Kimothi Cain, MD, MPH Psychiatry Psychosomatic Fellow

Persons 65 years or older 39.6 million in 2009 (the latest year for which data is available) or 12.9% of the U.S. population 72.1 million or 19% of the population estimated in 2030 Department of Health and Human Services, 2012

Of 39.6 million US seniors: 3 million have a depressive disorder 5 million have subsyndromal depression Less than 10% are treated 19% of all suicides are by patients over 65 The second highest U.S. suicide rates are white men over age 65

More somatic complaints: Persistent, vague, unexplained physical complaints such as pain, GI disturbances, weakness, insomnia, anergy Less likely to present with depressed mood Agitation, anxiety Memory problems, difficulty concentrating Social withdrawal

In primary care, depressed geriatric patients frequently present with somatic complaints Simon GE, et al. N Engl J Med. 2012;341(18): Chief complaints of 1043 geriatric patients in a primary care setting who were subsequently diagnosed with Major Depressive Disorder

Hypothyroidism Calcium B12 deficiency Vitamin D deficiency Heart disease Neurological illnesses Cancer COPD Autoimmune diseases CVA Trauma Alzheimer disease Other neurodegenerative diseases etc.

Evidence for Drug-Induced Depression associated with drug groups **Reflects authors’ global assessment of evidence; --- little or no convincing evidence; +/- limited evidence; + moderately strong evidence; ++ strong evidence; +++ very strong/unequivocal evidence. Evidence for Drug-Induced Depression associated with drug groups DRUG CLASS/DRUGLEVEL OF EVIDENCE AVAILABLE LITERATURECOMMENTS Calcium channel blockers +/- Prescription symmetry analysis, cohort study examining suicide rates Results are conflicting—newer have fewer reports. ACE inhibitors +/- Prescription symmetry analysis No comment ARBs +/- Case reports No comment Alpha interferons ++ Uncontrolled and controlled studies No comment Beta interferons +/- 4 RCTs and 1 naturalistic study No comment **Reflects authors’ global assessment of evidence; --- little or no convincing evidence; +/- limited evidence; + moderately strong evidence; ++ strong evidence; +++ very strong/unequivocal evidence Rogers et al, Psychiatry, 2008; 5(12): 28–41 Corticosteroids + Case control study, cross-sectional analysis Results of trials are suggestive of DID, especially over >65

Geriatric Depression Scale DSM-V criteria for MDD At least 5 of 9 symptoms, present nearly every day for 2 or more weeks: 1.Depressed mood or irritable most of the day** 2.Decreased interest or pleasure in most activities (anhedonia)** 3.Significant weight change (5%) or change in appetite 4. Change in sleep: Insomnia or hypersomnia 5. Change in activity: Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Guilt/worthlessness 8. Concentration: diminished ability to think, concentrate, or indecisiveness 9. Suicidality: Thoughts of death or suicide, or has suicide plan ** Depressed/irritable or anhedonia required for diagnosis

Geriatric depression can be challenging to diagnose and treat Consider psychotherapy, group therapy Healthy lifestyle Behavior activation Consider an antidressant antidepressant

Increases use of primary care medical resources Depressive symptoms significantly reduce survival of medical illness Increases risk of suicide

Decrease in lean body mass and total body water Increase in body fat, prolongs half life Hepatic metabolism decreases, as well as production of albumin Decrease in renal function

Antidepressant Target sxStarting dose Incremental increase Target dose (Not the same for seniors) SertralineDepression Anxiety Cardioprotective 25mg qday25mg q3-6 weeks Usually requires less than 200mg. Max 200mg EscitalopramDepression Anxiety 5mg qday5mg q3-6 weeksMax 20mg MirtazapineInsomnia Poor appetite Depression Anxiety 7.5mg qhs7.5mg q3-6 weeksMax 45mg

1.Fluoxetine -Long half-life metabolites -Drug-drug interactions 2.Paroxetine -Anticholinergic -Short-half life with marked withdrawal sx