gms | German Medical Science

Background: While the prevalence of depressive illnesses decreases in old age, the consistently high prescription rates for antidepressant medication in older people exceed the prevalence of depressive illnesses by a substantial margin. Often embedded in polypharmacy regimens, antidepressants are found in the medication plans of around a quarter of older people aged 80 and above.

In order to investigate patients' perceptions (patient-reported outcomes) regarding the efficacy and safety of their individual antidepressant therapy, a structured questionnaire was administered to geriatric and psychiatric patients.

Materials and Methods: A total of 300 patients from acute psychiatry (Alexianer Hospital, Aachen), outpatient psychiatry (Zagreb, Croatia) and geriatrics (Franziskus Hospital, Aachen) were asked about their self-perceived symptoms, efficacy and side effects of antidepressants using a standardized interview lasting approximately 20 minutes. Patients regularly taking at least one antidepressant over an extended period due to an affective disorder were included in the study. All diagnoses and comedications were assessed.

Results: Comparative analysis of patient perceptions in an acute psychiatric, outpatient psychiatric and a geriatric patient cohort revealed that all patient cohorts were highly adherent, but differed significantly in their relationship to their own medication, with geriatric patients being the least informed. There was a high level of agreement that a patient was more likely to categorise a symptom as a medication-related side effect, giving a positive causality assessment of at least possible on our part.

Depressive symptoms such as negative mood, cognitive impairment and motivation loss were perceived less frequently in the older people than in the (significantly younger) psychiatric patients. In contrast, pain and sleep disorders were similarly distributed.

The self-perceived effectiveness of antidepressant medication was very low in older patients, aligning with the prevalence of symptoms; only 14% of geriatric patients were able to regain their joy for life with the antidepressant, while 60% of psychiatric patients reported an improvement in mood and joy for life.

In contrast, both cohorts reported no effect on pain and sleep disorders. Side effects were perceived to be less severe in the geriatric group in terms of weight gain and sexual dysfunction, but the older patients were 10 times more likely (50% versus 5%) to have experienced a fall while on treatment.

Seventeen possible symptoms/side effects were queried in the systematic enquiry about side effects. We formed a number of side effects with a causality assessment of at least possible per patient and called this ‘Sum’.

In addition, we calculated an average degree of impairment per patient for these side effects and named it ‘Mean’.

Based on both parameters, we calculated a burden score per patient by multiplication and named it ‘Score’.

The ‘Sum’, ‘Mean’ and ‘Score’ values differed significantly (Sum: p= 0.035; Mean: p= 0.007; Score: p= 0.0001) when comparing patients who gave an affirmative answer to the open question about side effects since antidepressant therapy with those who gave a negative answer.

Conclusion: The high prescription rates of antidepressant medication in older people raise questions about the efficacy and safety of these therapies in old age. The patient-reported outcome reinforces the impression that there is a negative risk-benefit ratio for antidepressants in old age and supports the recommendation for de-prescribing, especially in the case of an uncertain diagnosis of depression.

The ‘Sum’, ‘Mean’ and ‘Score’ values differed significantly when comparing patients who gave an affirmative answer to the open question about side effects since antidepressant therapy with those who gave a negative answer. This suggests that a higher ‘burden’ of side effects may lead to patients actually giving an answer to the open question about side effects and that some side effects may remain unrecognised in practice if the patient does not achieve such a ‘burden cut-off’ in individual cases. In any case, our results show that a systematic enquiry about symptoms/side effects appears to be essential, as some symptoms are presumably perceived by patients as disease-related rather than drug-related and could possibly be avoided. Especially in geriatric patients, often treated with polypharmacy, it is imperative to avoid side effects and prescription cascades.

To further investigate the individual benefit versus risk, calculations are examined and compared holistically.