Treatment of depression in older adults beyond fluoxetine

Abstract

This review aimed to discuss the importance of the comprehensive treatment of depression among older adults in Brazil. The abuse of selective serotonin reuptake inhibitors, including fluoxetine hydrochloride, as antidepressants has been considered a serious public health problem, particularly among older adults. Despite the consensus on the need for a comprehensive treatment of depression in this population, Brazil is still unprepared. The interface between pharmacotherapy and psychotherapy is limited due to the lack of healthcare services, specialized professionals, and effective healthcare planning. Fluoxetine has been used among older adults as an all-purpose drug for the treatment of depressive disorders because of psychosocial adversities, lack of social support, and limited access to adequate healthcare services for the treatment of this disorder. Preparing health professionals is a sine qua non for the reversal of the age pyramid, but this is not happening yet.

INTRODUCTION

Human aging is a natural process characterized by increasing vulnerability. Brazilian public policies have been receiving support from research groups to gain a better understanding of this problem. ^{8 , 9} This support involves evaluating strategies that are essential for the improvement and consolidation of healthcare programs and even for the reporting of possible damage caused by certain technologies in health. The demographic and epidemiological transition imposes challenges to public health, aging, and the training of primary healthcare professionals for the diagnosis, maintenance, and treatment of older adults with depression.

This article discusses the importance of comprehensive treatment for depression among older adults in Brazil other than using pharmacotherapy, which mainly involves selective serotonin reuptake inhibitors (SSRI). It focuses on the importance of professional training and improvement of healthcare policies for this specific population group.

DEPRESSION IN OLDER ADULTS

As with other mental disorders, depression in older adults is due to biological, psychological, and social factors. The depressive symptoms in this age group are more common in women or when the symptoms are associated with Alzheimer’s disease and constitute predictors for the development of dementia. ¹ The disease usually manifests in individuals living with psychosocial adversities, such as breaking of family ties, loss of social contacts, previous history of depression, stressful life events, widowhood, living in clinics or nursing homes, low-income status, and lack of social support. Moreover, analysis of the incidence of symptoms in older age groups indicates that morbidity and frailty are the most important factors in the etiology of this disease. ^{1 , 11}

The treatment of depression in older adults should consider all the factors involved in the disorder, i.e., the treatment should involve a combination of psychotherapy and pharmacotherapy. There is a consensus that neither of these therapies alone is effective for the remission of depression in older adults. ¹³

MEDICAL THERAPY

With regard to pharmacotherapy, the use of antidepressants among older adults has evolved over the years. ¹³ However, since the introduction of SSRI to the market in the 1980s, a preference has developed for them. Although they are metabolized by cytochrome P450 isoenzymes (which increase the possibility of drug interactions with other drugs metabolized by the same route), they have a lower risk of adverse reactions compared with the other antidepressants previously available in primary care health services, including tricyclic drugs and monoamine oxidase inhibitors. ⁴

In addition, because of variations in dose, duration of treatment, and the low incidence of adverse effects, SSRI are the drug of choice for the treatment of patients with depression. The most important active ingredients in these drugs are sertraline hydrochloride, escitalopram, and venlafaxine; however, fluoxetine hydrochloride is the most commonly used at present. ¹³

In Brazil, the National List of Essential Medicines ^a lists only fluoxetine hydrochloride within this class of antidepressants. From 2005 to 2009, the sales of antidepressants increased by 44.8% from R$647.7 million to R$976.9 million. ^b With regard to fluoxetine hydrochloride, in 2009, a defined daily dose (DDD) of 2.62 mg per 1,000 inhabitants per day was established in Brazil. Santa Catarina, Rio Grande do Sul, Federal District, Paraná, and Goiás ^b were the five states with the largest per capita consumers.

PHARMACOTHERAPY

The introduction and maintenance of pharmacotherapy among older adults have increased. The number of fluoxetine prescriptions is increasing annually in this population group, even among the very old. ¹⁰ In addition, the use of fluoxetine is increasingly prevalent among older adults with characteristics common to those who abuse benzodiazepines, i.e., women who report anxiety complaints, loneliness, and lack of family or social support. As previously observed for benzodiazepines, pressure from the pharmaceutical industry, associated with the low cost of the drug, positive reinforcement of chronic users, wrong indication, and a lack of academic preparation of professionals who interact with the patients, result in excessive drug prescription and dispensing. ¹²

This is the context into which “another drug in the polypharmacy of older adults” ⁷ is being incorporated. The main indications for treatment with SSRI in older patients should be reviewed, as was done with the use of benzodiazepines. ¹² The current discussions focus on who prescribes, how it is prescribed, for what reasons, and how it is dispensed. Moreover, even in developed countries, it is known that the type of treatment for depression among older adults depends significantly on socioeconomic factors. In addition, the conditions offered by the healthcare systems are obsolete. ⁶

General practitioners claim that older patients do not need to seek specialized care in mental health centers because these professionals are confident in their diagnosis and in the pharmacotherapy strategy adopted, and they are the ones who prescribe most psychotropic drugs. For this reason, with the dissemination of new and safer treatments, the number of diagnoses of depression has increased significantly among older adults, who are rarely evaluated from the perspective of geriatric diagnostic criteria. Furthermore, these patients are diagnosed with disorders other than depressive disorders during treatment with SSRI. ⁶

It is not only doctors who should be held responsible for the increased use of these drugs. Pharmacists play an essential role in the interaction with this population group, because they are responsible for dispensing the drugs. Polypharmacy is complex and involves the whole production chain of the medication – production, regulation, availability in the health care systems, and dispensing. ⁵ With regard to the latter, most Brazilian pharmacists who work as in-charge pharmacists in drugstores or primary healthcare services do not understand their role as health professionals. With the exception of those who specialize in clinical pharmacy and those who work in geriatrics, pharmaceutical care for older adults is inadequate. Training these professionals to help them understand the demographic transition and the importance of observation and notification of drug overuse or increased prescription occurs in very few academic curricula.

SERVICES, POLICIES, AND HEALTH PROMOTION

Although the psychosocial support centers (PSC) have been created to organize municipal healthcare services for individuals with severe and persistent mental disorders, geriatric care is limited in the healthcare network, not to mention the inequity in the access to these services. As recommended by the World Health Organization regarding the incorporation of the determinants of health in the organization of effective healthcare networks, ^c the innovation of mental health care services for this population group is essential.

In fact, the guidelines of the National Health Policy for Older Adults ^d include prevention, recovery, and rehabilitation of older patients with mental disorders to assure that they experience aging free of disabilities. ^e However, effective healthcare planning requires diagnoses that involve appropriate clinical assessment, which can only be done by geriatricians and healthcare professionals with problem-solving abilities related to the treatment of several pathologies in older adults and not simply by prescribing medications.

Individuals with chronic conditions are more likely to develop depressive symptoms and are less able to control various aspects of their lives, which directly affects their subjective perception in evaluating and coping with stressful conditions. ¹⁵ Therefore, the sociocultural factors that negatively affect the quality of life in this population need to be minimized in order to contribute to the promotion of health. In fact, these factors cannot be addressed simply with the use of SSRI, benzodiazepines, or any other drugs that target the central nervous system, because our society demands the incorporation of older adults in their full potential.

CONCLUSION

This wide range of biological and psychosocial factors associated with depressive disorders among older adults requires the implementation of public policies, including those related to healthcare, in all their spheres of complexity; and this strategy should contemplate the comprehensive nature of the disease ³ not only to decrease the stigma caused by depression but also to improve the quality of life in aging and treatment efficacy and effectiveness. ² In the United States, approximately 10.0% of older patients suffering from depression attempt suicide each year. ¹³ In Brazil, an exploratory analysis conducted between 2005 and 2007 in Brazilian cities that recorded deaths due to suicide among individuals around 60 years of age indicated that these deaths were positively correlated with mood disorders. ¹⁴ In this context, it is necessary to recognize the many ramifications of depression among older patents for proper treatment, which should not be based on pharmacotherapy alone.

The abuse of SSRI by older adults reflects the lack of preparation of healthcare professionals for the treatment of depression in this group. In addition, the use of these medications for other purposes other than their main indication makes fluoxetine hydrochloride an objectionable all-purpose drug to treat disorders associated with psychosocial adversity, lack of social support, and limited access to healthcare services necessary for the treatment of mental disorders. Therefore, preparing healthcare professionals for the reversal of the age pyramid is essential, but this is not happening yet.