Try Nondrug Therapies First in Dementia Depression

Abstract

San Antonio – Limited evidence suggests that some people with dementia can benefit from antidepressant medications, but use of these drugs should be limited, according to Dr. Dulce M. Cruz Oliver. Dementia patients who may benefit include those with recurrent or severe depression and those who have responded previously to antidepressants, Dr. Cruz Oliver, an assistant professor at St. Louis University School of Medicine, said at AMDA Long Term Care Medicine – 2012. However, these drugs should be used only after nonpharmacologic approaches, such as cognitive behavioral therapy and cognitive stimulation therapy, have proved inadequate. Dr. Cruz Oliver reviewed studies challenging antidepressant therapy and some support for cognitive behavioral therapy and cognitive stimulation therapy. Although depression in dementia lacks even a consensus definition or agreement on the best scale for assessing the condition, it is clear that depression represents a substantial burden to dementia patients. They don’t live as long or have quality of life and functionality to match those with dementia free of depression, Dr. Cruz Oliver noted. The depressed patients’ obvious needs may explain why physicians continue to prescribe antidepressants for them despite controversy over the drugs’ efficacy in this population, she said. Extrapolating antidepressant data from patients without dementia to those with dementia could be a mistake, Dr. Cruz Oliver said. The authors of the most recent meta-analysis of studies on depression in dementia came to the equivocal conclusion that the seven studies they looked at “are limited to detect any difference [between treatment and placebo] and do not establish that antidepressants are ineffective,” said Dr. Cruz Oliver ( J. Am. Geriatr. Soc. 2011;59:577-85). The investigators were unable to complete analyses of response based on severity of depression or based on the drug used (although the odds ratios were higher in trials that included only patients with major depression), Dr. Cruz Oliver noted. Most of the studies, which were 6–12 weeks in duration, included fewer than 50 subjects. Two examined tricyclic antidepressants, four were studies of selective serotonin reuptake inhibitors (SSRIs), and one looked at venlafaxine. Some of the studies did not correct for severity of dementia and did not adequately describe randomization. In an attempt to overcome such shortcomings, British researchers conducted a randomized controlled trial – the largest and longest to date to look at depression in dementia in nursing home patients – but their conclusions were not much different. Published in 2011, the study included 325 subjects. The response to antidepressants, based on Cornell Scale scores at 13 and 39 weeks, was compared in patients on sertraline, mirtazapine, and placebo. No difference was seen among the groups on this main outcome measure, although quality of life was better in the mirtazapine group, according to participant measures. Caregiver measures, however, indicated that response was better in the placebo group (Lancet 2011;378:403-11). Loss to follow-up in this study was high at 24% in all three groups, and although the subjects were enrolled from a psychiatric clinic, the investigators were not able to quantify or control for psychotherapy or other nonpharmacologic treatment received by participants, Dr. Cruz Oliver said. Taken together, the findings of the meta-analysis and this randomized controlled study underscore how controversial the use of these medications is in this patient population, she concluded. The controversy has been heightened by depression drugs’ side effects. SSRIs have been associated with mortality, cerebrovascular accidents, falls, epilepsy, and hyponatremia, and venlafaxine and mirtazapine have been linked with mortality, suicide, cerebrovascular accidents, fracture, and epilepsy (BMJ 2011;343:d4551). “We should first try nonpharmacologic interventions before considering giving these medications,” Dr. Cruz Oliver said. She outlined studies of that approach. Cognitive behavioral therapy – 30–60-minutes 2–3 times per week for 6–16 weeks – was shown in two small U.S. nursing home studies to have a significantly beneficial effect on Dementia Mood Assessment Scale and Cornell Scale scores (Res. Gerontol. Nurs. 2009;2:26775 and Nurs. Res. 2010;59:417-25). Cognitive stimulation therapy, in a single-blind, multicenter, randomized, controlled trial of 201 patients, showed no difference in Cornell score but did find that quality of life and scores on the MiniMental State Exam significantly improved in patients who participated in 45-minute sessions twice weekly for 7 weeks (Br. J. Psychiatry 2003;183:248-54). Although these therapies are effective, they can be associated with their own side effects, such as reduced self-esteem and agitation, Dr. Cruz Oliver said. However, research suggests that the risks associated with antidepressant drugs outweigh those of the cognitive therapies, which also appear to improve behavioral and affective symptoms, she noted. She concluded that much more research is needed into the use of antidepressants in nursing home patients. Such studies should define the outcomes from the start, assess for severity of depression, and measure cost-effectiveness, Dr. Cruz Oliver said. She reported having no conflict of interest. CfA