Use of antidepressants in older patients with co-morbid medical conditions: guidance from studies of depression in somatic illness.

Advanced age and medical complexity are characteristics not often associated with participation in randomised, placebo-controlled trials of antidepressants. Thus, evidence for the efficacy of antidepressant treatment among typical seniors with somatic illness and advanced age is scant. Furthermore, there appears to be no clear empirically based delineation between depressive symptoms and depressive disorders among very old, physically ill adults. The increasing numbers of antidepressants and adjunctive medications add to the practitioner's perplexity when confronted with a very old, very depressed patient. Nonetheless, a growing body of evidence from antidepressant studies in the context of age-related somatic illnesses allows reasonable inferences to guide diagnosis and treatment. Once the practitioner and patient agree upon an antidepressant trial, the benefits of prescribed medication should be assessed within the first days rather than first weeks of treatment. The patient and practitioner should expect to escalate the antidepressant to the established therapeutic range rather than seek the lowest dose that is effective. Patients who experience no benefit whatsoever within the first weeks of treatment despite being within the therapeutic range should be offered an alternative promptly. With the results of studies of depression in co-morbid disorders and analyses of treatment response trajectory, the practitioner can be assured that advanced age, physical illness and depression need not go hand in hand.