Antidepressants and older age: risks of pharmacotherapy

High prevalence of depression among older adults is a significant global public health concern. The situation is further aggravated by population aging, which increases the number of individuals requiring care. Alongside with psychotherapy, pharmacotherapy is widely used in depression management. However, its use in older adults poses substantial challenges due to age-related physiological changes and an elevated risk of adverse drug reactions. Multimorbidity and associated polypharmacy further contribute to the likelihood of harmful drug-drug interactions. In addition, aging-related changes affect drug elimination. Various classes of antidepressants with generally comparable efficacy are available on the pharmaceutical market. Tricyclic antidepressants, such as amitriptyline and imipramine, are not recommended in older adults due to a high incidence of adverse effects, including sedation, dry mouth, constipation, and orthostatic hypotension. Serotonin reuptake inhibitors, such as fluoxetine, sertraline, and citalopram, have a more favorable safety profile and are considered first-line agents in the treatment of depression in the elderly, although they are not without drawbacks. Selective serotonin and norepinephrine reuptake inhibitors, such as venlafaxine and duloxetine, act on two neurotransmitter systems, which may increase the likelihood of adverse effects. Atypical antidepressants (mirtazapine, trazodone, vortioxetine, and agomelatine) constitute a heterogeneous group of agents that differ in their mechanisms of action and safety profiles. Thus, when treating older adults, the rational choice of an antidepressant should consider its side effect profile, potential drug interactions, comorbid conditions, and cost of therapy.