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Treatment for severe depression in the elderly, difference between epstein barr virus and chronic fatigue syndrome - For Begninners

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Had at least 2 weeks of a major depressive episode which caused significant distress or disability.
Major Depressive Disorder is a condition characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes. Completed suicide occurs in up to 15% of individuals with severe Major Depressive Disorder. Alcoholism and illicit drug abuse dramatically worsen the course of this illness, and are frequently associated with it. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. There is a greater likelihood of developing additional episodes of this disorder if: (1) there was pre-existing Persistent Depressive Disorder, (2) the individual has made only a partial recovery, (3) the individual has a chronic general medical condition. Manic Episode never disappears completely, however many Major Depressive Episodes have been experienced.
Stressors may play a more significant role in the precipitation of the first or second episode of this disorder and play less of a role in the onset of subsequent episodes. First-degree biological relatives of individuals with this disorder are 2-4 times more likely to develop Major Depressive Disorder. Treatment refractory depressions may respond to a combination of an antidepressant plus lithium or electroconvulsive therapy (ECT). Although almost two-thirds of individuals with major depressive disorder respond to current therapies; at least one-third of those entering remission relapse back into depression 18 months posttreatment.
In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.
An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania). A disorder characterized by repeated episodes of depression, the current episode being mild, as in F32.0, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being of moderate severity, as in F32.1, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being severe without psychotic symptoms, as in F32.2, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being severe with psychotic symptoms, as in F32.3, and with no previous episodes of mania. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or to another medical condition. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
There are 4 main problems that interfere with wisdom: irrationality, forgetfulness, distractibility and lack of interest (apathy). Most behaviors have an optimal level, and too much or too little of the behavior is maladaptive. Over 5 years (2005-2011) I studied my outpatient psychiatric patients that had a DSM-IV diagnosis of Major Depressive Disorder.
Fatigue, sleep disturbance, appetite disturbance, occupational impairment and social impairment are all part of the diagnostic criteria for major depressive disorder. Depressed mood, guilt, self-harm, agitation, distractibility, apathy, and impaired executive functioning are all part of the diagnostic criteria for major depressive disorder. It's important to note that, except for 2 patients that committed suicide, none of the other depressed patients remained suicidal. The most striking finding was the extent to which depression had impaired my patients' social functioning. On the sixth day of starvation, a male member of the group just gave up, and said that they had no chance of getting any more food. Fortunately, on the seventh day of starvation, the four group members that still had the energy and optimism to hunt, actually killed an elk using their caveman spears. When you watch the video of this caveman experiment, you can see practically all of the symptoms of major depressive disorder appear.
In terms of survival, hibernation or "shutting down" makes sense if there is nothing more you can do in the face of adversity. The factors associated with good mental health are listed on our "Mental Health Rating Scale". When severely depressed, people often become socially withdrawn, and stop their usual social activities.
The average major depressive episode lasts less than one year, but up to 15% of severely depressed individuals commit suicide because they prematurely give up any hope of recovery. During a depression, self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. Summary Of Practice Guideline For The Treatment Of Patients With Major Depressive Disorder. Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement.
With the patient's permission, family members and others involved in the patient's day-to-day life may also benefit from education about the illness, its effects on functioning (including family and other interpersonal relationships), and its treatment [I]. Patients should also be told about the need to taper antidepressants, rather than discontinuing them precipitously, to minimize the risk of withdrawal symptoms or symptom recurrence [I].
Educational tools such as books, pamphlets, and trusted web sites can augment the face-to-face education provided by the clinician [I].
An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder [I] and definitely should be provided for those with severe major depressive disorder unless ECT is planned [I].
For most patients, a selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), mirtazapine, or bupropion is optimal [I]. In patients who prefer complementary and alternative therapies, S-adenosyl methionine (SAMe) [III] or St. Patients receiving pharmacotherapy should be systematically monitored on a regular basis to assess their response to treatment and assess patient safety [I]. If antidepressant side effects do occur, an initial strategy is to lower the dose of the antidepressant or to change to an antidepressant that is not associated with that side effect [I]. Bright light therapy might be used to treat seasonal affective disorder as well as nonseasonal depression [III]. In women who are pregnant, wish to become pregnant, or are breastfeeding, a depression-focused psychotherapy alone is recommended [II] and depending on the severity of symptoms, should be considered as an initial option [I]. As with patients who are receiving pharmacotherapy, patients receiving psychotherapy should be carefully and systematically monitored on a regular basis to assess their response to treatment and assess patient safety [I].
Marital and family problems are common in the course of major depressive disorder, and such problems should be identified and addressed, using marital or family therapy when indicated [II].
The combination of psychotherapy and antidepressant medication may be used as an initial treatment for patients with moderate to severe major depressive disorder [I]. Combining psychotherapy and medication may be a useful initial treatment even in milder cases for patients with psychosocial or interpersonal problems, intrapsychic conflict, or co-occurring personality disorder [II]. Onset of benefit from psychotherapy tends to be a bit more gradual than that from medication, but no treatment should continue unmodified if there has been no symptomatic improvement after 1 month [I]. Generally, 4-8 weeks of treatment are needed before concluding that a patient is partially responsive or unresponsive to a specific intervention [II]. For individuals who have not responded fully to treatment, the acute phase of treatment should not be concluded prematurely [I], as an incomplete response to treatment is often associated with poor functional outcomes.
For patients in psychotherapy, additional factors to be assessed include the frequency of sessions and whether the specific approach to psychotherapy is adequately addressing the patient's needs [I]. For patients treated with an antidepressant, optimizing the medication dose is a reasonable first step if the side effect burden is tolerable and the upper limit of a medication dose has not been reached [II].
For patients who have not responded to trials of SSRIs, a trial of an SNRI may be helpful [II].
For patients whose symptoms have not responded adequately to medication, ECT remains the most effective form of therapy and should be considered [I]. It is important for the clinician discuss the initiation of medication versus a specific type of psychotherapy with the informed consent of the parents or guardian. Medication algorithm for treating children and adolescents who meet DSM-IV criteria for major depressive disorder. We may add an augmenting medication if the child has had a partial response to the initial medication has occurred in prior treatment or when there is the possibility of drug-drug synergy. Medication is more effective for: OCD, Generalized anxiety, School Phobia and Separation anxiety, Panic attacks and agoraphobia. These medications can be used on a short-term basis to control severe anxiety while waiting for SSRI or tricyclic to take effect.
We may use the newer antipsychotics in treatment-resistant OCD but less often in individuals with other forms of anxiety. These are sometimes used as an augmentation strategy in individuals with treatment-resistant OCD.
Beta blockers are useful for peripheral aspects of anxiety, shakiness, palpitations, good for performance-related anxiety, May need EKG or BP check in some cases.
Buspirone (BuSpar): Relatively little in the way of controlled studies that show that it works as a primary medication for anxiety. Medications may be useful for symptoms which interfere with participation in educational interventions or are a source of impairment or distress to the individual.
Alpha Agonists (clonidine guanfacine) These medication sometimes decrease tic frequency and help with explosive behavior and mood swings.
Baclofen and botulinum toxin type A were each effective in treatment of tics in Tourettes syndrome, according to this large open study. Controlled studies in Neurology 2001 showed some benefit but not at impressive as the 1999 study. At this time there is inadequate empirical support for the use of any particular medication to treat PTSD in children (March et al., 1996). Due to the lack of empirical studies evaluating efficacy of treatment for PTSD in children, it is premature to recommend a hierarchy of interventions. Although the research on medication treatment of early-onset bipolar is limited, most clinicians feel that psychopharmacological intervention is a necessary part of treatment.
In the acute phase, an anti-manic medication should be given at a therapeutic dose for at least 4 to 6 weeks before we can tell if it will be effective.

Current evidence suggests that the relapse rate is quite high for early-onset bipolar disorder. Depakote (less likely to cause stomach upset than divalproex sodium) It may be better than lithium for those with rapid cycling mania and depression. The anti-manic medications are often not as effective for bipolar depression, so we may add an antidepressant. If a child is depressed and has a strong family history of bipolar disorder, we may start treatment with a mood stabilizer before starting an antidepressant.
We are located in Northern Baltimore County and serve the Baltimore County, Carroll County and Harford County areas in Maryland. Our services include psychotherapy, psychiatric evaluations, medication management, and family therapy. ABSTRACT: Depression in the elderly significantly affects patients, families, and communities. Depression is the most common mental health problem in the elderly[1] and is associated with a significant burden of illness that affects patients, their families, and communities and takes an economic toll as well. Because of our aging population, it is expected that the num­ber of seniors suffering from depression will increase. Suicide rates are high in the elderly, with an average of 1.3 suicides committed daily by Canadian seniors.
There is also often a tendency for people to see their symptoms as part of the normal aging process, which they are not. The Geriatric Depression Scale (GDS) is a well-validated screening tool for depression in the elderly that comes in two common formats: the 30-item (long form) and 15-item (short-form) self-rating scale. The CCSD relies on an interview with a family member or caregiver as well as with the patient, and is validated for use with nondemented and demented depressed elderly. Diagnostic challenges in the elderly often include the absence of depressed mood, significant cognitive impairment, and high degrees of somatic or physical problems.
TreatmentThe current Canadian practice guidelines for the treatment of depression in the elderly were developed by the Canadian Coalition for Seniors’ Mental Health (CCSMH) in 2006.[1] They were created by experts in the field, are evidence-based, and include both pharmacological and nonpharmacological strategies. Note that most depression studies have been conducted on younger populations, and when mixed-aged groups have been studied older adults have been underrepresented.
If older adults are unresponsive to low doses of antidepressants, higher doses may be required to achieve a therapeutic effect. Choice of antidepressantFortunately there are several antidepressants that have been shown to be efficacious in elderly patients being treated for a major depressive episode without psychotic features. The selective serotonin reuptake inhibitors (SSRIs) and the newer antidepressants buproprion, mirtazapine, moclobemide, and venlafaxine (a selective norepinephrine reuptake inhibitor or SNRI) are all relatively safe in the elderly.
It is important to check sodium levels 1 month after starting treatment on SSRIs, especially in patients taking other medications with a propensity to cause hyponatremia, such as diuretics. Of the SSRIs, fluoxetine is generally not recommended for use in the elderly because of its long half-life and prolonged side effects. Many medical conditions seen in the elderly, such as dementia, Parkinson disease, and cardiovascular problems can be worsened by a tricyclic antidepressant. Also, it is recommended that an ECG and postural blood pressure reading be obtained before starting a patient on a tricyclic antidepressant and after increasing the dose.[1] Tricyclic antidepressant blood levels should be monitored since tricyclics are associated with more toxicity and since blood levels can be high despite low doses because some patients can be slow metabolizers.
Given the side effect profile and high rates of drug-drug interactions, monoamine oxidase inhibitors (MAOIs) are not considered first- or even second-line agents for depression in the elderly.
DosingOnce an antidepressant is selected for an older patient, the starting dose should be half that prescribed for a younger adult[1] in order to minimize side effects.
In the past the recommendation was to “start low and go slow,” although now evidence suggests that it may not be necessary to titrate upwards so slowly in all individuals.
If there is no significant improvement after 2 to 4 weeks on an average therapeutic dose, further increases should be made until there is either a clinical improvement, intolerable side effects, or the maximum suggested dose is reached. It is also important at each visit to monitor for any worsening of depression, emergence of agitation or anxiety, as well as for suicide risk, especially in the early stages of treatment. Treatment to remissionAccording to the current CCSMH guidelines, if there is no improvement in depressive symptoms after 4 weeks or insufficient improvement in symptoms after 8 weeks on the maximum recommended or tolerated dose of an antidepressant, then the antidepressant should be changed. Cross-titrating can be done—weaning the patient off the old antidepressant while introducing the new one—although caution is needed to ensure that there are no interactions between the two antidepressants. If there is significant improvement but not full remission after 4 weeks on the optimized antidepressant, the recommendation is to wait another 4 weeks and then consider add-on treatment if remission is still not achieved.[1] Add-on options include either an antidepressant of a different class, another agent such as lithium, or psychotherapy such as cognitive-behavioral therapy or interpersonal therapy. Newer pharmacological approachesSince the CCSMH guidelines document was published in 2006, newer antidepressant agents have become available including duloxetine and desvenlafaxine, both SNRIs. Atypical antipsychotics used as add-on therapy in the treatment of depression shows some promise. The latest 2009 CANMAT national practice guidelines for the treatment of major depressive disorder in adults[28] recommend the use of atypical antipsychotic agents such as rispiridone, olan­zapine, and aripiprazole as first-line add-on agents in the treatment of depression, while quetiapine is recommended as a second-line add-on agent owing to fewer studies. The use of atypical antipsychotics poses particular problems in older adults given the risk of extrapyramidal symptoms and falls as well as sedation, weight gain, dyslipidemia, and diabetes. Nonetheless, atypical antipsychotics may prove to be an effective treatment for severe or refractory depression in the elderly who fail to respond fully to other medications. SummaryDepression in the elderly is a significant, common, and growing problem that requires treatment. Together, these strategies can help promote the safe use of antidepressants in the elderly.
AcknowledgmentsI would like to thank Dr Martha Donnelly for her encouragement and support in the preparation of this manuscript. Dr Wiese is a clinical instructor in the  Department of Psychiatry at the University of British Columbia.
These Major Depressive Episodes are not due to a medical condition, medication, abused substance, or Psychosis. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.
Computerized diagnosis is less accurate when done by patients (because they often lack insight). There is a fourfold increase in deaths in individuals with this disorder who are over age 55.
Persistent Depressive Disorder often precedes the onset of this disorder for 10%-25% of individuals. The prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in those aged 60 or older. These vascular depressions are associated with greater neuropsychological impairments and poorer responses to standard therapies. About 5%-10% of individuals with Major Depressive Disorder eventually convert into Bipolar Disorder.
Major Depressive Disorder, particularly with psychotic features, may also convert into Schizophrenia, a change that is much more frequent than the reverse.
The presence or absence of stressful life events does not appear to provide a useful guide to prognosis or treatment selection. Heritability is approximately 40%, and the personality trait neuroticism accounts for a substantial portion of this genetic liability. Thus ECT is effective during the acute treatment phase in hospital, but steadily loses its benefit after hospital discharge. St John's wort and regular exercise appear mildly effective in the treatment of depression (but their effect size is small).
Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. The patient is usually distressed by these but will probably be able to continue with most activities. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-).
This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.
During major depressive disorder, individuals lack the essential social skills of self-confidence, optimism, belonging, and sociability.
Both cooperation and learning are made possible by the brain's emotional reward and punishment function. This instinctual response is built into the brains of all higher primates, as is the emotion of guilt. Unlike emotions, these 4 problems are not adaptive, but are symptoms of brain malfunctioning. For example, there is an optimal level of eating: too much or too little is life-threatening. I recorded their progress on every office visit using my Internet Mental Health Quality of Life Scale. In this way, I could statistically determine which symptoms were elevated in major depressive disorder. As expected, these classical symptoms of major depression decreased as my patients recovered. Thus suicide is a tragic waste of life; especially when major depressive disorder is so time-limited. By the fourth day of starvation, the entire group suffered from severe fatigue, insomnia and apathy. So depression can be triggered by a physical illness or stress, an addiction to alcohol or drugs, or a significant psychological or social stress.
The following shows which items on this scale would be rated as abnormal for Major Depressive Disorder.
They have depressed or apathetic mood, loss of self-esteem, and ideas of worthlessness or guilt. John's wort [III] might be considered, although evidence for their efficacy is modest at best. It is also important to assess the quality of the therapeutic alliance and treatment adherence [I].
It is also important to inform and involve the child or adolescent to the extent that it is developmentally appropriate.
The Children’s Medication Algorithm Project algorithms are in the public domain and may be reproduced without permission, but with appropriate citation. However, many of us have seen children and adolescents who have clearly benefited from these medications. Advantages of augmentation include the fact that one need not stop the initial SSRI, the lack of a response lag, and the possibility of drug-drug synergy. Because the tricyclics are more likely to cause rhythm changes in children, consider baseline and periodic EKGs. They may help break the vicious cycle in which the peripheral aspects of anxiety increase the person’s perception of an impending panic attack. The medications are not specific to autism and do not treat core symptoms of the disorder and their potential side effects should be carefully considered. Families should be helped to make informed decisions about their use of alternative treatments.

However because of the long and short-term side effects of these medications, we often try other medications first. A total of 450 patients with tics in Tourettes syndrome, who had either inadequate response or intolerable side effects to conventional treatments, were enrolled. Drawing from the adult literature, it appears that the use of conventional psychotropic medication for PTSD is at most mildly effective (Davidson and March, 1997). However, outpatient psychotherapy is generally considered the preferred initial treatment, with psychotropic medications used as an adjunctive treatment in children with prominent depressive or panic symptoms. Awareness of predisposing and precipitating factors can help identify patients in need of screening with tools such as the Geriatric Depression Scale.
However, it is necessary first to identify and diagnose depression, which can be challenging in this population owing to communication difficulties caused by hearing or cognitive impairment, other comorbidities with physical symptoms similar to those of depression, and the stigma associated with mental illness that can limit the self-reporting of depressive symptoms. Depression in the elderly still goes undertreated and untreated, owing in part to some of these issues.
It is also important to minimize drug-drug interactions, especially given the number of medications elderly pa­tients are often taking. In choosing an antidepressant it is recommended that selection be based on the best side effect profile and lowest risk of drug-drug interactions. They have lower anticholinergic effects than older antidepressants and are thus well tolerated by patients with cardiovascular disease.
Increased side effects from antidepressant use in the elderly are thought to be due to changes in hepatic metabolism with aging, concurrent medical conditions, and drug-drug interactions.
Instead, the goal should be to increase the dose regularly as tolerated at 1- to 2-week intervals in order to reach an average therapeutic dose more quickly,[20] with the CCSMH guidelines suggesting therapeutic dosing be reached within a month. Thus, it is important to schedule regular follow-up visits to monitor treatment response while assessing for side effects and titrating accordingly.
This may result in a loss of clinical improvement as the patient is weaned off the agent and started on another. For example, if fluoxetine is being discontinued, then a wash-out period of several weeks is recommended because of the drug’s long half-life. If a second antidepressant is added, monitor for the emergence of serotonin syndrome, which can arise if both medications are serotonergic. However, the CANMAT recommendations are based on studies of younger adults and are not intended for the elderly. Atypical antipsychotics at the lowest doses for symptom control are also recommended for the treatment of psychotic symptoms associated with depression. Besides medications, other therapies for depression that might be considered include various forms of psychotherapy and neurostimulation, with electroconvulsive therapy still being the gold standard for severe or psychotic depression. National guidelines for seniors’ mental health: The assessment and treatment of depression. She is also a psychiatrist with the UBC Hospital Mood Disorders Centre, and the Geriatric Psychiatry Outreach Team at Vancouver General Hospital. The effectiveness of ECT vs sham ECT at one or more months posttreatment is still controversial.
Each of these 5 basic dimensions of human behavior functions with a separate set of emotions. Thus evolution has hard-wired humans to feel anger when others harm them, and to feel guilt when they harm others. The brain maintains self-control over many behaviors by using its "craving-disgust" emotional function. Three members of the group became dysfunctional and just spent the day lying down or sitting. As the child or adolescent gets older he or she should be increasingly involved in the treatment decisions.
Medications used to augment the SSRIs include Lithium, buspirone stimulants, and bupropion.
If there is suspicion that this is a manifestation of a bipolar disorder, one may also consider treating the patient with an antipsychotic alone or with an antipsychotic along with a mood stabilizer.
Minimal anticholinergic or cardiac side effects Anxiety and agitation may occur when starting or increasing the dose of an SSRI. The neuroleptics, selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium and mood stabilizers, and anxiolytics have been used in these patients with varying degrees of success. The older antipsychotics, such as haloperidol and thioridazine have been effective treatments but have significant short-term and long term side effects are problematic. After diagnosis, regular follow-up and active medication management are crucial to maximize treatment and remission.
Nonetheless, in recent years there is an increasing body of literature specific to the elderly (as referenced below), which helps guide the clinician in the appropriate prescription and use of antidepressants in this patient population. For a list of commonly used antidepressants and associated doses for older adults, see the accompanying Table.
Identification followed by a thorough assessment can help guide the selection of an appropriate antidepressant medication. When choosing a specific medication, one should consider what the child has responded to in the past and which medications have worked well in close relatives.
Some clinicians also use thyroid hormone to augment antidepressants, but there is limited data to support this. If the dose adjustment is done gradually, many people develop tolerance to this side effect develops. It is important to educate the child and family to understand the importance of continuing treatment even when the child feels fine. Some patients develop a more treatment-resistant form of bipolar disorder if effective medication is stopped.
One must check lab tests for blood level and check for lowered white blood cell count and for elevated liver studies. The FDA has approved risperidone for children and adolescents with aggressive, agitated behavior associated with autism.
Selection of an antidepressant medication should be based on the best side effect profile and the lowest risk of drug-drug interaction. There are several factors to consider when selecting, adjusting, and changing antidepressants in the elderly. If the brain decides that a cooperative or problem-solving effort should cease; you feel emotional detachment and stop caring. Self-control can break down and cause impulsivity when the brain's normal inhibitions fail. As compared to adults, adolescents are a bit more likely to become agitated or to develop a mania while they are taking an SSRI.
One hundred eighty-six patients received BTX-A injection in affected muscles of the neck, face, and extremities.
Harmon and Riggs (1996) reported a decrease in at least some PTSD symptoms in all seven children included in an uncontrolled clinical trial using clonidine patches. Because of their favorable side effect profile and evidence supporting effectiveness in treating both depressive and anxiety disorders, SSRIs often are the first psychotropic medication chosen for treating pediatric PTSD. There is some suggestion that children and adolescents may be more susceptible weight gain associated with these medications.
If remission is not achieved, then add-on treatments, including other drugs and psychotherapy, may be considered. Now we will treat these individuals but will follow the tics with Tourettes tic checklists.
Of these, 31 required small doses of baclofen for complete control of vocal tics, and 4 required vocal cord injections of BTX-A to achieve even partial control of vocal tics.
Further, the older antipsychotics were helpful for the positive symptoms of schizophrenia such as agitation and hallucinations.
In cases of severe, psychotic, or refractory depression in the elderly, electroconvulsive therapy is recommended. In Schizophrenia and related disorders, there is malfunctioning of the brain's "detachment" function. These older medications were not as good at addressing the negative symptoms social withdrawal and emotional blunting. In my own experience I see somewhat more restlessness and disinhibition and a bit less of the sexual side effects in children and adolescents. Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. Fluoxetine now has FDA approval for the treatment of depression in children and adolescents. The association of depression and mortality in elderly persons: A case for multiple, independent pathways. National guidelines for seniors’ mental health: The assessment of suicide risk and prevention of suicide. In mid 2003, the FDA recommended that paroxetine (Paxil) not be used in children or adolescents under 18. Development and validation of a geriatric depression screening scale: a preliminary report. Pharmacological and psychological treatments for depressed older patients: A meta-analysis and overview of recent findings. Feasibility and effectiveness of treatments for depression in elderly medical inpatients: A systematic review. Hyponatraemia in elderly psychiatric patients treated with Selective Serotonin Reuptake Inhibitors and venlafaxine: A retrospective controlled study in an inpatient unit. Antidepressant pharmacotherapy in the treatment of depression in the very old: A randomized, placebo-controlled trial.
The safety and tolerability of duloxetine in depressed elderly patients with and without medical comorbidity. Time to response for duloxetine 60 mg once daily versus placebo in elderly patients with major depressive disorder. Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults.
Efficacy and safety of adjunctive aripiprazole in major depressive disorder in older adult patients: A pooled subpopulation analysis. Placebo-controlled study of relapse prevention with risperidone augmentation in older patients with resistant depression. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults.
Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials.

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