Here are a few factoids about depression in older adults:
1. Start with monotherapy, usually an SSRI. I like sertraline for a starter.
2. If no improvement, try a different SSRI; eg citalopram or escitalopram. Paroxetine can be cognitively-blunting, and fluoxetine has a higher fall risk than other SSRIs.
3. If no improvement, AND if they have concurrent insomnia OR if you also want them to gain weight, add mirtazapine.
4. If partial response switch to venlafaxine or duloxetine (avoid duloxetine if kidney probs).
5. If depression severe, SI, or psychosis, add a second-generation antipsychotic (SGA) – best evidence supports quetiapine, olanzapine, aripiprazole.
6. If still no improvement, add buspirone, lithium, or lamotrigine.
And here’s another bit of trivia: “California Rocket Fuel” refers to the combo of a triphasic + biphasic (eg venlafaxine + mirtazapine). It’s overly stimulating because you are boosting NE from 2 separate agents. CRF can be useful for pts with severe vegetative sx, but be cautious. You don’t want to fix depression so aggressively that they have a stroke.
And finally: Always, always, always screen for suicide. Suicide rates are disproportionately elevated in older adults. Highest risk are white males with military service that own firearms.
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