Pharmacotherapy of depression in the elderly: Achieving and maintaining optimal outcomes

The treatment of major depressive disorder (MDD) should be viewed longitudinally. MDD treatment encompasses acute, continuation, and maintenance phases, each with different goals. Acute treatment aims to bring patients to symptomatic remission and, eventually, to functional recovery, while continuation and maintenance treatment aim to consolidate and prolong recovery and to prevent relapse and recurrence, respectively. Continuation therapy is recommended for all older adults with late-life depression for 6-12 months after remission. Attention should also be paid to whether the patient has a history of recurrent MDD, which would indicate that maintenance treatment should be continued for >1 year. Patients should receive the dose of medicine during continuation and maintenance therapy that was effective during the acute phase in order to minimize the burden of residual symptoms and the risk of relapse and recurrence. Those patients who do not evidence a satisfactory response (after a reasonable trial) to antidepressant treatment are considered treatment resistant. A substantial number of elderly patients who have treatment-resistant MDD may benefit from switching to another antidepressant, the addition of another antidepressant (combination therapy) or agent (augmentation), psychotherapy, or electroconvulsive therapy. Psychiatrists can help guide clinicians outside the field of mental health in the care of these patients.