Remarks y Depression is common among people with dementia and is associated with significant adverse effects, including decrease in quality of life, increased need for institutionalization, greater health care utilization, higher mortality rates and increased caregiver burden. y Psychological interventions may not be feasible as a treatment for people with severe dementia and symptoms of depression due to impaired cognitive function. An assessment by a suitably qualified health worker is the most appropriate means of judging the most appropriate treatment choice. y For treatment of severe depression in people living with dementia, also refer to the existing mhGAP recommendation, which was validated by the GDG for this update. It reads as follows: “In people with dementia and severe depression, or when psychosocial interventions prove ineffective, the use of selective serotonin reuptake inhibitors (SSRIs) (but not tricyclic antidepressants [TCAs]) should be considered. In people with dementia and mild-tomoderate depression, antidepressants should not be offered as a first-line treatment” (7). y The type of psychosocial intervention offered should be based upon the capacity of the health or care worker, family member or carer and individual preferences.

Implementation considerations y Psychological therapies may be preferred to antidepressant medicine, which has been shown to lack efficacy. High levels of treatment adherence were reported in most of the trials included in the 2014 Cochrane Review. y Presented evidence in the 2014 Cochrane Review is based on trials that included people living with mildto-moderate dementia (106). The ability of people living with more severe dementia to access and participate in these therapies depends not only on their mental capacity but also other comorbidities and their social context. The assessment by a suitably qualified health worker is therefore paramount in judging the most appropriate treatment choice. y Delivery of these interventions requires adequate training and supervision of a non-specialist health worker. y Additional tailoring of psychological interventions to the specific needs of people with dementia may be required based on the setting and dementia severity. For non-pharmacological interventions for depressive symptoms more broadly experienced by people with dementia (at all stages of disease), refer to the new PICO DEM3. A recent meta-analysis on the effectiveness of psychological interventions for depression in general (i.e. not specific to dementia or any other comorbid condition) across different age groups suggests that there are no differences in effect sizes for these interventions for older adults (55–75 years), and older old adults (75 years and older) (107). Moreover, meta-analytic evidence suggests the effectiveness of such interventions for people with other neurological conditions such as Parkinson’s disease and multiple sclerosis (108).