A new review reveals weak evidence to support the use of antidepressants in the elderly and illuminates a number of problematic, adverse effects (AEs) associated with antidepressant use.
The meta-analysis, published in Mental Health Science, analyzes current research literature on the effectiveness of antidepressants and associated AEs in the elderly population. The results of the analysis suggest that for persons over 65 years old, antidepressants are less effective, have limited benefits and that AEs are both common and problematic.
“A recent Scandinavian nationwide population study found that while the average use of antidepressants was 11.7%, the use among the elderly of 75 years or older was as high as 20.2%. This makes the elderly the single most frequent user of antidepressants across age groups,” writes researcher Michael Hvidberg of the University of York.
Major depressive disorder (MDD) is the most frequently diagnosed mental health issue among the elderly, and they use antidepressants more than any other age group. Yet, despite high antidepressant use, there are no guidelines for treating depression in older adults in the UK, and there is little available evidence to support the use of antidepressants in older adults.
To address this gap, Hvidberg examined existing reviews of research on the efficacy of selective serotonin reuptake inhibitors (SSRIs), a commonly prescribed class of antidepressants and includes drugs like Prozac and Zoloft, and AEs associated with these drugs, in the elderly population.
The current study differs from other reviews in that individual studies were omitted. Instead, only randomized controlled trials (RCT), the gold standard in measuring the efficacy of drugs, that were based on systematic reviews or reviews of multiple drug trials, meta-reviews, and meta-analyses were included. Only studies that assessed the effectiveness of SSRIs and individuals 55 and older were investigated. Ividberg examined ten reviews, covering over a decade’s worth of research and including thousands of elderly patients.
Hvidberg describes his results:
“Summed up, most reviews showed nonsignificant, varying, or mainly modest efficacy superiorities to placebo, if any. This was also the case for studies with positive‐worded conclusions. There was also evidence that age thresholds were crucial and declining efficacy with increasing age.”
Adverse events were explicitly addressed in six reviews, including symptoms like fatigue, constipation, dizziness, electrolyte disturbances, and proneness to bleeding, falls, and fractures. Three out of the the six studies found that risks of AEs, particularly those that could be problematic to the elderly population, like proneness to falls, were significantly increased and that 10 out of 17 of the drugs being researched had participants drop out or withdraw due to AEs experienced.
Moreover, half of the reviews found that only a small minority of antidepressants performed better than placebos in the remission of depression. Four of the reviews did not find remission reported at all.
In his discussion of the results, Hvidberg also highlights issues related to the quality of antidepressant RCTs and problems inherent in interpreting results, which can lead to misleading conclusions about how effective the drugs are.
“Not surprisingly, nearly all of the ten reviews also fail to explicitly describe, assess, and argue the qualitative value of the effect sizes. In sum, there seems to be an inherent risk that underlying subjective perceptions decide whether to focus on or interpret the glass as half empty or half full.”
While there are limitations to this study, including a lack of racial/ethnic demographics for the reviews, which is critical to determine if these findings are generalizable across racial/ethnic backgrounds, overall, the review had a robust sample size that included thousands of participants.
Hvidberg concludes by calling for further investigation into the efficacy and safety of antidepressant drugs for the elderly, including assessing long-term outcomes and AEs. He also calls for treatment guidelines that specifically address the elderly and suggests that these guidelines should explicitly address non-drug alternatives to treatment, as some argue that the elderly typically do not receive alternatives to medication, such as therapy, exercise, mindfulness, and so on.
Further, he recommends deepened understanding of the role that cultural issues, such as ageism and presumptions about the commonality of depression in old age, play in the treatment of depression. Understanding these cultural dynamics and their effect on older people is crucial to change how their experiences of depression are treated and understood.
Elsewhere, research has emphasized concerns related to elderly antidepressant use, such as overprescription of drugs and increased risk for heart disease, serotonin syndrome, hip fractures, and the development of dementia. Others have offered support for alternatives to medication in treating depression in the elderly, including minimal exercise, face-to-face contact, and music therapy.
The influence of neoliberal policies in increasing ageism and its detrimental effects on mental health in older people has been explored, and calls for policies prioritizing people rather than profits have been made. As Hvidberg illustrates, underlying societal issues must be addressed if any future policies and guidelines are going to be effective in changing how we understand and treat elderly persons struggling with depression.
Hvidberg, M. F. (2023). Are antidepressants effective in the treatment of depression in the elderly? A critical umbrella review on reviews, methods, and future perspectives. Mental Health Science, 1(2), 85-103. https://doi.org/10.1002/mhs2.14 (Link)