Depression in Dementia: Diagnosis and Treatment
By Kiran Rabheru, M.D.
November 1, 2004
Dr. Rabheru is chair of the division of geriatric psychiatry in the department of psychiatry at the University of Western Ontario in Canada.
In addition to pharmacological treatments (Table 1) and electroconvulsive therapy for more severe depression, a treatment plan for depression in dementia includes nonpharmacological therapies (Table 2) (Teri and Wagner, 1991; Teri et al., 1997). These are patient-focused interventions, as well as family or caregiver support. These interventions are very effective in milder depressions or when caregivers are depressed and should be considered first. Cognitive-behavioral therapy and pure behavior therapy for both patients and caregivers can be useful (Teri and Wagner, 1991; Teri et al., 1997). Pharmacological or nonpharmacological interventions do not totally eliminate depression in dementia symptoms, but they do decrease the symptom severity (Snowden et al., 2003). Figure 2 lists an algorithmic approach to treatment.
Relatively few controlled studies have been done due to limitations of sample size and different defining criteria for depression in dementia and efficacy. Few placebo-controlled antidepressant trials have been conducted. Antidepressants are effective for major depression, but data for mild depression are limited. High placebo response rates are seen particularly with milder depression, but more efficacy is noted with higher drug-placebo differences in trials with more severe forms of depression (Lyketsos et al., 2003).
Only one placebo-controlled trial has been reported with a tricyclic antidepressant. There was significant benefit for both imipramine(Drug information on imipramine) (Tofranil) and placebo in the treatment of major depression in AD, with no difference observed between the medication and placebo groups (Reifler et al., 1989). Two placebo-controlled trials of the selective serotonin reuptake inhibitor citalopram(Drug information on citalopram) (Celexa) in elderly patients, with or without dementia, found significant improvements in depression and decreases in mood lability on citalopram (Gottfries et al., 1992; Nyth and Gottfries, 1990). Fluoxetine(Drug information on fluoxetine) (Prozac) treatment did not differ significantly from placebo (Petracca et al., 2001). This study also confirmed the presence of a placebo effect in the treatment of depression in AD. Sertraline(Drug information on sertraline) (Zoloft) showed improvement in the CSDD scores and clinical global score in some studies (Lyketsos et al., 2003, 2000). Although moclobemide(Drug information on moclobemide) (Aurorix) has been shown to be safe, well tolerated and effective, it has limited clinical usefulness (Roth et al., 1996).
Antidepressant treatment often produces clinical improvement in 50% to 60% of patients with depression (Schneider and Olin, 1995), and side effects, particularly cardiovascular and anticholinergic, may be limiting (Moskowitz and Burns, 1986). Less improvement is noted with antidepressants in patients with white matter hyperlucencies and lacunar infarcts (Simpson et al., 1998, 1997). The efficacy of ECT appears particularly high in late-life depression (Flint and Rifat, 1998) and is safe for cardiac patients (Rice et al., 1994). No brain damage has been shown with ECT, but temporary cognitive problems can be frequent (Devanand et al., 1994; Scott, 1995).
A case series of 31 patients showed that ECT is effective, leading to improvements in both mood and cognition (Rao and Lyketsos, 2000). Multiple ECT treatments may be necessary before a significant improvement is achieved. Electroconvulsive therapy appears to be acceptable in terms of safety, but may need to be administered in lower doses and frequency than in nondemented patients.
In summary, depression in dementia is a common condition with a great impact on the quality of life of both patients and caregivers. It must be identified and treated promptly. Nonpharmacological and pharmacological therapies are helpful, but ECT may be needed in some cases. Depression in dementia is poorly understood in terms of prevalence and etiology, making it a challenge to conduct clinical trials and treat effectively.
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