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Psychological treatments for depression and anxiety in dementia and mild cognitive impairment

  1. Vasiliki Orgeta1,*,
  2. Afifa Qazi2,
  3. Aimee E Spector3,
  4. Martin Orrell1

Editorial Group: Cochrane Dementia and Cognitive Improvement Group

Published Online: 22 JAN 2014

Assessed as up-to-date: 11 JAN 2013

DOI: 10.1002/14651858.CD009125.pub2


How to Cite

Orgeta V, Qazi A, Spector AE, Orrell M. Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD009125. DOI: 10.1002/14651858.CD009125.pub2.

Author Information

  1. 1

    University College London, Mental Health Sciences Unit, London, UK

  2. 2

    North East London Foundation Trust, Goodmayes Hospital, Brentwood, Essex, UK

  3. 3

    University College, London, Research Department of Clinical, Educational and Health Psychology, London, UK

*Vasiliki Orgeta, Mental Health Sciences Unit, University College London, 67-73 Riding House Street, 2nd Floor, Charles Bell House, London, W1W 7EJ, UK. v.orgeta@ucl.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 22 JAN 2014

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Characteristics of included studies [ordered by study ID]
Burgener 2008

MethodsRCT

Repeated-measures randomised design

Outcomes at 20 weeks are included in this review

Control group: outcomes at 20 weeks only, delayed treatment group

(Control group was offered the intervention following the 20-week assessment)


ParticipantsN = 43 (23M, 20F)

Confirmed diagnosis of dementia (Alzheimer’s, Lewy body, vascular, frontal lobe, or mixed dementia)

A score of < 2.0 on the Clinical Dementia Rating Scale (early to early-middle disease)

Mean age = 76.95


InterventionsMultimodal intervention consisting of Tai Chi exercises, cognitive-behavioral therapy and support group

Tai Chi: strength and balance training and relaxation

CBT: challenging dysfunctional cognitions and developing positive coping skills

Support group: coping with dementia and positive problem solving

Duration of intervention: 20 weeks (however complete intervention offered for 40 weeks)

Control group received attention-control educational program


OutcomesPatient Outcomes

Cognitive function:

Mini-Mental State Examination (MMSE)

Physical functioning:

Single leg stance (SLS), Berg Balance Scale (BBS), and Cumulative Illness Rating Scale (CIRS)

Depression:

Geriatric Depression Scale (GDS)

Other behavioral outcomes:

Rosenberg’s Self-Esteem Scale (SES)

Outcomes measured at 20 weeks and 40 weeks for the intervention group and at 20 weeks only for the control group


NotesTreatment duration 40 weeks

Tai Chi exercises: 1 hour classes offered weekly

Cognitive-behavioral therapy: 90 minute sessions offered bi-weekly

Support group: 90 minute sessions offered bi-weekly alternating with the CBT group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details of randomisation described in the study, insufficient information about sequence generation

Allocation concealment (selection bias)Unclear riskNo details of method of concealment described to allow judgement

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo evidence of blinding in the study, all assessments and the intervention were conducted at a neutral location

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskAuthors communicated that assessors were blind in some but not all outcome assessments

Incomplete outcome data (attrition bias)
All outcomes
Low risk20% attrition for the treatment group and 24% for the control group, with reasons reported

Selective reporting (reporting bias)Low riskAll pre-specified outcomes reported

Other biasLow riskNo other apparent bias

Burns 2005

MethodsRCT


ParticipantsN = 40 (21M, 19F)

Dementia diagnosis according to NINCDS-ADRDA criteria, a Clinical Dementia Rating (CDR) of 1 indicating mild dementia, MMSE score > 15

Living in own home with a carer with regular contact

Clinically stable (for the last 2 months) if on anti-dementia or psychotropic medication

Mean age = 75.8


InterventionsPsychodynamic interpersonal therapy (improving social and interpersonal relationships, identification of conflicts that cause or maintain emotional distress). Therapist also spends time with carer (listening to their needs and informing them of therapeutic progress)

Duration of intervention: 6 weeks

Control group described as standard treatment in AD, consisted of general advice regarding the diagnosis and treatment of dementia, with out-patient review


OutcomesPatient Outcomes

Cognitive function: Mini-Mental State Examination (MMSE)

Depression: Cornell Scale for Depression in Dementia (CSDD)

Other patient outcomes:

Bristol Activities of Daily Living (BADLS)

Clinician’s Interview-Based Global Impression of Change (CIBI)

Caregiver outcomes

Revised Memory and Behavior Problems Checklist (RMBPC) - Carers reaction

General Health Questionnaire (GHQ-12)

Beck Depression Inventory ((BDI-II) (scores on this measure not available)

Ways of Coping Checklist (WCCL)

Outcomes reported at 6 weeks and 3 months (only 6 week data included in the review)


Notes6 sessions of psychodynamic interpersonal therapy of 50 minutes each over 6 weeks

NINCDS-ADRDA - National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskParticipants were allocated to one of the two groups using computer-generated random numbers

Allocation concealment (selection bias)Low riskComputer generated random numbers were organised independently

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo information is provided

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information is provided about assessors

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntention-to-treat analyses conducted

No attrition

Selective reporting (reporting bias)High riskOne pre-specified outcome (Beck Depression Inventory for carers) not reported

Other biasLow riskNo other apparent bias

Spector 2012

MethodsRCT not published but data are available

single-blind, multicentre, pilot RCT of CBT versus TAU for people with dementia


ParticipantsN = 50 (20M, 30F)

Inclusion criteria:
1. Meet DSM-IV criteria for dementia in mild to moderate range, Clinical Dementia Rating (CDR) score of 0.5, 1 or 2.
2. Clinical anxiety, as determined by a score of 11 or above on the Rating Anxiety in Dementia scale (RAID)

3. Living in the community
4. Presence of a carer who is willing to participate in the therapy
5. Ability to understand and communicate in English
6. Willing to engage in therapy involving discussion of thoughts and feelings
Exclusion criteria:
1. Co-morbid psychiatric disorder (e.g. psychosis) or challenging behaviour (e.g. severe agitation) likely to prevent engagement in therapy
2. Presence of a learning disability or severe physical illness that could impact on participation

Mean age was 78.4 (SD = 7.0), and MMSE mean score was 20.9 (SD = 5.2). A total of 26.3% scored .5 on the CDR scale, 47.4% had a rating of 1, and 14.0% had a rating of 2. Mean anxiety rating (RAID) at baseline was 19.7 (SD = 6.0), and the mean depression rating (CSDD) was 15.9 (SD = 6.2).


InterventionsCBT for people with anxiety and dementia

10 weekly sessions (60 minutes each) comprising of identifying strategies for feeling safe, calming thoughts and behavioural experiments, with telephone contact offered between sessions. The intervention was delivered by clinical or counselling psychologists, with experience of working with people with dementia

Control group: standard treatment available to people with anxiety and dementia, including medication or no treatment


OutcomesPrimary outcomes

Rating Anxiety in Dementia (RAID)

Clinical Services Receipt Inventory (CSRI)

Secondary outcomes

Hospital Anxiety and Depression Scale (HADS)

Quality of Life-Alzheimer’s Disease (QOL-AD) (self and proxy ratings)

Neuropsychiatric Inventory (NPI)

Mini-Mental State Examination (MMSE)

Cornell Scale for Depression in Dementia (CSDD)

Quality of Caregiver and Patient Relationship (QCPR)

Caregiver outcomes

Hospital Anxiety and Depression Scale (HADS)

Outcomes reported at 15 weeks and 6 months (only 15 week data included in the review)


Notes10 sessions of CBT for anxiety of 60 minutes each for 15 weeks

ISRCTN46521766

Data were made available by the lead investigator but are not currently published

CBT - Cognitive Behavioural Therapy

TAU - Treatment as Usual

DSM-IV - Diagnostic and Statistical Manual of Mental Disorders, 4th edition


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe author communicated that random allocation was performed with Stata's random allocation command with varying block sizes of four and six

Allocation concealment (selection bias)Low riskCentral allocation, randomisation conducted by telephoning an independent administrator within the Clinical Trials Unit

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo information is provided

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAll outcome measures administered by a researcher blind to group allocation

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition and reasons reported by the author. Use of intention-to-treat analyses

Selective reporting (reporting bias)Low riskAll pre-specified outcomes reported

Other biasLow riskNo other apparent bias

Stanley 2012

MethodsRCT

(randomisation in blocks of 4 or 6 stratified by CDR scores - 0.5, 1., or 2., completed in SAS)


Participantsn = 32 (13M, 19F)

Inclusion criteria

1) diagnosis of dementia (confirmed by the patient’s medical provider)

2) an NPI-A ≥ 4

3) CDR score of 0.5 to 2.0

Exclusion criteria

Ps with a primary psychiatric diagnosis of major depression, active psychosis, bipolar disorder, active suicidal intent, recent verbal or physical aggression

 

Dementia diagnosis

AD (62.5%), DLB (3.1%), VaD (9.4%) and 25.0% dementia not otherwise specified (NOS)

Principal DSM-IV Diagnoses

43.8% had a diagnosis of GAD, 18.8% a diagnosis of other anxiety disorder, 43.8% comorbid anxiety and depression, 34.4% no diagnosis and 3.1% a depression diagnosis.

A total of 46.9% of the sample scored a CDR of 0.5 or 1, and 75% were on at least one psychotropic medication


InterventionsA cognitive–behavioral therapy–based intervention for anxiety in dementia, of 12 weekly in-home based sessions and brief telephone sessions, involving self-monitoring for anxiety, deep breathing, and optional skills (coping self-statements, behavioral activation, and sleep management). Carers were involved as coaches. Additional materials were provided on communication, education of dementia and stress reduction for collaterals

Control group receives usual care incorporating diagnostic feedback


OutcomesPatient outcomes

Depression: Geriatric Depression Scale (GDS) self report

Anxiety: Neuropsychiatric Inventory–Anxiety (NPI-A) subscale (collateral anxiety report)

Rating Anxiety in Dementia (RAID) (administered as a clinical interview to the patient and the caregiver)

Geriatric Anxiety Inventory (GAI) self report

Worry: Penn State Worry Questionnaire–Abbreviated (PSWQ-A) self report

Quality of Life: Quality of Life in Alzheimer disease (QOL-AD)

Carer Outcomes

Depression: Patient Health Questionnaire (PHQ-9)

Distress: distress item from the NPI-A


NotesPeaceful Mind was provided by two master’s-level graduate-student clinicians and a predoctoral intern supervised by clinical psychologists and a geriatric social worker. A total of 12 weekly in-home sessions were provided and up to 8 brief telephone sessions, for 6 months, with each session lasting 30 to 60 minutes.

AD - Alzheimer's disease

DLB - Dementia with Lewy bodies

VaD - Vascular Dementia

GAD - General Anxiety Disorder


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe author communicated that randomisation was completed in blocks of four or six stratified by CDR (Clinical Dementia Rating scores), in SAS

Allocation concealment (selection bias)Unclear riskNo details of method of concealment described to allow judgment

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo information is provided

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAll outcome measures were administered in-person by independent evaluators who were unaware of treatment assignment

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition and reasons reported, intention-to treat analyses

Selective reporting (reporting bias)Low riskAll pre-specified outcomes reported

Other biasLow riskNo other apparent bias

Tappen 2009

MethodsRCT

Two-groups repeated measures design


ParticipantsN = 36 (3M, 33F)

Dementia diagnosis according to NINCDS-ADRDA criteria

MMSE < 25 or less

Residents of long-term care facility

Mean age = 87.03

Age range 73-100

Range of length of stay in long-term care facility ranged from 160 to 1750 days

Ps that were mute were excluded


InterventionsIndividual therapeutic conversation based on modified counselling provided individually

Usual care control group (usual care by staff provided in the long-term care facility), described as a non-attention control group

Duration of intervention: 16 weeks


OutcomesPatient Outcomes

Depression: Montgomery-Asberg Depression Rating Scale (MADRS) (rated by clinicians)

Other behavioral outcomes:

Mood

Dementia Mood Assessment Scale (DMAS)

Alzheimer’s Disease and Related Disorders Mood Scale (AD-RD)

Outcomes measured at 16 weeks


NotesTherapeutic conversation of 30 minutes provided three times a week for 16 weeks


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo details of randomisation described in the study, insufficient information about sequence generation

Allocation concealment (selection bias)Unclear riskNo details of method of concealment described to allow judgement

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo information provided

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters were blind to group assignment

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition and reasons reported

Selective reporting (reporting bias)Low riskAll pre-specified outcomes reported

Other biasLow riskNo other apparent bias

Waldorff 2012

MethodsRCT

Multicentre rater-blinded trial

1:1 randomisation

Treatment as usual beyond the level of usual care


ParticipantsN = 330 (151M, 179F)

Clinical diagnosis of dementia using DSM-IV and NINCDS-ADRDA or McKeith criteria

Patients with mild recently diagnosed dementia

Mean age = 76.2

Living in the community, age ≥ 50 years with MMSE ≥ 20

Recruited only patients receiving a conventional diagnostic evaluation by specialists

Excluded: Participants with severe somatic or psychiatric comorbidity, participating in other interventions, living in nursing home at baseline, or having frontotemporal dementia


InterventionsMutlifaceted and semi-tailored intervention consisting of counselling sessions, teaching, education and outreach telephone support to patients and carers

Provided individually and as a group intervention

Duration of intervention 8 to 12 months

Control group was provided with overall information and guidance, and was directed towards local support programmes (provided to both the control and treatment group)


OutcomesPatient Outcomes

Depression: Cornell Scale for Depression in Dementia (CSDD)

Other behavioral outcomes:

EuroQoL VAS (patient and proxy rated) (EQ-VAS)

Quality of Life in Alzheimer's Disease (patient and proxy rated) (QoL-AD)

Neuropsychiatric Inventory Questionnaire (NPI-Q)

Alzheimer’s Disease Cooperative Study Activities of Daily Living Scale (ADSC-ADL)

Cognitive function: Mini Mental State Examination (MMSE)

Caregiver outcomes:

Geriatric Depression Scale (GDS)

EuroQoL VAS (Quality of Life) (EQ-VAS)

Outcomes measured at 6 months and at 12 months


NotesIntervention consisted of 6 or 7 counselling sessions, 5 educational courses, 5-8 telephone calls within a 3- to 4-week intervals approximately

DSM-IV - Diagnostic and Statistical Manual of Mental Disorders, 4th edition

NINCDS-ADRDA - National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomisation was performed using a computer programme

Allocation concealment (selection bias)Low riskCentral allocation process was used to randomise participants by a third party

Blinding of participants and personnel (performance bias)
All outcomes
Low riskRaters were not employed by the same institution as study coordinators and counsellors

Blinding of outcome assessment (detection bias)
All outcomes
Low riskRaters were blind

Incomplete outcome data (attrition bias)
All outcomes
Low riskInformation on attrition and reasons provided, authors mention use of intention-to-treat analyses

Selective reporting (reporting bias)Low riskAll outcomes specified were reported

Other biasLow riskNo other apparent bias

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abraham 1992Participants did not fulfil criteria for a diagnosis of dementia

Cognitive impairment was measured and defined by scores < 80 on the Modified Mini-Mental State Examination (3MS) (Teng 1987)

Beck 2002Intervention does not meet criteria for a psychological intervention

Intervention based on psychosocial activities (i.e. drawings, life review). Outcomes based on direct observations of PwD

Brodaty 2003Intervention does not meet criteria for a psychological intervention

Multi-component case management approach

Cheston 2003This study was not conducted as a RCT

Feasibility study of a 10 week psychotherapy group aimed at reducing depression in people with dementia

Dartigues 2008Intervention does not meet criteria for a psychological intervention

RCT of cognitive training, and reminiscence therapy. Control group received psychoeducation for carers

Finnema 2005Intervention does not meet criteria for a psychological intervention

RCT evaluating an emotion oriented care program acknowledging residents' experiences

Fischer-Terworth 2011Intervention does not meet criteria for a psychological intervention

A TEACCH (Treatment and Education of Autistic and related Communication handicapped Children)-based cognitive-behavioural and environmental intervention. This study was not conducted as an RCT and the control group received occupational therapy

Fossey 2006Intervention does not meet criteria for a psychological intervention

Cluster RCT of training and support to nursing home staff for managing agitation

Garland 2007Intervention does not meet criteria for a psychological intervention

Intervention primarily targeted agitated behaviour. This study was not conducted as an RCT

Helcer 2012Intervention does not meet criteria for a psychological intervention

RCT of memory training (MT), or CBT in conjunction with MT targeting hopelessness in PwD

Hinchliffe 1997Intervention does not meet criteria for a psychological intervention

RCT of an intervention helping carers to cope with specific problem behaviours

Hyer 2008Participants did not fulfil criteria for a diagnosis of dementia

Cognitive decline measured and defined by the MMSE (Folstein 1975). RCT of CBT in residents with depression in long-term care

Joosten-Weyn Banningh2011This study was not conducted as an RCT

Intervention was psychoeducation, cognitive rehabilitation in conjunction with CBT in people with MCI

Kiosses 2010Participants did not fulfil criteria for a diagnosis of dementia

Older adults with depression, cognitive decline, and disability. 23.3% had probable or definite dementia. RCT comparing PATH (problem-solving therapy) to supportive therapy. No eligible control or comparison group

Kiosses 2011Participants did not fulfil criteria for a diagnosis of dementia

Cognitive impairment measured and defined by scores 90 - 133 inclusive on the Dementia Rating Scale (DRS). RCT comparing PATH (problem-solving therapy) to supportive therapy. No eligible control or comparison group

Kolanowski 2011Intervention does not meet criteria for a psychological intervention

RCT of an activities-based intervention in reducing agitation in nursing home residents with dementia

Konnert 2009Participants did not fulfil criteria for a diagnosis of dementia

Cognitive decline measured and defined by scores < 21 on the MMSE. RCT of a CBT intervention in nursing home residents at risk of depression

Kurz 2012Intervention does not meet criteria for a psychological intervention

RCT of cognitive rehabilitation with CBT elements

Laakkonen 2012Intervention does not meet criteria for a psychological intervention

RCT of self-management for PwD based on a rehabilitation model

Lam 2010Intervention does not meet criteria for a psychological intervention

RCT of skills training occupational therapy with CBT elements

Lichtenberg 2005Intervention does not meet criteria for a psychological intervention

Intervention of behavioural activities delivered by nursing home assistants in dementia care units

Logsdon 2010Intervention does not meet criteria for a psychological intervention

RCT of support groups for PwD that did not follow a psychological model (can not be described as a supportive therapy intervention)

McSweeney 2012Intervention does not meet criteria for a psychological intervention

Cluster RCT of a multidisciplinary specialist mental health consultation for depression in dementia provided to care staff

Mittelman 1996Intervention does not meet criteria for a psychological intervention

RCT of counselling and support for caregivers to delay nursing home placement in PwD

Onor 2007Intervention does not meet criteria for a psychological intervention

RCT of a multimodal rehabilitation program of cognitive stimulation therapy and psychoeducation for carers

Prick 2011Intervention does not meet criteria for a psychological intervention

RCT of home-based physical exercise for people with dementia and their carers

Proctor 1999Intervention does not meet criteria for a psychological intervention

RCT of a staff training and educational programme in residential care

Rovner 2012Intervention does not meet criteria for a psychological intervention

RCT of a Behavioural Activation (BA) program to prevent cognitive decline in MCI. No eligible control or comparison group

Selbaek 2010Intervention does not meet criteria for a psychological intervention

Staff nursing training program based on CBT. This study was not conducted as an RCT

Teri 2003Intervention does not meet criteria for a psychological intervention

RCT of home-based exercise combined with caregiver training for delaying institutionalisation in PwD

Vespa 2002Intervention does not meet criteria for a psychological intervention

Evaluation of a creative activities-based therapy in reducing anti-social behaviour in PwD

Yesavage 1981Participants did not fulfil criteria for a diagnosis of dementia. This study was not conducted as a RCT. No eligible control or comparison group

 
Characteristics of studies awaiting assessment [ordered by study ID]
Carreel 1990

MethodsUnknown whether this study was an RCT

ParticipantsElderly depressed older adults with dementia

InterventionsGroup sessions with therapeutic aim described as conversation groups

OutcomesLinguistic skills

NotesArticle in French

 
Characteristics of ongoing studies [ordered by study ID]
Forstmeier 2011

Trial name or titleCognitive-Behavioral Treatment for Mild Alzheimer's Patients and Their Caregivers (CBTA)

MethodsRCT

ParticipantsInclusion criteria:
1) 50 to 95 years
2) meeting NINCDS-ADRDA criteria for probable or possible AD McKhann 1984
3) only AD cases with a mild dementia severity will be included, determined by the Clinical Dementia Rating (CDR) scale, with scores 0.5 or 1, and by MMSE scores ≥20
4) Patient must suffer any non-cognitive symptom that motivates him/her to accept psychotherapeutic help
5) A caregiver must be available to take part in most of the therapy sessions

Exclusion Criteria:
1) concomitant alcohol/drug addiction, history of malignant disease, severe organ failure, metabolic or hematologic disorders, or other neurological conditions.

InterventionsCBT-based multi-component programme of 8 modules (diagnosis & goal setting; psycho-education; engagement in pleasant activities; cognitive restructuring; live review; training caregiver in behavior management techniques; interventions for the caregiver; and couples counselling).

20 weekly sessions (and 5 single sessions with caregiver).

The control group receives standard medical and psychosocial care (each patient/caregiver will receive at least three out of six interventions: (1) psychoeducation on dementia and treatment of dementia (oral and written); (2) appropriate medical treatment; (3) social counseling by specialized staff; (4) memory training in group setting; (5) self-help group for the patient; (6) self-help group for the caregiver)

OutcomesPrimary patient outcomes
Geriatric Depression Scale (GDS)

Secondary patient outcomes
Neuropsychiatric Inventory (NPI), Bayer-Activities of Daily Living (B-ADL), Stress Coping Inventory (SCI), Apathy Evaluation Scale (AES)
Caregiver outcomes

Center for Epidemiologic Studies Depression Scale (CES-D), State Trait Anxiety Inventory (STAI), Anger-in and anger-out scales of the State Trait Anger Expression Inventory (STAXI), Short-Form Health Survey (SF-12), Zarit Burden Interview (ZBI), and Stress Coping Inventory (SCI)
Outcomes are measured at 15 weeks and 12 months

Starting dateJanuary 2011

Contact informationDr Simon Forstmeier, University of Zurich, s.forstmeier@psychologie.uzh.ch

NotesClinicalTrials.gov Identifier: NCT01273272

 
Comparison 1. Psychological treatment versus treatment as usual

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Depression6439Std. Mean Difference (IV, Fixed, 95% CI)-0.22 [-0.41, -0.03]

 2 Anxiety RAID265Mean Difference (IV, Fixed, 95% CI)-4.57 [-7.81, -1.32]

 3 Anxiety Self ratings265Std. Mean Difference (IV, Fixed, 95% CI)0.05 [-0.44, 0.54]

 4 Anxiety NPI-A126Mean Difference (IV, Fixed, 95% CI)-2.4 [-4.96, 0.16]

 
Comparison 2. Psychological intervention versus treatment as usual

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Quality of Life (Self ratings)3334Mean Difference (IV, Fixed, 95% CI)0.37 [-1.01, 1.75]

 2 Quality of Life (Proxy ratings)2313Mean Difference (IV, Fixed, 95% CI)0.66 [-0.77, 2.09]

 3 Activities of daily living2313Std. Mean Difference (IV, Fixed, 95% CI)-0.13 [-0.35, 0.09]

 4 Neuropsychiatric symptoms2311Std. Mean Difference (IV, Fixed, 95% CI)0.06 [-0.16, 0.28]

 5 Cognition (Mini Mental State Examination)4381Mean Difference (IV, Fixed, 95% CI)-0.80 [-1.70, 0.11]

 
Comparison 3. Psychological intervention versus treatment as usual

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Carer Depression3337Std. Mean Difference (IV, Fixed, 95% CI)0.07 [-0.14, 0.29]

 
Summary of findings for the main comparison. Psychological treatment compared to treatment as usual for depression and anxiety in dementia and mild cognitive impairment

Psychological treatment compared to treatment as usual for depression and anxiety in dementia and mild cognitive impairment

Patient or population: Patients with depression and anxiety in dementia and mild cognitive impairment
Settings: Community, residential care
Intervention: Psychological treatment
Comparison: Treatment as usual

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Treatment as usualPsychological treatment

Depression
Geriatric Depression Scale (range of scores 0-15, 0-30), Cornell Scale for Depression in Dementia (range of scores 0-38), Montgomery-Asberg Depression Rating Scale (range of scores 0-50)
Follow-up: 6 - 48 weeks
The mean depression in the intervention groups was
0.22 standard deviations lower
(0.41 to 0.03 lower)
439
(6 studies)
⊕⊕⊕⊝
moderate1
SMD -0.22 (-0.41 to -0.03)

Anxiety RAID
Rating Anxiety in Dementia. Scale from: 0 to 54.
Follow-up: 15 - 48 weeks
The mean anxiety RAID ranged across control groups from
17.89 to 17.2 points2
The mean anxiety RAID in the intervention groups was
4.57 lower
(7.81 to 1.32 lower)
65
(2 studies)
⊕⊕⊝⊝
low3,4
Higher scores indicate higher levels of anxiety symptoms

Anxiety Self ratings
Hospital Anxiety and Depression Scale (range of scores 0 - 21), Geriatric Anxiety Inventory (range of scores 0-20)
Follow-up: 15 - 48 weeks
The mean anxiety self ratings in the intervention groups was
0.05 standard deviations higher
(0.44 lower to 0.54 higher)
65
(2 studies)
⊕⊕⊝⊝
low5,6
SMD 0.05 (-0.44 to 0.54)

Anxiety NPI-A
Follow-up: 6 months
The mean anxiety NPI-A in the intervention groups was
2.4 lower
(4.96 lower to 0.16 higher)
26
(1 study)
See commentHigher scores indicate higher levels of anxiety symptoms

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 In two of the studies blinding of outcome assessment is not sufficiently reported. There is evidence of selective reporting at least in 1 study. Only 1 study describes blinding of personnel.
2 These values are based on scores in the control group across studies in the systematic review
3 Potential selection bias in one of the studies included (allocation concealment was not specified).
4 Small number of studies
5 Potential selection bias in one of the studies included (allocation concealment was not specified).
6 Small number of studies
 
Table 1. Overview of characteristics of included studies

StudySampleMethodMeasuresInterventionOutcome Data Timepoints

Burgener 2008n = 43

Inclusion criteria

(1) confirmed diagnosis of dementia (AD, Lewy body, vascular, frontal lobe, or mixed dementia)

(2) CDR < 2.0
RCT

 
Patient Outcomes

Depression

Geriatric Depression Scale (GDS-15)

Other behavioral outcomes

Rosenberg’s Self-Esteem Scale (SES)
Type

Multimodal CBT including Tai Chi, CBT, and support group

 

Duration

20 weeks

(note that intervention lasted 40 weeks) 
Outcome data included in the Review

20 weeks

 

Baseline CDR and MMSE  

Treatment group

CDR 1.15

MMSE 24.8

Control group

CDR 1.22

MMSE 22.9
Control group

Attention-control educational program
Cognition

Mini-Mental State Examination (MMSE)

Physical function

Single leg stance (SLS)

Berg Balance Scale (BBS)

Cumulative Illness Rating Scale (CIRS)
Intensity/Frequency

Tai Chi

3 times a week (60 minutes)

CBT

2 times a week (90 minutes)

Support group

2 times a week

(90 minutes, alternating with CBT)
Outcome data reported (for both groups) at 20 weeks

control group enters treatment at 20 weeks, scores at 40 weeks (representing no treatment) not

available

Burns 2005n = 40

 

Inclusion criteria

1) diagnosis of AD - NINCDS–ADRDA criteria

2) CDR of 1

3) MMSE ≥ 15

4) living in own home with carer in regular contact

5) ability to communicate verbally
RCTPatient Outcomes

Depression

Cornell Scale for Depression in Dementia (CSDD)

Function

Activities of Daily Living (BADLS)

Other patient outcomes

Cognition

Mini-Mental State Examination (MMSE)

Clinician’s Interview-Based Global Impression of Change (CIBI)
Type

Psychodynamic interpersonal therapy based on interpersonal theory

 

Duration

6 weeks

 
Outcome data included in the Review

6 weeks

Medication

20% on antidepressants

68% on cholinesterase inhibitors

Baseline MMSE

Treatment group

MMSE 24.4

Control group

MMSE 21.5
Control group

Standard treatment in AD, (general advice on diagnosis and treatment of dementia, with out-patient review)
Carer outcomes

Revised Memory and Behavior Problems Checklist (RMBPC) - Carer's reaction

General Health Questionnaire (GHQ-12)

Beck Depression Inventory (BDI-II) (scores not reported)

Ways of Coping Checklist (WCCL)
Intensity/Frequency

Once a week (50 minutes - of which 10 minutes are spent with carer)
Outcome data reported at 6 weeks (end of the intervention)

and 3 months

Spector 2012n = 50

Inclusion criteria

1) Meet DSM-IV criteria for mild to moderate dementia, CDR of 0.5, 1 or 2
2) Clinical anxiety, ≥ 11 on the RAID

3) Living in the community
4) Presence of carer willing to participate in the therapy
5) Ability to understand and communicate in English
6) Willing to engage in therapy

Exclusion criteria
1) Co-morbid psychiatric disorder or challenging behaviour
2) Learning disability or severe physical illness
RCTPatient outcomes

Rating Anxiety in Dementia (RAID)

Clinical Services Receipt Inventory (CSRI)

Secondary outcomes

Hospital Anxiety and Depression Scale (HADS)

Quality of Life-Alzheimer’s Disease (QOL-AD) (self and proxy ratings)

Neuropsychiatric Inventory (NPI)

Mini-Mental State Examination (MMSE)

Cornell Scale for Depression in Dementia (CSDD)

Quality of Caregiver and Patient Relationship (QCPR)
Type

CBT

identifying strategies for feeling safe, calming thoughts and behavioural experiments, with telephone contact offered between sessions.

Carers involved

Duration

15 weeks
Outcome data included in the Review

15 weeks

Control group

Standard treatment including medication or no treatment
Carer outcomes

Hospital Anxiety and Depression Scale (HADS)

Quality of Caregiver and Patient Relationship (QCPR)
Intensity/Frequency

10 sessions (60 minutes) for 15 weeks, and telephone contact
Outcome data reported at 15 weeks (end of intervention) and 6 months

Stanley 2012n = 32

 

Inclusion criteria

1) diagnosis of dementia (confirmed by the patient’s medical provider)

2) an NPI-A ≥ 4

3) CDR score of 0.5 - 2.0

Exclusion criteria

-primary psychiatric diagnosis of major depression

-active psychosis, bipolar disorder, active suicidal intent

-recent verbal or physical aggression

 
RCTPatient outcomes

Depression

Geriatric Depression Scale (GDS) (self report)

Quality of Life

Quality of Life in Alzheimer disease (QOL-AD) (self report)

Other outcomes

Anxiety

Neuropsychiatric Inventory–Anxiety (NPI-A) subscale (collateral report)

Rating of Anxiety in Dementia (RAID) (administered as a clinical interview to patient and carer)

Geriatric Anxiety Inventory (GAI) (self report)

Worry

Penn State Worry Questionnaire–Abbreviated (PSWQ-A) (self report)
Type

CBT targeting anxiety (self-monitoring/deep breathing), written materials on dementia education, collateral stress and communication.

Carers involved as coaches

Duration

6 months

 
Outcome data included in the Review

6 months

Dementia diagnosis

AD (62.5%), DLB (3.1%), VaD (9.4%) and 25% dementia not otherwise specified (NOS)

Principal DSM-IV Diagnoses

43.8% GDA, 18.8% other anxiety disorder, 43.8% comorbid anxiety and depression, 34.4% no diagnosis, 3.1% a depression diagnosis

Dementia Severity

46.9% CDR of 0.5 or 1

Medication

75% on at least one psychotropic medication
Control group

Receives diagnostic feedback
Carer Outcomes

Depression

Patient Health Questionnaire (PHQ-9)

Distress

Distress item from the NPI-A
Intensity/Frequency

12 weekly sessions (30 to 60 minutes) for 3 months, 8 telephone booster appointments during months 3–6
Outcome data reported at 3 and 6 months (end of intervention)

Tappen 2009n = 36

 

Inclusion criteria

1) diagnosis of probable AD, NINCDS-ADRDA criteria

2) MMSE ≤ 25

3) ability to speak English

 

Exclusion criteria

1) Individuals entirely mute
RCTPatient Outcomes

Depression

The Montgomery-Asberg Depression Rating Scale (MADRS)

 
Type

Modified counselling offered individually consisting of therapeutic conversation

 

Duration

16 weeks

 
Outcome data included in the Review

16 weeks

Mean stay in nursing care

Treatment group

561 days

Control group

595 days

 

Baseline MMSE

Treatment group

10.60

Control group

12.26
Control group

Usual care (not an attention-control group)
Other Patient Outcomes

Mood

Dementia Mood Assessment Scale (DMAS)

The Alzheimer’s Disease and Related Disorders (AD-RD) Mood Scale
Intensity/Frequency

3 times a week (30 minutes)
Outcome data reported at 16

weeks (end of intervention)

 

Waldroff 2012n = 330

 

Inclusion criteria

1) community-dwelling

2) age ⋝ 50 years

3) MMSE ⋝ 20

4) diagnosis of probable AD, mixed AD with vascular components or DLB, established in the last 12 months, meeting DSM-IV, NINCDS-ADRDA or the McKeith 1996 criteria for DLB

Exclusion criteria

1) severe somatic or psychiatric comorbidity

2) participating in other intervention studies

3) residing in a nursing home at baseline

5) diagnosis of frontotemporal dementia  
RCT

 
Patient Outcomes

Depression

Cornell Scale for Depression in Dementia (CSDD)

Function

Alzheimer’s Disease Cooperative Study Activities of Daily Living Scale (ADSC-ADL)

Quality of Life

Quality of Life in Alzheimer's Disease (patient and proxy ratings) (QoL-AD)

Other outcomes

EuroQoL VAS (patient and proxy ratings Quality of Life) (EQ-VAS)

Neuropsychiatric Inventory Questionnaire (NPI-Q)

Mini Mental State Examination (MMSE)
Type

Mutlifaceted and semi-tailored intervention consisting of counselling sessions, teaching, education and outreach telephone support to patients and carers.

Provided individually and as a group intervention

Duration

8 to 12 months
Outcome data included in the Review

12 months

Dementia diagnosis

AD 72.4%, Mixed or VaD 24.8%, DLB 2.7%  

Medication

93.3% on cholinesterase inhibitors

1% memantine

Baseline MMSE

Treatment group

24.0

Control group

24.1
Control group

Provided with overall information and guidance, directed towards local support programmes (provided to both the control and treatment group)
Carer outcomes

Depression

Geriatric Depression Scale (GDS)

Other outcomes

Quality of Life

EuroQoL VAS (EQ-VAS)
Intensity/Frequency

6 counselling sessions (plus one optional session)

5 educational courses (2 hours)

5-8 telephone support calls within 3-4 week intervals

 
Outcome data reported at 6 and 12 months (end of intervention)