Treatment-Resistant Depression in Older Adults
Abstract
This article provides a comprehensive clinical framework for diagnosing and managing treatment-resistant depression (TRD) in older adults. Defined as inadequate response to at least two antidepressant trials of adequate dose and duration, TRD in later life is influenced by biopsychosocial factors such as comorbidities, bereavement, chronic dysthymia, and substance use. The evaluation emphasizes validated tools like the PHQ-9, screening for bipolar disorder and cognitive impairment, and assessment of coexisting medical conditions. The article outlines a stepped-care approach including medication optimization, switching or augmenting antidepressants, and psychotherapy. Evidence supports use of second-generation antipsychotics (e.g., aripiprazole), lithium, or dual therapies in cases of partial response. For severe, refractory cases, referrals for electroconvulsive therapy (ECT), esketamine, or transcranial magnetic stimulation are recommended. Collaborative care models, such as IMPACT or PROSPECT, are encouraged to coordinate treatment, enhance adherence, and monitor progress. The article calls for personalized care strategies aligned with remission goals, emphasizing safety, functional outcomes, and age-specific considerations.
Keywords:
treatment-resistant depression
older adults
antidepressant augmentation
collaborative care
electroconvulsive therapy
psychotherapy
medication switching
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