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Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes.
To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia.
A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0–13 weeks and 0–39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods.
There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively.
In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.
Electroconvulsive therapy (ECT) is an effective treatment for major
depression. Optimising efficacy and minimising cognitive impairment are
goals of ongoing technical refinements.
To compare the efficacy and cognitive effects of a novel electrode
placement, bifrontal, with two standard electrode placements, bitemporal
and right unilateral in ECT.
This multicentre randomised, double-blind, controlled trial (NCT00069407)
was carried out from 2001 to 2006. A total of 230 individuals with major
depression, bipolar and unipolar, were randomly assigned to one of three
electrode placements during a course of ECT: bifrontal at one and a half
times seizure threshold, bitemporal at one and a half times seizure
threshold and right unilateral at six times seizure threshold.
All three electrode placements resulted in both clinically and
statistically significant antidepressant outcomes. Remission rates were
55% (95% CI 43–66%) with right unilateral, 61% with bifrontal (95% CI
50–71%) and 64% (95% CI 53–75%) with bitemporal. Bitemporal resulted in a
more rapid decline in symptom ratings over the early course of treatment.
Cognitive data revealed few differences between the electrode placements
on a variety of neuropsychological instruments.
Each electrode placement is a very effective antidepressant treatment
when given with appropriate electrical dosing. Bitemporal leads to more
rapid symptom reduction and should be considered the preferred placement
for urgent clinical situations. The cognitive profile of bifrontal is not
substantially different from that of bitemporal.
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