Management of Treatment Resistant Depression in the Elderly

Clinical Assessment and Treatment Strategies

Premiere Date: January 20, 2020
Expiration Date: July 20, 2021

This activity offers CE credits for:

1. Physicians (CME)
2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

The goal of this activity is to provide an understanding of treatment resistant depression (TRD) in elderly patients.

LEARNING OBJECTIVES

After engaging with the content of this CME activity, you should be better prepared to:

• Differentiate the presentation of TRD in older patients

• Describe medical comorbidities in older patients with TRD

• Explain treatment strategies for elderly patients with TRD: switching versus augmentation

• Describe FDA approved pharmacological agents for treating depression and TRD

TARGET AUDIENCE

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership Physicians’ Education Resource®, LLC and Psychiatric Times. Physicians’ Education Resource®, LLC is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource®, LLC. No commercial support was received.

OFF-LABEL DISCLOSURE/DISCLAIMER

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

FACULTY, STAFF, AND PLANNERS’ DISCLOSURES

Fred Liu, MD; Awais Aftab, MD; and the staff of Physicians’ Education Resource®, LLC and Psychiatric Times have no relevant financial relationships with commercial interests.

Jonathan Alpert, MD (peer, content reviewer): grants received from the Patient-Centered Outcomes Research Institute; research support from Otsuka Pharmaceuticals and Axsome Therapeutics.

For content-related questions, please email us at [email protected]; for questions concerning the accreditation of this CME activity or how to claim credit, please contact [email protected] and include “Management of Treatment Resistant Depression in the Elderly: Clinical Assessment and Treatment Strategies” in the subject line.

HOW TO CLAIM CREDIT

Once you have read the article, please use the following URL to evaluate and request credit: https://education.gotoper.com/activity/ptcme20jan.

If you do not already have an account with PER,® you will be prompted to create one. You must have an account to evaluate and request credit for this activity.

Disclosures: 

Dr Liu is a fourth-year Psychiatry Resident, University of California, San Diego, CA. Dr Aftab is an Attending Psychiatrist, Northcoast Behavioral Healthcare, Ohio Department of Mental Health and Addiction Services, Northfield, OH.

References: 

1. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry.1999;174:307-311.

2. Wragg RE, Jeste DV. Overview of depression and psychosis in Alzheimer disease. Am J Psychiatry. 1989;146:577-587.

3. Alpert JE, Fava M. Nutrition and depression: the role of folate. Nutrition Rev. 1997;55:145-149.

4. Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322:622–631.

5. Mazeh D, Shahal B, Aviv A, et al. A randomized, single-blind, comparison of venlafaxine with paroxetine in elderly patients suffering from resistant depression. Int Clin Psychopharm. 2007;22:371-375.

6. Karp JF, Whyte EM, Lenze EJ, et al. Rescue pharmacotherapy with duloxetine for selective serotonin reuptake inhibitor nonresponders in late-life depression: outcome and tolerability. J Clin Psychiatry. 2008;69:457-463.

7. Kim T, Xu C, Amsterdam JD. Relative effectiveness of tricyclic antidepressant versus monoamine oxidase inhibitor monotherapy for treatment-resistant depression. J Affect Disord. 2019;250:199-203.

8. Lenze EJ, Mulsant BH, Blumberger DM, et al. Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life: a randomised, double-blind, placebo-controlled trial. Lancet. 2015;386:2404-2412.

9. Kok RM, Vink D, Heeren TJ, Nolen WA. Lithium augmentation compared with phenelzine in treatment-resistant depression in the elderly: an open, randomized, controlled trial. J Clin Psychiatry. 2007;68:1177-1185.

10. Buspavanich P, Behr J, Stamm T, et al. Treatment response of lithium augmentation in geriatric compared to non-geriatric patients with treatment-resistant depression. J Affect Disord. 2019;251:136-140.

11. Nierenberg AA, Fava M, Trivedi MH, et al. A comparison of lithium and T 3 augmentation following two failed medication treatments for depression: a STAR* D report. Am J Psychiatry. 2006;163:1519-1530.

12. Lavretsky H, Reinlieb M, St Cyr N, et al. Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial. Am J Psychiatry. 2015;172:561-569.

13. Han Y, Chen J, Zou D, et al. Efficacy of ketamine in the rapid treatment of major depressive disorder: a meta-analysis of randomized, double-blind, placebo-controlled studies. Neuropsych Dis Treat. 2016;12:2859-2867.

14. Bahr R, Lopez A, Rey JA. Intranasal esketamine (Spravato™) for use in treatment-resistant depression in conjunction with an oral antidepressant. P&T. 2019;44:340-375.

15. Omranifard V, Shirzadi E, Samandari S, et al. Memantine add on to citalopram in elderly patients with depression:a double-blind placebo-controlled study. J Res Med Sci .2014;19:525-530.

16. Lenze EJ, Skidmore ER, Begley AE, et al. Memantine for late-life depression and apathy after a disabling medical event: a 12-week, double-blind placebo-controlled pilot study. Int J Geriatr Psychiatry. 2012;27:974-980.

17. Bae JH, Kim G. Systematic review and meta-analysis of omega-3-fatty acids in elderly patients with depression. Nutrit Res. 2018;50:1-9.

18. Nolan RM Heeren TJ. Outcome of late-life depression after 3 years of sequential treatment. Acta Psychiatrica Scand. 2009;119:274-281.

19. Huang AX, Delucchi K, Dunn LB, Nelson JC. A systematic review and meta-analysis of psychotherapy for late-life depression. Am J Geriatr Psychiatry. 2015;23:261-273.

20. Kok RM, Reynolds CF. Management of depression in older adults: a review. JAMA. 2017;317:2114-2122.

21. Trevizol AP, Goldberger KW, Mulsant BH, et al. Unilateral and bilateral repetitive transcranial magnetic stimulation for treatment-resistant late-life depression. Int J Geriatr Psychiatry. 2019;34:822-827.

22. Dols A, Bouckaert F, Sienaert P, et al: Early- and late-onset depression in late life: a prospective study on clinical and structural brain characteristics and response to electroconvulsive therapy. Am J Geriatr Psychiatry. 2017;25:178-189.

23. Cristancho P, Lenard E, Lenze EJ, et al. Optimizing outcomes of treatment resistant depression in older adults (OPTIMUM): study design and treatment characteristics of the first 396 participants randomized. Am J Geriatr Psychiatry. 2019;27:1138-1152.