REVIEW OF: Orgeta V et al, Cochrane Database Syst Rev 2022;4(4):CD009125

STUDY TYPE: Systematic review and meta-analysis

We often think about antidepressants before therapy when treating depression in patients with mild cognitive impairment (MCI) or dementia. However, given potential side effects and poor efficacy in this population, alternatives are needed. Guidelines recommend psychotherapy as a first-line treatment for depression, so how do various psychological interventions compare in people with memory disorders?

This Cochrane review assessed the clinical efficacy of psychological interventions in reducing depression and anxiety in people living with MCI or dementia. It included 29 trials between 1997 and 2020 with a total of 2,599 participants. Twenty-four trials were in people with a diagnosis of dementia (most had mild to moderate severity) and five trials were in people with MCI. There were 15 trials of cognitive behavioral therapies (four cognitive behavioral therapy [CBT] trials, eight behavioral activation trials, and three problem-solving therapy trials). CBT was modified to include cognitive strategies in early stages of dementia and behavioral strategies in later stages. The authors also included 11 trials of supportive and counseling therapies, three trials of mindfulness-based cognitive therapy (MBCT), and one trial of interpersonal therapy. Control groups received treatment as usual, attention-control education (information about educational groups available), or enhanced usual care (mood and cognitive problem assessment and referral to services). Treatment duration and intensity varied between studies.

Cognitive behavioral therapies slightly outperformed treatment as usual or active control conditions in reducing depressive symptoms (standard mean difference [SMD] = -0.23; 95% confidence interval [CI]: [-0.37, -0.10]) and improved remission rates (RR = 1.84; 95% CI: [1.18, 2.88]). Furthermore, CBT improved both quality of life (SMD = 0.31; 95% CI: [0.13, 0.50]) and activities of daily living (ADLs) (SMD = -0.25; 95% CI: [-0.40, -0.09]). There was some evidence that the effect on depression might be related to depression severity and whether people had MCI or dementia. On the other hand, other forms of therapy had less impressive results. Supportive and counseling interventions had minimal effects on depressive or anxiety symptoms. Neither MBCT nor interpersonal therapy had enough data to allow us to draw clear conclusions about their efficacy.

Carlat Take

Consider CBT to treat depression in people with dementia or MCI. It’s the only psychological intervention that’s been shown to improve depressive symptoms, quality of life, and ADLs, although the effects are small.