Special Populations

Geriatric Age Group

In general, geriatric depression responds well to traditional therapies, but it takes longer to respond to antidepressant medications, and elderly patients can exhibit greater sensitivity to potentially activating agents (e.g., fluoxetine, sertraline, and bupropion). Use of TCAs and other agents that cause postural hypotension should be reserved for second- or third-line use. Use of venlafaxine in the elderly is associated with a higher-than-average risk of urinary hesitancy or retention. Patients with periventricular small-vessel disease and those with multiple lacunar infarcts can present with signs and symptoms that resemble depression (e.g., apathy, psychomotor retardation, lack of initiative), and for these reasons might respond to antidepressant medication suboptimally or not at all.

Children and Adolescents

All patients treated with antidepressants should be carefully monitored at all times for intensification of suicidal thinking, but especially following initiation of treatment. There appears to be a greater risk of antidepressant-induced suicidal ideation shortly after starting antidepressant medication in children and adolescents. It is believed that undiagnosed BPD may be an important variable that accounts for this finding.

Pregnant Women

All antidepressant medications are classified as Class C by the Food and Drug Administration. Although all antidepressant medications pose an unsubstantiated risk to the developing fetus, withholding of antidepressant medication in cases of moderate to severe depression also can pose substantial risk to both the mother and fetus. Therefore, any woman who becomes pregnant and is either taking antidepressant medication or might require it should be referred for consultation to a psychiatrist, preferably one with specialty knowledge in this area.

Substance Abusers

Detection of substance abuse, like MDD, often requires a high index of suspicion. When both occur simultaneously, the standard of care is to require cessation of substance abuse followed by reassessment to determine continuing indication for antidepressant treatment. Many MDEs that occur in the context of substance abuse resolve with cessation of the abused substance, particularly alcohol. Cessation of cocaine dependence, however, is typically followed by severe depression that requires aggressive antidepressant treatment. Treatment with antidepressant medication is necessary when MDD is comorbid with substance abuse, but timing is important to avoid implying to the patient that antidepressant treatment is compatible with continued substance use.

Suicidal Patients and Others at Risk

Not all patients who voice suicidal thinking are at imminent risk of self harm. Because of the difficulty of accessing specialty services it behooves the generalist to develop some sophistication in risk assessment.

Psychotic Patients

Patients with MDD and psychosis require aggressive antidepressant and antipsychotic treatment. If oral medication is ineffective, then ECT is indicated. In general, the first priority in the treatment of psychotic depression is control of psychotic thinking and behavior. Administration of an atypical antipsychotic usually serves this purpose. Olanzapine (Zyprexa) 2.5 to 5 mg or quetiapine (Seroquel) 25 to 100 mg daily are recommended starting doses. Referral to a psychiatrist is recommended if improvement is not rapid.

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