Question. I am writing this e-mail on behalf of my dad. He was diagnosed with depression about 7 years ago. ECT Treatments did not help. Although he has been on several anti-depressants over the years, none appear to help. His major symptoms include tiredness and a lack of interest in the things that always were important to him. Unfortunately, he lives in a small rural town and expert medical attention is hardly available on a consistent basis. I realize it may be difficult to recommend at this point but in general, what medication would you recommend for an 80-year-old man who seems to have a difficult time with side effects? This is a desperate request and any help/advice you can give would be greatly appreciated.

Answer. I certainly appreciate how frustrating and difficult this situation must be for you, your father, and your family. Most of us have had elderly relatives or friends with depression, and it is truly a terrible illness. While treatment is effective in most cases, your father demonstrates that, unfortunately, this isn’t always so.

Without evaluating your father, I’m not in a position to recommend any specific treatment. But I do have some ideas that you and your father’s doctor may want to discuss.

First, I think establishing the correct diagnosis is crucial. Depression and tiredness are very general terms, and may be due to a variety of underlying medical and neurological disorders, including low thyroid function, repeated small strokes, or medication side effects. Has your father had a complete medical and neurological evaluation? If not, getting him seen by a specialist in geriatric medicine or geriatric psychiatry would be advisable, even though this won’t be easy for you. If there is a medical school Department of Psychiatry near you, this might be a place to start. Or, you can try logging on to www.elderweb for resources.

I don’t know what your father has already taken in the way of medications, but here are some options to consider: bupropion [Wellbutrin], venlafaxine [Effexor], mirtazepine [Remeron], methylphenidate [Ritalin], or a special type of antidepressant called a MAOI. This last option would require careful dietary monitoring and would need to be compatible with other medications your father may be taking. The older tricyclic antidepressants have fallen out of favor, but they may actually be superior to newer agents for elderly depressed patients; e.g., nortriptyline [Pamelor] is worth considering. A number of these agents may also be used in combination (except for the MAOI). A new agent called modafanil [Provigil] is now being used to treat excessive daytime sleepiness in patients with narcolepsy, and is being investigated as an adjunctive treatment for depression, but this has not yet been approved by the Food & Drug Administration for use in depression.

Finally, if your father had only unilateral (on one side of the brain) ECT, a trial of bilateral ECT should be considered. I think it will be critical, however, to find an experienced geriatrician who can at least follow-up on your father’s response from time to time. If your local doctors can’t do this, the Internet now can connect them to a number of experts worldwide. I hope your father finds some help soon.