Nortriptyline in geriatric depression resistant to serotonin reuptake inhibitors: Case series

Research on treatment-resistant depression in the elderly has been limited, and recommendations for clinical management have often been extrapolated f rom studies using nongeriatric patients. This report describes a series of 10 elderly patients with refractory depression who were treated with nortri ptyline after failing to respond to an adequate trial of a serotonin reupta ke inhibitor. Seven (70%) of the patients responded to the addition or subs titution of nortriptyline. All seven of the responders have remained on nor triptyline for maintenance therapy, none of whom have experienced recurrenc e of their depression after an average treatment duration of 1 year. Respon se to nortriptyline occurred in about 4 weeks in most patients. The mean da ily dose of nortriptyline was 54 mg, and the mean plasma level was 97 ng/mL . Minor side effects occurred in three patients. No patients developed sign ificant electrocardiogram changes. Nortriptyline, possibly due to its diffe rent mechanism of action, may be effective as either an adjunctive or repla cement antidepressant in some cases of geriatric depression that are resist ant to serotonin reuptake inhibitors.