As discussed last week, depression is frequent in both community dwelling elders (by most standards those over 55) and those with dementia. Depression is more likely in dementias due to either vascular disease (strokes) or Lewy body disease than in Alzheimer’s disease (maybe there’s a benefit to short term memory loss). In short, depression is a common but not inevitable outcome for all of us as we age. What are the best treatments for depression? How well do different treatments work for those who are demented as well as for those who are not?

Medications in the class called selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac, Zoloft, Celexa, and Paxil are the most common medical treatment for depression. However, they are not a panacea – especially in the elderly and those who are demented. A large portion of the elderly obtain only a partial response to medications and fewer than 30% display full remission. Antidepressant medications have an even poorer track record in those with dementias. There is little evidence that they are more effective than placebos in the treatment of depression in Alzheimer’s disease.

Furthermore, there is a negative interaction between use of SSRIs to treat depression and age. Treatment with SSRIs may lead to worsening cognition in those over 75. The reason behind this finding is unclear at present. Is this a result of inaccurate diagnoses? Is it a result of increasing risk of dementia with age? Is it a result of confusing the symptoms of dementia (e.g., apathy, poor initiative, changes in sleep patterns) with those of depression? Is it a negative side effect of the SSRRIs associated with aging?

There is treatment that is effective for depressed elders. Don’t reach for the medications too quickly in the treatment of depression. Adding psychotherapy to use of medications dramatically improves outcome. Use of an SSRI produced 29% treatment response in one study. Adding psychotherapy improved treatment response to 58%. Psychotherapy (broadly defined) is also effective in treating depression in those with Alzheimer’s disease. Effective treatments include: reminiscence, music, cognitive stimulation, conversation, and physical activity.

A first approach to treat depression in the elderly or demented is to start with nonmedical interventions and then add medications if needed. Start with cognitive therapy that addresses the lack of worth. Be sure to also include a treatment plan for increasing exercise and socialization immediately. Whether the issue is apathy or depression, the treatment needs to follow a plan that promotes and structures physical and social re-engagement. The most effective treatment for depression is to get activated even though you don’t want to.