Antidepressants in older adults: handle with CARE

In older adults, depression and anxiety often intertwine with age-related issues such as chronic illness, cognitive decline, grief, loss and social isolation. 

According to Australian Institute of Health and Welfare (AIHW) data, approximately 1 in 4 Australians aged over 65 were prescribed antidepressants in 2022-2023. This rate is substantially higher than the 1 in 7 reported across all age groups – despite older adults reporting lower rates of depression and anxiety (1).

Additionally, the average duration of antidepressant therapy in Australia is about four years (2), whereas current guideline recommendations are 6–12 months for a single episode of depression (3), and at least 12 months for managing anxiety (4), after an acceptable response is achieved. These discrepancies raise concerns about the impacts of both unnecessary and prolonged medication use, especially in older adults who have increased sensitivity to the adverse effects and long-term harms of antidepressants.

To address these issues, the Quality Use of Medicines Alliance is focusing on addressing unnecessary antidepressant use in older populations. 

One approach to providing a patient-centred framework to support shared decision-making, appropriate monitoring, and safe deprescribing of antidepressants can be captured using the CARE mnemonic—Choose wisely, Assess effectiveness, Review regularly, Explore and encourage deprescribing. 

Key components of CARE 

Choose wisely

• Initiate appropriate treatment using shared decision-making. 

• Choose treatments based on factors such as comorbidity, frailty, digital literacy, socioeconomic status, access to services, cultural preferences and cognitive capability.

• Prioritise non-pharmacological interventions like lifestyle changes, social connections and psychological therapies. 

• Tailor treatment to the individual, if antidepressants are initiated, and discuss the potential benefits and risks.

• Set clear expectations for duration of therapy and schedule regular reviews to optimise outcomes.

Assess effectiveness

• Review early ensuring that treatments are effective and appropriate, noting that in many older adults response may be delayed. 

• Adjust the dose or consider alternative therapies as needed to optimise treatment outcomes and prevent unnecessary long-term medicine use. 

Review regularly 

• Follow up frequently to allow for ongoing assessment of treatment efficacy, side effects and overall mental health and well-being.

• Encourage engagement in lifestyle strategies, social connections and psychological therapies.

Explore and encourage deprescribing 

• Discuss the benefits and risks of continuing or stopping medication with the patient and their family or care team.

• Address potential withdrawal symptoms and build confidence in the ongoing value of non-pharmacological strategies.

• Challenge misconceptions that may normalise the long-term need for antidepressant medicine, such as the belief that depression or anxiety is due to a chemical imbalance.

A national program approach

Antidepressants and Older Adults is the third federally funded national education program from The Quality Use of Medicines Alliance. By conducting extensive formative research and engaging with people with lived experience and health professionals, this program aims to support person-centred care from treatment initiation through to deprescribing antidepressants.

Key features include virtual educational visiting, webinars, podcasts, mini audits and a suite of clinical practice and consumer resources. By empowering patients and their carers, this program seeks to optimise antidepressant use and improve mental health outcomes in older Australians.

For more free Quality Use of Medicines education, check out QHUB on Medcast