6. Treating depression
A person with depression should be offered a range of treatments, depending on how severe or long-standing their depression is. These may include self-help, talking therapies or antidepressant medication.
For mild depression, which may lift by itself over time, the preferred approach is often self-help (for example, exercise) or a support group. If someone has severe or persistent depression, the GP will generally prescribe antidepressant medication, together with or followed by a referral for talking therapy, such as cognitive behavioural therapy (CBT). Someone with moderate depression may be offered a talking therapy, an antidepressant or both.
These approaches – especially an antidepressant combined with a talking therapy – are often effective, but they all take time to work: a few weeks, rather than a few days. However, this may vary for a person with dementia. For example, a person with dementia may not be able to benefit from talking therapies because of their reduced attention, communication, memory or reasoning.
Use of antidepressants as the first treatment for people with dementia is also widespread, but such drugs seem to be much less effective in people with dementia than in people who don’t have dementia.
Guided self-help, activities and lifestyle changes
These approaches for dementia with mild depression do not require a counsellor, psychotherapist or doctor to deliver them, although professional guidance is still likely to be very helpful.
Research shows that people with depression and dementia may respond to:
- regular physical exercise, such as short walks, tai chi or whatever is appropriate to the person’s ability to move or what they enjoy
- a reassuring daily routine
- regular activities with other people - social isolation can make depression worse
- increased time spent doing enjoyable activities – examples include reminiscence and life story work (in which the person sits with someone to build a scrap book or photo album of their life)
- more one-to-one interaction, such as talking, hand holding, or gentle massage, if appropriate
- changes to the person’s environment – for example, reducing bright lights, loud noises or avoiding large groups of people.
Support groups, where people can talk to others who are going through a similar experience, may also be very helpful. For information about groups near you, contact Alzheimer’s Society’s National Dementia Helpline on 0300 222 1122.
Psychological therapies (talking therapies)
Psychological therapies or talking therapies encourage people to talk about their feelings. Talking therapies are based on a model of how the mind works and are delivered by a counsellor, psychotherapist or other professional with training and a recognised qualification. There is some evidence that sessions of talking therapy, given over several weeks, reduce depression and anxiety in people with dementia, particularly in the early stages of the condition.
The therapy usually needs to be modified to suit the person’s level of communication, understanding and memory. A therapist who has experience of working with people with dementia is therefore likely to be best. Talking therapies may be less appropriate in the later stages of dementia, when people are likely to have problems with attention, communication, understanding and memory.
There are many different types of talking therapies available, including counselling, interpersonal therapy and CBT. The type of therapy that will be most suitable will depend on what the person would like to get out of therapy and the stage of their dementia. However, suitable talking therapies are not always available in a person’s area, and older people are less likely to receive a talking therapy than younger people, particularly those with depression living in care homes. For more information see factsheet 445, Talking therapies (including counselling, psychotherapy and CBT).
It is thought that depression is caused by low levels of certain chemicals (known as ‘neurotransmitters’) in the brain. Antidepressants are thought to increase the levels of these chemicals, which helps to restore brain function.
Someone with depression and dementia is likely to be offered antidepressant medication, particularly if the depression is severe or has not responded to other treatments. However, the evidence that antidepressants work in people with dementia is not conclusive: two research trials published since 2010 reported no overall benefits on symptoms of depression from two widely-used drugs in people with Alzheimer’s disease.
When someone takes antidepressants, the dose will start low and gradually increase, and there may be a delay of several weeks before the person feels any benefits. There may also be side-effects to begin with, possibly more often than in a younger person, but these should lessen as the body adjusts to the drugs. If the side-effects continue, the doctor may decide to change the dose or provide an alternative antidepressant. Sometimes the person will need to try a few different types of antidepressant before they find one that is effective for them. Antidepressants are usually taken for at least six months and often longer. It is important that the person takes the medication as prescribed, even if the drugs do not appear to be working.
Some people find that they have difficulty coming off antidepressants and may experience withdrawal symptoms, such as increased anxiety, if their antidepressants are suddenly stopped. For this reason, antidepressants should always be withdrawn slowly.
There are many different types of antidepressants, including:
- SSRIs and SNRIs – SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin-noradrenaline reuptake inhibitor) drugs are commonly used treatments for depression. This is because their side-effects are usually less severe than those of other drugs, although they can produce headaches and nausea (especially in the first week or two of treatment). Most people with dementia who are prescribed an antidepressant are currently offered an SSRI (such as sertraline or citalopram) first.
- Older antidepressants – These include tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs). They are less commonly used and are likely to increase confusion in people with dementia. Side-effects are common, especially in older people. A strict diet must be followed when taking MAOIs, and these drugs should not be taken by people who have had a stroke or those with a history of heart disease.