Treating depression in patients with dementia: a guide to drug choice.

Depression is present in about 40% of patients with dementia. Whereas most studies of depression in dementia are carried out in patients with Alzheimer’s dementia, depression is also a frequent finding in other types of dementia, such as ischaemic vascular dementia, dementia with Lewy bodies and fronto-temporal dementia. Longitudinal studies have demonstrated that untreated major depressions may last for more than 1 year in patients with dementia, whereas minor depression is of shorter duration. Despite the high incidence of depression in patients with dementia, few controlled studies have examined the usefulness of antidepressant drugs. Tricyclic antidepressants (TCAs) such as imipramine and clomipramine may be effective, but a high incidence of adverse effects such as orthostatic hypotension and urinary retention may limit their use to the subgroup of patients in whom tolerability is acceptable. Selective serotonin (5-hydroxy-tryptamine; 5-HT) reuptake inhibitors (SSRIs) such as citalopram and fluoxetine have efficacy similar to that of TCAs, but the incidence of adverse effects is substantially lower. Monoamine oxidase inhibitors have rarely been assessed in patients with dementia, although moclobemide has demonstrated good efficacy and tolerability in a single study. Although antidepressant drugs usually demonstrated greater efficacy than placebo, these differences were mostly slight and require further evaluation.