Frank Christopher
St Mary's of the Lake Hospital, 340 Union St, Kingston, ON K7L 5A2.
Can Fam Physician. 2014 Feb;60(2):121-6.
To discuss pharmacologic treatment of depression in the elderly, including choice of antidepressants, titration of dose, monitoring of response and side effects, and treatment of unresponsive cases.
The 2006 Canadian Coalition for Seniors' Mental Health guideline on the assessment and treatment of depression was used as a primary source. To identify articles published since the guideline, MEDLINE was searched from 2007 to 2012 using the terms depression, treatment, drug therapy, and elderly.
The goal of treatment should be remission of symptoms. Improvement of symptoms can be monitored by identifying patient goals or by use of a clinical tool such as the Patient Health Questionnaire-9. Treatment should be considered in 3 phases: an acute treatment phase to achieve remission of symptoms, a continuation phase to prevent recurrence of the same episode of illness (relapse), and a maintenance (prophylaxis) phase to prevent future episodes (recurrence). Initial dosing should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases. Common side effects of medications include falls, nausea, dizziness, headaches, and, less commonly, hyponatremia and QT interval changes. Strategies for switching or augmenting antidepressants are discussed. Older patients should be treated for at least a year from when clinical improvement is noted, and those with recurrent depression or severe symptoms should continue treatment indefinitely. Treatment of specific situations such as severe depression or depression with psychosis is discussed, including the use of electroconvulsive therapy. Criteria for referral to geriatric psychiatry are provided; however, many family physicians do not have easy access to this resource or to other nonpharmacologic clinical strategies.
The effectiveness of pharmacologic treatment of depression is not substantially affected by age. Identification of depression, choice of appropriate treatment, titration of medications, monitoring of side effects, and adequate duration of treatment will improve outcomes for older patients.
探讨老年抑郁症的药物治疗，包括抗抑郁药的选择、剂量滴定、疗效及副作用监测，以及对无反应病例的治疗。
以2006年加拿大老年人心理健康联盟关于抑郁症评估与治疗的指南作为主要信息源。为查找该指南发布后的文章，于2007年至2012年期间在MEDLINE数据库中使用“抑郁症”“治疗”“药物治疗”及“老年人”等检索词进行检索。
治疗目标应为症状缓解。可通过明确患者目标或使用如患者健康问卷-9等临床工具来监测症状改善情况。治疗应分三个阶段进行：急性治疗阶段以实现症状缓解，巩固治疗阶段以预防同一疾病发作的复发（再发），维持（预防）治疗阶段以预防未来发作（复发）。初始剂量应为成人常用起始剂量的一半，并定期滴定，直至患者有反应、达到最大剂量或出现副作用限制进一步增加剂量。药物的常见副作用包括跌倒、恶心、头晕、头痛，较少见的有低钠血症和QT间期改变。文中讨论了更换或增加抗抑郁药的策略。老年患者自临床症状改善起应至少治疗一年，对于复发性抑郁症或症状严重的患者应无限期持续治疗。文中讨论了如重度抑郁症或伴有精神病性症状的抑郁症等特殊情况的治疗，包括使用电休克治疗。提供了转诊至老年精神病学的标准；然而，许多家庭医生难以获得该资源或其他非药物临床策略。
抑郁症药物治疗的有效性不受年龄的显著影响。识别抑郁症、选择合适的治疗方法、滴定药物剂量、监测副作用以及给予足够的治疗时长，将改善老年患者的治疗效果。
