Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysisBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n532 (Published 24 March 2021) Cite this as: BMJ 2021;372:n532
All rapid responses
Re: Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis
This extensive paper is doubtless of great value.
May I be permitted a few simple thoughts?
1. Depression may result from inability to receive verbal signals.
Frustration and anger follow.
2. Stimulation of the brain by invoking activities long ceased -for social reasons, loss of certain motor functions, or indeed emotional reasons may assist in reversing the depression.
Dr Leverton, one of the two rapid responders may recall that a volunteer lady conducted sessions of music therapy with dance, at the geriatric unit at Doddington Hospital, Cambridgeshire, in the late 20th century. It was not published in a journal, but Anglia Television reported it. The patients were reported to have benefited. No statistics as I recall.
3. With reference to point 1, above, hearing loss in the elderly may be treatable ( eg, WAX). Or may be ameliorated.
But first we have to detect it.
Please see the reference below.
Anand JK, Court I
Hearing loss leading to impaired ability to communicate in residents of homes for the elderly.
BMJ, 1989 May 27:298 (6685) 1429-1430
Competing interests: Rather old (89);. Memory diminishing. Hearing diminishing. All neurological functions must be diminishing.
Re: Comparative efficacy of interventions for reducing symptoms of depression in people with dementia
Watt et al’s wide-ranging review of efficacy of interventions to reduce depression symptoms in people with dementia, and Divyani Garg’s thoughtful response, both fail to mention what might be called ‘the elephant in the room’, namely the high incidence of hearing loss among both patients with dementia and people with depression.
This is disappointing as in the absence of adequate hearing most of the non-drug approaches described will, at the very least, be less likely to be effective.
By the age of 79, 70% of people will have significant hearing loss, and people with hearing loss have increased rates of depression (1).
The association between hearing loss and cognitive performance is more marked with more severe hearing loss (2), while hearing loss itself is perhaps the greatest single treatable risk factor for dementia (3).
No research into dementia or depression should take place unless the research subjects hearing ability has been taken into consideration. Research which fails to report this clearly should no longer be accepted.
1. Chisolm TH, Johnson CE, Danhauer JL, Portz LJ, Abrams HB, Lesner S, et al. A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults. Journal of the American Academy of Audiology. 2007;18(2):151-83.
2. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. (2011) Hearing loss and incident dementia. Archives of Neurology. 2011;68(2):214-20.
3. Livingston G, Sommerlad A, Orgeta V, et al. (2017) Dementia prevention, intervention, and care. The Lancet Commissions http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31363-6.pdf
Competing interests: No competing interests
We read the article by Watt et al. entitled “Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis” with great interest. In this network meta-analysis, ten interventions were determined to be effective compared to usual care among individuals with dementia who had symptoms of depression but not major depression. These included: animal therapy, environmental modification, psychotherapy with reminiscence therapy, cognitive stimulation, cognitive stimulation with a cholinesterase inhibitor, exercise with cognitive stimulation and social interaction, massage and touch therapy, multidisciplinary care, occupational therapy, and reminiscence therapy. Importantly, non-pharmacological interventions were either as or more effective at depression relieved than some pharmacological measures.
Management of depression among persons with dementia is driven by pharmacological interventions, presumably premised on the doubtful ability of persons with dementia to participate in non-pharmacological therapies, as well as a certain therapeutic nihilism towards effects of these interventions, which are employed as social activities instead of targeted intervention. In fact, multiple other barriers to administration of nonpharmacological interventions have been described, which may be related to the patient per se (unwillingness, unresponsiveness, availability), external barriers (related to family or caregivers, environmental etc.). If non-pharmacological interventions must be prescribed, barrier assessment and strategies to mitigate them must also go hand-in-hand. How these strategies may be seamlessly blended into dementia care is another challenging aspect.
The paper by Watt et al. raises some important concerns. Namely, whether these interventions are as efficacious among persons with dementia with major depression. Major depressive disorder may be underrepresented in persons with dementia, and attributed to behavioral changes. Certainly, whether the paradigm of nonpharmacological interventions would be as impressively effective in major depression remains to be seen. Secondly, whether these interventions also yield similar results among non-Alzheimer’s dementias, such as those due to vascular causes, Parkinson’s disease, Huntington’s disease, and the like. Specifically, among persons with Parkinson’s disease, where antidepressant therapy may exacerbate motor symptoms, the role of nonpharmacological interventions has increasing relevance. In a meta-analysis of repetitive transcranial magnetic stimulation (rTMS) and cognitive-behavioral therapy, rTMS was found to alleviate symptoms of depression for a short duration of time. This raises another issue, that is, with respect to the appropriate duration of therapy of nonpharmacological interventions, and the longevity of their effect in maintaining symptom relief.
The effort by Watt et al. in disentangling the vital role of nonpharmacological interventions and bringing these to the therapeutic armamentarium as a definitive therapy to manage depression among persons with dementia is certainly laudatory and lays the seeds for further monumental work in tackling other aspects of this problem.
1. Watt JA, Goodarzi Z, Veroniki AA, et al. Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis. BMJ. 2021;372:n532. doi:10.1136/bmj.n532
2. Backhouse T, Killett A, Penhale B, Gray R. The use of non-pharmacological interventions for dementia behaviours in care homes: findings from four in-depth, ethnographic case studies. Age and Ageing. 2016;45(6):856-863. doi:10.1093/ageing/afw136
3. Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M. What are the barriers to performing nonpharmacological interventions for Behavioral symptoms in the nursing home? J Am Med Dir Assoc. 2012;13(4):400-405. doi:10.1016/j.jamda.2011.07.006
4. Enache D, Winblad B, Aarsland D. Depression in dementia: epidemiology, mechanisms, and treatment. Curr Opin Psychiatry. 2011;24(6):461-472. doi:10.1097/YCO.0b013e32834bb9d4
5. Chen J, He P, Zhang Y, et al. Non-pharmacological treatment for Parkinson disease patients with depression: a meta-analysis of repetitive transcranial magnetic stimulation and cognitive-behavioral treatment. Int J Neurosci. 2021;131(4):411-424. doi:10.1080/00207454.2020.1744591
Competing interests: No competing interests