Hard on the Liver??? . . . Good for the mood???

My mother has cirrhosis of the liver and also severe depression. She is 70 yrs. old What would be the safest med for her to take??? She seems to be unable to live and manage her issues due to depression.

In general, depression in the elderly can be very difficult to treat.  As with children, they are very often NOT the masters of their environment as much as we “adults” are.  They are increasingly dependent on others for their needs and look forward to a future where that dependence grows.  They have a variety of aches and pains and, again, look forward to a future where that pattern of aches and pains tends to grow.  Add to that the growing number of peers/family/friends that have passed on along with a growing sense that your time is coming soon . . . lots of reasons to feel sad.  Sometimes, that normal stage of life sadness that must be addressed can move over into true clinical depression.  The criteria are the same as depression in the adult population, but the presentation can be a little different.  Too often, the presentation of the depression is chalked up to “grandma getting older . . .” .  This can include reductions in appetite, increase in sleep, worsening concentration, etc.  Older folks can truly look and act quite demented when, in fact, it is not related to an organic cognitive decline, but be part of the depressive syndrome.  Because of the overlap of depression with “normal aging”, dementia, medical illness, and side effects from medicine (an often missed cause of mood issues in older adults), it is imperative that you have your mother seen by a psychiatrist who is competent in the management of older adults.  There are some psychiatrists who specialize in the management of the geriatric population (there is a Board Certification that is now available), many general psychiatrists have extensive experience and good clinical skills and can do just fine.  As in the search for a psychiatrist for anyone, it often takes a bit of searching and probing to find the right fit.  If your parent is very dependent on you, you might even go in with them to the interview to make sure that all the information is given to the provider.

As far as medication for depression in the elderly, most of the SSRI’s are just fine.  Of that group, I tend to use Zoloft and Lexapro more often that the others.  Prozac is just so slowly metabolized, anyway, and in someone with a compromised liver, I would shy away from that.  Paxil and Prozac tend to have more drug-drug interactions than Zoloft and Lexapro.  Of the antidepressants in general, Cymbalta is the medicine to stay away from if you have compromised liver functioning.  Studies have shown significant delay in metabolizing this medicine effectively, making it more difficult to manage and it can possible be damaging to the liver if liver disease already exists.

–Dan Hartman, MD

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