Depression and Alzheimer's disease.

Depressive symptoms, due either major depression or clinically significant, subsyndromal depression, occur commonly in the course of Alzheimer's disease. For a variety of clinical and methodological reasons, this remains an area that begs for new investigation. At the very least, these depressive symptoms should be viewed as a cause of significant and treatable "excess disability" (Kramer and Reifler, 1992). Demented patients with clinically significant depression (e.g., depressed mood, significant loss of appetite, insomnia, fatigue, irritability, and agitation) should be considered for a trial of antidepressant therapy, even when they fail to meet full diagnostic criteria for major depression. These symptoms will, in most instances, respond to antidepressant therapy. The "rules" for treatment of depression in dementia are slightly different than for cognitively intact patients: (a) start low, go slower, (b) pay attention to cognitive toxicity of all medication combinations, and (c) depressive symptoms do not persist as long as in cognitively intact patients. Current treatments, especially those SSRI's like fluoxetine and sertraline that have cognitive enhancing effects, should be considered the "first line" antidepressants. We need to emphasize early detection and treatment of depressive symptoms in dementia in all arenas.