Choosing appropriate antidepressant therapy in the elderly - A risk-benefit assessment of available agents

This article discusses the advantages and disadvantages of tricyclic antidepressants (TCAs), tetracyclic antidepressants (i.e. mianserin), selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), triazolopyridines (i.e. trazodone), phenylpiperazines (i.e. nefazodone), serotonin and noradrenaline (norepinephrine) reuptake inhibitors (i.e. venlafaxine), and aminoketones [i.e. amfebutamone (bupropion)] in the treatment of late-life depression. A limitation of the existing literature is that most data regarding drugs are derived from studies that have involved medically stable outpatients who do not have dementia and who are less than 80 years of age. There is a paucity of data on the use of antidepressants in very elderly individuals, patients who have significant medical comorbity and patients with dementia or other neurological problems. No one class of antidepressant has been found to be more effective than another in the acute treatment of geriatric major depression. However, given design shortcomings in many of these studies, the possibility of a real difference in efficacy between drugs (especially in the treatment of severe or melancholic depression) cannot be excluded. With respect to adverse effects, drug interactions, and dosage and administration, each class of antidepressant has its benefits: and limitations. There is no one 'first-line' antidepressant for elderly patients with depression. Selection of an antidepressant should be made on a case by case basis, taking into account each patient's characteristics.