Turning the tide on depression in older adults: new evidence for optimal management of treatment-resistant depression

TRD is common in older adults and is rising with the aging of the population. After two failed trials of antidepressants - the consensus definition of TRD - older adults need options other than SSRIs and SNRIs.  Historically, we have had limited evidence-based treatment choices for older adults with TRD, including TMS, and ECT.  Many pharmacological options have been developed, including augmentation and switch strategies, but without solid data in older adults, patients and clinicians are left in the dark for how to decide on next steps.  Further, novel treatments with rapid clinical benefit have emerged, but again with minimal data on older adults.  Challenges in TRD treatment in this age group include co-occuring executive function impairment, high rates of medical comorbidities such as cardiovascular disease, and high rates of polypharmacy. These adversely affect depression treatment outcome, leading to reduced treatment response and tolerability, as well as safety issues such as falls.