Antidepressants for elderly patients — what works and what to watch for

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

Depression in older adults looks different than it does in younger people. Your parent might not say they feel sad. Instead, they might say everything feels pointless, they don't enjoy things anymore, they don't see a reason to get out of bed. They might have physical complaints instead of emotional ones. Their knees hurt, their stomach is off, they're tired all the time. They might get irritable easily. Sometimes depression in older adults is so subtle that everyone misses it. Your parent is just quiet and withdrawn, and people attribute it to normal aging.

Depression is common in older adults, especially if they've had losses like death of a spouse, loss of independence, health problems, or loss of roles they've had their whole lives. Depression is treatable, and medication helps many people. But antidepressants in older adults come with different considerations than in younger people. Your parent's body processes medication differently. They might be on other medications that interact. Some side effects are tolerated differently in older bodies.

When an antidepressant works for an older adult, it can be transformative. Your parent starts engaging with life again, talking more, wanting to do things. They eat better because food has taste again. They sleep better. They're more patient and pleasant. But getting to that point requires trying medications, watching for side effects, being patient about how long it takes, and adjusting doses. It's not instant.

Recognizing Depression

Depression in older adults is often missed because the presentation is different. Your parent might seem withdrawn but say they're fine. They might have physical complaints that seem unrelated to mood. A doctor might investigate the physical symptoms and miss that depression is driving them. You might notice that your parent isn't their usual self but not realize it's depression.

Your parent might talk about not wanting to be a burden, wanting to die, not seeing a reason to continue. These are serious signs of depression, not normal aging. If your parent is expressing these thoughts, that's definitely time to see a doctor.

Sometimes depression comes after a medical event. Your parent has a heart attack or stroke, and then becomes depressed. They lose a spouse, and sink into depression. This is understandable and common, but it's still depression that deserves treatment.

Depression is also related to other medical conditions. Chronic pain causes depression. Thyroid disease causes depression. Vitamin deficiency causes depression. Sometimes treating the underlying condition helps the depression. But sometimes your parent needs antidepressant medication too.

When your parent has other medical conditions, depression affects them. If your parent has heart disease, depression increases risk of heart problems. If they have diabetes, depression makes blood sugar harder to control. If they're recovering from surgery, depression slows healing. Treating depression improves treatment of other conditions.

The Medication Options

SSRIs are the first-line choice for depression in older adults. Sertraline, citalopram, and escitalopram are commonly prescribed. They work by increasing serotonin, which affects mood. They take two to four weeks to start working, which is frustrating when your parent is suffering and wants relief now. But after a few weeks, most people notice improvement.

SSRIs are generally well tolerated in older adults. Common side effects include nausea, which usually improves with time. Some SSRIs cause sexual dysfunction, but alternatives exist. Some cause low sodium, especially if doses are too high or if your parent is also on certain other medications. Your parent needs blood work to check sodium if on high-dose citalopram.

SNRIs like venlafaxine work similarly to SSRIs but affect serotonin and norepinephrine. They sometimes have more energy-boosting effects than SSRIs, which can be helpful for depressed older adults. They can increase blood pressure, which is something to monitor. They can cause sexual dysfunction.

Mirtazapine is an older antidepressant that's not usually first-line but is helpful for specific situations. It increases appetite, which is great for older adults who are losing weight from depression. It's sedating, which helps if your parent has insomnia. But the sedation can be problematic if your parent is already having cognitive issues or balance problems.

Bupropion works differently from SSRIs, affecting dopamine and norepinephrine instead of serotonin. It can be energizing and is sometimes better for depression with fatigue. It can cause insomnia and can increase blood pressure. It's not the best choice for anxious depression because it can increase anxiety.

Tricyclic antidepressants like amitriptyline and nortriptyline are older medications that are less commonly used now but sometimes still prescribed. They have more side effects in older adults including orthostatic hypotension and cognitive impairment. They're not usually first-line choice.

Starting and Monitoring Treatment

Antidepressants follow a "start low, go slow" approach in older adults. The starting dose is lower than in younger people, and the increase to full dose happens slowly over weeks. Your parent's doctor might start at half the dose that would be used in a younger person. This reduces the chance of side effects and gives the body time to adjust.

It takes time for antidepressants to work. Two weeks in, your parent might not feel different. At three weeks, they might notice a little improvement. At four to six weeks, they might feel significantly better. This waiting period is hard when your parent is suffering. Some doctors add a short course of a low-dose benzodiazepine during this waiting period to help with anxiety, with a plan to stop it once the antidepressant is working. This is different from long-term benzodiazepine use and is more defensible.

Monitoring for improvement means asking your parent how they feel. Are they sleeping better? Do things seem more hopeful? Are they engaging more? Are they thinking about suicide less? Improvement doesn't mean all symptoms go away. It means life feels more bearable.

Monitoring for side effects means asking about nausea, sleep changes, sexual dysfunction, any new symptoms. Some side effects improve with time. Some require dose adjustment. Some mean trying a different medication.

Combining With Other Treatment

Antidepressants work better when combined with therapy. Your parent sees a therapist while taking medication. Therapy helps your parent process the loss or difficulty that's underlying the depression. It gives them tools to manage negative thoughts. Combined, medication plus therapy is more effective than either alone.

Exercise helps depression. It's not just psychological, it's biochemical. Regular exercise, especially aerobic exercise, changes neurotransmitters and helps depression. Your parent doesn't need to train for a marathon. A daily walk helps.

Social connection helps depression. Your parent who's isolated is more depressed. Seeing people, participating in activities, being part of something helps. Loneliness is painful and worsens depression. Finding ways for your parent to connect matters.

Adequate sleep helps depression. Your parent on an antidepressant that makes them sleep well might start feeling better just because they're sleeping well. Your parent on an antidepressant that causes insomnia might feel worse. Sleep matters.

When to Change Approach

If your parent is on an antidepressant for six weeks and feeling no better, that's worth discussing. Maybe the dose needs to go higher. Maybe a different medication would work better. Maybe the issue is that the antidepressant isn't addressing the underlying problem, and therapy is what's most needed.

Suicide risk is something to monitor when starting antidepressants. In the first few weeks, as energy returns but mood hasn't fully improved yet, risk of suicide can increase. Your parent should have close monitoring. You should know the warning signs: your parent talking about not wanting to live, giving away possessions, saying goodbye to people. These need immediate attention.

After improvement, the question becomes how long your parent should stay on antidepressants. For a first episode of depression in response to a life event, maybe a year is appropriate. For recurrent depression, longer term might be better. For depression in the context of chronic medical illness, it might be long-term. This is a conversation with the doctor.

Stopping antidepressants requires tapering. Stopping suddenly can cause discontinuation symptoms, feeling like the antidepressant is wearing off. Your parent might feel worse temporarily before feeling better. Tapering slowly gives the brain time to adjust.

Depression in older adults is treatable and responds well to antidepressants in most cases. Your parent can feel better. The key is getting the medication right, being patient about how long it takes, combining with therapy and lifestyle changes, and monitoring both for improvement and for side effects. Your parent deserves to feel hope again.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.