Co-authored by Barnett S. Meyers, MD
Antidepressant medications may not be more effective than placebos in the treatment of depression in older adults who also have dementia, and the risks of antidepressant treatment may outweigh the benefits, particularly if the depression is not severe, according to two studies published this year. (1), (2)
Between 20 percent and 40 percent of people with dementia experience a diagnosable depressive disorder, nearly half major depression. This condition not only can be painful, it also increases risks of physical illness, disability and premature mortality. (3) In addition, it often results in decline in cognitive and functional capacity over and above the decline that results from dementia alone. Depression appears to have a particularly negative impact on "instrumental activities of daily living," including preparing meals, housework, managing finances, shopping, caring for others, etc. (4)
Clearly, overcoming depression is important for people with dementia. But, recent studies have failed to demonstrate that antidepressants improve depression more than the attention received by participating in a research study.
One study, done with the support of the British National Health Service to evaluate the standard approach to treating depression in people with dementia, showed no benefit of antidepressants compared to placebos but did show more adverse side-effects. For this reason the authors strongly recommend a change in the standard treatment approach. Instead of starting with an antidepressant, they suggest that the first step should be "watchful waiting" while helping people with dementia and their caregivers to cope better with the difficulties typical of living with dementia. They suggest that many depressive episodes in dementia patients may resolve on their own. If not, psychotherapy provided by a specialist may help. The authors maintain that antidepressants should be reserved for depression that is severe or persistent. (1)
Another study, which analyzed results from all placebo-controlled studies of depression associated with dementia, was more tempered in its conclusions, noting only there have been very few adequate trials and that analysis "resulted in inconclusive findings'' about the efficacy of antidepressants in the treatment of depression in people with dementia. The authors say, "Antidepressants are more effective in people with severe depression and people with recurrent depressive episodes ... A reasonable clinical approach is to use antidepressants to treat people ... who have ... these features." (2)
The findings of these new studies are consistent with previous work that suggests that depression in people with Alzheimer's is sufficiently different from the usual clinical picture of major depression to warrant using different diagnostic criteria (5) and to begin treatment with "low intensity psychosocial interventions" rather than antidepressant medications.
What does this mean? In part, it means dealing with the concrete problems that emerge in the lives of people with dementia, who may not be able to manage day-to-day activities adequately, as well as responding to the needs of both family caregivers -- who provide 80 percent of all care -- and paid caregivers.
The lack of a strong effect of antidepressants also speaks to the importance of directly addressing the depressive symptoms in people with dementia, particularly loss of interest in previously pleasurable activities -- which, in severe cases, may appear like profound apathy -- and avoidance of social interactions. It is important to engage people with dementia who are depressed even if they shy away from interaction. Identifying activities that appeal to personal interests can facilitate engagement, while acknowledging the person's individuality and continuity with the self before dementia.
None of this is easy. Family caregivers have to somehow learn to juggle the demands of their own lives and the needs of the family member with dementia. They often need support to do this. In addition, relationships change dramatically between spouses, between children and a parent, and between friends when one of them suffers major memory loss. Conversations may become difficult. Loss of shared memory is often emotionally painful. (6) Fortunately, effective methods of family support have been developed (7), and methods have been suggested for having meaningful interactions (8).
Addressing the major symptoms of depression is also difficult for assisted living facilities, continuing care communities, nursing homes and other residential settings where older adults with dementia may be living. It is the nature of institutions to follow standard caregiving routines, which have the inherent tendency to overlook the uniqueness of individuals. It may be easier for institution staff, such as social workers or nurses, to encourage physicians to prescribe antidepressants for residents who appear depressed rather than trying to understand the source of a specific resident's distress and individualizing interventions to engage a depressed resident with dementia.
Addressing depression in older adults with dementia without using an antidepressant can be difficult and requires additional effort to consider their individual circumstances and to engage them. But psychosocial interventions that focus on helping people with dementia and their caregivers cope with the consequences of cognitive loss would be the best first step.
Barnett S. Meyers, MD is Clinical Professor of Psychiatry at The Weil Medical College of Cornell University.
(1) Banajee, Sube et al. "Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-contolled trial." Lancet, July 11, 2011.
(2) Nelson, J.Craig and Devanand, Davangere. "A Systematic Review and Meta-Analysis of Placebo-Controlled Antidepressant Studies in People with Depression and Dementia." Journal of The American Geriatrics Society, 2011.
(3) Blazer, Dan. "Depression in Late Life: Review and Commentary". FOCUS: The Journal of Lifelong Learning in Psychiatry, Winter, 2009.
(4) Steffens, David et al. "Disability in Geriatric Depression". American Journal of Geriatric Psychiatry, 1999.
(5) Olin JT, et al. "Provisional diagnostic criteria for depression of Alzheimer disease: rationale and background." American Journal of Geriatric Psychiatry, 2002.
(6) Friedman, M. et al. "What Can You Do When A Loved One Is Lost in Time? The Huffington Post, October 12, 2011.
(7) Mittelman, M. et al. "Sustained Benefit of Supportive Intervention for Depressive Symptoms in Caregivers of Patients With Alzheimer's Disease" in The American Journal of Psychiatry, May 2004. http://ajp.psychiatryonline.org/cgi/content/abstract/161/5/850
(8) Friedman, M. "How To Have A Conversation When Memory Fades" in The Huffington Post, February 6, 2011.