Our study is the first to use a placebo-controlled randomized design of the antidepressant treatment of caregiver depression. We report improvement in depression, anxiety, resilience, and subjective distress in caregivers receiving escitalopram compared to those on a placebo despite the fact that caregivers had higher levels of distress compared to other studies of caregiver stress (total scores with mean of 32–34 in our sample compared to 11–17 in other samples) (28
). Although some prior studies used pharmacological approaches in a subgroup of patients, no prior reports used a placebo-controlled trial (4
). Based on our findings, we concluded that antidepressant use in depressed family dementia caregivers with either major or minor depression can be used to improve symptoms of depression, boost resilience to stress, and improve coping with caregiver stress.
The accumulating evidence on the personal, social, and health impacts of caregiving has generated multiple psychosocial intervention studies aimed at decreasing the burden and stress of caregiving. Although the empirical evidence has shown that psychosocial and educational interventions can lower caregivers’ depressive symptoms and enhance mental health (36
), the effects of interventions vary greatly in relation to the contents of programs, characteristics of caregivers and patients, and other contextual factors (39
). The existing psychosocial interventions are minimally-to-modestly effective and rarely include biological measures of stress-response or document improvements in distress or resilience in caregivers as the result of these interventions (40
Recent research focusing on more rigorous randomized controlled-trial designs evaluated a broader range of intervention programs involving individual or family counseling, case management, skills training, environment modification, behavior-management strategies, anger and depression management, and combination thereof (38
). The recent multi-site study referred to as REACH I and II (Resources for Enhancing Alzheimer’s Caregiver Health) (1
) is a unique, multi-site research program sponsored by the National Institute on Aging and the National Institute on Nursing Research, studied a total of 1,222 caregivers and care-recipients with various psycho-educational interventions, home-based interventions, support groups; counseling, behavioral skills training, and medications for care-recipient and caregiver with moderate effects on caregiver depression and stress (1
). Evidence from these supportive and behavioral interventions indicates that combined interventions targeting multiple levels of the stress/health model and multiple individuals simultaneously (i.e., caregiver and patient) produce a significant improvement in caregiver depression/burden, subjective well-being, perceived caregiver satisfaction, ability/knowledge, and, sometimes care-recipient symptoms (39
). In the recent meta-analysis, Pinquart and Sorensen (2006) integrated the results of 127 intervention studies with dementia caregivers published or presented between 1982 and 2005 (47
). Interventions had, on average, significant but small effects on burden, depression, subjective well-being, ability/knowledge and symptoms of care recipient. Only multicomponent interventions reduced the risk for institutionalization. Psychoeducational interventions that require active participation of caregivers had the broadest effects. Effects of cognitive-behavioral therapy, support, counseling, daycare, training of care recipient, and multicomponent interventions were domain specific. The authors concluded that because most interventions had domain-specific outcomes, clinicians must tailor interventions according to the specific needs of the individual caregivers. Given the magnitude of the caregiver burden and the great variety of caregiver intervention studies funded by the federal and private funding, it is surprising that a number of intervention studies have consistently failed to document positive outcomes, and there has been very little translation of the interventions into clinical practice.
On the other hand, our results are fairly striking compared to the placebo-controlled antidepressant studies of geriatric or mixed-age depression (48
). While a relatively modest remission rate of 30–35% and high placebo response rate nearing 30–40% has been well documented in geriatric and mixed–age samples including a large cohort of the recently completed Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study (48
), 86% of caregivers in our sample on escitalopram were able to achieve remission compared to 44% in those on placebo. In fact, the commonly believed and expected effect of antidepressants to help depressed patients achieve remission or improvement only happens in 30–50% of patients with geriatric depression in clinical trials. Nearly half of all placebo-controlled clinical trials fail to find drug-placebo differences in geriatric patients. Fluoxetine performed equal or worse than placebo in improving depressive symptoms in several trials of geriatric depression, similarly to other SSRI antidepressants (18
). We believe that heterogeneity of depression is one of the factors responsible for overall disappointing results in geriatric depression trials. We are impressed with the observed benefit of escitalopram and the speed of response between weeks two and four in the remitters and the improved burden and coping that are important in reducing suffering in caregivers. In the narrative subjective reports, most caregivers uniformly stated in the first two to four weeks that they felt as if they were removed from the immediate harmful effect of stress that gave them an opportunity to be more objective and less reactive to the difficulties of caregiving tasks. None of psychosocial interventions that dominate caregiver depression field provided such fast and reliable relief. There have been no placebo-controlled studies of antidepressants in caregivers, ours is the first to demonstrate such effects.
In conclusion, our study provides new evidence of antidepressant efficacy in caregiver depression that also improves resilience and coping with caregiver stress. One might consider the characteristics of our samples as the limitations of the study that includes mixed and relatively small sample of adult children and spousal caregivers who suffered from either major or minor depression. However, this sample is representative of community caregivers and these features also allowed us to examine the effects of age and severity of depression, as well as comorbid conditions associated with aging such as medical and vascular burden. We did not find any significant effects of the above variables in our outcomes. We concluded that the use of antidepressants is a viable option in helping caregivers cope with their depression and the stress of caregiving. We attribute the greater rate of remission in this cohort compared to the average study of geriatric depression to the nature of depression caused by the similar life stressors compared to the heterogeneous groups of elderly depressed patients selected by the non-discriminating-by-cause descriptive DSM diagnostic categories. Although some heterogeneity in individual life circumstances exists, for the most part, caregivers are depressed because of severe chronic stress of caregiving. They may also have lesser genetic loading, medical burden, and cognitive impairment than subjects in the studies of geriatric depression that may explain better antidepressant response in our trial. However, this study needs to be replicated in a larger study. Other non-pharmacological mind-body approaches to stress reduction such as yoga and meditation should also be tested in this difficult-to-manage population.