What Older People Should Consider Before Taking an Antidepressant

Medication may be the best thing for you, but there are alternatives that you and your doctor may decide you should try first.
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This essay was co-authored with Kenneth G. Terkelsen, MD.

Antidepressants are helpful to some older people , but they also have their risks. You and your doctor should weigh the risks and benefits before starting an antidepressant. Keep in mind that exercise and psychotherapy can also be effective in reducing depression. So can spending time with people and keeping busy with activities you enjoy.

Medication may be the best thing for you, but there are alternatives that you and your doctor may decide you should try first.

Here are some key questions to ask:

Do I have a disorder responsive to antidepressants?
Antidepressants are often prescribed for conditions other than depression. Although these medications can be used for other conditions, it is important to be reasonably sure that you have a condition responsive to an antidepressant.

The primary such condition is major depressive disorder (MDD), which is not to be confused with being sad -- as we human beings often are -- or with symptoms of depression such as difficulty sleeping, which can, and often do, have causes other than MDD. Recent research suggests that antidepressants are more effective when depression is severe and less effective, and perhaps ineffective, when the depression is mild or even moderate.

Antidepressants are also used for the treatment of anxiety disorders. Again, being nervous is not the same as having an anxiety disorder. Is your anxiety severe enough for medication to be the way to go?

Antidepressants are also used for the treatment of nerve pain or to ease the emotional swings some women experience during and after menopause.

Use of medications, including antidepressants, for purposes not formally approved by the Federal Drug Administration ("off-label" use) is not uncommon, but it's important to discuss with your doctor beforehand.

Do I have a physical problem that may be worsened or improved by an antidepressant?
A recent study found an association between antidepressant use by older adults and falls, heart disease, stroke, gastro-intestinal distress and more. In addition, some antidepressants are associated with weight gain and obesity, which create greater risks for diabetes, heart disease, etc.

So, if you have balance problems, cardiovascular disease, diabetes, gastrointestinal distress or weight problems, it only makes sense to have a conversation with your doctor about the wisdom of taking an antidepressant.

This is complicated because numerous studies, have shown depression increases the risk of disability or premature death in people with cardiac disease, diabetes, and other chronic conditions. Taking antidepressants, when effective, can substantially reduce these risks, but weighing the value of treating depression with medication against the risks of adverse consequences is something to talk out with your doctor.

Should I take an antidepressant if I have dementia?
About 20 percent of people with Alzheimer's or other forms of dementia are also depressed. A number of studies have called into question the standard practice of prescribing antidepressants for older adults with dementia as the first line of intervention. A group that did a study for the British National Health Service concluded that it is preferable to start with "watchful waiting" and help dealing with the difficulties typically experienced by people with dementia and their caregivers, then try psychotherapy, and use anti-depressants only as a last resort.

Are there drug interactions I should be concerned about?
Adding an antidepressant to other medications may have adverse effects. For example, some drugs used to prevent blood clots and reduce risk of heart attack become more potent if certain antidepressants are added. This can be very dangerous if you have an injury that causes bleeding. You should check for potentially dangerous drug interactions with your doctor and/or pharmacist.

Can I use antidepressants if I drink alcohol or use drugs?
Taking antidepressants if you have more than a drink or two a day or if you use other potentially addictive substances such as opiates or cocaine can be very dangerous. Be honest with your doctor about alcohol and drug use so that you can decide together whether it is safe for you to take an antidepressant. Of course, you could decide to stop using these substances, but that is far easier said than done.

Which antidepressant is right for me?
Antidepressants are not interchangeable. Some are associated with weight gain; some are not. Some have sexual side effects; some usually do not. Some often produce a sense of agitation; some are less likely to. Some may help you sleep; others may not. Some are particularly useful for people who have an anxiety disorder as well as a major depressive disorder.

You and your doctor should sort out which antidepressant is most likely to work and to have the fewest side-effects for you.

But you should also carefully monitor your reaction. Individuals have different reactions to the same medications. You should talk with your doctor about your experience. You may need to try a number of different antidepressants before finding one that works for you.

Should I take more than one medication for depression?
Some individuals with medical conditions such as high blood pressure do better if treated with more than one medication. Similarly, some people with depression who do not get adequate relief with one medication may benefit from adding another. Some drug companies are advertising antipsychotic medications as possibly beneficial when antidepressants are not adequately effective. But antipsychotic medications also have risks. Combining two or more medications is something you should discuss with your doctor if you are not getting relief from one medication.

Bottom line:
Answering the questions above will not guarantee that you and your doctor will make the right decision about taking an antidepressant, but it will certainly help.

Michael B. Friedman, LMSW is Adjunct Associate Professor at Columbia University. Kenneth G. Terkelsen, MD is Associate Medical Director for Behavioral Health, Community Health Center of Cape Cod.

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