Treatment-resistant depression (TRD) is a significant clinical problem that continues to pose major challenges in Psychiatry. Despite years of clinical research and multiple attempts to implement into practice consensus conference-derived treatment algorithms, pharmacologic treatment options for TRD continue to yield inconsistent and often unsatisfactory outcomes. The management of mood disorders in the elderly poses unique challenges, due to biologic and psychosocial factors that often complicate response to treatment. In addition, the frequent atypicality of the clinical presentation of depression in the elderly and frequent neuropsychiatric and medical comorbidities tend to blur diagnostic issues. The published evidence-basis regarding pharmacologic treatment options for TRD in the elderly is sparse. A wide variety of (often creative) combination treatment regimens and augmentation options have been described (e.g.: lithium; tri-iodothyronine; psychostimulants; beta-blockers; concomitant treatment with serotonergic, noradrenergic, and dopaminergic agents; and other tactics), reflecting the inadequacy of available treatments. Further, this is essentially an uncontrolled (open-label) literature, and there is minimal consensus among clinicians regarding appropriate treatment approaches. Serotonin-dopamine antagonists (SDA’s), prescribed as and generally referred to as atypical antipsychotic drugs, have aroused interest in their possible utility for clinical problems beyond psychotic-spectrum disorders, e.g. in mood and anxiety disorders. It has been suggested that SDA’s with CNS alpha-adrenergic activity may have particular efficacy in these disorders. The utility of augmentation with the SDA risperidone in patients with non-refractory mood disorder has been previously reported A pilot open-label study of low doses of risperidone, as augmentation therapy for TRD in a sample of patients of different age, suggested enhanced efficacy of this agent for TRD . Since risperidone is widely used in the elderly and has been well studied in older adult populations with other disorders , it has been speculated that it might be helpful in the treatment of TRD in this population. We conducted a retrospective review of the records of older adults referred for treatment of TRD in a community-based tertiary-referral geropsychiatry practice. Most of these patients were treated with combinations of different medications, many with augmentation approaches. We report here our experience in the use of risperidone as a specific augmentation strategy in older adults with mood disorders resistant to other treatments. We will describe demographics, medical history including comorbidity prevalence, and history of prior treatment for depression. Treatment outcomes including efficacy parameters and tolerability of treatment will be reported. We will address heterogeneity of response to risperidone augmentation, dose-response relationship, and will identify possible predictors of response to this strategy.
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