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Abandon antidepressants as first-line option for depression in dementia, GPs told

GPs should not use medication first-line to treat depression in patients with dementia, according to an NHS-funded evaluation which has called for a change in practice after finding antidepressants had no effect compared with placebo.

The Health Technology Assessment found two commonly prescribed antidepressants failed to improve depression symptoms in patients with suspected Alzheimer’s disease, calling into question NICE advice that those with a ‘major depressive disorder’ should be offered antidepressants.

GP experts said the trial highlighted the lack of evidence for the use of antidepressants in this group of patients, and urged GPs to consult specialists on how to manage patients with dementia showing signs of depression.

The randomised trial looked at 326 patients with probable or possible Alzheimer’s disease and co-existing depression lasting for at least four weeks – with a Scale for Depression in Dementia (CSDD) score of eight or higher.

The UK researchers reported there was no significant difference in CSDD score after 13 and 39 weeks of treatment with either sertraline or mirtazapine compared with placebo. After adjusting for baseline depression and centre, the mean difference in CSDD scores was 1.17 between placebo and sertraline, 0.01 between placebo and mirtazapine, and 1.16 between mirtazapine and sertraline groups at 13 weeks; none of the between-group differences were statistically significant.

NICE currently recommends all patients with dementia with depression or anxiety should be offered cognitive behavioural therapy and a range of tailored psychological interventions, while people with dementia who also have ‘major depressive disorder’ should be offered antidepressant medication.

The HTA concludes: ‘The data suggest that the antidepressants tested, given with normal care, are not clinically effective for clinically significant depression in Alzheimer’s disease. This implies a need to change current practice of antidepressants being the first-line treatment of depression in Alzheimer’s disease.’

The team adds that future research should evaluate whether newer classes of antidepressants, such as venlafaxine, or antidementia medications, such as cholinesterase inhibitors, could show different results.

Speaking to Pulse, Professor Steve Iliffe, professor of primary care for older people at University College London, said the findings demonstrated the lack of evidence for the use of antidepressants in people with dementia.

He said: ‘The trial was well designed with an adequate treatment period, so I think these findings should influence treatment decisions.’

Professor Iliffe added, however, that a lack of evidence for non-pharmacological approaches to depression means ‘clinicians are left without much power to intervene’.

He noted that cholinesterase inhibitors in particular are promising alternative medications, ‘because clinical experience suggests that they can have significant effects on anxiety and mood’.

In the meantime, he said, ‘GPs need to take advice from their local old age psychiatrist on how best to help older people with depression and dementia, taking into account severity, duration, suicide risk, and past psychiatric history’. 

Dr Donal Hynes, a GP in Somerset and co-vice-chair at the NHS Alliance, said the study showed that medication may not be the ‘simple answer’ for this group of patients, but warned against not treating them at all.

He said: ‘I don’t think the recommendation should be to abandon these patients completely in terms of managing their depression.’

‘Particularly if the GP feels there has been a response, to destabilise that and shift to something that hasn’t been proven to be of benefit would be a bit concerning.’

Health Technol Assess 2013; 17: 1–166

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