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Clinical Atlas Prestige · Evidence-first

Psych VivasOld age psychiatry — mood disorders

Psych Vivas · Old age psychiatry — mood disorders

Late-life depression — structured clinical viva

Fellowship viva covering vascular depression phenotype, under-treatment versus true non-response, older-adult antidepressant safety, ECT, suicide lethality, and maintenance evidence.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar. An 81-year-old woman with hypertension and prior lacunar stroke presents with six months of apathy, slowed thinking, low mood, and executive dysfunction on bedside testing. Family say she is 'not herself' since her husband died last year. She has failed an inadequate six-week trial of sertraline 25 mg daily. Discuss formulation (including vascular depression), further assessment, next treatment steps including dosing philosophy, ECT indications, suicide risk in older adults, and maintenance after recovery.

Interpretation

Reveal interpretation

Formulate as late-life major depression with vascular features and bereavement context, not "normal ageing" or automatic irreversible dementia. Vascular depression is a phenotype linking cerebrovascular disease to depression with executive dysfunction — useful for prognosis and treatment expectations, not a separate DSM code.[1][5]

The sertraline 25 mg trial is inadequate (token dose / incomplete titration). Re-check adherence, bipolarity, substances, medical contributors, sodium if any SSRI exposure, cognition with collateral, and suicide risk with means. Then treat to a therapeutic dose of a suitable agent or switch, with sodium and falls monitoring, while offering adapted psychotherapy and addressing isolation/grief.[5][6]

If severe melancholic/psychotic features, high risk, or true non-response after adequate trials, discuss ECT early using PRIDE-informed framing of efficacy in geriatric depression.[3] Older adults have high suicide lethality — ask directly and restrict means.[4] After recovery, plan maintenance antidepressant rather than early cessation (Reynolds NEJM 2006).[2]

Key points

Vascular phenotype changes expectations

Executive dysfunction and vascular burden may slow or attenuate response — still treat actively and optimise vascular risk.

25 mg is not an adequate trial

Start low, go slow, but go to therapeutic dose and duration before declaring resistance.

Maintenance after remission

Continuation treatment reduces recurrence risk in older adults after recovery from major depression.
[1] [2] [5]

References

  1. [1]Alexopoulos GS, Meyers BS, Young RC, et al. 'Vascular depression' hypothesis Arch Gen Psychiatry, 1997.PMID 9337771
  2. [2]Reynolds CF 3rd, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age N Engl J Med, 2006.PMID 16540613
  3. [3]Kellner CH, Husain MM, Knapp RG, et al. Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study Am J Psychiatry, 2016.PMID 27418379
  4. [4]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168
  5. [5]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
  6. [6]Fabian TJ, Amico JA, Kroboth PD, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study Arch Intern Med, 2004.PMID 14769630