20th July 2023

Management

The management of depression in older patients is similar to that recommended for adults, however there are some additional considerations. NICE provides a separate guideline for those with a chronic physical health problem, which is likely to be relevant to the older population.

All patients should be asked about suicidal ideation and intent in order to assess risk and ensure appropriate support and treatment is put in place.

Management should be guided by the clinical needs, patient preference and treatment history. Treatment options range from guided self-help, group-based therapies to individual counselling and pharmacological management.

When considering pharmacological treatment options, it is important to consider the patient’s medical history, current medications, and any previous experience of antidepressants. The patient should also be informed about potential adverse events associated with pharmacological treatment e.g., discontinuation symptoms and relevant side effects.

Generally, selective serotonin reuptake inhibitors (SSRI) are used first line, such as citalopram. In all patients, but particularly older adults, it is important to consider the increased risk of bleeding associated with SSRIs. Medications should also be prescribed at age-appropriate doses.

It is also crucial to assess suicide risk, as those at high risk will need closer monitoring when starting treatment.

Response to treatment should be reviewed in the first 2-4 weeks, however the person should be assessed sooner if there is a particular risk of suicide or pharmacological treatment has been started for a person aged 18-25 years.

To prevent relapse, antidepressants should be continued for at least 6 months after remission of symptoms.

For severe depression or refractory depression, electroconvulsive therapy can be considered.