Table 1.
Antidepressant Medication in Older Adults.*
| Medication | Starting Daily Dose | Target Daily Dose | Comments |
|---|---|---|---|
| Selective serotonin-reuptake inhibitors (SSRIs) | As a class, SSRIs should be used with caution in patients with a history of falls21 | ||
| Citalopram | 10–20 mg | 20 mg | FDA recommends 20 mg as maximal daily dose in patients >60 yr of age owing to risk of prolongation of the QT interval on ECG |
| Escitalopram | 10 mg | 10–20 mg | Possible risk of QT prolongation22 |
| Fluoxetine | 10–20 mg | 10–40 mg | Drug interaction based on both CYP450 and protein binding; lack of QT prolongation in most studies22 |
| Fluvoxamine | — | 50–300 mg | Dose reduction recommended in older adults23; lack of QT prolongation in most studies22 |
| Paroxetine | 10–20 mg | 20–40 mg | Some concern about use in older adults owing to anticholinergic effects; lack of clinically significant QTc prolongation in all studies22 |
| Sertraline | 25–50 mg | 50–200 mg | Has mild dopaminergic activity, which may help with motivation; lack of QT prolongation in most studies22 |
| Serotonin-norepinephrine reuptake inhibitors | |||
| Desvenlafaxine | — | 50 mg | 25-mg dose is available for frail older adults or those with renal impairment |
| Duloxetine | — | 60 mg | May help with chronic pain; may increase fall risk among older adults21 |
| Levomilnacipran | 20 mg | 40–120 mg | Limited evidence for use in late-life depression |
| Venlafaxine XR | 75 mg | 75–300 mg | At doses >150 mg may have more noradrenergic effects |
| Other nontricyclic antidepressants | |||
| Bupropion SR | 100–150 mg | 150–400 mg | Avoid in patients with history of seizures and psychosis |
| Bupropion XL | 150 mg | 150–450 mg | Avoid in patients with history of seizures and psychosis |
| Mirtazapine | 7.5–15.0 mg | 15–45 mg | Good evidence for mirtazapine monotherapy in older adults with depression24; may increase risk of falls21 |
| Trazodone | 25–50 mg | 50–300 mg | Sedating effects often preclude use as monotherapy; may increase risk of falls21 |
| Vilazodone | 10 mg | 20–40 mg | Low potential for drug-drug interactions |
| Vortioxetine | 5 mg | 5–20 mg | Low potential for drug-drug interactions; limited data in patients ≥65 yr of age |
| Tricyclic antidepressants | |||
| Desipramine | 50 mg | Depends on plasma level | Monitor ECG; target plasma levels to achieve plasma level of 200–400 ng per millilter; monitor closely for anticholinergic side effects |
| Nortriptyline | 25 mg | Depends on plasma level | Monitor ECG; target plasma levels to achieve plasma level of 50–150 ng per millilter; monitor closely for anticholinergic side effects |
| Augmenting agents | |||
| Aripiprizole | 2.5 mg | 5–15 mg | Aripiprazole augmentation shown to be more efficacious with respect to psychological well-being than a switch to bupropion25 |
| Lithium | 150–300 mg | Depends on plasma level; target, 0.6 mmol per liter25 | Lithium augmentation efficacy for unipolar depression is well-documented; monitor renal function and be alert to potential drug-drug interactions |
| Methylphenidate | 5 mg | 5–40 mg | Combination of citalopram and methylphenidate shown to be superior in efficacy for major depression as compared with monotherapy with either agent26 |
| Pramipexole | 0.125 mg | 0.25–2.0 mg | May be helpful in depression associated with Parkinson’s disease; dose range for monotherapy or as augmenting agent in major depression is not well- established |
| Quetiapine SR | 50–150 mg | 100–300 mg | Limited data on use of quetiapine as an augmenting agent with SSRIs, tricyclic antidepressants, and atypical antidepressants27 |
*
CYP450 denotes cytochrome P450, ECG electrocardiogram, FDA Food and Drug Administration, QTc corrected QT interval, SR sustained release, XL extra-long extended release, and XR extended release.