Inquadramento diagnostico e gestione farmacologica della depressione senile Assessment and pharmacological management of elderly depression

Late-life depression is chronic and disabling and is an important factor for elderly suicide. The prevalence of depression in the elderly has attracted extensive research effort and yelded a wide range of estimates, depending on diagnostic criteria, the method of detecting depression, the experience of the interviewers and, most importantly, the characteristics of this population. Major Depression appears to be less common in the elderly than in younger adults, but subsyndromal depression is more prevalent. DSM diagnostic criteria require either depressed mood or loss of interest, but these symptoms appear to be less prominent in the elderly, being anxiety, irritability and physical symptoms more significant indicators of elderly depressive states. Depression in the elderly is essentially heterogeneous and has a multifactorial etiopathogenesis (Fig. 1): this has contributed to its underrecognition, underestimation and undertreatment. The “atypical” clinical presentation of depression in the elderly as somatic symptoms, anxiety, changes in functional ability, loss of capacity to enjoy life or loss of interest in usual activities, can be misleading for the clinician and masks an underlying mood disorder. Even “pseudodementia” is clinically important since it may result in failure to recognize and treat either depression or dementia. Comorbidity with a physical illness such as cardiovascular disease or other psychiatric symptoms (e.g. anxiety) is frequent in late-life depression, and the presence of one or more medical illnesses may influence the diagnosis of depression; moreover, it represents a negative prognostic factor for response to antidepressant therapy. The pharmacological management of depression in late life is complicated by physiological changes associated with aging (Fig. 2), higher sensitivity to develop side-effects, concomitant medical disorders with drug-drug interaction phenomena and compliance problems. These factors need to be carefully taken into account when selecting antidepressants for the treatment of depressive states in the elderly. Antidepressants are as effective in the elderly as they are earlier in life. The development of newer antidepressants has focused on compounds that are better tolerated, with reduced unwanted effects and more likely to be used in long-term treatment. Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonergic/Noradrenergic Reuptake Inhibitors (SNRI), (e.g. venlafaxine) and Noradrenergic/Serotonergic Specific Antagonist (NaSSA), (e.g.mirtazapine), show a more favourable side-effects profile and appear to be more suitable for the treatment of elderly depression. In selecting the appropriate treatment, the physician should take account of concomitant illnesses and current therapies, choosing an agent with a simple once-daily regimen and a larger pharmacodynamic and therapeutic spectrum (e.g. on depressive and anxiety symptoms). However, a comprehensive management of elderly depressive states should include not only the physician, but also a psychological and psychosocial support, which appears important to explore stressors for depression and to educate patients and their families about depressive illness and its treatment. Correspondence: Prof. A.C. Altamura, Cattedra di Psichiatria, Dipartimento di Scienze Cliniche “Luigi Sacco”, Universita di Milano, via G.B. Grassi 74, 20157 Milano Tel. +39 02 39042904 Fax +39 02 39042510 E-mail: c.altamura@hsacco.it