Background
Experiencing anxiety and depression is very common in people with dementia and mild cognitive impairment (MCI). Psychological interventions have been suggested as a potential treatment for these populations. Current research suggests that people with dementia and mild cognitive impairment have limited opportunities to receive psychological treatments aimed at improving their well-being. A systematic review of the evidence on its effectiveness is likely to be useful in terms of improving outcomes for patients and for future practice recommendations.
Goals
The primary objective of this review was to evaluate the effectiveness of psychological interventions to reduce anxiety and depression in patients with dementia or mild cognitive impairment (MCI).
Search methods
We searched the Cochrane Dementia and Cognitive Improvement Group’s Specialized Register and additional sources for published and unpublished data.
Selection criteria
We included randomized controlled trials (RCTs) that compared a psychological intervention with usual care or a placebo intervention (social contact control) in people with dementia or MCI.
Data selection and analysis
Two reviewers worked independently to select trials, extract data, and assess studies for risk of bias, using a data extraction form. Authors were contacted when no further information was available on the published articles.
Main results
Six RCTs with 439 participants with dementia were included in the review, but no studies of participants with MCI were identified. The studies included people with dementia living in the community or in nursing homes and were conducted in several countries. Only one of the studies was classified as having low risk of bias.
Five studies had unclear or high risk of bias due to uncertainties about randomisation, blinding and selective reporting of results. The studies used the different psychological approaches of cognitive behavioral therapy (CBT), interpersonal therapy and counselling.
Two studies were of multimodal interventions that included specific psychological therapy. Comparison groups received usual care, attention management educational programs, diagnostic feedback, or services slightly above usual care.
The meta-analysis showed a positive effect of psychological treatments on depression (six trials, 439 participants, standardized mean difference (SMD) -0.22, 95% confidence interval (CI) -0.41 to -0. 03, moderate quality evidence) and in clinician-rated anxiety assessment (two trials, 65 participants, mean difference (MD) -4.57, 95% CI -7.81 to -1.32, evidence low quality), but not on self-rated anxiety (two trials, SMD 0.05, 95% CI -0.44 to 0.54) or caregiver-rated anxiety (one trial, MD -2.40; 95% CI: -4.96 to 0.16).
The results were consistent with both benefit and harm on secondary outcomes of patient quality of life, activities of daily living (ADL), neuropsychiatric symptoms and cognition, or caregiver self-rated depressive symptoms, but most of the studies did not measure these outcomes. There were no reports of adverse events.
Authors’ conclusions CBT-based treatments added to usual care probably slightly reduce depressive symptoms in patients with dementia and MCI and may increase depression remission rates. There may be important effect modifiers (baseline degree of depression, cognitive diagnosis, or intervention content). CBT-based treatments probably also have a small positive effect on quality of life and daily activities. Support and counseling interventions may not improve symptoms of depression in people with dementia. The effects of both types of treatment on anxiety symptoms are very uncertain. There is also no certainty about the effects of other types of psychological treatments and about the persistence of the effects over time. To inform clinical guidelines, future studies should evaluate the detailed components of these interventions and their implementation in different patient populations and in different settings. Implications for practice Evidence from six RCTs shows that psychological treatments based on a psychological model can benefit people with dementia by reducing depressive symptoms. Evidence from two studies shows that psychological treatments reduce symptoms of clinician-rated anxiety in patients with dementia. Psychological treatments for people with dementia appear to be safe, with no adverse events reported in the literature. This review concludes that psychological treatments that primarily target depression and anxiety have the potential to improve the psychological well-being of people with dementia. |
Comments
Feelings of anxiety and depression are common in people living with dementia and mild cognitive impairment, but the best way to treat these symptoms is currently unknown, as medications often used to treat these symptoms may not be effective for people with dementia and may cause side effects. .
The findings of the new and updated Cochrane review article are important because it is the first review to show that psychological interventions (talking therapies) are effective and valuable in the context of ineffective medications for depression in dementia. The review also shows that they may provide additional benefit in terms of improving the patient’s quality of life and daily function.
The researchers call for clinical guidelines for dementia to be revised to recommend psychological therapies and, specifically, Cognitive Behavioral Therapy (CBT).
Lead author Dr Vasiliki Orgeta (UCL associate professor of psychiatry) said: “We currently do not have standard treatments for depression for people with dementia, as antidepressants do not work for them. However, despite the lack of supporting evidence, they are still prescribed to many people living with dementia, which is a major problem given the growing body of evidence suggesting that not only do they not improve symptoms, but they may increase the risk of mortality. .”
“Previous evidence on the clinical effectiveness of psychological treatments has been limited. By reporting on the most up-to-date evidence, we found that these treatments, and specifically those that focus on helping people with dementia use strategies to reduce distress and improve well-being, are effective in reducing symptoms of depression.”
People with dementia are twice as likely as other people their age to be diagnosed with major depressive disorder. Studies have estimated that 16% of people with dementia experience depression, but this can be as high as 40%, so there is a great need for effective treatments. Depression and anxiety can also increase the severity of neurological impairment itself, reducing independence and increasing the risk of entering long-term care.
Dr Orgeta added: “Our findings break the stigma that psychological treatments are not worth it for people living with cognitive impairment and dementia, and show that we must invest in more research in this area and work to increase access to psychological services for people with dementia. across the globe. “We want people experiencing cognitive decline and dementia to have the same access to mental health treatments as everyone else.”
The paper, published by the Cochrane Library as part of its database of systematic reviews, incorporated evidence from 29 clinical trials of psychological treatments for people with dementia or mild cognitive impairment, including nearly 2,600 study participants in total.
Psychological interventions varied somewhat, including CBT and counseling and support interventions, but generally aimed to support well-being, reduce distress and improve coping.
The review shows that psychological treatments for people with dementia can improve not only depressive symptoms, but also several other outcomes, such as quality of life and the ability to carry out daily activities. Although more research is needed, the study found that these treatments can also improve depression remission. The authors say that the potential to improve many outcomes with a psychological intervention can be very cost-effective and could be key to improving the quality of life and well-being of people with dementia.
The authors considered the evidence to be of moderate quality overall; This means that it is of high enough quality to warrant clinical recommendations supporting the use of psychological therapies. They say larger studies are needed as they may identify a more substantial effect.
Co-author Dr Phuong Leung (UCL Psychiatry) said: “There is now good enough quality evidence to support the use of psychological treatments for people with dementia, instead of prescribing medication, and without the risk of medication side effects. . “What we need now is for more doctors to opt for talking therapies for their patients and to commit to funding more high-quality research in this area.”
Dr. Orgeta added: “Pharmacological treatments in dementia have been prioritized in trials for many years, as a result they benefit from greater investment, so it will be important to invest more in the study of psychological treatments. “There is a need for novel treatments, developed specifically together with people with dementia, their families and those who contribute to their care.”
The review was carried out by researchers from UCL, the University of Nottingham, the University of Jaén and Salford Royal NHS Foundation Trust, and was supported by the National Institute for Health Research.
