For treatment-resistant depression, two medications may be better than one

Treating stubborn cases of depression in older adults is challenging and often requires multiple treatments, says UConn Health psychiatrist David Steffens. His criticism in the New England Journal of Medicine gives doctors evidence-based advice on how to help depressed patients who don’t feel better on the first or second try.

Depression is common among adults, with about 5% suffering from it worldwide, according to the World Health Organization. Treatment-resistant depression, when a person with depression does not respond to two different treatments each for eight weeks, is also quite common.

“Estimates vary widely that 20 to 70 percent of people don’t respond to the first two treatments,” says David Steffens, past president of the American Association of Geriatric Psychiatry and current chair of psychiatry at the University School of Medicine. UConn. “The general response rate to initial treatment is 30 to 40 percent, so many people don’t respond completely at first” and have to try multiple medications and psychotherapies before finding a treatment that works, Steffens says.

Steffens, who works primarily with people over 60, describes how doctors must carefully assess the basic symptoms of depression to be able to track improvement. The standard scale, the Patient Health Questionnaire-9 (PHQ-9), ranges from 0 to 27, assessing a person’s level of depression based on their responses to questions such as low mood, decreased energy and loss of interest in previously enjoyable activities. activities. Higher scores indicate more severe depression.

People can be reassessed with the PHQ-9 a few weeks after starting treatment to get an objective measure of how their symptoms are changing. Sometimes individuals respond partially to a medication but still consider themselves depressed. These people will need to have their medications adjusted and some will benefit from the addition of psychotherapy.

Steffens also recommends reviewing a patient’s medical history to identify other health conditions that may be contributing to depression. For example, older people usually suffer from diseases such as high blood pressure and metabolic diseases such as heart disease or diabetes. These conditions can cause or exacerbate symptoms of depression, and helping patients control these conditions can help them feel better overall.

The nature of a patient’s symptoms should also influence the choice of antidepressant medications. Some depressed patients experience insomnia and agitation; the choice of medications for them would be different than for a patient who sleeps almost all the time and has difficulty motivating themselves to do anything.

Other depressed people suffer from chronic pain, and antidepressant medications known to reduce pain would likely be worth a try for these patients. Coping strategies to manage pain are also helpful.

Steffens also notes that taking two different antidepressants together often helps people with more severe forms of treatment-resistant depression. With slow but steady dose increases, older adults can generally tolerate the same therapeutic dose of antidepressants as younger adults. Clinicians should therefore not be afraid to combine two medications or increase the dose if warranted.

“Depression is really a serious problem in older adults, not only because of the way it affects mood and interest in being in the world, but also because of how it can greatly affect the person in whole” by affecting how they manage their health issues, particularly vascular conditions, Steffens says. Depression can increase the risk of heart disease in general and increases the likelihood of death from a heart attack. But proper treatment can make all the difference.

“Depression is not a normal part of aging. Nothing could be further from the truth.”