Recent developments in antidepressant therapy in special populations.

Major depressive disorder (MDD) in the elderly, children, and patients with unstable angina or acute myocardial infarction (MI) is a serious disorder. In elderly patients, where major depression is often overlooked and may have a significant impact on the quality of life, the goal of therapy is full remission. Selective serotonin reuptake inhibitors (SSRIs) have the most favorable combination of efficacy and side-effect profile for the elderly with MDD, regardless of the presence of medical comorbidities. Although the dual agent venlafaxine has been proposed as an alternative agent for older patients who are either nonresponders or partial responders to SSRIs, the frail elderly may be particularly vulnerable to its side effects. Most elderly patients have a relapse of depression when antidepressants are stopped; depression subsides when antidepressants are resumed. Because recent evidence suggests that the dosage of an antidepressant that achieves remission in the elderly does not always protect against recurrence, in addition to long-term maintenance, consideration should be given to increased dosage. Patients with major depression and either unstable angina or acute MI should be identified and considered for antidepressant treatment. Findings from the recent Sertraline Anti-Depressant Heart Attack Randomized Trial suggest that SSRIs may have antiplatelet and endothelium-protective properties that may benefit patients with depression and comorbid coronary artery disease and ischemic stroke. Concern regarding the safety of SSRIs in children has prompted new studies. Evidence suggests that the risks of SSRIs, except for fluoxetine, might outweigh benefits in the treatment of depression in children and adolescents.