Beyond the pills: navigating depression and antidepressant use in older adults

Case scenario

Janet, an 82-year-old regular customer at your pharmacy, lives alone after her husband’s death 6 years ago. She takes ramipril for hypertension, and is an avid baker who often shares her baked goods with the pharmacy. After a few weeks of absence, she comes to see you and mentions she’s been struggling to get out of bed in the morning and lacks the motivation to bake or attend her aerobics class. In the consultation room, you use the Geriatric Depression Scale–15¹ (GDS–15) as a guide for discussion on depression screening. Janet scores 10/15 on the GDS–15, indicating potential depression. You refer her to her GP for further assessment.

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Introduction

Mental health issues affect millions of Australians. In recent years, the prevalence of conditions such as depression have surpassed other serious illnesses due to various social, economic and environmental factors. Recent data estimates that 15% of Australians aged 55 and over experience depression or anxiety.²

Antidepressant use in older adults continues to rise, with approximately 1 in 4 Australians aged over 65 prescribed antidepressants in 2022–2023 compared to 1 in 5 for those aged 18 years and over, raising concerns about the appropriateness of such prescriptions, given that older adults report lower rates of depression and anxiety.³

Depression in older adults

The exact mechanisms behind depression remain unclear, and the once-popular theory of neurochemical imbalance is now being increasingly questioned.⁴ However, this theory significantly influenced the widespread use of antidepressants as the primary treatment for depression for many decades.

Depression in older adults can cause significant distress, functional and cognitive impairment, and increased suicide and non-suicide mortality.⁵

There are many risk factors associated with depression in older adults, including^6–8:

• social isolation and loneliness
• grief and loss
• increased health problems
• history of depression.

Clinical features 

According to the International Classification of Diseases-11 (ICD-11)⁹, depression is characterised by persistent feelings of sadness or diminished interest in activities, most of the day, nearly every day for at least two weeks.¹⁰ These are accompanied by other symptoms, including^10,11:

• reduced ability to concentrate or marked indecisiveness
• beliefs of low self-worth, or excessive guilt
• hopelessness about the future
• recurrent thoughts of death or suicidal ideation
• significantly disrupted or excessive sleep
• significant changes in appetite or weight.
  

Diagnosing depression in older adults can be challenging due to the misinterpretation of depressive symptoms as normal aging,¹² or confusion with other conditions like dementia.¹³ Depression, which is commonly accompanied by anxiety,¹⁰ is also often intertwined with chronic illness, cognitive decline and social isolation, leading to underdiagnosis, misdiagnosis and inappropriate treatment.¹⁴ Older adults may present
with other signs, including pain, poor self-care, or reliance on tranquilising medicines or alcohol.¹⁵

Treatment

A stepped approach to treatment is important for older adults, and incorporates lifestyle modifications, psychological therapies, and medicine where appropriate. The Quality Use of Medicines (QUM) Alliance discussion aid resource can support discussions with patients about different options.

Psychological interventions

Psychological therapies are first line for mild–moderate depression, and should also be offered in conjunction with antidepressants for moderate–severe depression, depending on availability and patient preference.¹¹ Therapies such as cognitive behavioural therapy (CBT), internet-based CBT, interpersonal therapy (IPT) and problem-solving therapy have demonstrated effectiveness in older adults, although there may be challenges with cognitive impairment (see Resources for further support).^16,17

Other non-pharmacological interventions

Lifestyle factors such as diet and exercise play an important role for older adults. Regular exercise has good efficacy data, with yoga and aerobic exercise alongside psychotherapy appearing to be somewhat more effective than other forms of exercise for older adults.¹⁸ Dietary changes may also benefit mood and psychological wellbeing, however further high-quality research is warranted.¹⁹

Social prescribing is another emerging approach in healthcare for connecting patients with non-medical services and community resources to improve their mental and physical wellbeing. It can involve referring patients to activities – such as exercise programs, art classes, volunteering or support groups – which complement traditional treatment options. Organisations such as Inclusee and Act Belong Commit offer programs for older people.

Medicine use

Antidepressants are indicated for moderate–severe depression, in combination with psychological therapies.^11,16

Antidepressants have variable efficacy that is modest at best when treating depression in older adults, and this modest benefit must be carefully weighed against the potential risk of harm.²⁰ Notably, there is no reliable evidence supporting long-term use, while concerns about associated harm continue to grow.¹⁶ Hence, choice should be based on balancing the risk of adverse effects, patient considerations (e.g. comorbidities, drug interactions, age), tolerability when ceasing treatment, and patient preferences.  Additional factors to consider in older adults include^10,11,21:

• The impact of physical comorbidities and possible medicine interactions
• Antidepressant adverse effects, which older adults may be more sensitive to (limiting choice of available agents)
• The impact of anticholinergic adverse effects (urinary retention, dry mouth, constipation, confusion)
• Increased risks of falls and fractures (greatest risk in first 3 months of treatment)
• Hyponatraemia (can cause delirium, seizures or even death), with the risk higher for selective serotonin reuptake inhibitors (SSRIs)/serotonin and norepinephrine reuptake inhibitors (SNRIs) over tricyclic antidepressants (TCAs)
• Caution is needed with patients at high risk of gastrointestinal (GI) bleeding (e.g. previous GI bleed or taking aspirin/non-steroidal anti-inflammatory drugs (NSAIDs)), risk is higher with SSRIs and SNRIs
• Lower doses may be needed and may take longer to achieve treatment response.

Antidepressants vary in their effects on older adults. For example, paroxetine’s short half-life and stronger anticholinergic properties may cause significant withdrawal effects, particularly if ceased quickly.¹⁶ In contrast,  fluoxetine’s long half-life may slow the reversal of adverse effects.²²

Escitalopram and citalopram are more commonly associated with QT prolongation and risk of arrhythmias, and caution should be taken with higher doses.¹⁶

TCAs carry risks of cognitive adverse effects, QT prolongation and higher rates of falls and fractures.

Guidelines suggest antidepressant use for 6–12 months post-recovery from depressive episodes,¹¹ yet Australian data shows average use exceeds 4 years.²³ It is important that expectations around treatment duration are discussed early on.

There is a lack of evidence supporting antidepressant use for dementia-associated depression. See QUM Alliance antidepressants drug table.

Knowledge to practice

Supporting treatment initiation and ongoing review

The early stages of antidepressant treatment are critical for recently diagnosed patients or those experiencing stigma surrounding their diagnosis. It is important for pharmacists to reassure patients that depression is not a normal part of aging, and that effective treatments are available. Older adults requiring pharmacotherapy may need lower starting doses and more gradual dose increases to minimise adverse effects, and may respond more slowly to treatment.¹¹ Pharmacists play a key role in educating patients about antidepressant benefits and risks, monitoring adverse effects, expected time to benefit, setting expectations about duration of treatment and future deprescribing.

Deprescribing of antidepressants

Deprescribing is a critical consideration in optimising antidepressant use, particularly in older adults as the risks change. The underlying mental health condition may have resolved, adverse effects may develop, or comorbidities and drug interactions may
necessitate reassessment.

Deprescribing approaches must be tailored to the individual. Pharmacists can utilise the QUM Alliance deprescribing safety plan to discuss tapering approaches with prescribers and patients.

Considerations for older adults

Withdrawal symptoms when stopping antidepressants (see Table 1 above) are a significant concern, affecting about 15% of patients,²⁴ although some data suggests over 50% of patients experience them, with half being severe symptoms.¹⁶

It is critical to differentiate withdrawal symptoms from the underlying condition.

In older adults, the risks of adverse outcomes are greatest in the first month after discontinuing antidepressants, with elevated risk persisting for 3 months.²⁷ 

Tapering recommendations

Most guidelines recommend gradually reducing antidepressant doses over several weeks, typically by halving the dose every week or two.^10,11,16 The Maudsley Deprescribing Guidelines recommend a slower extended taper over several months or even longer, especially for long-term users and those on high doses.²⁶ An extended hyperbolic tapering pattern, where dose reductions get smaller as the total dose decreases, theoretically allows the brain time to adjust, potentially minimising withdrawal symptoms. However, commercially available dosage forms may not always allow for precise adjustments, often necessitating compounded or liquid formulations.

Pharmacists can support the deprescribing process by:

• providing critical information about deprescribing and tapering
• compounding medicines for gradual dose reduction
• conducting medication management reviews to optimise care and reduce risk of harms 
• offering reassurance and support to patients undergoing deprescribing
• working closely with other healthcare professionals for a cohesive approach to deprescribing.

Future opportunities

Pharmacists have an increasing role in mental healthcare and mental illness screening.^28,29 By receiving mental health training, pharmacists can enhance their knowledge, skills and use of screening tools (e.g. GDS–15) to support early detection of depression in this population.^1,30

Conclusion

Depression can significantly impact the lives of older Australians, carers and their families. Pharmacists offer valuable education and support, helping older patients understand the risks and benefits of their treatment and monitoring for adverse effects. They can collaborate with patients and other healthcare professionals to ensure appropriate antidepressant use and provide advice on safe deprescribing when required.

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Key points

• Depression should not be considered a normal part of aging.
• Pharmacists can provide a safe environment for patients and carers supporting early detection, treatment optimisation and ongoing review of antidepressant use.
• Deprescribing requires a tailored approach that considers potential withdrawal symptoms and ongoing patient support.

References 

1. 1. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Geronto 1986;5(1–2):165–73. 
   2. Australian Institute of Health and Welfare. Mental Health: prevalence and impact of mental illness. 2024. At: www.aihw.gov.au/mental-health/overview/prevalence-and-impact-of-mental-illness  
   3. Australian Institute of Health and Welfare. Mental health prescriptions – mental health. 2024. At: www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions  
   4. Moncrieff J, Cooper RE, Stockmann T, et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry 2023;28(8):3243–56. 
   5. Blackburn P, Wilkins-Ho M, Wiese B. Depression in older adults: diagnosis and management. BC Med J 2017;59(3):171–7. 
   6. Better Health Channel. Depression and ageing. 2018. At: www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression-and-ageing 
   7. Aziz R, Steffens DC. What are the causes of late-life depression? Psychiatr Clin North Am 2013;36(4):497–516. 
   8. Szymkowicz SM, Gerlach AR, Homiack D, et al. Biological factors influencing depression in later life: role of aging processes and treatment implications. Transl Psychiatry 2023;13(1):160. 
   9. World Health Organisation (WHO). International Statistical Classification of Diseases and Related Health Problems, Eleventh Revision (ICD–11). Geneva; 2019/21. 
   10. National Institute for Health and Care Excellence (NICE). Depression in adults: treatment and management. (NICE Guideline, No. 222.) 2022. At: www.ncbi.nlm.nih.gov/books/NBK583074/ 
   11. Psychotropic Expert Group. eTG Psychotropic Version 8. Melbourne:  Therapeutic Guidelines; 2021. 
   12. Castillo S, Begley KJ, Ryan-Haddad A, et al. Depression in the elderly: a pharmacist’s perspective. Formulary 2013;48:388–94. 
   13. Byers AL, Yaffe K. Depression and risk of developing dementia. Nat Rev Neurol 2011;7(6):323–31. 
   14. Allan CE, Valkanova V, Ebmeier KP. Depression in older people is underdiagnosed. Practitioner 2014;258(1771):19–22,2–3. 
   15. Kok RM, Reynolds CF, 3rd Management of depression in older adults: a review. JAMA 2017;317(20):2114–22. 
   16. Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2021;55(1):7–117. 
   17. Taylor WD. Depression in the elderly. N Engl J Med 2014;371(13):1228–36. 
   18. Noetel M, Sanders T, Gallardo-Gómez D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ 2024;384:e075847. 
   19. Firth J, Marx W, Dash S, et al. The effects of dietary improvement on symptoms of depression and anxiety: a meta-analysis of randomized controlled trials. Psychosom Med 2019;81(3):265–80. 
   20. Hvidberg MF. Are antidepressants effective in the treatment of depression in the elderly? A critical umbrella review on reviews, methods, and future perspectives. Mental Health Science 2023;1(2):85–103. 
   21.  Rossi S, ed. Australian medicines handbook. AMH Aged care companion. 2024.  
   22. Taylor D, Barnes T, Young A. The Maudsley prescribing guidelines in psychiatry. 13th edition. New York: John Wiley & Sons; 2018. 
   23. Kjosavik SR, Gillam MH, Roughead EE. Average duration of treatment with antidepressants among concession card holders in Australia. Aust N Z J Psychiatry 2016;50(12):1180–5. 
   24. Henssler J, Schmidt Y, Schmidt U, et al. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry 2024;11(7):526–35. 
   25. Keks N, Hope J, Keogh S. Switching and stopping antidepressants. Aust Prescr 2016;39(3):76–83. 
   26. Horowitz M, Taylor D. The Maudsley deprescribing guidelines in psychiatry: antidepressants, benzodiazepines, gabapentinoids and z-drugs. Hoboken, NJ: Wiley-Blackwell;2024. 
   27. Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551. 
   28. Ou K, Gide DN, El-Den S, et al. Pharmacist-led screening for mental illness: a systematic review. Res Social Adm Pharm 2024;20(9):828–45. 
   29. Moore C, Powell D, Kyle J. The Role of the community pharmacist in mental health. US Pharmacist 2018;43(11):13–20. 
   30. Gide DN, El-Den S, Lee YLE, et al. Community pharmacists’ acceptability of pharmacist-delivered depression screening for older adults: a qualitative study. Int J Clin Pharm 2023;45(5):1144–52. 

Our authors

Claire O’Reilly BPharm(Hons), PhD, FPS is an Associate Professor at the University of Sydney. She is a pharmacist and mental health researcher and educator.

Duha Gide BPharm is a pharmacist and PhD candidate at the University of Sydney. Her research focuses on pharmacist-delivered depression screening.

Rawa Osman MPharm, MClinTRes, FSHPA, FANZCAP is a clinical pharmacist, a Director at QUM Connect, and the Research and Design Lead for the Quality Use of Medicines Alliance.

Our reviewer

Morna Falkland BPharm

Conflict of interest declaration

Rawa Osman is the Design Lead for the Quality Use of Medicines Alliance, which is leading a national program focused on antidepressants for older people.