Mark Myers expert answer to: My wife has frequent bouts of suicidal depression but refuses anti-depressants. What can I do?

Antidepressants For Older Adults? Be Careful!

A study published in The British Medical Journal this month raises questions about the risks of antidepressant medications for adults 65 and older who have been diagnosed with depression. The major conclusion of the article -- that care should be taken in prescribing and in selecting which antidepressant medication to prescribe for older adults -- is unquestionably correct and is nothing new. However, the specific findings of this study -- that taking antidepressants was associated with increased death rates and other adverse consequences, and that the new antidepressants (SSRIs ) may have greater serious risks than those associated with previous generations of antidepressants -- are provocative, important and uncertain.

The study's two major findings are frightening on their face.

Compared with older primary care patients who had diagnoses of depression in their records but who did not take antidepressants, those who did take antidepressants had higher rates of death, attempted suicide, falls, fractures, upper gastro-intestinal bleeding and heart attacks.

Those who took SSRIs (which are the most commonly prescribed antidepressants) had higher rates of death, stroke, falls, fractures and seizures than those who took tricyclics or other earlier forms of antidepressant.

Because of possible implications for current standards of practice, the importance of this research and of doing prospective future research to resolve questions that this study leaves unanswered cannot be overstated.

In recent years, much research has indicated that older adults who are depressed -- especially those who also have a chronic physical condition -- and who are not treated for depression are at increased risk for disability and premature mortality. Specifically, previous studies have linked depression to greater functional decline, increased risk of falls and greater cardiovascular mortality among older persons who are not taking antidepressants. As a result, there has been a push to screen for depression and to treat it, using both psychotherapy and antidepressants. This study seems to call this standard approach to depression into question.

In addition, it is known that SSRIs have fewer side effects (e.g., dry mouth, constipation and cardiovascular complications) than earlier forms of antidepressants. Are they also safer? The findings of this study suggest that they may not be. Should preferences regarding antidepressants for older adults therefore change?

Carol Coupland and her colleagues, the authors of this new study, are modest in their conclusions and recommendations, saying only, "The potential risks and benefits of different antidepressants ... need careful consideration when these drugs are prescribed for older adults."

Why not issue an alarm about the use of antidepressants, and particularly about the use of SSRIs, by older adults? First, this study examines patient records in ways that identify associations of facts but do not reveal causation. The standard way to establish causation would involve random selection of depressed patients prescribed antidepressants. In the BMJ study, the decision was not made randomly, raising the possibility that an unidentified factor led physicians to prescribe antidepressants, and particularly SSRIs, to their depressed patients who were at greatest risk for adverse outcomes.

Similar studies have demonstrated that antidepressants are associated with reduced risks of suicide and reduced risks of death from conditions such as strokes and cardiac disease.

Second, this study does not adequately distinguish between older adults with major depressive disorder (MDD) and those with other mood problems, and it does not adequately examine those with moderate or severe MDD compared to those with mild disorders. Clinical research regarding the use of antidepressant medications indicates that they are more effective for people with disorders that meet the threshold for a clinical diagnosis, particularly if moderate to severe . It would be useful to repeat this study leaving out people with mild depression or without depression at all, keeping in mind that a diagnosis of depression in a patient's chart is not necessarily accurate.

Third, this study does not clearly distinguish between those who began the study with a serious physical condition and those who did not. It would be useful to follow patients with serious physical illnesses and depression to see whether -- as other studies suggest -- treatment for depression brings down their risk of death and other adverse consequences.

Despite these reservations, the findings of this study are very important both with regard to overall risks of antidepressants for older adults and with regard to the possibility that SSRIs have more adverse consequences than earlier generations of antidepressants.

Are antidepressant medications dangerous for older adults? Would it be preferable to treat depression only with psychotherapy despite evidence that the combination of psychotherapy and medication is generally more effective than either alone? Should earlier-generation antidepressants be used more frequently than SSRIs despite evidence that the SSRIs have fewer side effects? This study does not give definitive answers, but it does reinforce the fact that the use of antidepressants by older adults is not risk-free. Physicians and their patients should clearly exercise caution.

Coupland, Carol et al. "Antidepressant use and risk of adverse outcomes in older people: population based cohort study" in BMJ, August 2, 2011. http://www.bmj.com/content/343/bmj.d4551

Harrison, Pam. "Depression in Older Adults Increases Mortality Risk". Medscape News, February 26, 2010. http://www.medscape.com/viewarticle/717663

Fergueson, James. "SSRI Antidepressant Medications: Adverse Effects and Tolerability" Journal of Clinical Psychiatry, February 2001. http://www.ncbi.nlm.nih.gov/pubmed/14514497http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/

Jorge, Ricardo et al. "Mortality and Post-Stroke Depression: A Placebo-Controlled Trial of Antidepressants" in American Journal of Psychiatry, October 2003. http://www.ncbi.nlm.nih.gov/pubmed/14514497

Glassman, Alexander et al. "Psychiatric Characteristics Associated with Long-term Mortality Among 361 Patients Having an Acute Coronary Syndrome and Major Depression: Sever-Year Follow-up of SADHART Participants" in Archives of General Psychiatry, September 2009. http://archpsyc.ama-assn.org/cgi/content/abstract/66/9/1022

Fournier, Jay et al. "Antidepressant Drug Effects and Depression Severity: A Patient Level Meta-Analysis" in Journal of the American Medical Association, January, 2010. http://jama.ama-assn.org/content/303/1/47.full

Bartels, Stephen et al. Evidence-Based Practices in Geriatric Mental Health in Psychiatric Services, November 2002. http://www.ps.psychiatryonline.org/cgi/content/full/53/11/1419

American's Use of Anti Depressants on the Rise.

Americans are popping more antidepressants than ever before to deal with everyday stress, and non-psychiatrists are increasingly willing to prescribe the drugs to patients with no mental health diagnosis, a new study finds. more

Depression

Depression is a common illness that affects up to 12% of men and 25% of woman during their lifetime. The symptoms may persist for most of the day, nearly every day, or throughout

the day. It may develop over days to weeks. The severity of it could also vary among individuals. Depression is not merely feeling down and out. It could have a profound and devastating

impact on individuals and families. Depression is a medical illness that can be treated with counseling and\or medication. It is not a

weakness or character defect. 

Individuals suffering from depression are likely to experience:

# A depressed mood for most of the day

# Loss of interest in pleasurable\recreational pursuits

# Sudden changes and excess in eating and sleeping habits

# Feeling fatigued or rundown

# Persistent feelings of hopelessness

# Difficulties concentrating and\or making decisions

# Anxious feeling

# Feeling hopeless

Causes of Depression

There are both physical and psychological causes of depression. Some people are born being more susceptible to depression through family history, illnesses, and chemical imbalances. Others may be experiencing psychological or emotional causes involving death of loved ones, divorce, loss of job, or

other life circumstances.

Treatment for Depression 

 If you are treated by a therapist, a variety of approaches may be introduced. One approach in and of itself, may not be the answer. A combination of approaches might significantly reduce your symptoms. Therapy can help you gain new insight and awareness into thoughts as well as, behavior that contributes to depression.

Altering lifestyle and approach to life often have a positive impact on an individual. Included are some suggestions for addressing symptoms of depression. Nutrition Significant progress has been made in

investigating how nutrition can influence mood and behavior. Caffeine is a nervous system stimulant which

can affect sleep. Processed and sugary foods tend to deplete the body’s energy reserves in the long run

which could influence fatigue factors. Consider the use of vitamins and mineral supplements. Your doctor or

other trained professionals can assist you in making nutritional choices. 

Exercise

Exercise can help disrupt the pattern of depression and fatigue. The body becomes better able to handle the

effects of physical and emotional stress. Exercise can positively affect the neurochemistry of the brain.

Many find that going for walks, especially in the morning, can improve one’s outlook on life. Exercising could also improve an individuals self confidence in setting and achieving physical goals. 

Supportive Relationships 

There is an increasing correlation between supportive relationships and health. Relationships provide encouragement and help fulfill a very important human need. Often being with others helps balance the focus

between oneself and others. It is important to identify individuals who are truly supportive. Be careful to choose supportive people rather than those who may be negative or demanding. It is also important to understand peoples limitations in giving support. Some individuals may not be able to offer the consistent support that you need. If you expand your resources through community networks (i.e., Y.M.C.A.’s,

support groups, etc.), this would enable you to have the ongoing support you require.

Education Individuals can learn about the treatment of depression from doctors, books, the Internet, and peers. Knowledge can be empowering and reduce depression symptoms because individuals understand their symptoms better. 

Realistic Expectations 

Sometimes, individuals have difficulties setting realistic expectations. Their goals for themselves are usually very high or low. Cognitive restructuring can be helpful in providing structure for realistic goal setting.

Rational Thoughts

Thoughts play a key role in influencing feelings and behavior. Cognitive restructuring can assist you in learning

how to change often predictable and self-defeating thoughts. Through increased awareness and practice,

unrealistic thought patterns can be replaced with more rational ones. 

Medication

Medication can help stabilization of functioning and create opportunities for other aspects of treatment to be

beneficial. Medication is often utilized when there is significant impairment in day to day functioning. Because each person differs biologically and psychologically, it is important to discuss the use of medication with your

doctor or psychiatrist.