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DIRECTIONS : Respond to at least two of your colleagues on 2 different days who selected different disorders. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature. 

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For this week discussion on special considerations related to vulnerable populations I chose depression in older adults. Depression is often under-recognized and under-treated in older adults. Without treatment, depression can impair an older adult’s ability to function and enjoy life and can contribute to poorer overall health. Compared to older adults without depression, those with depression often need greater assistance with self-care and daily living activities, and often recover more slowly from physical disorders (Stickle & Onedera, 2017).

Among the criteria for a major depressive disorder, at least 5 of the following symptoms must have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood):

1. Depressed mood

2. Diminished interest or loss of pleasure in almost all activities

3. Significant weight change or appetite disturbance

4. Sleep disturbance (insomnia or hypersomnia)

5. Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Feelings of worthlessness

8. Diminished ability to think or concentrate; indecisiveness

9. Recurrent thoughts of death, recurrent suicidal ideation without a

specific plan, or a suicide attempt or specific plan for committing

suicide.

When it comes to antidepressants for seniors, SSRIs or selective norepinephrine reuptake inhibitors (SNRIs) are recommended, which help increase the brain chemicals serotonin and norepinephrine. These drugs tend to have fewer serious side effects and drug interactions than older antidepressants. One FDA drug I would recommend is Wellbutrin (bupropion).  Bupropion is an antidepressant with excellent tolerability and few side effects or drug interactions (Goodnick, 2019).

The off-label drug I would recommend is Trazodone. Though trazodone is rarely used to treat depression alone anymore, it’s widely prescribed off-label at lower doses for treating insomnia. Trazodone increases natural neurotransmitters in the central nervous system, essentially restoring depleted chemicals in the brain. One of these important neurotransmitters, serotonin; regulates our internal clock for resting and being awake, as well as mood, appetite, digestion, memory, sexual function and desire (Bossini et al., 2018).

Evidence suggests that people with depression typically prefer nonpharmacological intervention and they value outcomes such as positive mental health and a return to usual functioning above simple reduction of symptom. Cognitive behavioral therapy (CBT) is one of the most evidence-based psychological interventions for the treatment of several psychiatric disorders such as depression, anxiety disorders, somatoform disorder, and substance use disorder.

Careful risk assessment is an important part of evidence-based practice. Initial assessments of depressive symptoms can help determine possible treatment options, and periodic assessment throughout care can guide treatment and gauge progress. One risk assessment that I would use to inform my treatment decision making is the Geriatric Depression Scale (GDS) which is specifically designed to screen and measure depression in older adults. It contains 30 forced choice “yes” or “no” questions, a format that is helpful for individuals with cognitive dysfunction. Questions relate to how an individual has felt in a specified time frame.

Even without FDA approval, there may be clinical trials and other evidence demonstrating that a drug works well for an off-label use. This can happen if the drug company decides not to pursue additional drug use approvals due to cost or lack of resources, or if the drug is in the process of receiving FDA approval but they have not yet finalized it (Kendrew, 2017).  

However, off-label prescribing is not always safe. This is especially true if there is a lack of evidence about a drug’s off-label use. Off-label drug use can put people at risk of receiving ineffective or even harmful treatment. To avoid these risks, the authors suggest that doctors only prescribe drugs off-label when they have solid evidence that the benefits outweigh the risks (Kendrew, 2017).

Clinicians strive to individualize treatments. So how might one follow evidence-based clinical practice guidelines, yet honor the individuality of patients? For an older patient a comprehensive assessment can help identify factors that might require modifications to a treatment recommended by clinical practice guidelines. These include patient factors such as race; ethnicity; socioeconomic status. culture and/or heritage; or other features of their identities, values, or preferences.

In addition, the patient’s comorbidities, social support, and ability to obtain childcare when needed, as well as the clinician’s accessibility, location, hours of operation, available appointments, proximity to public transportation, and other resources that can affect treatment, must be considered.

References

Bossini, L., Coluccia, A., Casolaro, I., Benbow, J., Amodeo, G., De Giorgi, R., & Fagiolini, A. (2018). Off-label trazodone prescription: Evidence, benefits and risks. Current Pharmaceutical Design, 21(23), 3343-3351.

Goodnick, P. (2019). Bupropion in response in depression. Southern Medical Journal, 84(Supplement), 39.

Kurlowicz, L., & Greenberg, S. (2017). The Geriatric Depression Scale (GDS). AJN, American Journal of Nursing, 107(10), 67-68.

Stickle, F., & Onedera, J. (2017). Depression in older adults. Adult span Journal, 5(1), 36-46.

Kendrew, M. (2017). Off-label prescribing by nurse prescribers: Best practice?. Nurse Prescribing, 15(9), 452-456.