Antidepressant Use In Older Adults Research Articles

Antidepressants and the Risk of Ischemic Stroke in Older Adults According to the Degree of Serotonin Reuptake Inhibition: A Retrospective Cohort Study

The effects of serotonin reuptake inhibition induced by antidepressants on ischemic stroke and its pathophysiology remain unclear despite the frequent use of antidepressants and high fatality of ischemic stroke. We estimated the risk of ischemic stroke associated with antidepressant use in older adults according to the degree of serotonin reuptake inhibition. Retrospective cohort study. The cohort consisted of older adult patients who were treated with antidepressants. We estimated the risk of ischemic stroke associated with antidepressant use in older adults according to the degree of serotonin reuptake inhibition using Korea's National Health Insurance System-Senior Cohort. Exposure to antidepressants was categorized by type (strong, intermediate, or weak serotonin reuptake inhibitors [SRIs]) and by the mean prescribed dose per day and treatment duration. The risk for the strong and intermediate SRIs group was compared with that of the weak SRIs group using a Cox proportional hazards regression model. Of 97,411 were weak SRIs users, and 107,152 and 18,783 were users of strong and intermediate SRIs. The risk of ischemic stroke was 1.192- and 1.057-fold higher in strong and intermediate SRI users, respectively than in weak SRI users. Hazard ratios were increased in higher dose and shorter duration user groups. The risk increased 1.753-fold in strong SRI users with anticonvulsants and 1.387-fold in intermediate SRI users with PPIs. The use of strong and intermediate SRIs should be considered carefully in older adult patients, especially when high-dose antidepressants are prescribed even for a short duration.

Trends, Patterns and Associated User Characteristics of Antidepressant Prescriptions in Older Adults: A Nationwide Descriptive Cohort Study in Denmark.

Antidepressant use in older adults (≥65 years) is understudied in large population-based samples, particularly in recent years and regarding user characteristics. We aimed to describe the trends, patterns, and associated user characteristics of all antidepressant prescriptions redeemed by older adults at community pharmacies in Denmark during 2015-2019. This register-based study used a cross-sectional design to characterize antidepressant prescription trends and patterns, and a cohort design to describe user characteristics associated with antidepressant prescription initiation. We used descriptive statistics to characterize trends and patterns, and Poisson regression for analyzing user characteristics. During the years 2015-2019, 17.9% of 1.2 million older adults redeemed 4.84 million antidepressant prescriptions, where 48.5% were selective serotonin reuptake inhibitors, followed by noradrenergic and specific serotonergic antidepressants (26.2%), serotonin-norepinephrine reuptake inhibitors (12.7%), tricyclic antidepressants (11.2%), and others (1.4%). Amitriptyline and nortriptyline, considered potentially inappropriate medications, were among the 10 most frequently redeemed antidepressants. Only 60.5% of prescriptions had a treatment indication of depression. Prescription-proportion trends by drug classes and individual antidepressants remained consistent. A higher incidence rate ratio (IRR) and 95% confidence interval (CI) of initiating antidepressants was associated with female sex (IRR 1.20, 95% CI 1.07-1.34), older age (e.g., 81-85years vs. 65-70years: IRR 1.74, 95% CI 1.44-2.11), living in rural areas (North Denmark vs. Capital Region: IRR 1.31, 95% CI 1.09-1.58), and having somatic and psychiatric diagnoses (e.g., per one psychiatric diagnosis: IRR 1.10, 95% CI 1.05-1.15), while a lower ratio was associated with being non-Western (vs. Danish: IRR 0.50, 95% CI 0.28-0.89) and having hospital contacts for psychiatric treatment (per each contact: IRR 0.96, 95% CI 0.93-1.00). SSRIs were the most commonly redeemed antidepressants, with consistent trends in Danish older adults. Besides clinical conditions, sociodemographics, e.g., sex, age, ethnicity, and place of residence, may influence antidepressant use.

Long-term antidepressant use in a cohort of older people.

Depression is the most common mental health problem in older adults and untreated is associated with significant burden of illness for patients. This study aimed to examine longitudinal patterns of antidepressant use in older adults and determine which factors were associated with changes in use. Adults aged 50 and over, from The Irish Longitudinal Study on Ageing (TILDA), who participated at any one of the four TILDA waves (n=8175) were included in the analysis. Repeated measures latent class analysis (RMLCA) is the model-based approach we used to identify underlying subgroups in a population. We found antidepressant use ranged from 6% to 10%, over a 6-year period. RMLCA identified three distinct classes of antidepressant use. Notably, 6% of older adults were categorised in a 'long-term antidepressant use' class, with consistent use across all four waves, and 6% were categorised in an 'Intermittent/Developing Use' class. We found long-term antidepressant use to be a characteristic of older adults with chronic conditions at baseline of study and striking low uptake of psychological and psychiatric services. These findings provide evidence of the complex presentations of depression with comorbidities in long-term antidepressant users. While prolonged use of antidepressants in an older cohort is often rationalised due to recurrent depression and comorbidities, this study suggests little deprescribing of antidepressants and a need for greater access and provision of psychological services tailored to later life seem necessary improve management of this condition.

Why we need to evaluate long-term antidepressant use in older patients with depression.

In this commentary, we address current clinical practice of long-term antidepressant use in older adults with depression, and recommend improvements. Compared with younger adults, older adults more frequently use antidepressants in the long term, although they may not always benefit from them, and in spite of an increased risk for adverse events. Unfortunately, evaluations of long-term antidepressant use are sparse, especially in older age groups. To prevent and reduce inappropriate long-term use and adverse events, antidepressant use in older age groups should be regularly evaluated.

Antidepressant use and its relationship with current symptoms in a population-based sample of older Australians

BackgroundAustralia has the second highest per capita users of antidepressants globally, and their use is pronounced in older Australians. A better understanding of antidepressant use in older adults is important because the elderly are often prescribed multiple drugs, without review, for long periods. MethodsThis study analysed questionnaire data obtained from the Personality and Total Health through life project. Individual respondent data was linked to Pharmaceutical Benefits Scheme (PBS) records. Associations between self-reported medicine use and current symptoms with antidepressant dispensing were examined. Results1275 participants aged over 65 were included in the final analysis. One hundred and forty-six (11.5%) participants were dispensed an antidepressant within the specified timeframe. Of those, 38.4% self-reported that they use medicine for depression, 12.3% for anxiety, 17.8% for both depression and anxiety, 6.2% for sleep problems and 3.4% for pain. One fifth of those dispensed an antidepressant did not self-report use of the medicine. Being female or reporting symptoms of depression, anxiety or suicidality were significant predictors of being on an antidepressant. Increasing pain severity was also associated with increased likelihood of being on an antidepressant. LimitationsWe have presented a cross-sectional analysis, which can only provide associations between current symptoms and medicine use. We have only assessed respondents who received their scripts with PBS concession, which limits generalizability. ConclusionOur analysis highlights the high use of antidepressants in the elderly for various reasons. Our findings also uncovered a high amount of under-reporting of antidepressant use by respondents.

Multinational comparison of new antidepressant use in older adults: a cohort study

ObjectivesWe used an international pharmacosurveillance network to estimate the rate and characteristics of antidepressant use in older adults in countries with more conservative (UK) and liberal depression guidelines (Canada, USA).SettingElectronic...

Continuing versus New Antidepressant Use in Older Adults: US Prescribing Trends from 2006 to 2015.

Antidepressant use has increased in older adults recently. This study examines the trends of antidepressant prescribing by prescription status (continuing vs. new prescriptions). Data were collected from 2006-2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based outpatient visits. I limited the sample to adults aged 65 or older (n=10,708 unweighted). Using a repeated cross-sectional design with survey sampling techniques, prevalence rates of antidepressant prescriptions were estimated by prescription status. Stratified analyses were also performed by key variables (e.g., age, gender, and race/ethnicity). Continuing antidepressant prescriptions increased over time significantly (OR=1.07; 95% CI, 1.03-1.11), and no temporal trend was found in new antidepressant prescriptions. In stratified analyses, the increasing trends of continuing antidepressant prescriptions were pronounced in visits to primary care physicians (OR=1.06; 95% CI, 1.01-1.12). Increasing antidepressant prescribing trends were found in continuing prescriptions. Continued antidepressant prescribing among older adults should be monitored for appropriate use.

Evaluating the risk of QTc prolongation associated with antidepressant use in older adults: a review of the evidence.

Antidepressants are widely used medications for a range of medical conditions such as mood disorders and chronic pain in older adults. A vast body of evidence exists concerning the risks of QT interval prolongation associated with these agents and healthcare providers should critically evaluate the potential for QT prolongation when selecting antidepressant agents. Long QT syndrome is a disorder of myocardial repolarization that manifests as a prolonged QT interval on an electrocardiogram (ECG) and has been demonstrated to increase with age. The objective of this review is to present and evaluate existing literature regarding the risk of QT prolongation in older adults, age 60 years and older, and discuss the implications for clinical practice. A PubMed search was conducted to identify studies evaluating the QT prolonging effects of antidepressant medications and publications were chosen based on pertinent criteria. Depending on the antidepressant agent and patient-specific factors, clinicians should assess and monitor electrolytes and EGCs to evaluate the risks and benefits for older adults receiving agents known to prolong the QT interval.

Determinants of follow-up care associated with incident antidepressant use in older adults

ObjectivesTo determine the proportion of older adults receiving guideline concordant antidepressant therapy and to determine patient, prescriber and organizational factors associated with adequate antidepressant therapy.MethodsThe study included secondary analyses of data collected in the Étude sur la Santé des Aînés (ESA) Services study on older adults recruited while consulting in primary care clinics in one of the largest health regions of the province of Québec. Antidepressant users (n = 349) were identified from information collected from the Régie de l’Assurance Maladie du Québec (RAMQ) pharmaceutical database which holds information on all drugs dispensed to all residents covered under the public drug plan. Adequacy of antidepressant treatment was measured using three criteria: adequacy of daily dose; length of prescription (≥455 days); and ≥3 visits to the antidepressant-prescribing physician in the first 3 months after initiation of therapy. Multivariate logistic regression analyses were used to study antidepressant treatment adequacy as a function of individual, provider and healthcare system factors.ResultsAmong the antidepressant users, 44% received an adequate antidepressant treatment filling all three criteria. None of the factors studied were associated with the probability of receiving adequate treatment filling all three criteria. Psychological distress was associated with having an adequate number of visits in the 3 months following initiation. Males and those living in a metropolitan and urban area were less likely to receive an adequate dose.ConclusionsFuture research should consider factors associated with perceived effectiveness and patient treatment preferences that may explain receipt of adequate antidepressant treatment in older adults.

New antidepressant use in older adults: a Canadian population-based study (1997–2013)

ABSTRACTObjective: There has been much attention on appropriate prescribing in older adults in recent years. Recent guidelines favor the use of newer antidepressants over older agents based on their safety profile in this population. This study aimed to examine whether there has been a decline in older antidepressants and an increase in newer antidepressants used by older adults.Method: A retrospective cross-sectional study using administrative databases examined the annual incidence of antidepressant use (per 1000) of community-dwelling adults ≥60 years old between 1997/1998 and 2012/2013 in Manitoba, Canada.Results: The population of Manitoba ≥60 years increased by 25.6% from 188,296 to 236,569 from 1997/1998 to 2012/2013. New antidepressant use peaked to 45.9 per 1000 in 1999/2000, and then decreased steadily to 30.5 per 1000 in 2012/2013 (p < 0.0001). Incident amitriptyline use was high but declined from 15.5 to 7.4 per 1000 (p < 0.001). An increase in incident trazodone, mirtazapine, and venlafaxine use was observed (p < 0.001).Conclusions: There has been an overall decrease in the annual incidence of antidepressant users in older adults over the last 16 years, with a marked decline in new amitriptyline use and an increase in the incidence of newer agents.

Antidepressant use and functional limitations in U.S. older adults

ObjectiveThe upsurge in prevalence and long-term use of antidepressants among older adults might have profound health implications beyond depressive symptom management. This study examined the relationship between antidepressant use and functional limitation onset in U.S. older adults. MethodsStudy sample came from 2006 and 2008 waves of the Health and Retirement Study, in combination with data from 2005 and 2007 Prescription Drug Study. Self-reported antidepressant use was identified based on the therapeutic classification of Cerner Multum's Lexicon. Functional limitations were classified into those pertaining to physical mobility, large muscle function, activities of daily living, gross motor function, fine motor function, and instrumental activities of daily living. Cox proportional hazard models were performed to assess the effects of antidepressant use on future functional limitation onset by limitation category, antidepressant type, and length of use, adjusted by depression status and other individual characteristics. ResultsAntidepressant use for one year and longer was associated with an increase in the risk of functional limitation by 8% (95% confidence interval=4%–12%), whereas the relationship between antidepressant use less than a year and function limitation was statistically nonsignificant. Antidepressant use was associated with an increase in the risk of functional limitation by 8% (3%–13%) among currently nondepressed participants but not currently depressed participants. ConclusionLong-term antidepressant use in older adults should be prudently evaluated and regularly monitored to reduce the risk of functional limitation. Future research is warranted to examine the health consequences of extended and/or off-label antidepressant use in absence of depressive symptoms.

Major depressive disorder in older adults: benefits and hazards of prolonged treatment.

Antidepressants have been shown to reduce the risk of depression recurrence in adults, justifying prolonged antidepressant maintenance therapy for most if not all patients. However, older depressed adults may be at increased risk for antidepressant adverse effects. This article discusses the benefits and hazards of continued treatment in elderly depressed patients, and indicates which patients should and should not receive maintenance phase antidepressants. Most clinical trials conducted so far suggest that prolonged antidepressant use in older adults is efficacious to reduce recurrence rates. The benefits of prolonged antidepressant use may not be restricted to preventing recurrence but also include preservation of overall well-being, social functioning, reduced mortality risk from medical disorders, and reduced risk of dementia. Although generally safe, the prolonged use of antidepressants has been associated with higher risk of osteopenia/osteoporosis (in particular the selective serotonin reuptake inhibitors) and cardiovascular toxicity (tricyclic antidepressants). Fewer data are available for special populations, like those with multiple medical comorbidities or those with dementia; thus, the benefits of prolonged antidepressant use are not clear in these individuals.

The relationship between syncope, depression and anti-depressant use in older adults

syncope is a common problem which increases in older age groups. In syncope clinics, patients who are depressed have higher rates of unexplained syncope and higher rates of recurrent syncope. : we aim to examine the rates of depression in older patients reporting syncope and the effect of anti-depressants (ADs) on the rates of syncope. : epidemiological, point-prevalence study. : data came from the Irish Longitudinal Study on Ageing, which includes 8,175 adults aged 50 and older, living in the community in Ireland. : the Centre for Epidemiological Studies Depression scale was used to assess levels of depression. Multinomial regression was used to analyse the data with a P-value of <0.05 determining significance. : 7,993 participants aged 50 and older were included, and of these 349 reported at least one syncopal episode in the last year. Prevalence of syncope was 4.4%. After controlling for participant characteristics and general health, those with severe depression had a greater risk of single and multiple syncopal events (relative risk ratios [RRR]: 2.78 and 2.84, respectively, P < 0.050) and participants treated with tricyclic anti-depressants (TCAs) were also at greater risk for single and multiple syncopal episode in the last year (RRR: 2.31, P = 0.062; RRR: 2.95, P < 0.05). : this study demonstrates an increased risk of syncope in patients with depression, with higher rates of syncope reported with increasing severity of depression. Treatment with TCAs increases both the risk and frequency of syncope in the community. Depression is a potentially modifiable risk factor for syncope but treatment options need to be tailored in the older patient population.

Datapoints: Prevalence of QT Prolongation Among Veterans With Severe Mental Illness

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Prevalence of QT Prolongation Among Veterans With Severe Mental IllnessEileen M. Stock, Ph.D., Laurel A. Copeland, Ph.D., M.P.H., Ruth L. Bush, M.D., M.P.H., and John E. Zeber, Ph.D., M.H.A.Eileen M. StockSearch for more papers by this author, Ph.D., Laurel A. CopelandSearch for more papers by this author, Ph.D., M.P.H., Ruth L. BushSearch for more papers by this author, M.D., M.P.H., and John E. ZeberSearch for more papers by this author, Ph.D., M.H.A.Published Online:1 Oct 2013https://doi.org/10.1176/appi.ps.201300212AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The QT interval refers to the time required for the heart to repolarize after ventricular depolarization. The U.S. Food and Drug Administration (FDA) has issued Drug Safety Communications on drugs associated with QT prolongation and fatal ventricular arrhythmias. Antidepressants received attention after the 2011 FDA communication on citalopram, often prescribed off-label for posttraumatic stress disorder (PTSD).Aggregated data (diagnosis codes and outpatient prescriptions) were examined for all Veterans Health Administration (VHA) patients treated between October 2005 and September 2009. Among 7.1 million patients, 1,224 had a diagnosis of QT prolongation (ICD−9 code 426.82). Chi square tests assessed the association of prior-year severe mental illness with QT prolongation.Among patients with QT prolongation, the mean age was similar to that for all VHA patients (about 61 years). However, rates of severe mental illness were higher (28% versus 12% for all VHA patients). Risk factors for QT prolongation included gender (35 females versus 16 males per 100,000) and African-American race (31 per 100,000 versus 20 for all patients). QT prolongation among patients with severe mental illness was nearly triple that among patients without severe mental illness (40 per 100,000 versus 14), and it was elevated for specific illnesses (Figure 1). Citalopram was prescribed to 8% of the study sample, more commonly for patients with PTSD (16%) or major depression (21%). Receipt of any drug associated with QT prolongation varied by illness: without severe mental illness, 14%; schizophrenia, 20%; PTSD, 24%; and major depression, 28%.Figure 1 Prevalence of QT prolongation among Veterans Health Administration patients, October 2005 to September 2009aa95% confidence intervals reported in parentheses. PTSD, posttraumatic stress disorderFindings highlight the need to reevaluate types and combinations of medications that may potentiate heart disease or death among patients with severe mental illness. A study limitation is that the data precede the 2011–2012 FDA Drug Safety Communications, and citalopram use may change in the wake of the warnings.Except for Dr. Bush, the authors are affiliated with the Center for Applied Health Research, which is jointly sponsored by the Central Texas Veterans Health Care System and Scott & White Healthcare, 2102 Birdcreek Dr., Temple, TX 76502 (e-mail: eileen.[email protected]gov). All authors are affiliated with Texas A&M Health Science Center, Bryan, Texas. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column.Acknowledgments and disclosuresThe study was supported by grant IIR-09-335 from VA Health Services Research and Development. The views do not necessarily represent those of the Department of Veterans Affairs.The authors report no competing interests. FiguresReferencesCited byDetailsCited byPsychotropic Pharmacotherapy Associated With QT Prolongation Among Veterans With Posttraumatic Stress Disorder11 April 2018 | Annals of Pharmacotherapy, Vol. 52, No. 9Evaluating the risk of QTc prolongation associated with antidepressant use in older adults: a review of the evidence4 May 2018 | Therapeutic Advances in Drug Safety, Vol. 9, No. 6 Volume 64Issue 10 October 2013Pages 942-942 Metrics Acknowledgments and disclosuresThe study was supported by grant IIR-09-335 from VA Health Services Research and Development. The views do not necessarily represent those of the Department of Veterans Affairs.The authors report no competing interests.PDF download History Published online 1 October 2013 Published in print 1 October 2013

Aging and Clinical Pharmacology: Implications for Antidepressants

The elderly frequently have changes in pharmacokinetics, sensitivity to medications, homeostatic reserve (ability to tolerate physiological challenges), exposure to multiple medications, and adherence. All of these age-associated factors can potentially influence total exposure to medication, adverse effects, and subsequent treatment outcome. Most clinical trials are performed with healthy, younger adults. Extrapolating the results of these trials to the elderly may be inappropriate, particularly for the antidepressant treatment of depression. The authors review these age-associated differences and discuss their implications for antidepressant use in older adults.