We bring you the 2021 updated guidance regarding management of depression among older adults from the Canadian Coalition for Seniors Mental Health (CCSMH) and Canadian Academy of Geriatric Psychiatry (CAGP).
*Strength of recommendation is graded from [A] to [D] based on strength of evidence.
Prevention
Recommendation 1: *NEW: Group-based therapy in LTC settings reduces social isolation [B]
Recommendation 2: *NEW: Social prescribing to community-based non-clinical services can improve mild to moderate depression [C]
Recommendation 3: *NEW: Community-dwelling older adults with subthreshold depression or anxiety benefit from a stepped-care approach [B]
Recommendation 4: *NEW: Physical activity lowers the risk of developing depression [B]
Recommendation 5: *NEW: Instilling hope and positive thinking is an important therapeutic tool to prevent depression in all healthcare settings [D]
Screening and Assessment
Recommendation 1: *UPDATE: Older adults without cognitive impairment should use self-rating screening tools, with new guidelines recommending the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire-9 (PHQ-9) [B]
Treatment and Management
Recommendation 1: *UPDATE: New guidelines indicate severe depression with psychotic features or suicidal ideation can safely and effectively be managed with a combination of antidepressants and antipsychotics. At the clinician’s discretion patients with severe symptoms or risk of poor outcomes can be offered Electroconvulsive therapy (ECT) [B]
Recommendation 2: *NEW: Repetitive transcranial magnetic stimulation (rTMS) can be considered for those who fail pharmacotherapy, but not for those who fail ECT [B]
Recommendation 3: *UPDATE: Cognitive behaviour therapy (CBT) and problem solving therapy (PST) have the most evidence and should be available to all older adults with depression [A]. Internet-delivered therapy increases accessibility and can be considered comparable to face-to-face [C]
Recommendation 4: *NEW: Exercise is an effective non-pharmacological intervention to improve mood [B]
Recommendation 5: *UPDATE: Duloxetine or sertraline are preferred SSRIs for acute depression, as
escitalopram and citalopram are effective but risk QT prolongation at therapeutic doses [A]. Fluoxetine and paroxetine are no longer recommended in older adults. Updated guidelines recommend serum sodium levels at 2-4 weeks of initiation of SSRI and SNRI therapy instead of 30 days [C]
Recommendation 6: *UPDATE: We suggest using antidepressants with the lowest anticholinergic properties, leaving tricyclic antidepressants (TCA) as third line agents [C]
Recommendation 7: *UPDATE: See patients every 1–2 weeks from initiation of antidepressants to assess response and dose titration [D]
Recommendation 8: *UPDATE: Patients with incomplete recovery, consider augmentation with additional antidepressants, lithium or psychotherapy. Updated guidelines suggest atypical antipsychotics (e.g. aripiprazole) are effective in some groups [C]
Recommendation 9: *UPDATE: New guidelines prefer behavioural intervention to pharmacotherapy for mild to moderate depression in patients with dementia [D]
Recommendation 10: *UPDATE: SSRIs are still first-line treatment for post-stroke depression, using SNRI or mirtazapine as second line. Updated guidelines suggest use of Methylphenidate if apathy is significant [B]
Recommendation 11: *NEW: SSRI is preferred first-line therapy for patients with co-existing Parkinson’s disease [B]
Recommendation 12: *NEW: The core of management is an individualized care plan with collaboration of interprofessional staff and a stepped care approach [A]