Anxiety symptoms in elderly patients with depression what is the best approach to treatment?

Depressed elderly persons frequently have concurrent symptoms of anxiety or comorbid anxiety disorders. Such comorbidity is associated with a more severe presentation of depressive illness, including greater suicidality. Additionally, most antidepressant treatment studies in the elderly have found poorer treatment outcomes in those with comorbid anxiety (including delayed or diminished response and increased likelihood of dropout from treatment). While antidepressants such as selective serotonin reuptake inhibitors and tricyclic agents are efficacious for late-life depression, there is no evidence that either class is superior, in terms of efficacy or tolerability, in the treatment of anxious depression. Rather, the amount and quality of clinical management, and not the particular medication chosen, appears to influence the likelihood of re, mission or treatment withdrawal in anxious depressed elderly patients. Co-prescription of benzodiazepines, typically lorazepam, is also warranted in some cases for severe anxiety or insomnia, but carries the risk of cognitive or motor impairment. It is our experience that close clinical monitoring, together with maximisation of antidepressant treatment (by maximising dosage, augmenting or switching agents in cases of partial or no response, and/or adding psychotherapy) will almost always result in remission of depressive symptoms, together with improvement of anxiety, in these individuals. Therefore, optimism should be maintained when treating the depressed elderly individual, even when comorbid anxiety is present. The term 'anxious depression' refers to individuals in a major depressive episode who concurrently have significant anxiety symptoms. This presentation is common, because anxiety and depressive symptoms are overlapping and share risk factors.([1]) Symptoms of anxiety are seen in as many as 65% of older patients with depression.([2]) Anxious depression can also be used to describe individuals with depression who have a comorbid anxiety disorder. While in adults these comorbid anxiety disorders are common,([3]) similar studies of older adults have shown mixed results, with some studies finding low rates of comorbid anxiety disorders ([4,5]) and others showing higher rates. ([1,6]) The most common comorbid anxiety disorders in elderly patients with depression are phobias and generalised anxiety disorder (GAD). This review of the literature on anxious depression in the elderly will show that the disorder is associated with increased suicidality and treatment resistance compared with nonanxious depression (the combination of suicidality and treatment resistance is of obvious concern). Possible reasons for treatment resistance are discussed, as are clinical management strategies for improving treatment outcomes in anxious depression.