Use of serotonin selective reuptake inhibitors in geriatric depression

The treatment of depression can be problematic in the elderly patient. The advent of the serotonin selective reuptake inhibitors (SSRIs) represents a significant advance in the treatment of depression. Sufficient data from controlled studies now exist on the efficacy and safety of these agents in geriatric patients to recommend them as a primary treatment for major depressive disorder. SSRIs appear to have significant advantages over older drugs, especially tricyclic agents, in this age group. The lack of significant anticholinergic and antihistaminergic side effects results in better tolerability and better compliance. While SSRIs are not free of side effects, those that occur can usually be managed in the context of continued treatment of the depressive episode. This article reviews data from controlled studies of the treatment of geriatric depression for all four available SSRIs in the United States-fluoxetine, sertraline, paroxetine, and fluvoxamine (which is approved in the United States for treating only obsessive-compulsive disorder). Differences among the SSRIs are examined, particularly with reference to clinically relevant differences in pharmacokinetics and hepatic isoenzyme inhibition. Principles of clinical management are discussed, including dose initiation and titration, side effect management, augmentation and combinations, and length of treatment. Finally, the use of SSRIs in special elderly populations is discussed.