Treatment‐Resistant Depression in the Elderly

epression is a common and potentially lethal illness in the elderly. It reportedly occurs with a prevalence of 13% in this population' and in 20 to 35% of medically ill elderly patients.2*3 Those older than age 65 account for 25% of all suicides, although comprising only 12% of the p ~ p u l a t i o n . ~ , ~ In addition, untreated depression can lower life expectancy and is associated with an increased risk of cardiac disease.6 * Thus, the diagnosis of depression warrants careful consideration in all elderly patients. This paper discusses common difficulties encountered in treating elderly depressed patients and outlines diagnostic and treatment strategies for patients who appear resistant to initial antidepressant treatment. Many elderly patients diagnosed with major depression are incorrectly or prematurely labeled "treatment resistant." A number of factors should be considered before concluding that an elderly patient's depression is unresponsive to standard pharmacologic treatment (Table 1). Underlying medical problems or concurrently prescribed medications which can produce depressive symptoms should be identified and corrected whenever possible. Unrecognized noncompliance with medication as well as drug trials that are too brief or fail to achieve therapeutic blood levels can result in the incorrect label of treatment resistance. Heightened sensitivity of elderly patients to drug side effects often results in premature discontinuation of treatment. Another factor that may contribute to inadequate treatment is a tendency for clinicians to dismiss depression as an inevitable accompaniment of aging. After assessment of these fac-

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