If It Ain’t Broke: Reflections on Long-Term Pharmacotherapy in Geriatric Depression

When I first met C.W. in 2003, he was a 66-year-old African American who heard about our longitudinal depression study from his primary care physician. C.W., a tall, thin gentleman, had done a lot for his community, giving back by using his CPA background to help low-income people with finances, mowing people’s lawns—activities that necessitated his spending time away from home. “I guess I neglected my wife,” he said. He had recently moved into an apartment at his wife’s request, and she had initiated divorce proceedings. Later, he found out that she had met someone else. They had been married over 40 years and had two daughters.

He endorsed low mood and marked social withdrawal. “I don’t feel like doing anything anymore,” he said. He no longer felt motivated to help others, and he was finding it increasingly difficult to help others with taxes and finances due to poor concentration, to the point that he was afraid that he’d get someone into trouble with the IRS or creditors.

His energy was low, he had middle insomnia, his appetite had dropped, and he had lost about five pounds in the prior two months. His blood sugar and blood pressure were both up. He had no active suicidal thoughts, but he often felt “not worth a damn” and occasionally wished that he could “just die in my sleep.”

In the study, everyone was started on sertraline. He did, of course, meet criteria for major depression, but given the life circumstances surrounding his depression, I wasn’t entirely convinced that medication would be all that helpful. In fact, he didn’t experience much relief at 50 mg after four weeks, so he was titrated up to 100 mg. To both of our amazement, three months into the study, he was in remission! His mood and outlook were much better (despite the marital issues), and he was feeling better physically; his diabetes and hypertension were both under better control without any new medications. “I’m feeling myself again,” he announced at his 12-week visit.

Was this a true response to medication? On the one hand, sertraline had been shown to be effective in patients with vascular risk. On the other hand, I had a nagging suspicion about a placebo effect, and even thought about the fact that his participation in the study meant that he met not only with me, but with a research coordinator as well, two people interested in hearing his story and offering encouragement. Some might call that supportive psychotherapy.

In the ensuing six months, he thrived. A new love interest entered the picture, and he took some pride in saying that he was “moving on.” We started to have discussions about backing off on the medication, and at nine months we decided that he should begin gingerly, with a taper to 75 mg daily for two weeks then to 50 mg daily. The plan was to meet in six weeks—in retrospect, far too long, but in my defense, I wasn’t absolutely convinced about the sertraline. He called a week before the appointment to give me a “heads up” that “things aren’t going that well for me.” His anhedonia and motivation had sunk, and his concentration had dipped. He didn’t want to do anything with his medications at that time.

The following week, in the office, he described how things “went south” a couple of weeks after he dropped his dose to 50 mg. After reviewing some options, we decided to titrate him back to 100 mg. Two weeks later, he was fine, and we quickly set a course to stick with this dose for the foreseeable future. In the ensuing years, we periodically spoke of decreasing the dose, but C.W. was vehemently against it. “It’s working for me, and I don’t want to make a change” was a familiar refrain.

What I learned from C.W. is what I have been teaching for years—there are many ways for older adults to get into a major depression, and they usually involve some kind of loss, but if you have targetable depression symptoms, medications have an important role in treating depression and preventing relapse over the long haul. Sometimes it takes a patient like C.W. to punctuate how important it is to practice what we preach. ■