Depression is common in dementia. It often causes distress, reduces quality of life, worsens cognitive and functional impairment, increases mortality, and also brings about stress and depression in carers.
The NICE Clinical Guideline on Dementia (CG42) recommends that people with dementia and major depressive disorder should be offered antidepressant medication. Treatment should follow the NICE Clinical Guideline On Depression (CG90) and involve a risk-benefit assessment.
Note: NICE indicates that antidepressants with anticholinergic effects should be avoided as these affect cognition adversely. At the start of treatment, the importance of adherence, the timing to onset of action and risks of withdrawal effects should be explained.
New Evidence and Changes to Guidance
The Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial assessed the efficacy and safety of sertraline and mirtazapine for treatment of depression in people with dementia, compared with placebo. Results indicated that decreases in depression scores after 13 to 39 weeks showed no difference between the groups, yet fewer control group participants had adverse reactions (26%) than did participants in the sertraline group (43%) or mirtazapine group (41%). The researchers therefore suggested that the routine use the two antidepressants to treat depression in people with dementia should be reconsidered.
There is a growing body of evidence suggesting that antidepressants have only limited benefit for treating depression in dementia. A recent systematic review (Nelson and Devanand, 2011) found similar results.
On Balance: Acknowledged Uncertainty and Greater Caution
Antidepressants may be effective in some patients and may remain a therapeutic option, although used more caution than previously.
“Depression is a common manifestation of behavioural and psychological symptoms of dementia (BPSD) with the two disorders having a multiplicative effect. Depression in dementia is complicated by difficulties in detection and diagnosis; many of the symptoms in the two disorders overlap, with one often being mistaken for the other”.
Warner, J. [and] Bailey, A. NHS Evidence expert commentary: Treating depression in people with dementia. Eyes on Evidence December 2011; Issue 32. London: NHS Evidence, December 16th 2011.
Full Text Link (b) (Access requires an Athens password or journal subscription).
Banerjee, S. Hellier, J. [and] Dewey, M. [et al] (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet, July 30th 2011, Vol.378(9789), pp.403-11. (Click here to view the PubMed abstract).
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Nelson, JC. Devanand, DP. (2011). A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. Journal of the American Geriatrics Society, April 2011, Vol.59(4), pp.577-85. (Click here to view the PubMed abstract).
Full Text Link (d) (Access requires an Athens password or journal subscription).
Rodda, J. [and] Walker, Z. (2011). Depression in older adults. BMJ (Clinical research ed.), September 28th 2011, Vol.343(d5219).