Tackling depression and improving wellbeing in people with dementia
Dr Joshua Stott investigates the links between wellbeing and dementia, and how we can treat mental health problems in dementia.
Depression and anxiety are more common in people with dementia than in those without the condition. Around 40% of people with mild to moderate dementia experience mental health problems like anxiety or depression.
As well as being distressing, these conditions can worsen dementia symptoms. Studies show that depression and anxiety in people with dementia are associated with poorer outcomes, including greater caregiver burden and earlier institutionalisation.
Despite this, people living with dementia are not commonly seen in psychological therapy services. Dr Joshua Stott leads a clinic at the UCL Dementia Research Centre and research through the UCL ADAPT lab, looking at how traditional therapies for mental health problems can be adapted to help people with the condition.
He believes that tailoring therapies according to an individual’s level of functioning could have a significant impact in alleviating the problem of depression and anxiety among those with dementia.
For example, feeling anxious about memory problems may prevent a person from attending social events. When people are withdrawn from social activity, this tends to hasten their cognitive decline. By challenging a person’s beliefs, therapies like cognitive behavioural therapy (CBT) could enable a person to access social situations again – which in turn is likely to positively affect their mood.
There has been little research in this area, and in the largest study of psychological therapies to date, Dr Stott’s work is the first to establish that people with dementia can benefit from a routinely provided primary care psychology service (NHS talking therapies – previously known as IAPT). He has also conducted research examining what elements of therapy people with dementia might find helpful or, conversely, challenging.
CBT typically involves reflecting on and discussing the consequences of what's happening in terms of someone’s thoughts, feelings and behaviours. Dr Stott explains that for people with dementia, it can often be more effective to prioritise behavioural changes and reduce the cognitive demands that psychological therapy can involve. Scheduling pleasant events and activities into a daily routine, for example, could have a noticeably positive effect on someone’s long-term mood.
Dr Stott also works with neurologists, other psychologists and the UCL-run Rare Dementia Support service at the UCL Dementia Research Centre which supports people with rare forms of dementia, such as young onset and genetic inherited dementias. Here, his work often involves acceptance and commitment therapy with patients in his clinic, which is about learning ‘radical acceptance’ as a strategy. This involves activities like practising mindfulness, appreciating that thoughts are just mental events, identifying an individual’s values and allowing them to live in line with these as far as possible in the context of dementia, as well as cultivating the ability to stay in the present moment.
In addition to working with people who have both depression and dementia, Dr Stott is also interested in dementia prevention – particularly in relation to whether improving mood and wellbeing might be useful dementia prevention activities.
A number of studies have shown that people who have depression in late life subsequently go on to develop dementia. It’s difficult to establish causality because while this relationship may be causal – due to depression leading to brain or behaviour change that then increases risk of dementia – it could also be due to other non-causal reasons. For example, depression could be an early symptom of dementia or people may notice signs of cognitive change and experience depression as a result.
Given this work, researchers have been interested in whether treating later life depression reduces the risk of dementia. While previous studies have investigated antidepressant medication, Dr Stott’s work is the first to look at whether psychological therapies like CBT could help prevent dementia. Looking at a sample of over 120,000 over 65-year-olds without identified dementia, he established that successful psychological therapy was associated with reduced risk of dementia.
However, Dr Stott cautions while this finding may indicate that successful psychological therapy for depression can reduce the risk of developing dementia, there are other potential explanations too. In particular, ‘reverse causality’, whereby people with undiagnosed early dementia may find therapy less effective than people who don’t have dementia, could explain the finding.
As well as his interest in the relationship between negative mental health like depression and anxiety and future dementia, Dr Stott is also interested in whether increased positive mental health might be associated with reduced risk of dementia.
In a recent meta-analysis where his team pulled together all the findings done in this area, Dr Stott found that while aspects of meaning in life we call ‘eudemonic wellbeing’ (the pursuit and experience of meaning and personal growth) were associated with lower risk of dementia years later, findings were much more mixed for what is termed ‘hedonic wellbeing’ (the pursuit and experience of pleasure, e.g. happiness and positive evaluations).
“Understanding the links between positive mental health and reducing the risk of dementia is important because we need to put this on the map. We’ve found that some aspects of wellbeing, such as purpose in life, could be linked with a reduced risk of dementia.
“We are currently doing work to generate new knowledge about these associations between wellbeing and dementia. For example, is the association causal? Are there biological reasons underpinning the association? And we’re looking at whether intervention for wellbeing can have benefit as a potential dementia prevention activity,” Dr Stott explains.
By building on his previous research, Dr Stott ultimately hopes to understand whether we can treat mental health problems in dementia – and whether treating mental health problems and improving wellbeing in people without dementia might be useful in preventing the condition.