Depression in Older Adults

Late-life depression (LLD) is relatively common in older adults. It is associated with deleterious health outcomes, exacerbates frailty and functional decline, and contributes to all-cause mortality. LLD tends to have a chronic course, with frequent recurrences and relapses. This chapter reviews the clinical presentation, assessment, and etiologies of LLD. The chapter also focuses on therapeutic targets of LLD, which include pharmacotherapy, neurostimulation, and psychosocial treatment. An antidepressant treatment algorithm based on a summary of current data, clinical evidence and expert opinion is included to help guide physicians. Additionally, psychotropic medications with novel mechanisms of action are discussed with some directions for further research.

Postpartum Depression

Perinatal care, including the management of mental health issues, is often under the auspices of primary care providers. This chapter provides an overview of identification, diagnosis, and treatment of postpartum depression (PPD). It reviews the prevalence of PPD in the general and minority populations, related disorders, common symptoms, and genetic and psychosocial risk factors to facilitate PPD management in the primary care clinic. The most commonly employed screening scale, the Edinburgh Postnatal Depression Scale, has several advantages in the primary care setting. The potential adverse consequences of untreated PPD on the mother and her family underscore the importance of identifying and providing effective interventions, including preventive strategies, in high-risk groups. As a class, antidepressant medications have amassed a large reproductive safety literature, including considerable data in breastfeeding and women with PPD. Notably, psychosocial therapies have demonstrated equal efficacy in women with PPD and are viable treatment options.

Neurobiology

This chapter explores the evidence of disturbances in various neurobiological pathways in depression. No unifying pathophysiological mechanism has yet been discovered. Depression is more than simply a deficiency in a single neurotransmitter or pathway, as neurobiological correlates of depression have been identified in diverse studies. This chapter reviews depression-related changes in neurotransmitter systems, neurogenesis, inflammation, stress response, and functional genomics including epigenetics, and how these might contribute to the depressive phenotype. The diverse neurobiological findings of depression reflect the nature of its symptomatology, and likely etiological heterogeneity. Current evidence suggests that depression is not a single condition, but rather multiple overlapping phenotypes with converging and diverging underlying pathophysiological processes. New treatments may be identified with a better understanding of depression neurobiology. Such advances could also lead to the development of prognostic and diagnostic markers, which would allow for more personalized treatment and resource allocation.

Exercise as a Treatment for Depression

Beginning with epidemiological evidence and moving to randomized controlled trials, researchers have established evidence supporting the effectiveness of exercise in the treatment of depression. This chapter will provide an overview of the benefits of exercise for patients with depression, discuss the challenges clinicians face in using exercise as a treatment in clinical practice, and provide practical advice on exercise prescription. The chapter concludes with a discussion of areas of need for future research, focusing on three areas: identifying strategies to ensure patient adherence with exercise prescriptions, identifying predictors of treatment response that will facilitate a personalized medicine approach to exercise prescription, and the use of exercise as a complementary agent with other depression treatments.

Child and Adolescent Depression

Early onset depression is prevalent and causes significant morbidity, mortality, and psychosocial impairment. Evidence-based psychosocial and psychopharmacological treatments are available for depressed youth, but many children and adolescents do not receive sufficient treatment. Pediatric and adult depressive disorders involve essentially the same symptoms, with the exception of irritability, as depressed youth may present with irritable mood in the absence of explicit sadness. This chapter examines aspects of depression that are unique to children and adolescents. It focuses on diagnosis and symptomatology, epidemiology, and pharmacological, psychotherapeutic, and other treatments. The chapter also addresses barriers to treatment of early onset depression and future research directions.

First-Line and Combination Therapeutics for Major Depressive Disorder

Major depressive disorder (MDD) affects one in five adults during their lifetime. Patients with MDD and their clinicians have a multitude of options to select for management of this chronic and/or recurrent condition. Selection of treatment modalities may be guided by the severity of illness. Nonpharmacologic treatments such as psychotherapy or exercise may be considered for those with mild symptom severity, with pharmacologic treatment reserved for those with moderate or higher symptom severity. Severe or very severe depression may warrant the combination of both pharmacologic and psychotherapeutic treatments. In patients who fail to improve adequately with one or more first-line treatments, augmentation with second-generation antipsychotics should be considered. There currently are no objective markers to guide the selection of one first-line treatment over other. Exciting ongoing research in the field of depression may inform new methods to personalize treatment selection and potentially lead to the development of mechanistically novel antidepressants.

Pharmacological Strategies for Targeting Residual Symptoms in Depression

Achieving full symptom remission in major depressive disorder (MDD) should be the ultimate objective in the treatment of depressed patients. However, antidepressant monotherapies have shown to have limited efficacy in the treatment of MDD, as evidenced by the relatively high rate of residual symptoms even among responders to antidepressant treatments. These symptoms, which include anxiety, irritability, insomnia, somnolence/fatigue, apathy, and cognitive and executive dysfunction, are associated with an increased risk of relapse and poor psychosocial functioning. Comprehensive clinical data are not yet available to guide management of these symptoms—whether residual or drug-related—in patients treated pharmacologically for depressive disorders. Suggested approaches to the management of residual symptoms include addressing treatment-emergent side effects and comorbid conditions, optimizing antidepressant dosing, and using augmentation therapies. In this chapter, we will review how best to assess residual symptoms and some of the preferred pharmacological strategies to address them.

Psychodynamic and Supportive Psychotherapy

Patients with mood disorders often can benefit from psychotherapy, whether as a primary treatment for depression or as an adjunct to medications or other biological treatments. Today, therapeutic approaches such as cognitive–behavioral therapy and interpersonal therapy are commonly thought of as first-line evidence-based treatments of depression, yet there is also evidence that psychodynamic psychotherapy (PDT) and supportive psychotherapy (SPT) can be effective treatments of depression. Both PDT and SPT are commonly used in clinical practice, by a wide range of clinicians and in many different settings. This chapter describes the theoretical background of each of these therapies, therapeutic techniques, how they can be adapted for treatment of depression, and patient populations for which they may be indicated.

Primer on Depression

Depression is a commonly occurring illness in the general population. Existing systems for identifying and treating depression vary greatly, and the adoption of a universal, standardized method of addressing the disorder within primary care is lacking. New guidelines and recommendations by accrediting bodies have resulted in the development of some initiatives and the increased recognition of depression, yet treatments continue to rely on referrals to specialty psychiatric care providers. Given that primary care may be the only point of health care access for many individuals, this serves as an opportune setting to initiate treatment at the time that depression screening is completed. With adequate support, guidance, and a systemic approach (i.e., measurement-based care), primary care providers can be as effective as psychiatric specialty care in treating depression. This chapter providers evidence for this approach, along with direct recommendations to primary care providers.

Precision Medicine for the Treatment of Depression

Although in recent years we have gained a deeper understanding of the pathophysiology of major depressive disorder, this improved understanding has not translated into improved treatment outcomes. Therefore, the screening of putative biological markers may be crucial to facilitate more rapid, successful treatment. Ongoing research has explored the importance of studying physiological biomarkers, including neuroimaging, neurophysiology, genomics, proteomics, and metabolomics, as well as cognition, to gain a better understanding of subtypes of depression and treatment response. However, only through an integrated, multimodal biomarker approach can we truly achieve better outcomes.