for a first episode with late or very late onset, neurological signs, or treatment-resistant depression.
Assessment and evaluation
With a first episode in later life, look for underlying physical illness; review all medicines (including over-the-counter and traditional remedies) against the timing of symptoms; and ask about alcohol and other substances.
Assessment and evaluation
Some authors advise checking sodium before starting an antidepressant and monitoring it in the first weeks, especially when there are risk factors for hyponatraemia.
Treatment options: selecting a specific antidepressant
Treatment
Antidepressants can be used at any severity. They are favoured after a previous good response, for severe symptoms, marked sleep or appetite disturbance or agitation, or when maintenance treatment is likely to be needed. Respect a preference for psychotherapy in milder depression.
Acute phase treatment
Depression with psychotic features may need an antidepressant plus an antipsychotic, and/or ECT. ECT is also indicated for catatonia not responding to benzodiazepines, high suicide risk, physical illness that rules out antidepressants, food refusal with nutritional compromise, or a previous good response to ECT.
Treatment options
Expect improvement after 4–6 weeks and the full effect after 2–3 months. If there is less than 25% improvement after 6 weeks, review and consider a change; with 25–50% improvement, increase to the maximum tolerated dose; if improvement is still under 50% after 6–8 weeks at that dose with good adherence, consider switching.
Acute phase treatment
When response is inadequate, first recheck the diagnosis, adherence and factors affecting drug levels. Then optimise the dose, switch (preferably to a drug with a different or broader mechanism), augment, add or intensify psychotherapy, or consider ECT.
Acute phase treatment
Treatment-resistant depression means no response to two adequate antidepressant trials. Lithium is usually the first augmentation choice, continued for at least a year after remission; aripiprazole added to venlafaxine has some supporting evidence.
Management of treatment resistant depression
Benzodiazepines or other hypnotics for insomnia or anxiety should be short-term only, with patients and carers warned about over-sedation.
Acute phase treatment
Strengthen social and family support, encourage a regular activity schedule, walking, socialising and mental activity; aerobic exercise, yoga and mindfulness may also help.
Improve social support; Lifestyle modifications; Other interventions
Explain the illness, that benefit takes at least 3–4 weeks to appear, the need to continue after feeling better, what to do about side effects, and the early signs of relapse. Involve the family at every stage, including supervising medicines.
Enhance treatment adherence; Psychoeducation
When stopping an antidepressant, taper over several weeks to a few months, more slowly for short-acting drugs. Paroxetine, venlafaxine, tricyclics and MAOIs cause discontinuation symptoms more often; restart and taper more slowly if symptoms are severe.
Discontinuation of active treatment
Important geriatric considerations
Older people are more sensitive to anticholinergic effects, so prefer newer antidepressants. If a tricyclic is needed, avoid strongly anticholinergic ones such as amitriptyline (nortriptyline causes less orthostatic hypotension), and avoid drugs that are very sedating or lower blood pressure.
Treatment options: selecting a specific antidepressant
Hyponatraemia is commoner with older age, female sex, low body weight, physical illness, diuretics, previous hyponatraemia, low baseline sodium, summer, and the first weeks of treatment.
Treatment options: selecting a specific antidepressant
Serotonergic antidepressants increase the risk of gastrointestinal bleeding, particularly with NSAIDs, aspirin, clopidogrel, warfarin or corticosteroids, a history of peptic ulcer, or liver disease. When an antidepressant is needed in someone at risk, the guideline advises a proton pump inhibitor.
Treatment options: selecting a specific antidepressant
Sertraline and citalopram have the least potential for drug interactions. Monitor blood pressure on venlafaxine in people with cardiovascular disease or on higher doses.
Treatment options: selecting a specific antidepressant
ECT is as effective in older people as in younger adults and is well tolerated even over the age of 80. Watch for falls and post-ECT confusion; pre-existing cognitive impairment raises the risk of lasting cognitive effects, which high-dose right unilateral ECT reduces. The seizure threshold rises with age.
ECT in elderly
“Vascular depression” (onset at 65 or later, executive dysfunction, slowing, apathy, vascular risk factors) responds less well to treatment and carries a higher risk of cognitive decline.
Diagnostic complexities: vascular depression
Recurrence is common: 50–90% within two to three years, so plan for relapse prevention from the start.
Maintenance phase
Drug doses
Start antidepressants at about half the usual adult dose, or a quarter when there is significant physical illness, and increase slowly according to response and side effects.
Acute phase treatment
For lithium augmentation in older people, aim for a serum level of 0.5–0.6 mmol/L.
Management of treatment resistant depression
When to refer
Choose the treatment setting by severity, physical and psychiatric comorbidity, suicidal or homicidal risk, ability to self-care and available support. Consider admission for high suicide risk; inpatients should have a family carer with them.
Determine a treatment setting; Assessment and evaluation
If a change of treatment still brings no moderate improvement after a further 4–8 weeks, reassess the diagnosis, adherence, physical and psychiatric comorbidity (including alcohol) and psychosocial barriers; if nothing new is found, consider ECT.
Acute phase treatment
Red flags
Suicide risk is higher with older age, male sex, severe anxiety or panic, living alone, severe depression, bereavement (especially in men), alcohol misuse, physical pain, previous attempts and a family history of suicide.
Assessment and evaluation
Psychotic features, catatonia, high suicide risk, or refusal of food with nutritional compromise are among the indications for ECT or combined treatment.
Treatment options
ECT is relatively contraindicated after a recent myocardial infarction and with a brain tumour, cerebral aneurysm or uncontrolled heart failure.
Treatment options
Recent updates
This 2018 guideline updates the Indian Psychiatric Society's 2007 guideline on depression in older people and should be read with its 2017 guideline for adults.
Introduction