What dose max for mirtazapine?
Response: 45 if no renal impairment, dose adjustment needed if renal impairment.

Do you recommend ECG on all patients 65 and up starting an antidepressant?
Response: no

Often patients require a secondary molecule. Can you give suggestions on choices for add on therapy.
Response: If you start with an SSRI then adding on mirtazapine or quetiapine is often an effective strategy.

Should we wait 10-12 weeks for all patients to expect a response? What about the classic 4-6 weeks?
Response: It can take longer for older adults to fully respond, although some effect should be felt by 4-6 weeks.

SSRI can be activating and increase anxiety initially I think. What is your approach. Benzos for a few weeks?
Response: No, I typically inform pts that this may happen and warn them to wait it out, it is rarely intolerable to the point of needing sedatives, but this is why frequent follow-ups and reassurance often goes a long way.

How long can one stay on SSRI, how many years?
Response: As long as tolerated, depends on reason for starting it, see slides for minimum duration of treatment for anxiety.

Do you have any recommendations for addressing resistance to exploration of these issues with older adults?
Response: Psychoeducation regarding anxiety to pts and enlisting family/caregivers.

How do we refer pts to geriatrics psychiatry?
Response: Refer to psychiatry in your sector and the triaging system will direct to our services based on age or profile.

Practically speaking, if you have a patient of 40 mg of citalopram and wanting to change over to sertraline in an elderly, how would you approach that (straight switch/cross taper/other)?
Response: Cross taper.

Do you always request an EKG prior to starting citalopram, even if using small doses 10-20 m g PO QD?
Response: I tend to yes, which is why I usually steer away from it, not all psychiatrists do.

What is the prognosis of GAD in the elderly? Is the course of the condition more refractory and difficult to treat compared to younger adults?
Response: yes

What are your thoughts on Buspar either in addition or instead of an antidepressant?
Response: Can work sometimes, it all depends on your level of comfort with the medication in your education to the patient.

Is there a particular SSRI you would recommend for patients who also have ADHD?
Response: Not particularly. There is evidence for atomoxetine in younger adults.

Would you ever consider that a marked anxiety increase in an elderly female (80yrs) could be "unmasking" of ADHD. (Both the pts sons have been so diagnosed)
Response: Difficult to say. Only way to know for sure is neuropsych assessment. I would want to rule out NCD.

For chronic anxiety w incomplete response to SSRI, augment with: vraylar vs rexulti vs abilify?
Response: There is evidence for abilify for augmentation in depression not in anxiety.

How often to do ECG in elderly on SSRI (Citalopram), when stabilized on maximum dose (40 mg) and unable to decrease due to mental health worsening?
Response: I do q6-12 months although no official guidelines.

Are there differences in how to switch antidepressants in elderly adults compared to younger? (e.g. is it better to cross-taper between SSRIs instead of switching immediately to the equivalent dose?)
Response: Cross taper is recommended.