📋 Key Information Summary
- Late-life depression affects approximately 10–15% of older Australians living in the community and up to 35% in residential aged care facilities (RACFs), yet remains significantly under-recognised and under-treated.
- Depression in older adults frequently presents atypically — somatic complaints, cognitive decline ("pseudodementia"), functional deterioration, irritability and social withdrawal may predominate over low mood.
- The Geriatric Depression Scale-15 (GDS-15) and PHQ-9 are validated screening tools in Australian primary care; GDS-15 is preferred in older adults due to exclusion of somatic symptom items.
- Anxiety disorders are the most common mental health condition in older adults, often comorbid with depression, and are frequently overlooked in routine clinical encounters.
- Insomnia and sleep disturbance are both risk factors for and symptoms of depression; behavioural interventions (CBT-I) should precede pharmacotherapy where possible.
- Late-life psychosis may stem from delirium, dementia (especially Lewy body dementia), late-onset schizophrenia, or medication adverse effects — a thorough medical workup is essential before initiating antipsychotics.
- Older Australian men (particularly those ≥85 years) have the highest suicide rate of any age group; all depression assessments must include explicit suicide risk evaluation using a structured tool.
- SSRIs are first-line pharmacotherapy for late-life depression — sertraline and escitalopram are preferred due to favourable safety profiles; citalopram must not exceed 20 mg/day in patients ≥65 years due to QTc prolongation risk.
- Psychological therapies — particularly CBT, problem-solving therapy and interpersonal therapy — have strong evidence in older adults and should be offered alongside or instead of medication.
- Benzodiazepines should be avoided in older adults (Beers Criteria); if used for acute crisis only, short-acting agents at half the standard adult dose with a clear taper plan are recommended.
- Antipsychotics in dementia-related behavioural disturbance carry a TGA black triangle warning for increased cerebrovascular events and mortality; use should be time-limited with regular review and non-pharmacological strategies trialled first.
- Aboriginal and Torres Strait Islander older adults face significantly higher rates of psychological distress, grief, and suicide; culturally safe, trauma-informed, and community-led mental health care is essential.
- Polypharmacy is common in older adults — all psychotropic prescribing requires a medication review to identify drug–drug and drug–disease interactions, particularly with anticholinergic burden.
Introduction & Australian Epidemiology
Mental health conditions in later life represent a major and growing public health challenge in Australia. As the population ages — with those aged ≥65 years projected to comprise over 20% of the Australian population by 2066 — the burden of late-life depression, anxiety, psychosis, sleep disorders and suicide risk will increase substantially. These conditions frequently coexist with chronic medical illness, polypharmacy, cognitive decline, sensory impairment, bereavement, social isolation and functional dependency, making diagnosis and management complex.
Late-life depression may present with somatic symptoms, cognitive complaints ("pseudodementia") or functional decline and often coexists with medical illness. Unlike younger adults, older people are more likely to express distress through physical complaints, apathy, anorexia or psychomotor retardation rather than overt sadness. This atypical presentation contributes to the widely documented under-diagnosis of depression in Australian primary care, where fewer than 50% of cases are identified.
| Condition | Community Prevalence (≥65 yrs) | RACF Prevalence | Key Australian Data Source |
|---|---|---|---|
| Major depressive disorder | 1–5% | 10–20% | ABS National Survey of Mental Health and Wellbeing |
| Depressive symptoms (clinically significant) | 10–15% | 25–35% | AIHW Older Australians Report 2023 |
| Generalised anxiety disorder | 3–7% | 10–15% | Beyond Blue, The Snapshot Report |
| Insomnia disorder | 20–40% | 50–70% | Sleep Health Foundation |
| Delirium (acute psychosis aetiology) | 1–2% (community) | 10–40% (acute hospital) | Australasian Delirium Association |
| Dementia-related behavioural disturbance | ~425,000 Australians with dementia overall | 50–90% exhibit BPSD | Dementia Australia / AIHW |
| Suicide (males ≥85 years) | ~35 per 100,000 (highest rate nationally) | N/A | ABS Causes of Death 2022 |
Under-diagnosis is the norm: Fewer than half of older Australians with clinically significant depression receive a diagnosis, and fewer still receive evidence-based treatment. Older adults are significantly less likely to be referred to mental health services compared with younger adults presenting with equivalent symptom severity.
Risk factors for late-life mental health conditions include: chronic pain, cardiovascular disease, stroke, diabetes, cancer, sensory impairment (vision/hearing), polypharmacy, cognitive decline, prior psychiatric history, social isolation, bereavement, loss of independence, residential transition (e.g. entering RACF), financial stress, and history of trauma. Medications with psychiatric adverse effect potential — including corticosteroids, beta-blockers, opioids, anticholinergics, fluoroquinolones and some antihypertensives — must always be reviewed.
Depression Screening and Diagnosis
Systematic screening for depression is recommended for all adults aged ≥65 years in Australian primary care settings, particularly those with chronic medical conditions, recent bereavement, social isolation, sensory impairment or functional decline. The RACGP red book recommends routine screening at annual health assessments (MBS item 701, 703, 705, 707).
Validated Screening Tools for Older Adults
| Tool | Items | Cut-off | Strengths | Limitations |
|---|---|---|---|---|
| Geriatric Depression Scale-15 (GDS-15) | 15 | ≥5 (depression likely) | Excludes somatic items; well validated in older adults; suitable for mild cognitive impairment | Requires verbal communication; not suitable for severe aphasia |
| PHQ-9 | 9 | ≥10 (moderate depression) | Widely used in Australian primary care; assesses severity; monitors treatment response; free to use | Includes somatic items that may inflate scores in medically unwell patients |
| PHQ-2 | 2 | ≥3 (proceed to full screen) | Rapid initial screen; suitable for time-limited consultations | Insufficient alone; must be followed by PHQ-9 or GDS-15 if positive |
| Kessler-10 (K-10) | 10 | ≥22 (likely disorder) | Measures general psychological distress; widely used in Australian population surveys | Not depression-specific; less validated in the very elderly |
| Cornell Scale for Depression in Dementia (CSDD) | 19 | ≥8 (probable depression) | Designed for patients with cognitive impairment; incorporates informant report | Requires trained rater; takes 20 min; limited availability outside RACFs |
Diagnostic Criteria — DSM-5 and ICD-11 in Older Adults
Major depressive disorder in older adults is diagnosed using the same DSM-5 criteria as in younger adults: ≥5 of 9 symptoms during the same 2-week period, representing a change from previous functioning, with at least one being depressed mood or loss of interest/pleasure. However, several diagnostic nuances apply in the geriatric population:
- Depressed mood may present as apathy, irritability, or "I don't care anymore" rather than overt sadness — always probe beyond "Do you feel depressed?"
- Cognitive symptoms (poor concentration, indecisiveness, memory complaints) may dominate, mimicking dementia ("pseudodementia") — depression-related cognitive impairment typically has a more acute onset, patient awareness of deficits, and patchy performance on cognitive testing compared with the insidious, anosognosic pattern of true dementia.
- Somatic symptoms (fatigue, appetite change, sleep disturbance) are common in both depression and medical illness — a clinical judgment is required regarding attribution.
- Bereavement — the DSM-5 removed the bereavement exclusion, but clinicians must distinguish normal grief from major depression. Grief is characterised by waves of emotion tied to memories, preserved self-esteem and gradual improvement over months; depression involves pervasive low mood, marked functional impairment, suicidal ideation and worsening over time.
- Persistent depressive disorder (dysthymia) is common in older adults and may be a chronic unrecognised condition; requires ≥2 years of depressed mood on most days.
- Substance/medication-induced depressive disorder must always be considered — review all medications, alcohol intake, and over-the-counter preparations.
Never attribute new cognitive decline to depression without full assessment. "Pseudodementia" is a diagnosis of exclusion. All patients with new-onset cognitive symptoms and low mood require cognitive screening (MoCA or MMSE), basic bloods (TSH, B12, folate, glucose, renal function) and, when indicated, brain imaging and specialist referral. Missing early dementia or a space-occupying lesion has devastating consequences.
Differential Diagnosis Checklist
- Dementia (Alzheimer disease, vascular, Lewy body, frontotemporal)
- Delirium (hypoactive delirium is frequently mistaken for depression)
- Hypothyroidism or hyperthyroidism
- Vitamin B12 or folate deficiency
- Normal pressure hydrocephalus
- Medication adverse effects (beta-blockers, corticosteroids, opioids, anticholinergics, interferon, isotretinoin)
- Substance use (alcohol, benzodiazepine dependence)
- Chronic pain syndromes
- Grief and adjustment disorder
- Parkinson disease (apathy and depression are common non-motor features)
Anxiety and Sleep Disorders
Anxiety Disorders in Older Adults
Anxiety disorders are the most prevalent mental health conditions among older Australians, with generalised anxiety disorder (GAD) being the most common subtype. Prevalence estimates range from 3–7% for diagnosable anxiety disorders to 15–20% for clinically significant anxiety symptoms in community-dwelling older adults. Anxiety in later life is frequently comorbid with depression (50–60% of cases), chronic pain, cardiac disease and respiratory disease, and is associated with increased disability, healthcare utilisation and reduced quality of life.
Older adults with anxiety may present with:
- Excessive worry about health, finances, family safety or functional decline
- Somatic symptoms: chest tightness, dyspnoea, dizziness, GI disturbance (which may trigger cardiac and respiratory investigations)
- Avoidance behaviour: refusing to leave home, declining medical appointments, fear of falling
- Sleep disturbance (onset and maintenance insomnia)
- Reassurance-seeking behaviour in medical consultations
- Irritability and restlessness
Screening Tools for Anxiety
- GAD-7 (≥10 suggests generalised anxiety disorder) — free, validated in older adults, widely used in Australian primary care
- Geriatric Anxiety Inventory (GAI) — 20-item dichotomous (agree/disagree) tool specifically designed and validated for older adults; avoids somatic symptom items; cut-off ≥10/20
- Mini-Social Phobia Inventory (Mini-SPIN) — 3-item screener for social anxiety
Sleep Disorders in Later Life
Sleep disturbance affects 20–40% of community-dwelling older adults and up to 70% of RACF residents. Age-related changes in sleep architecture (decreased slow-wave sleep, increased nighttime awakenings) are normal, but clinically significant insomnia disorder is not an inevitable consequence of ageing. Insomnia in older adults is both a risk factor for and a symptom of depression, anxiety, chronic pain, nocturia and medication adverse effects.
| Sleep Disorder | Key Features | Differential Considerations |
|---|---|---|
| Insomnia disorder | Difficulty initiating/maintaining sleep, early morning waking, non-restorative sleep ≥3 nights/week for ≥3 months with daytime impairment | Depression, anxiety, chronic pain, nocturia, caffeine, medication effects, restless legs syndrome |
| Obstructive sleep apnoea (OSA) | Snoring, witnessed apnoeas, excessive daytime somnolence, morning headache | Obesity, heart failure, stroke; CPAP adherence is often poor in elderly — consider mandibular advancement devices |
| Restless legs syndrome (RLS) | Uncomfortable leg sensations at rest, relieved by movement, worse in evening | Iron deficiency (check ferritin), renal impairment, SSRIs may worsen symptoms |
| REM sleep behaviour disorder | Dream enactment, vocalisation, violent movements during sleep | Strong association with synucleinopathies (Parkinson disease, Lewy body dementia); requires neurological referral |
| Circadian rhythm disruption | Advanced sleep phase (early evening drowsiness, early morning awakening), sundowning in dementia | Reduced light exposure, institutional schedules, neurodegenerative disease |
Screen for sleep apnoea before prescribing sedating agents. Benzodiazepines and sedating antihistamines worsen OSA, increase fall risk, and cause cognitive impairment in older adults. Always consider OSA in overweight or obese older adults with daytime somnolence and refer for sleep study (MBS item 12203/12250) when suspected.
Psychosis and Suicide Risk
Late-Life Psychosis
Psychotic symptoms (hallucinations, delusions, disorganised thinking) in older adults require urgent and thorough evaluation because the differential diagnosis is broad and the aetiology determines management. Unlike younger adults where schizophrenia is the most common cause, psychosis in later life is more likely due to delirium, dementia, medication effects or medical illness.
| Aetiology | Key Features | Initial Approach |
|---|---|---|
| Delirium | Acute onset (hours–days), fluctuating course, inattention, altered consciousness, disorientation | Medical emergency — identify and treat underlying cause (infection, metabolic, medication, constipation, pain, urinary retention) |
| Dementia-related psychosis (BPSD) | Visual hallucinations (especially Lewy body), paranoid delusions (theft, infidelity), agitation; chronic and progressive course | Non-pharmacological strategies first; antipsychotics only if severe distress/safety risk — risperidone 0.25–0.5 mg BD (authority required for PBS) |
| Late-onset schizophrenia (≥60 years) | Persecutory/paranoid delusions, often preserved affect, auditory hallucinations; more common in women, socially isolated, sensory impairment | Low-dose antipsychotic (see drug cards below); hearing/vision correction; social support |
| Depressive psychosis | Nihilistic delusions, guilt, hypochondriacal beliefs, somatic delusions in context of severe depression | Treat as severe depression — antidepressant ± antipsychotic ± ECT |
| Medication-induced | Anticholinergics, dopaminergic agents, corticosteroids, opioids, benzodiazepine withdrawal | Medication review and cessation of offending agent |
| Medical causes | UTI (especially in women), pneumonia, metabolic derangement, hepatic encephalopathy, B12 deficiency, syphilis, HIV | Full medical workup including bloods, urinalysis, chest X-ray, brain imaging as indicated |
TGA Warning — Antipsychotics and Dementia: All antipsychotics carry a TGA black triangle warning for use in dementia-related behavioural disturbance. Risperidone is the only antipsychotic with a PBS Authority Required listing for this indication (behavioural disturbances of dementia where non-pharmacological measures have failed). These agents are associated with increased risk of cerebrovascular events (1.5–3×), mortality (1.6×), falls, metabolic syndrome and QTc prolongation. Use the lowest effective dose for the shortest possible duration with regular documented review.
Suicide Risk in Older Australians
Suicide in later life is a critical and under-recognised public health emergency. Older Australian men (particularly those aged ≥85 years) have the highest suicide rate of any demographic group at approximately 35 per 100,000. Older adults who die by suicide are more likely to have consulted a GP in the month before death, to have communicated intent to a healthcare professional, and to use highly lethal methods compared with younger adults.
Key risk factors for suicide in older adults:
- Male sex (men account for ~75% of late-life suicides)
- Social isolation and living alone
- Recent bereavement (especially loss of spouse/partner)
- Depression (present in 70–90% of completed suicides)
- Previous suicide attempt (strongest predictor of future attempt)
- Chronic pain and terminal illness
- Functional decline and loss of independence
- Alcohol misuse
- Access to firearms (particularly in rural/remote Australia)
- Institutional transitions (hospital discharge, RACF admission)
- Perceived burdensomeness and thwarted belongingness
Ask directly about suicidal ideation. Asking about suicide does not increase risk and is a mandatory part of every depression assessment. Use direct, clear language: "Sometimes when people feel the way you do, they have thoughts of ending their life. Have you had thoughts like that?" If the answer is yes, assess: plan, access to means, intent, timeline, reasons for living, protective factors. If immediate risk is identified, call 000 or present to the nearest ED. For non-acute risk, develop a safety plan and arrange urgent mental health referral (contact your local Older Persons Mental Health Service or call Lifeline 13 11 14).
Suicide Risk Assessment — Structured Approach
1
Ask directly
Screen all depressed older adults for suicidal ideation using clear, direct questions. Document response.
2
Assess intent and plan
Has the person formulated a plan? Do they have access to means (medications stockpiled, firearms, bridges)? Is there a timeline?
3
Evaluate protective factors
Reasons for living, social connections, religious/spiritual beliefs, engagement with grandchildren, future plans, therapeutic alliance.
4
Determine risk level
Low: ideation without plan. Moderate: ideation with vague plan. High: ideation with specific plan, intent, access to means, recent attempt.
5
Act and document
Immediate: 000 or ED if acute. Urgent: crisis team / Older Persons Mental Health. Planned: GP safety plan, mental health referral, restrict means, involve family/carers with consent. Document risk assessment in notes.
Investigations
All older adults presenting with new-onset depression, anxiety, psychosis or cognitive change require a baseline medical workup to exclude reversible causes. The following investigations are recommended as part of the initial assessment:
Essential
Full blood examination (FBE)
Exclude anaemia, infection, haematological malignancy. MBS item 65060.
Essential
Thyroid function tests (TFTs)
Hypothyroidism and hyperthyroidism both cause mood and cognitive disturbance. MBS item 66719.
Essential
Vitamin B12 and folate
Deficiency causes depression, cognitive impairment, peripheral neuropathy. MBS item 66825/66822.
Essential
Renal function tests (eGFR, electrolytes)
Renal impairment affects drug metabolism; hyponatraemia causes confusion and mood change. MBS item 66515.
Essential
Liver function tests (LFTs)
Hepatic dysfunction affects psychotropic metabolism; exclude alcohol-related liver disease. MBS item 66515.
Essential
Blood glucose / HbA1c
Diabetes is associated with depression; hypoglycaemia causes confusion. MBS item 66551.
Available
Calcium, phosphate, magnesium
Hypercalcaemia, hypomagnesaemia cause psychiatric symptoms.
Available
Urinalysis / MSU
UTI is a common precipitant of delirium and psychosis in older adults, particularly women and RACF residents.
Available
Cognitive screening (MoCA or MMSE)
Baseline cognition must be assessed in all new presentations of late-life depression. MoCA is more sensitive than MMSE for mild cognitive impairment. MBS item 701 (within health assessment).
Available
ECG (12-lead)
QTc assessment before commencing citalopram, escitalopram, TCAs, antipsychotics. MBS item 11700.
Referral
CT/MRI brain
Consider if cognitive impairment, focal neurological signs, head trauma history, or when dementia is suspected. MBS item 63080/63520 with appropriate clinical indication.
Specialist
Neuropsychological assessment
Referral to clinical neuropsychologist when diagnosis between depression-related cognitive impairment and dementia is uncertain. Limited availability in public system — consider private referral with GP Mental Health Treatment Plan (MBS item 80110).
Specialist
Sleep study (polysomnography)
For suspected obstructive sleep apnoea or REM sleep behaviour disorder. MBS item 12203/12250.
GP Mental Health Treatment Plan (MBS item 2710/2712): Eligible patients can access up to 20 individual and 10 group sessions of psychological therapy per calendar year under Medicare, with a valid GP Mental Health Treatment Plan. This is the primary funding mechanism for accessing psychology and allied mental health services in Australian primary care. Referral letters should specify the diagnosis, treatment goals and preferred therapeutic modality.
Risk Stratification & Severity Assessment
Severity assessment in late-life depression guides treatment intensity and determines the appropriate clinical setting. The following framework integrates PHQ-9/GDS-15 scores with functional impact and suicide risk to guide management decisions:
Mild
Mild Depression
PHQ-9 5–9 or GDS-15 5–8. Subthreshold or mild symptoms. Minimal functional impairment. May represent adjustment difficulties or early presentation. No suicidal ideation.
Setting: GP-led care, watchful waiting with review in 2–4 weeks, active monitoring, psychoeducation, social prescribing, lifestyle interventions (exercise, sleep hygiene, social engagement). Consider GP Mental Health Treatment Plan for psychological therapy.
Moderate
Moderate Depression
PHQ-9 10–19 or GDS-15 9–11. Clear depressive symptoms causing significant distress and functional impairment (ADLs, IADLs, social participation). May have passive suicidal ideation without plan. Comorbid anxiety common.
Setting: GP-led with mental health treatment plan. Combination therapy recommended: antidepressant (SSRI first-line) + structured psychological therapy (CBT, PST or IPT). Refer to psychologist under MBS item 2710. Consider older persons mental health team if not responding at 6–8 weeks.
Severe
Severe Depression / Psychotic Depression / Active Suicidality
PHQ-9 ≥20 or GDS-15 ≥12. Marked functional impairment, possible psychotic features (nihilistic delusions, hallucinations), active suicidal ideation with plan and/or intent, severe weight loss, psychomotor retardation, refusal of care.
Setting: Urgent referral to Older Persons Mental Health (OPMH) service. Consider psychiatric admission. ECT is first-line for psychotic depression, life-threatening depression, or treatment-resistant cases with acute risk. Combination pharmacotherapy (antidepressant + antipsychotic for psychotic features). NIMHE consultation if inpatient care required.
The PHQ-9 may overestimate severity in medically unwell older adults because somatic items (fatigue, appetite change, psychomotor disturbance, poor concentration) overlap with medical illness. Always consider clinical context and use the GDS-15 as a complementary tool when somatic comorbidity is prominent.
Psychological, Social and Pharmacological Treatment
Psychological Therapies
Psychological therapies have robust evidence in older adults and should be considered first-line for mild-to-moderate depression and anxiety, and as an essential adjunct to pharmacotherapy in moderate-to-severe depression. Access is via GP Mental Health Treatment Plan (MBS item 2710 for preparation; MBS item 80110 for psychologist sessions).
| Therapy | Evidence Level | Indications | Considerations in Older Adults |
|---|---|---|---|
| Cognitive Behavioural Therapy (CBT) | Level I (multiple RCTs in older adults) | Depression, GAD, insomnia (CBT-I), panic disorder | May require adaptation for hearing impairment (written materials, slower pace), cognitive impairment (simplified worksheets, repetition), and physical disability (telehealth delivery). CBT-I is equally effective in older adults. |
| Problem-Solving Therapy (PST) | Level I | Depression, adjustment to chronic illness, post-stroke depression | Particularly suited to older adults with practical concerns (housing, finances, care transitions). Brief format (6–8 sessions). Can be delivered by trained GPs, OTs, social workers. |
| Interpersonal Therapy (IPT) | Level I | Depression associated with bereavement, role transitions, interpersonal conflict, social isolation | Addresses common late-life psychosocial stressors. Evidence for efficacy in bereavement-related depression. May be combined with pharmacotherapy for moderate-severe cases. |
| Behavioural Activation (BA) | Level I | Depression (particularly effective when physical health limits activity) | Simple, activity-based intervention; can be delivered by trained practice nurses, OTs, and peer workers. Suitable for people with mild cognitive impairment. |
| Reminiscence / Life Review Therapy | Level II | Depression in older adults, particularly RACF residents, end-of-life care | Utilises life narrative and meaning-making. Group or individual format. Well-tolerated even with mild cognitive impairment. Culturally adaptable for Aboriginal and Torres Strait Islander Elders. |
| CBT for Insomnia (CBT-I) | Level I | Chronic insomnia disorder (first-line treatment per AASM/ESRS guidelines) | Sleep restriction therapy, stimulus control, cognitive restructuring of sleep beliefs. Delivered by trained psychologists. Available via telehealth platforms (e.g. Sleepio). Equivalent efficacy to medication with superior durability of effect. |
Social and Non-Pharmacological Interventions
- Structured exercise: 150 minutes/week moderate-intensity activity (walking, swimming, tai chi) — evidence from multiple RCTs shows antidepressant effect equivalent to SSRIs for mild-moderate depression; also reduces falls, improves sleep and cognition. Refer to exercise physiologist (MBS item 10952 under Team Care Arrangements).
- Social prescribing: Linking patients to community-based activities (Men's Sheds, community gardens, volunteer programs, U3A). Address social isolation proactively.
- Technology-assisted interventions: Telephone-based support (e.g. beyondblue helpline 1300 22 4636), internet-delivered CBT (MindSpot Clinic — free, Australian), telehealth consultations.
- Carer support: Assessment of carer burden and mental health, referral to Carer Gateway (1800 422 737), respite care, Dementia Australia counselling (1800 100 500).
- Environmental modification: For RACF residents — increase natural light exposure, reduce noise, maintain consistent routines, person-centred care approaches for BPSD.
- Sensory impairment correction: Arrange audiology and optometry assessment — hearing loss and vision impairment are potent and treatable contributors to depression, anxiety and social isolation in older adults.
Pharmacological Treatment — Antidepressants
Pharmacotherapy is indicated for moderate-to-severe depression, when psychological therapy alone is insufficient, or when the patient prefers medication. The following principles apply in older adults:
- "Start low, go slow, but go" — initiate at half the standard adult dose; titrate every 2–4 weeks based on response and tolerability.
- SSRIs are first-line — sertraline and escitalopram have the most favourable safety profiles in older adults.
- Adequate trial duration: 4–6 weeks at therapeutic dose before declaring non-response; 6–12 months of maintenance after remission (indefinite for recurrent episodes).
- Avoid TCAs as first-line — anticholinergic burden, cardiac toxicity, falls risk, fatal in overdose.
- Monitor for hyponatraemia (SIADH) in the first 2–4 weeks — SSRIs and SNRIs are the most common medication cause of hyponatraemia in older adults. Check sodium at baseline, 1–2 weeks and 4 weeks.
- Bleeding risk: SSRIs increase GI bleeding risk by ~40% — co-prescribe PPI if on concurrent anticoagulant/antiplatelet or history of GI bleeding.
Sertraline
Zoloft® · Generic available · SSRI
Adult dose (≥65 yrs)
Start 25 mg PO OD, titrate to 50–100 mg PO OD over 2–4 weeks; max 200 mg OD
Paediatric dose
N/A (not indicated for this topic)
Renal adjustment
No adjustment required
Hepatic adjustment
Reduce dose or use with caution in severe hepatic impairment
Key interactions
MAOIs (contraindicated), tamoxifen (reduces active metabolite), increased bleeding risk with anticoagulants/NSAIDs
PBS status
✔ PBS General Benefit
Escitalopram
Lexapro® · Generic available · SSRI
Adult dose (≥65 yrs)
Start 5 mg PO OD, titrate to 10 mg PO OD; max 20 mg OD. Some guidelines recommend max 10 mg in elderly due to QTc risk.
Renal adjustment
No adjustment required
Hepatic adjustment
Max 10 mg OD in hepatic impairment
Key interactions
MAOIs (contraindicated), QTc-prolonging agents — dose-dependent QTc prolongation
PBS status
✔ PBS General Benefit
Citalopram
Cipramil® · Generic available · SSRI
Adult dose (≥65 yrs)
Start 10 mg PO OD, max 20 mg OD in patients ≥65 years (TGA/FDA dose ceiling due to QTc prolongation risk at higher doses)
Renal adjustment
No adjustment required
Hepatic adjustment
Max 10 mg OD in hepatic impairment
Key interactions
QTc prolongation risk — avoid with other QTc-prolonging agents (antiarrhythmics, antipsychotics, macrolides, ondansetron)
PBS status
✔ PBS General Benefit
Venlafaxine XR
Effexor-XR® · Generic available · SNRI
Adult dose (≥65 yrs)
Start 37.5 mg PO OD, titrate to 75–150 mg PO OD; max 225 mg OD. Blood pressure monitoring required (dose-dependent hypertension).
Renal adjustment
Reduce dose by 50% if eGFR <30 mL/min
Hepatic adjustment
Reduce dose by 50% in moderate hepatic impairment
Key interactions
MAOIs (contraindicated — serotonin syndrome), may worsen hypertension, discontinuation syndrome on abrupt cessation
PBS status
✔ PBS General Benefit
Duloxetine
Cymbalta® · SNRI
Adult dose (≥65 yrs)
Start 30 mg PO OD for 1 week, then 60 mg PO OD; max 120 mg OD. Dual benefit for neuropathic pain (PBS authority for this indication).
Renal adjustment
Avoid if eGFR <30 mL/min
Hepatic adjustment
Contraindicated in severe hepatic impairment
Key interactions
MAOIs (contraindicated), CYP1A2/2D6 inhibitors, increased bleeding risk
PBS status
✔ PBS General Benefit (depression) · Authority Required (neuropathic pain)
Mirtazapine
Avanza® · Generic available · NaSSA
Adult dose (≥65 yrs)
Start 15 mg PO ON (at bedtime), titrate to 30 mg PO ON. Lower doses (7.5–15 mg) are more sedating — useful when insomnia is prominent. Higher doses (30–45 mg) are more noradrenergic.
Renal adjustment
Use with caution; reduce dose if eGFR <30 mL/min
Hepatic adjustment
Reduce dose by 50% in hepatic impairment
Key advantages
Sedation assists insomnia; appetite stimulation beneficial in cachexia/anorexia; no GI bleeding risk above baseline; no sexual dysfunction; less nausea than SSRIs
Key cautions
Weight gain, metabolic effects, rare agranulocytosis (warn patient to report sore throat/fever)
PBS status
✔ PBS General Benefit
Citalopram 20 mg maximum in patients ≥65 years. Doses above 20 mg/day cause dose-dependent QTc prolongation and risk of fatal cardiac arrhythmia (Torsades de Pointes). This is a TGA-mandated dose ceiling. If higher serotonergic efficacy is required, switch to escitalopram or sertraline rather than exceeding the citalopram dose limit.
Pharmacological Treatment — Psychotic Symptoms and Behavioural Disturbance
Risperidone
Risperdal® · Atypical antipsychotic
Adult dose (≥65 yrs) — dementia-related BPSD
Start 0.25 mg PO BD, titrate slowly; usual range 0.25–1 mg/day. Maximum 2 mg/day but aim for ≤0.5 mg/day in frail elderly.
Adult dose — late-onset schizophrenia
Start 0.5 mg PO OD or BD, titrate to 1–2 mg PO BD; use lowest effective dose
Key cautions
TGA black triangle warning in dementia: ↑CVA risk (1.5–3×), ↑mortality (1.6×). Monitor: ECG, weight, fasting glucose/lipids, falls, parkinsonian features. Avoid in Lewy body dementia (severe neuroleptic sensitivity).
PBS status
Authority Required — behavioural disturbances of dementia where non-pharmacological measures have failed and there is documented risk of harm to self/others
Quetiapine
Seroquel® · Atypical antipsychotic
Adult dose (≥65 yrs)
Start 12.5–25 mg PO ON, titrate slowly; range 25–200 mg/day divided doses. Lower doses (25–50 mg) are sedating; higher doses for psychosis.
Key cautions
Same TGA warnings as risperidone in dementia. Metabolic syndrome (weight gain, hyperglycaemia, dyslipidaemia). Falls risk. Orthostatic hypotension. Post-marketing reports of aspiration pneumonia in elderly.
PBS status
✔ PBS General Benefit (schizophrenia/psychosis) · Not PBS-listed for dementia-related BPSD
Lewy body dementia — extreme caution with antipsychotics. Patients with Lewy body dementia (or Parkinson disease dementia) may develop severe, potentially fatal neuroleptic sensitivity reactions (profound rigidity, autonomic instability, reduced consciousness) with any antipsychotic, including atypical agents. Avoid antipsychotics in these patients where possible. If psychotic symptoms are severe and unavoidable, use the lowest dose of quetiapine under specialist supervision with close monitoring.
Pharmacological Treatment — Anxiety
SSRIs and SNRIs are first-line pharmacotherapy for anxiety disorders in older adults (same agents as for depression). Specific anxiety management also includes:
- Pregabalin (Lyrica®) 25–75 mg PO BD, titrate to 150–300 mg/day — PBS Authority Required for generalised anxiety disorder when SSRIs/SNRIs have failed. Renal adjustment required (eGFR-dependent dosing). Less drug interaction burden than SSRIs but sedation and falls risk in elderly.
- Benzodiazepines — should be avoided in older adults (Beers Criteria). Associated with falls, hip fractures, cognitive impairment, delirium, road traffic accidents, and paradoxical agitation. If absolutely necessary for acute severe anxiety/distress: use short-acting agent (oxazepam 7.5–15 mg PO PRN or lorazepam 0.5 mg PO/SL PRN) at half the standard adult dose for the shortest possible duration (≤2 weeks). Always prescribe with a documented taper plan.
Do not initiate long-term benzodiazepine therapy in older adults. Benzodiazepines are associated with increased all-cause mortality, falls with hip fracture (number needed to harm ~50 per year), cognitive decline, and dependence even at low doses. Many older Australians are maintained on long-term benzodiazepines prescribed decades ago — these patients should be offered a gradual taper (reduce by 10–25% every 2–4 weeks) with psychological support (CBT for anxiety/insomnia). Contact the RACGP's "ReScript" programme for taper support resources.
Pharmacological Treatment — Insomnia
CBT-I is first-line. When pharmacotherapy is considered, the following agents may be used with caution:
Melatonin (modified-release)
Circadin® · Modified-release melatonin
Dose (≥65 yrs)
2 mg PO ON, 1–2 hours before bedtime. Modified-release formulation preferred for sleep maintenance.
Advantages
No falls risk, no cognitive impairment, no dependence, no respiratory depression. May be particularly useful in dementia-related circadian disruption.
PBS status
Authority Required — for patients ≥55 years with insomnia characterised by poor sleep quality, where non-pharmacological measures have been tried
Trazodone
Molipaxin® · Serotonin antagonist/reuptake inhibitor
Dose (≥65 yrs) for insomnia
25–50 mg PO ON at bedtime. Low-dose trazodone is widely used off-label as a hypnotic in older adults. Dose for depression: 50–150 mg/day in divided doses.
Key cautions
Orthostatic hypotension (falls risk), priapism (rare but serious — warn patients), priapism risk, sedation carryover. Avoid in combination with SSRIs (serotonin syndrome risk with fluoxetine/paroxetine due to CYP2D6 inhibition).
PBS status
✔ PBS General Benefit
Electroconvulsive Therapy (ECT)
ECT is a highly effective treatment for severe depression in older adults and is under-utilised. Indications in the geriatric population include:
- Psychotic depression (ECT is first-line)
- Severe depression with acute suicide risk where pharmacotherapy onset is too slow
- Treatment-resistant depression (failed ≥2 adequate antidepressant trials)
- Catatonia
- Severe depression where medication is contraindicated (e.g. hepatic failure, drug interactions, severe cardiac disease — relative)
ECT in older adults has response rates of 50–70% for medication-resistant depression. Bilateral electrode placement is most effective; ultra-brief pulse right unilateral ECT may have fewer cognitive adverse effects. Referral to a consultant psychiatrist with ECT privileges is required. ECT services are available in most Australian public hospitals.
Monitoring
Regular monitoring is essential for all older adults receiving treatment for mental health conditions. The following schedule is recommended:
Baseline
FBE, UEC, LFTs, TFTs, B12/folate, glucose/HbA1c, ECG (before citalopram, escitalopram, TCAs, antipsychotics). PHQ-9/GDS-15 score. Weight, blood pressure, lying/standing BP (for mirtazapine, venlafaxine, antipsychotics). Cognitive screen (MoCA/MMSE). Suicide risk assessment documented.
Week 1–2
Phone or telehealth review: tolerability, adverse effects, adherence. Assess for activation/suicidality (particularly in first 2 weeks of SSRI initiation). Serum sodium if on SSRI/SNRI (risk of SIADH).
Week 4
Face-to-face review: symptom reassessment (PHQ-9), response evaluation. If partial response, consider dose titration. If no response, check adherence and diagnosis. Repeat sodium if on SSRI/SNRI. Weight check.
Week 6–8
Assess treatment response. If inadequate response despite adequate dose and adherence: consider switching agent, augmentation, or specialist referral. For antipsychotics: document review of ongoing need, efficacy and adverse effects (TGA requirement).
Week 12
Reassess functioning, mood, cognition, suicidality. Medication review — polypharmacy, anticholinergic burden. Repeat bloods if clinically indicated.
Months 3–6
Maintenance phase. Regular GP review every 2–4 weeks, then monthly. Continue medication for minimum 6–12 months after remission. Ongoing psychological therapy. Suicide risk reassessment at every visit.
Month 6–12+
Plan for medication continuation or taper. First episode with remission: taper after 6–12 months (reduce by 25% every 4 weeks). Recurrent episodes or severe presentation: consider indefinite maintenance. Annual health assessment with depression screening (MBS item 701/707).
SSRI discontinuation syndrome — can occur with abrupt cessation of any SSRI/SNRI, particularly paroxetine and venlafaxine. Symptoms include dizziness, nausea, "electric shock" sensations, irritability, insomnia and rebound anxiety. Taper over 4–8 weeks (or longer if on high-dose or long-duration therapy). Educate patients not to stop antidepressants abruptly.
Anticholinergic Burden Assessment
The cumulative anticholinergic burden of medications is a critical consideration in geriatric psychopharmacology. Many commonly prescribed medications have anticholinergic properties — TCAs (particularly amitriptyline, doxepin, nortriptyline), antipsychotics (chlorpromazine, olanzapine), antihistamines (promethazine, diphenhydramine), bladder antispasmodics (oxybutynin, tolterodine), and some analgesics (codeine combinations). Use the Anticholinergic Cognitive Burden (ACB) Scale to audit medication lists. Total score ≥3 is associated with increased risk of cognitive decline, delirium, falls, constipation and urinary retention. Aim to reduce total ACB where possible.
Special Populations
Frail Elderly (>80 years / Frailty Score ≥5)
All psychotropics
Start at minimum dose and titrate very slowly. Hepatic and renal clearance is reduced. Increased volume of distribution changes for lipophilic drugs. Falls risk is the primary safety concern — assess lying/standing BP at every visit. Use liquid formulations for dose flexibility. Consider blister packs (Webster packs) for adherence.
Antidepressant choice
Sertraline (25 mg start) or mirtazapine (7.5–15 mg) are generally best tolerated. Avoid all TCAs. Avoid fluoxetine (very long half-life, accumulation risk, drug interactions via CYP2D6).
Non-pharmacological priority
Behavioural activation, gentle exercise (seated exercises, hydrotherapy), music therapy, social engagement, sensory stimulation. RACF-specific interventions: Montessori-based activities, Namaste Care for advanced dementia.
Chronic Kidney Disease
Venlafaxine
Reduce dose by 50% if eGFR <30 mL/min. Active metabolite accumulates.
Duloxetine
Avoid if eGFR <30 mL/min.
Pregabalin
Dose reduction mandatory: eGFR 30–60: max 150 mg/day; eGFR 15–30: max 75 mg/day; eGFR <15: max 25 mg/day.
Lithium
Contraindicated in severe CKD unless under specialist supervision with very frequent level monitoring. Narrow therapeutic index. Nephrotoxic with long-term use.
Preferred agents
Sertraline (no renal dose adjustment) and escitalopram (no renal dose adjustment) are safest in CKD.
Hepatic Impairment
General principle
Most psychotropics are hepatically metabolised. Reduce doses by 50% in moderate hepatic impairment (Child-Pugh B). Avoid duloxetine in severe hepatic impairment. Use sertraline or escitalopram at reduced doses with caution.
Mirtazapine
Reduce dose by 50% in hepatic impairment — clearance is significantly reduced.
Alcohol-related liver disease
Screen for co-occurring alcohol use disorder (AUDIT-C). Thiamine supplementation. Avoid benzodiazepines completely — risk of hepatic encephalopathy and worsened liver function.
Post-Stroke Depression
Screening
Depression affects 30–50% of stroke survivors. Screen all patients from 2 weeks post-stroke using PHQ-2/PHQ-9 or the Stroke Aphasia Depression Questionnaire (SADQ) for those with communication difficulties.
Preferred agents
SSRIs (sertraline, fluoxetine) — evidence supports both antidepressant and potential neuroplasticity benefits post-stroke. Problem-solving therapy has specific evidence for post-stroke depression.
Drug interactions
SSRIs increase bleeding risk — caution with concurrent antiplatelet agents (aspirin, clopidogrel) and anticoagulants (warfarin, DOACs). Consider PPI co-prescription. Sertraline has least CYP interaction profile.
RACF Residents
Prevalence
25–35% of RACF residents have clinically significant depression, yet screening is inconsistent. The Aged Care Funding Instrument (ACFI) and the new AN-ACC model include mental health domains but under-detection persists.
BPSD management
Behavioural and Psychological Symptoms of Dementia should be managed with a stepped-care, person-centred approach: identify unmet needs (pain, constipation, loneliness, boredom), environmental modification, staff training in de-escalation, structured activities, music therapy, aromatherapy — before considering pharmacological intervention. Document failed non-pharmacological interventions before initiating antipsychotics.
Psychotropic stewardship
Regular medication review is mandated under NSQHS standards and the Aged Care Quality Standards. Deprescribing programs for benzodiazepines and antipsychotics in RACFs have demonstrated safety and improved outcomes. Engage pharmacist-led Home Medicines Review (MBS item 900) every 12 months.
Palliative Care Context
Prevalence
Depression affects 25–50% of palliative care patients. Existential distress, demoralisation and grief must be distinguished from major depression. Demoralisation syndrome (loss of meaning, helplessness) responds better to psychotherapy than medication.
Pharmacotherapy
Methylphenidate (10–30 mg PO morning/midday) — rapid onset antidepressant effect within days (vs weeks for SSRIs); useful in prognosis <4 weeks. Mirtazapine — anxiolytic, appetite-stimulating, sedating properties beneficial in palliative care. Dexamethasone (4–8 mg PO OD) — short-term mood elevation and appetite improvement.
End-of-life distress
Palliative sedation for refractory existential/psychological distress at end of life should be discussed with the palliative care team and the patient (where capacity allows). This is distinct from euthanasia and is an accepted practice under Australian palliative care guidelines.
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Australians experience significantly higher rates of psychological distress, social and emotional wellbeing concerns, suicide, and grief-related mental health conditions compared with non-Indigenous Australians. The AIHW reports that Indigenous Australians are 2.7 times more likely to experience high or very high psychological distress. Social determinants — including intergenerational trauma from colonisation and the Stolen Generations, systemic racism, incarceration, housing insecurity, loss of cultural identity, and remoteness — profoundly impact mental health in older Aboriginal and Torres Strait Islander adults.
The concept of "social and emotional wellbeing" (SEWB) is preferred over the Western biomedical model of "mental health" in many Indigenous communities. SEWB encompasses connection to body, mind and emotions, family and kinship, community, culture, Country, and spirituality. Disruption to any of these domains can manifest as distress, and healing requires restoration of these connections — not merely pharmacological symptom management.
Culturally appropriate resources and referrals:
- 13YARN (13 92 76) — crisis support line for Aboriginal and Torres Strait Islander people, staffed by Indigenous crisis counsellors
- Aboriginal and Torres Strait Islander Healing Foundation — trauma and healing programmes for Stolen Generations survivors
- VACCHO (Victorian Aboriginal Community Controlled Health Organisation) — SEWB programmes
- Gayaa Dhuwi (Proud Spirit) Australia — national Indigenous leadership in mental health and suicide prevention
- ACCHOs — the preferred model for delivery of mental health and SEWB services to Indigenous communities (e.g. AMSANT, QAIHC, AHCWA)
📚 References
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- 4. Dementia Australia. Behaviour and Psychological Symptoms of Dementia (BPSD) Practice Guide. Melbourne: Dementia Australia; 2023.
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- 11. Pharmaceutical Benefits Scheme. Schedule of Pharmaceutical Benefits. Australian Government Department of Health and Aged Care; 2024. Available from: https://www.pbs.gov.au
- 12. Australasian Delirium Association. Australasian Clinical Practice Guidelines for the Management of Delirium in Older People. Melbourne; 2023.
- 13. Gayaa Dhuwi (Proud Spirit) Australia. National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2023–2030. Canberra; 2023.
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- 15. Aged Care Quality and Safety Commission. Aged Care Quality Standards. Australian Government; 2024. Available from: https://www.agedcarequality.gov.au