Exploring the Relationship Between Depression and Dementia

1. Exploring the Relationship Between Depression and Dementia Review of article for CMDA Nov 6, 2018 Sing Palat MD CMD

2. Overview Article under Medical News and Perspectives, JAMA. 2018;320(10):961-962. doi:10.1001/jama.2018.11154 • Highlights recent studies on relationship between depression and dementia • Examines how Depression with Dementia is different than Depression, and effects of interventions

3. Does depression cause dementia? • Depression and dementia both associated with neurodegeneration and inflammation • Mixed data • 2014 review: Yes • 2017 longitudinal study: • Midlife depression: No • Later life depression: Yes • 2017 Australian study: Yes, especially in men

4. Does dementia cause depression? • At least 20% of patients with dementia develop depression. • Dementia is linked to social isolation and severity of depression symptoms.

5. Difficult Diagnosis • Many symptoms are common to both depression and dementia • Loss of interest • Social withdrawal • Impaired thinking • Complications • Reluctance to discuss (stigma) • Under-reporting and under-recognition • Increase in somatic symptoms

6. Difficult Diagnosis • Late life depression is concerning for dementia. • A first episode of depression in older adult should be considered a sentinel event. • Dementia diagnosis requires ruling out depression.

7. Benefits of concurrent treatment • Treating depression may delay dementia • From Mild Cognitive Impairment: Citalopram delayed the progression of MCI to Dementia by 3 years. • Treating dementia may improve depression • However, only 18% of dementia treatment trials study neuropsychiatric symptoms as primary target.

8. Do we really want to prescribe more? Increase in antidepressants prescribed for depression with dementia between 2005 to 2015 (UK study 2017)

9. Antidepressants not effective Antidepressants are not helpful for depression in people with dementia. • Cognitive control dysfunction may be resistant to SSRI. • Antidepressants did not improve severity of depressive symptoms in community dwelling older adults. • Antidepressants did not improve depression symptoms in dementia per Cochrane review.

10. New nonpharmacotherapy ideas • Behavioral and psychotherapy difficult as dementia progresses. • Windows with natural light decreased depression scores in dementia community. • Social isolation was associated with severity of depression; antidepressants use was not. • Break stigma, build cultures of support

11. 2018 CMDA Annual Conference Which is predominant? Lea Watson MD, Geriatric Psychiatry

12. 2018 CMDA Annual Conference -Watson • Most studies of antidepressants done in young, healthy people in an acute episode. • Antidepressants do not work well at all in people with dementia, history of treatment resistance, or multiple chronic illnesses. • Banerjee, Lancet 2011: 208 people with AD and depression: no difference on sertraline, mirtazapine, placebo – all improved.

13. Pearls • Depression/ Dementia: assess for both • Recognize that Depression in Dementia is a different illness • Early or Midlife depression: SIG E CAPS, DSM-V • Late life depression: PHQ9, GDS, Cornell Scale • Treat symptoms with as little medication as needed.