Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Neurology

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Guidelines for dementia or Parkinson’s disease with depression or anxiety: a systematic review

  • Zahra Goodarzi1, 2, 10Email author,
  • Bria Mele1,
  • Selynne Guo3,
  • Heather Hanson1, 4,
  • Nathalie Jette1, 5, 6,
  • Scott Patten1, 8, 9,
  • Tamara Pringsheim1, 5, 6, 7 and
  • Jayna Holroyd-Leduc1, 2
BMC NeurologyBMC series – open, inclusive and trusted201616:244

https://doi.org/10.1186/s12883-016-0754-5

Received: 30 June 2016

Accepted: 10 November 2016

Published: 25 November 2016

Abstract

Background

Depression and anxiety remain under-diagnosed and under-treated in those with neurologic diseases such as dementia or Parkinson’s Disease (PD). Our objectives were to first, to provide a synthesis of high quality guidelines available for the identification and management of depression or anxiety in those with dementia or PD. Second, to identify areas for improvement for future guidelines.

Methods

We searched MEDLINE, PsycINFO, and EMBASE (2009 to July 24, 2015), grey literature (83 sources; July 24-Sept 6, 2015), and bibliographies of included studies. Included studies were evaluated for quality by four independent reviewers the AGREE II tool. Guideline characteristics, statements and recommendations relevant to depression or anxiety for dementia and PD were then extracted. (PROSPERO CRD: 42016014584)

Results

8121 citations were reviewed with 31 full text articles included for assessment with the AGREE II tool. 17 were of sufficient quality for inclusion. Mean overall quality scores were between 4.25 to 6.5. Domain scores were lowest in the areas of stakeholder involvement, applicability, and editorial independence.

Recommendations for the screening and diagnosis of depression were found for PD and dementia. There was little evidence to guide diagnosis or management of anxiety. Non-pharmacologic therapies were recommended for dementia patients. Most advocated pharmacologic treatment for depression, for both PD and dementia, but did not specify an agent due to lack of evidence.

Conclusions

The available recent high quality guidelines outline several recommendations for the management of comorbid depression or anxiety in PD or dementia. However there remain significant gaps in the evidence.

Keywords

Parkinson’s DiseaseDementiaDepressionAnxietyGuidelines

Background

Persons experiencing neurologic disorders, such as dementia or Parkinson’s disease (PD), and depressive or anxiety disorders have poorer outcomes with reduced quality of life, poor functional status and worsened cognition [18].

It is estimated that the prevalence of depression in dementia is approximately 25% with anxiety occurring in up to 75% [7, 911]. In PD, approximately 17% of patients experience major depression and anxiety between 3.6 to 40% [2, 12].

Despite awareness of these comorbidities, depression and anxiety remain under-diagnosed and under-treated in those with neurologic diseases [1, 3, 1317]. Only 20% of PD patients diagnosed with depression receive therapy [18]. This represents a significant knowledge-to-practice gap. One way to address this is through the use of Clinical Practice Guidelines (CPGs) [19]. CPGs synthesize available evidence based on a systematic review of the literature, clinical expertise and patient preferences [19]. CPGs are targeted at practitioners who apply the recommendations to clinical decision-making and reduce disparities in care [1922].

Thus, in the setting of PD and dementia, CPGs should enable the appropriate management of depression and anxiety [2326]. Despite available CPGs, these disorders remain under-managed, suggesting these CPGs are underused or lack sufficient recommendations [2628]. Multiple available guidelines of varied quality leads to uncertainty as to which CPGs should be used in practice. Our primary aim is to synthesize the high-quality evidence-based CPGs available for diagnosis, and management of depression or anxiety in those with dementia or PD. We chose to summarize and evaluate guidelines as the majority of physicians will use CPGs as a tool to review evidence and inform practice. Secondarily we aim to, identify areas gaps within the existing guidelines to inform future guideline development. This provides a broad over view of evidence in the area and identifies areas for further study and development.

Methods

The study protocol follows the recommendations provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)—Protocols Statement [29] and guidelines and the protocol was registered with PROSPERO [30] (CRD: 42016014584).

Search strategy

The literature search was developed in conjunction with an experienced librarian (DL) and was verified independently by a second librarian (HLR), using the Peer Review of Electronic Search Strategies (PRESS) methodology [31]. Any recommendations were incorporated into the final search.

Databases included MEDLINE, EMBASE, and PsycINFO. Clusters of terms (controlled vocabulary and key words) were used to search each database; these include dementia, Parkinson’s disease, depression, anxiety and CPGs (Additional file 1: Box S1). The search was completed by cluster, first searching the terms in each cluster (combined with the Boolean operator ‘OR’) and keyword searches of abstracts and titles. The clusters were then combined with ‘AND’. We searched for several pathological variants of dementia including Alzheimer’s disease, vascular, frontotemporal, Lewy Body disease, Huntington’s Disease, CADASIL, primary progressive aphasia, and Creutzfeldt Jakob (Additional file 1: Box S1). We included relevant derivatives of terms or broad key words related to depressive or anxiety disorders (Additional file 1: Box S1).

This was augmented by a search of the grey literature (Additional file 2: Table S1). This search was limited from 2009 to search date, such that we would only capture CPGs developed within the past 5 years; given the evidence that CPGs may become out of date after only 3 years [32]. All languages were included in this search.

Selection & eligibility

All citations were reviewed for eligibility by two independent authors; citations meeting initial eligibility criteria were included in full text review. If there was disagreement at the abstract stage, the full article was pulled for review. Bibliographies for all included articles were searched. If multiple CPGs were identified from a single agency on the same topic the most recent was used.

At the first stage of abstract review, any article that represented a guideline for PD or dementia was included. Eligibility at the full text stage required that the CPGs included at least one recommendation related to depression and/or anxiety in patients with PD and/or dementia. The kappa statistic was used to quantify inter-rater reliability.

For non-English articles that met eligibility at the full text stage, the language was determined using online translation software. Citations were translated using the online (Google translate) function to determine if an article was a guideline. When included, the documents were searched using translated relevant terms; for example, if a guideline pertained to PD in the abstract, the text was searched for depression or anxiety (and all translated synonyms). If those criteria were met, the full guideline was translated and reviewed.

Assessment of quality

The Appraisal of Guidelines Research & Evaluation (AGREE II) tool was used to assess guideline quality [33]. This tool was designed to evaluate guideline quality and to aid in guideline development and reporting [33]. The tool includes 6 domains covering scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence [33]. Within each domain there are between 2 to 8 questions, to a total of 23 [33]. Each item is rated from 1 (not included or very poorly reported) to 7 (exceptional reporting of all criteria outlined in the AGREE II Manual) [33].

Each domain was scored independently by four reviewers, along with the assignment of an overall score. An initial assessment of 5 citations was done and compared across all 4 reviewers [33]. The 4 reviewers met to discuss discrepancies and address questions about rating, before the remainder of the guidelines were reviewed and scored. This also served to ensure that all raters were aligned in their understanding of the AGREE II items. Any further discrepancies were resolved by discussion.

Domain scores pooled across the 4 assessors were calculated, as outlined in the AGREE II user manual [33]. The higher score indicates a higher quality across rated items. It has been demonstrated that the quality across the AGREE II domains predicts guideline implementation [33]. The mean overall quality scores with standard deviations (SD) were calculated, as well as for each domain item. CPGs with a mean overall quality score 5 or greater were assigned at least moderate quality and included in further analysis. CPGs with a score below 3 were excluded due to low quality. A score less than 5 but greater than 3 were re-evaluated and inclusion status was decided by consensus.

Data extraction & synthesis of evidence

Guideline characteristics were extracted by one author (ZG) and independently verified by a second author (BM). Items extracted included the primary conditions covered, region/organizations, number of committee members, numbers of references, and sources of funding.

Two independent reviewers then extracted relevant recommendations (ZG, BM). Specifically, guidelines were searched for any mention of relevant recommendations and supporting text or statements. Three authors reviewed the extracted recommendations (ZG, BM and JHL). Recommendations were compiled across the guidelines into relevant categories and subcategories, and reported using descriptive statistics including the quality, number of guidelines supporting the statement and subpopulations included. As the evidence in the guidelines is represented by practice recommendations, it was not amenable to meta-analysis. The main output of this systematic review was an appraisal of the quality of all guidelines pertaining to comorbid depression or anxiety in PD or dementia, and a synthesis of the recommendations across the different guidelines. Data were analyzed using STATA 13.1 (Stata Corp. College Station, TX).

Results

Study selection

The database search generated 4441 citations after duplicates were removed, with a further 3681 citations identified from the grey literature (Fig. 1). When screened for eligibility, 360 citations met criteria for full text review (κ = 0.88, 95.7% agreement). At this stage most articles were excluded because they were not relevant (n = 218), were not guidelines, or were unrelated guidelines. Other common reasons for exclusion at the full text stage were being out of the date range (n = 33) or a duplicate (n = 35). Excluded citations also included 26 mental health guidelines that did not address PD or dementia. Similarly there were 5 PD and 9 dementia guidelines that did not address depression or anxiety. The dementia guidelines primarily pertained to Alzheimer’s disease, vascular dementia, general dementia care and one referred to Lewy Body Disease. Of these articles, 4 were identified to be summary documents of included guidelines and were used as supplemental material to these included guidelines. Twenty-six CPGs met all eligibility criteria and were evaluated using the AGREE II tool, of which 17 met the quality cut off for inclusion.
Fig. 1

PRISMA Flow Diagram

Guideline characteristics

The 17 included guidelines addressed PD (n = 5), dementia (n = 8) and mental health (n = 4) CPGs (Table 1). They included recommendations from many regions, including Canada (n = 2), USA (n = 3), Pan-European (n = 4), UK (n = 2), Scotland (n = 1), Spain (n = 2), South Korea (n = 1) and international (n = 2). The associations or organizations are outlined in Table 1. All guidelines used a method for grading the evidence (Additional file 3: Figure S1). Most guidelines were funded through government or non-commercial funding; only two CPGs had some pharmaceutical funding.
Table 1

Guideline Characteristics

Author (year)

Organiz-ation

Primary conditiona

Focus

Region of origin

# of Committee membersi

#of Refs

Systematic search (Y/N)

Grading of evidence (Y/N)

Funding (NS, P, NC, G)j

Mean quality score

Zesiewicz et al. (2010) [35]

The American Academy of Neurology (AAN)

PD

Treatment

USA

9

40

Y

Y

NC

4.5

No Author (2010)b [37]

Scottish Intercollegiate Guidelines Network (SIGN)

PD

Diagnosis Treatment

Scotland

20

189

Y

Y

G

6

Grimes et al. (2012)c [34]

Canadian Neurological Sciences Federation (CNSF) & Parkinson Society Canada

PD

Diagnosis Treatment

Canada

22

62

Y

Y

NC & P

6.5

Berardelli et al. (2013) [38]

European Federation of Neurological Societies & Movement Disorder Society—European Section (EFNS-MDS-ES)

PD

Diagnosis

Europe

25

245

Y

Y

NS h

5

Ferreira et al. (2013) [40]

European Federation of Neurological Societies & Movement Disorder Society—European Section (EFNS-MDS-ES)

PD

Treatment

Europe

22

363

Y

Y

NC

4.5

Hort et al. (2010) [47]

European Federation of Neurological Societies (EFNS)

Dementia

Diagnosis Treatment

Europe

8

100

Y

Y

NC

4.25

No Author (2010) [42]

Ministry of Health, Social Services and Equality & Agency for Health Quality and Assessment of Catalonia (AIAQS)

Dementia

Diagnosis Treatment

Spain

67

688

Y

Y

NC & G

5.75

No Author (2011)d [41]

National Institute for Health and Care Excellence, National Collaborating Centre for Mental Health, British Psychological Society & The Royal College of Psychiatrists (NICE)

Dementia

Diagnosis & Treatment

UK

28

NNh

Y

Y

NC & G

6.5

Ihl et al. (2011) [44]

World Federation of Societies of Biological Psychiatry (WFSBP)

Dementia

Treatment

International

39

215f

Y

Y

NC

4.5

No Author (2011) [43]

Clinical Research Centre for Dementia (CRCD)

Dementia

Diagnosis

South Korea

20

NNh

Y

Y

G

5.25

O’Brien et al. (2011) [60]

British Association of Psychopharmacology (BPA)

Dementia

Treatment

UK

16

148f

N

Y

NC & P

4

Sorbi et al. (2012) [45]

European Federation of Neurological Societies & European Neurological Society (EFNS-ES)

Dementia

Diagnosis Treatment

Europe

17

189

Y

Y

NC

4.5

Gauthier et al (2012)e [50]

Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4)

Dementia

Diagnosis Treatment

Canada

38

19

Y

Y

NC

5.5

Gelenberg et al. (2010)g [39]

American Psychiatric Association (APA)

Depression

Treatment

USA

7

1170

Y

Y

NC

4.75

Dua et al. (2011) [49]

World Health Organization (WHO)

Mental Health

Diagnosis Treatment

International

29

36

Y

Y

NC & G

5.5

No Author (2012) [46]

Ministry of Health, Social Services and Equality & Galician Health Technology Assessment Agency (Availia-T)

Suicide

Diagnosis Treatment

Spain

24

683

Y

Y

NC & G

5

Mitchell et al. (2013) [48]

Institute for Clinical Systems Improvement (ICSI)

Depression

Diagnosis Treatment

USA

14

331

Y

Y

NC

5.75

a Dementia guidelines primarily included Alzheimer’s disease, vascular dementia, general dementia care and one referred to Lewy Body Disease

b Includes Grosset et al. [54]

c Includes Patel et al. [61]

d Originally created in 2007 and updated in 2011

e Includes Moore et al. [62], Herrman et al. [63]

f Number counted from the text

g Includes Recommendations Referenced in Rabin et al. [64]

h NS: Not Stated, NN: Not Numbered

i Committee members—extracted from paper as listed (e.g. authors listed, guideline development/working groups etc.)

j NC: Non-Commercial, G: Government, Pharmaceutical, NS: Not Stated

References: The American Academy of Neurology (AAN) [35], Scottish Intercollegiate Guidelines Network (SIGN) [37, 54], Canadian Neurological Sciences Federation (CNSF) [34], Parkinson’s Society Canada [34], European Federation of Neurological Societies (EFNS) (n = 4) [38, 40, 45, 47], Movement Disorders Society-European Section (MDS-ES) [38, 40], National Institute for Health and Care Excellence (NICE) [41], Ministry of Health, Social Services and Equality & Agency for Health Quality and Assessment of Catalonia (AIAQS) [42], British Psychological Society [41], The Royal College of Psychiatrists [41], World Federation of Societies of Biological Psychiatry (WFSBP) [44], Clinical Research Centre for Dementia (CRCD), British Association of Psychopharmacology (BPA) [60], European Neurological Society, Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) [50], American Psychiatric Association (APA) [39], World Health Organization (WHO) [49], Ministry of Health, Social Services and Equality & Galician Health Technology Assessment Agency (Availia-T) [46] and the Institute for Clinical Systems Improvement (ICSI) [48]

Study quality

These 26 CPGs were assessed for quality using all 23 items across the 6 domains of the AGREE II tool. Nine guidelines were excluded for low quality. Six were excluded with an overall mean rating ranging from 2.25 to 3.75. Three had ratings of 4–4.5, where decision to exclude was by consensus. A low rating was typically due to unclear methods; thus scoring low on rigour of development, applicability and editorial independence. Authors of guidelines were contacted for more information in the case that an item was unclear and responses were incorporated in the quality assessment.

The 17 included guidelines had mean overall scores from 4 to 6.5 (Table 2). When examining the individual domain scores, the highest rated domain was Domain 4: Clarity of Presentation (mean score 77.0; SD 11.4). This was followed by Domain 1: Scope and Purpose (mean score 72.1; SD 12.1). Domain 5: Applicability was the lowest rated domain (mean score 41.5; SD 22.6). Stakeholder involvement (Domain 2) also had a low score (mean score 54.5; SD 23.3).
Table 2

Domain scores from AGREE II evaluation

Guideline (year)

Domain 1 score scope & purpose

Domain 2 score stakeholder involvement

Domain 3 score rigour of development

Domain 4 score clarity of presentation

Domain 5 score applicability

Domain 6 score editorial independence

Parkinson’s Disease

 Zesiewicz et al. (2010) [35]

56.9

29.2

64.6

72.2

17.7

79.2

 SIGN (2010)a [37]

80.6

80.6

72.9

91.7

72.9

22.9

 Grimes et al. (2012)c [34]

70.8

95.8

90.6

87.5

60.4

58.3

 Berardelli et al. (2013) [38]

72.2

19.4

47.9

86.1

12.5

6.3

 Ferreira et al. (2013) [40]

47.2

15.3

43.2

66.7

6.25

20.8

Dementia

 NICE (2011)b [41]

83.3

81.9

86.5

87.5

64.6

47.9

 Hort et al. (2010) [47]

58.3

38.9

54.2

66.7

25.0

62.5

 AIAQS (2010) [42]

87.5

69.4

73.4

84.7

57.3

79.2

 Ihl et al. (2011) [44]

68.1

38.9

57.8

48.6

19.8

64.6

 CRCD (2011) [43]

86.1

62.5

74.5

81.9

51.0

54.2

 O’Brien et al (2011) [60]

59.7

63.9

46.4

76.4

20.8

68.8

 Sorbi et al. (2012) [45]

68.1

38.9

53.7

65.3

26.0

62.5

 Gauthier et al (2012)d [50]

73.6

70.8

70.8

87.5

50.0

79.2

Mental Health

 Gelenberg et al. (2010) [39]

68.1

41.7

61.5

66.7

32.3

60.4

 Dua et al. (2011) [49]

70.8

41.7

66.7

84.7

68.7

93.8

 Avalia-T (2012) [46]

88.9

70.8

79.2

75.0

49.0

60.4

 Mitchell et al. (2013) [48]

86.1

66.7

75.0

80.6

71.9

85.4

Average Domain Score (SD)

72.1 (12.1)

54.5 (23.3)

65.8 (13.9)

77.0 (11.4)

41.5 (22.6)

59.2 (23.7)

SD Standard Deviation

a Includes Grosset et al. [54]

b Originally created in 2007 and updated in 2011

c Includes Patel et al. [61]

d Includes Moore et al. [62], Herrman et al. [63]

The mean rating across each question in the domain scores were also examined to explore differences between domains (Additional file 4: Table S2). Question one pertaining to the overall objectives was the highest rated item at 5.88 (SD 0.61), followed by link between evidence and recommendations at 5.78 (SD 0.51). The lowest rated item was providing a procedure for updating the guideline is provided, with a mean rating of 3.16 (SD 1.73). The views and preferences of the target population have been sought was also rated poorly with a mean score of 3.25 (SD 1.92). All items in Domain 5 had low mean scores, ranging between 3.27 (SD 1.46) for resource implications and 3.72 (SD 1.53) for advice on putting recommendations into practice.

Guideline recommendations

The details of extracted recommendations are summarized in the Table 3 for PD and Table 4 for dementia. 21 categories of recommendations were extracted in total.
Table 3

Statements & recommendations for Parkinson’s disease

Anxiety

Evidence for the Management & Treatment of Anxiety in PD is Lacking.

 Level of Evidence

AAN Level U (Uncertain or Lack of Evidence)

 Guidelines

Zesiewicz et al. (2010) [35], Grimes et al. (2012) [34]

Depression

Screening for Depression in PD is recommended.

 Level of Evidence

EFNS Level A (Effective), SIGN Grade C (Case Control to Cohort Evidence)

 Guidelines

Berardelli et al. (2013) [38], Grosset et al. (2010) [54]

There are several available tools screening for Depression in PD.

 Level of Evidence

SIGN Level C & Good Practice Point (GDS, BDI, HADS, MADRS & HDRS) & EFNS Class I (Diagnostic Accuracy Study)(MDS-UPDRS)

 Guidelines

Grosset et al. (2010) [54], Berardelli et al. (2013) [38]

 Comment

A patient with PD should be screened for depression with either a clinician or self-rated tool. Diagnosis should not be based on the solely on the tool. Those with a positive screening test should be referred for further assessment and diagnosis (including collateral history).

Practitioners should have a low threshold for diagnosing Depression in PD.

 Level of Evidence

CFNS Good Practice Point

 Guidelines

Grimes et al. (2012) [34]

Treatment of Depression in PD needs to be individualized to each case.

 Level of Evidence

CFNS Good Practice Point

 Guidelines

Grimes et al. (2012) [34]

Anti-depressant Therapy is recommended; there is little evidence to suggest one agent over another.

 Guidelines

Gelenberg et al. (2010) [39], Grosset et al. (2010) [54]

Tricyclic Antidepressants (e.g. Amitriptyline or Desipramine) have some evidence for treatment, but this must be balanced with the adverse effects (e.g. Anticholinergic).

 Level of Evidence

CFNS Level C (Possibly Effective)

 Guidelines

Grimes et al. (2012) [34], Grosset et al. (2010) [54], Gelenberg et al. (2010) [39]

Selective Serotonin Reuptake Inhibitors have some evidence for treatment, but this must be balanced with the adverse effects (e.g. RLS, PLM, RBD).

 Level of Evidence

EFNS Class II (Prospective Matched Group Cohort or Controlled Trial) to Class IV (Uncontrolled Studies), APA Level II (Moderate Clinical Evidence)

 Guidelines

Ferreira et al. (2013) [40], Gelenberg et al. (2010) [39]

Certain agents such as Amoxapine or Lithium should be avoided due to worsening of PD Symptoms.

 Guidelines

Gelenberg et al. (2010) [39]

There is some evidence for the use of dopamine agonists (e.g. Pramipexole) & MAOI (e.g. Selegiline) for depression, but not for levodopa.

 Level of Evidence

EFNS Class I (RCT), Class III (Other Controlled Trial), APA Level I (Recommended with substantial confidence)

 Guidelines

Ferreira et al. (2013) [40], Gelenberg et al. (2010) [39], Grimes et al. (2012) [34]

There is insufficient evidence regarding the use of ECT, TCMS and psychotherapy in depression with PD.

 Guidelines

Ferreira et al. (2013) [40], Gelenberg et al. (2010) [39], Grimes et al. (2012) [34]

Table 4

Statements & recommendations for Dementia

Anxiety

Patients with Dementia should be assessed for Anxiety (e.g. HADS).

 Level of Evidence

AIAQS Level D (Expert Opinion)

 Guidelines

AIAQS (2010) [42], NICE (2011) [41]

Psychological Interventions can be considered for Anxiety in Dementia

 Guidelines

NICE (2011) [41]

There is little evidence about the treatment of Anxiety in those with Dementia.

Cholinesterase Inhibitors can be considered for treating Dementia-related behaviours, including anxiety.

 Level of Evidence

AIAQS Level A (Meta-analysis or RCT)

 Guidelines

AIAQS (2010) [42]

Depression

Patients experiencing Dementia should be evaluated for Depression, including possible secondary causes.

 Level of Evidence

CRCD Level A (Useful), AIAQS Level D, WFSBP Grade 3 (Limited Evidence from Controlled Studies), EFNS GPP

 Guidelines

NICE (2011) [41], AIAQS (2010) [42], CRCD (2011) [43], Sorbi et al (2012) [45], Ihl et al. (2011) [44]

Patients with Depression in Dementia should be evaluated for suicide risk, however evidence varies.

 Level of Evidence

APA Level I (Substantial Clinical Confidence) or Inconclusive

 Guidelines

Gelenberg et al. (2010) [39], Avalia-T (2012) [46]

Use of a valid screening tool (e.g. CSDD, GDS, HADS or DMAS) for Depression is recommended.

 Level of Evidence

AIAQS Level D to Good Practice Point, Low Quality Evidence, EFNS GPP/Class II (Prospective Study)

 Guidelines

Gelenberg et al. (2010) [39], AIAQS (2010) [42], Sorbi et al (2012) [45], Hort et al (2010) [47], Mitchell et al. (2013) [48]

fMRI needs further study to determine its utility in Depression in the context of Dementia

 Level of Evidence

CCCDT4 Grade 2C (Moderate Recommendation, Low Level Evidence)

 Guidelines

Gauthier et al. (2012) [50]

Therapy for Depression in Dementia should include a variety of Non-pharmacologic options.

 Level of Evidence

AIAQS Level C (Case-control, Cohort), APA Level II (Moderate Clinical Confidence)

 Guidelines

NICE (2011) [41], AIAQS (2010) [42], Gelenberg et al. (2010) [39], Mitchell et al. (2013) [48]

 Comment

These include: cognitive behavioural therapy, reminiscence therapy, multi-sensory stimulation, animal-assisted therapy, exercise, stimulation-oriented treatment (recreational or pleasurable activities), or improvements to a living situation. Consider the involvement of carers.

Although evidence is mixed, a trial of Anti-depressants could be considered for Depression in Dementia.

 Level of Evidence

CCCDT4 Grade 2A (Moderate Recommendation, High Level Evidence), EFNS Class IV (Un-blinded, Expert Opinion), WFSBP Grade 5 (Inconsistent Results), APA Level II (Moderate Clinical Confidence)

 Guidelines

Gauthier et al. (2012) [50], NICE (2011) [41], Sorbi et al (2012) [45], Gelenberg et al. (2010) [39], Ihl et al. (2011) [44], Dua et al (2011) [49]

When choosing an anti-depressant (E.g. SSRIs, SNRIs or TCAs) it is important to consider the anticholinergic side effects.

 Level of Evidence

EFNS Level B (Case-control, Cohort), EFNS Class IV (Un-blinded, Expert Opinion), APA Level I (Substantial Clinical Confidence) to APA Level II (Moderate Clinical Confidence), AIAQS Level B

 Guidelines

Gauthier et al. (2012) [50], NICE (2011) [41], Sorbi et al (2012) [45], Hort et al (2010) [47], Gelenberg et al. (2010) [39], AIAQS (2010) [42]

 Comment

SSRIs (Citalopram or Sertraline) and TCAs have similar efficacy, but TCAs are not recommended given anticholinergic effects. SSRIs appear to be better tolerated. Other agents such as bupropion, venlafaxine and mirtazapine may be effective.

Stimulants can be considered for treatment of Depression in Dementia.

 Level of Evidence

APA Level III (Depends on Individual Circumstances), AIAQS Level B (Case-control, Cohort)

 Guidelines

Gelenberg et al. (2010) [39], AIAQS (2010) [42]

Cholinesterase Inhibitors can be considered for treating Dementia-related behaviours, including depression.

 Level of Evidence

AIAQS Level A (Meta-analysis or RCT)

 Guidelines

AIAQS (2010) [42]

ECT can be considered in certain cases for Depression in those with Dementia.

 Level of Evidence

APA Level II (Moderate Clinical Confidence)

 Guidelines

Gelenberg et al. (2010) [39]

Cholinesterase Inhibitors may improve neuropsychiatric symptoms in Lewy Body Disease

 Level of Evidence

Level A (Meta-analysis or RCT)

 Guidelines

O’Brien et al (2011) [60]

Parkinson’s disease recommendations

Only two guidelines discussed anxiety in those with PD [34, 35]. These stated there was little evidence for either the diagnosis or treatment of anxiety in PD, and that there was insufficient evidence for the treatment of anxiety with levodopa [34, 35].

There were clear recommendations surrounding the diagnosis of depression in PD [34, 37, 38]. Clinicians should have a low threshold for the diagnosis of depression in PD given the difficulties making a diagnosis [34]. Use of a validated tool for detecting depression (or neuropsychiatric symptoms) was advocated by two guidelines, with varying levels of recommendations [37, 38]. Tools that were recommended include the HDRS, the MADRS or the UPDRS—Part 1 Non-Motor, among others [37, 38]. The diagnosis should be made based on a clinical interview and not based on the tool alone and should seek collateral information from carers [37].

Antidepressant therapy is recommended, however there is little evidence to support one agent over another (n = 2) [37, 39]. Additionally, the choice of an agent must be individualized (n = 1) and the practitioner should consider side effects and drug interactions prior to initiation [34]. There have been prior studies on the tricyclic antidepressants (TCAs), specifically amitriptyline, and although they were beneficial for mood, this was offset by the side effects (n = 3) [34, 37, 39]. One guideline noted that selective serotonin reuptake inhibitors (SSRIs) showed some benefit in uncontrolled studies [39, 40], but noted that the SSRIs could worsen PD symptoms of restless legs (RLS), periodic limb movement (PLM) and REM sleep behaviour disorder (RBD) (n = 2) [39, 40]. It is recommended to avoid amoxapine and lithium in those with PD, due to the risk of worsening motor symptoms (n = 1) [39].

There is some weak evidence supporting the use of dopamine agonists and monoamine oxidase inhibitors for the management of depression in PD (n = 3) [34, 39, 40]. Pramipexole was suggested to have an antidepressant effect not solely due a motor effect [40]. Selegiline has some antidepressant effects but further studies are needed [39]. If the mood symptoms are only present during off periods, it was suggested that patients might benefit from drugs addressing the motor symptoms [34]. However there was no evidence levodopa alone affected mood [40].

Other therapies for depression are not well explored in PD. The European Federation of Neurological Sciences (EFNS) concluded there was insufficient data to recommend psychotherapy, electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TCMS) [40]. Other guideline assert that ECT has been used in PD, but that there are no specific trials in PD and is associated with risk (n = 2) [34, 39].

Dementia recommendations

It is recommended that patients with dementia be assessed for anxiety (n = 2), however there is no clear consensus on what tools to use [41, 42]. One guideline recommended the use of the Hospital Anxiety Depression Scale [42]. The evidence for the treatment of anxiety in dementia is lacking (n = 1) [42].

It is recommended that patients with dementia be evaluated and re-evaluated over time for depression (n = 5) [4145]. As part of this assessment, patients should be evaluated for other secondary causes of depression. It is suggested that these patients be assessed for suicidality by one guideline [39], however another reported there was inconclusive evidence regarding this [46].

The use of a valid screening tool was recommended for depression case finding (n = 5) in dementia, including the CSDD, GDS or Dementia Mood Assessment Scale (DMAS) [39, 42, 45, 47, 48]. The CSDD was more commonly recommended given it is a clinician-rating tool that involves caregivers with higher sensitivity (n = 4) [39, 45, 47, 48].

Therapy for depression in those with dementia should include a variety of non-pharmacologic options (n = 4) such as stimulation oriented, cognitive behavioural, reminiscence, exercise or multi-sensory therapy [39, 41, 42, 48]. Pharmacologic therapy is recommended despite variable evidence (n = 6) [41, 42, 44, 45, 49, 50]. It is suggested by one guideline that, if there is no improvement with non-pharmacologic therapy, an antidepressant be considered [50]. Another notes that for moderate-severe depression, pharmacologic treatment is warranted (n = 1) [49]. However, there needs to be a clear risk-benefit assessment and discussion (n = 1) [41]. Based largely on clinical experience, most guidelines recommend the use of SSRIs given the lower side effect profile over TCAs (n = 6) [39, 41, 42, 45, 49, 50]. The concern with TCAs is largely anticholinergic side effects causing worsened cognition [42, 50]. Other antidepressants such as mirtazapine, bupropion, and venlafaxine may also be of benefit (n = 1) [42]. Other adjunct therapies recommended include stimulants (n = 2) [39, 42], cholinesterase inhibitors (n = 1) [42] and ECT on a case-by-case basis (n = 1) [39].

Discussion

This study provides a synthesis and quality assessment of available guidelines for the management of depression or anxiety in PD or dementia. We identified clear gaps in guideline quality and the evidence, which inform future research and knowledge translation.

Guideline quality

Guidelines that were excluded due to low quality were typically those that lacked explicit development methods, thus ratings across all the domains were low. When examining the AGREE II ratings overall, the lowest rating was in assessing the guideline description of barriers and facilitators, implementation, resource implications, or monitoring/auditing criteria (Domain 5). In fact, few guidelines had discrete sections addressing knowledge translation. The concern about guideline applicability was explored in a 2015 systematic review [51], which found that applicability scored lower than any other domain [51, 52]. If guidelines rarely address their implementation in practice, then there will be continued practice variation. There is clear evidence supporting the use of implementation tools to improve guideline uptake [51]. Thus making guidelines without a clear knowledge translation plan does a disservice to stakeholders [51].

The engagement of patients and caregivers was notably absent in CPG development. This process is important, as it is aimed at improving implementability, by ensuring the recommendations are comprehensive, adaptable and applicable to the target group and have an open process [53]. Given the constant changing nature of evidence, having up-to-date guidelines certainly makes a difference to the validity [32]. However, the lowest rated item was for the guideline update procedures.

Guideline content

There is an overall lack of recommendations related to the diagnosis or treatment of anxiety in either PD or dementia. This stems from the fact there is little evidence on how to approach the assessment. One guideline suggested the use Hospital Anxiety and Depression Scale for dementia, but they did not provide diagnostic accuracy information or suggestions for implementation [42]. There is also a concern that the medications traditionally used for anxiety can have major adverse effects [35], and there are few studies to guide treatment. Anxiety was less frequently mentioned than depression in the included CPGs, and in some cases was only mentioned in combination with other neuropsychiatric symptoms. The overall lack of evidence for anxiety care in PD and dementia is a major gap in the current research.

Guidance for depression was present in a higher proportion of guidelines. Despite this, there is variability in the reporting of levels of evidence and recommendations (Additional file 3: Figure S1). In some cases the recommendations for depression in PD only had 1 or 2 guidelines supporting them, indicating variance in guideline reporting. In other cases recommendations were vague, which can lead to difficulty with end user interpretation and implementation [36].

It is clear that screening for depression with a validated tool in PD is recommended, although evidence varies [37, 38]. It is recommended, as a good practice point, that any diagnosis of depression is not made solely on a brief assessment tool, as these tools are more focused on case finding [37]. Although this is an important concept in detection, it was only recommended by one guideline [54]. A 2015 systematic review identified several validated tools for the detection of depression in PD, with the GDS-15 having the highest pooled sensitivity (0.81; 95% CI 0.64, 0.91) and area under the curve (0.94) [55].

Recommendations surrounding non-pharmacologic therapy were few, stating there was insufficient evidence for the use of psychotherapy, ECT or TMS [34, 39, 40]. Two recent trials demonstrated the effectiveness of cognitive behavioural therapy in PD [56, 57]. This highlights the need for further large high quality studies on a range of non-pharmacologic therapies and the need for constant update of guidelines. Pharmacological therapy is recommended for managing depression in PD, but there is little evidence on choosing agents [39, 54]. This has resulted in a variety of treatment recommendations, with little evidence to direct clinical practice.

Depression in dementia was more frequently addressed. However, these recommendations also had varied guideline and evidentiary support. Guidelines supported the evaluation of depression in dementia, but evidence ranged from high quality to good practice points [4145]. Commonly recommended tools were the CSDD and GDS, with preference towards the CSDD due to better accuracy [39, 42, 45, 47, 48]. This was confirmed by a 2015 systematic review of depression tools for dementia, finding that the CSDD had a area under the curve of 0.89 [58].

Interestingly, the issue of evaluating for suicide risk was raised in two guidelines with divergent recommendations [39, 46]. One stating there was inconclusive evidence [46] and another stating substantial evidence [39]. It is unclear why there is such a difference in reported evidence; perhaps development groups have different evidence available or differing interpretations of the evidence.

There are stronger recommendations for non-pharmacologic treatment in dementia than in PD, outlining several options [41, 42, 45, 47, 48]. The evidence for pharmacologic therapy is described as mixed with Grade 2A (Moderate Recommendation, High Level Evidence) to Class IV (Un-blinded Study, Expert Opinion) [39, 41, 44, 45, 49, 50]. Again SSRIs and TCAs are the focus, with TCAs being less likely to be recommended due to side effects [39, 42, 45, 47, 50]. For those with dementia, there were more options recommended for therapy including stimulants, cholinesterase inhibitors and ECT [39, 42].

Limitations

There is a well-recognized issue with heterogeneity in the terms used to refer to guidelines [52]. For our database search we used indexed terms from each of the three databases as well as key words using known nomenclature for guidelines and the comorbidities. It is also possible that the addition of the depression or anxiety criteria to the search may have been restrictive, however without these terms the search was impractical. To address this, we developed the search strategy with experts in the area of guideline systematic review and an experienced librarian, and we had an external reviewer independently assess the search strategy. To reduce the risk of missing literature not indexed in databases we contacted experts, searched references of included studies and performed an extensive search of the grey literature search.

Conclusions

Given the burden of comorbid mental illness in dementia and PD, it is key that we understand clearly the current knowledge base so we can improve care for these populations. This study provides a synthesis and quality assessment of the relevant guidelines. By synthesizing the recommendations, we identified areas of knowledge that are potentially ready to be translated into practice but also clear evidence gaps. This data was further evaluated in a subsequent study by stakeholders in focus groups to understand the other barriers and facilitators to the use of guidelines. This was to inform and help develop a comprehensive knowledge/end-user focused plan for addressing these gaps.

Abbreviations

AAN: 

American Academy of Neurology

APA: 

American Psychiatric Association

AIAQS: 

Agency for Health Quality and Assessment of Catalonia

Avalia-T: 

Galician Health Technology Assessment Agency

BDI: 

Beck Depression Inventory

BPA: 

British Association of Psychopharmacology

CADASIL: 

Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

CCCDTD4: 

Canadian Consensus Conference on the Diagnosis and Treatment of Dementia

CNSF: 

Canadian Neurological Sciences Foundation

CPG: 

Clinical Practice Guideline

CRCD: 

Clinical Research Centre for Dementia

CSDD: 

Cornell Scale for Depression in Dementia

DMAS: 

Dementia Mood Assessment Scale

ECT: 

Electroconvulsive Therapy

EFNS: 

European Federation of Neuroscience

GDS: 

Geriatric Depression Scale

GRADE: 

Grading of Recommendations Assessment, Development and Evaluation

HADS: 

Hospital Anxiety and Depression Scale

HDRS: 

Hamilton Depression Rating Scale

ICSI: 

Institute for Clinical Systems Improvement

MADRS: 

Montgomery Åsberg Depression Rating Scale

MDS: 

Movement Disorders Society

NICE: 

National Institute of Clinical Excellence

PD: 

Parkinson’s Disease

PLM: 

Periodic Limb Movement Syndrome

PRESS: 

Peer Review of Electronic Search Strategies

PRISMA: 

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RBD: 

REM Sleep Behaviour Disorder

RCT: 

Randomized Control Trial

REM: 

Rapid Eye Movement

RLS: 

Restless Legs Syndrome

SD: 

Standard Deviation

SIGN: 

Scottish Intercollegiate Guidelines Network

SSRI: 

Selective Serotonin Reuptake Inhibitor

TCA: 

Tricyclic Acid Antidepressants

TCMS: 

Transcranial Magnetic Stimulation

UPDRS: 

Unified Parkinson’s Disease Rating Scale

WFBSP: 

World Federation of Societies of Behavioural Psychiatry

WHO: 

World Health Organization

Declarations

Acknowledgements

The authors would like to thank Diane Lorenzetti MLS, Research Librarian (DL) for her input into the search strategy, and Helen Lee Robertson MLIS, Liaison Librarian for Clinical Medicine for her (Peer Review of Electronic Search Strategies) PRESS review of our search strategy.

Funding

This project had funding from an Alberta Innovates Health Solutions—Knowledge to Action Grant.

Availability of data and material

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request. All data from this study are presented in detail. For the quality assessment the individual ratings are not published as the AGREE group recommends publication f the mean scaled domain scores. The extracted recommendations are summarized in the tables and text, full details are available in the source guidelines.

Authors’ contributions

ZG and BM performed all citation/full text screening, quality assessments, data extraction and analysis and drafted the manuscript. ZG completed all statistical analysis. SG was involved in the grey literature search and quality assessment. JHL supervised all parts of the systematic review and analysis, was involved in the quality assessment and determination of inclusion. ZG, BM, SG, HH, SS, TP, NJ and JHL provided input and reviewed the proposal, protocol, analysis and manuscript. ZG registered the protocol with PROSPERO [58]. All authors had access to the data, reviewed and approved the final manuscript. ZG and JHL had full access to the data in the study and take responsibility for the integrity of the data and accuracy of the data.

Competing interests

ZG has received funding by Canadian Institutes for Health Research—Canadian Graduate Student Scholarship, Alberta Innovates Health Solutions Clinician Fellowship Award, Canadian Society for Clinical Investigation Resident Research Award, Alberta Student and Western Regional Training Centre affiliate award. BM and SG report no disclosures. HH has no disclosures. SP holds funding from Hotchkiss Brain Institute (HBI), CIHR and a grant co-funded by the University of Calgary HBI and Pfizer Canada. TP has an unrestricted educational grants from Shire Canada. TP has research grant support from Sick Kids Foundation, Alberta Health Services Mental Health Strategic Clinical Network, Hotchkiss Brain Institute and Canadian Institutes for Health Research. NJ holds a Canada Research Chair Tier 2 in Health Services Research and is on the editorial board of Neurology and holds research grants from the Canadian Institutes of Health Research, Alberta Innovates Health Solutions, the Alberta Spine Foundation, the University of Calgary Cumming School of Medicine, Department of Clinical Neurosciences and HBIs and a grant co-funded by the University of Calgary HBI and Pfizer Canada. JHL has received funding from Alberta Health Services as the Scientific Director of the Seniors Health Strategic Clinical Network.

Consent for publication

Not Applicable.

Ethics approval and consent to participate

University of Calgary Conjoint Health Research Ethics Board (CHREB) REB 14-1449

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Community Health Sciences, University of Calgary
(2)
Department of Medicine, University of Calgary and Alberta Health Services
(3)
Faculty of Medicine, Undergraduate Medical Education, University of Toronto
(4)
Seniors Health Strategic Clinical Network, Alberta Health Services
(5)
Department of Clinical Neurosciences, University of Calgary
(6)
Hotchkiss Brain Institute, and O’Brien Institute for Public Health, University of Calgary and Alberta Health Services
(7)
Department of Psychiatry and Pediatrics, University of Calgary and Alberta Health Services
(8)
Department of Psychiatry, University of Calgary and Alberta Health Services
(9)
Mathison Centre for Mental Health Research and Education, University of Calgary
(10)

References

  1. Pachana NA, Egan SJ, Laidlaw K, Dissanayaka N, Byrne GJ, Brockman S, Marsh R, Starkstein S. Clinical issues in the treatment of anxiety and depression in older adults with Parkinson’s disease. Movement disorders: official journal of the Movement Disorder Society. 2013;28(14):1930–4.Google Scholar
  2. Reijnders JS, Ehrt U, Weber WE, Aarsland D, Leentjens AF. A systematic review of prevalence studies of depression in Parkinson’s disease. Mov Disord. 2008;23(2):183–9. quiz 313.View ArticlePubMedGoogle Scholar
  3. Schrag A, Leentjens AF. Parkinson disease: scales to detect depression in Parkinson disease. Nat Rev Neurol. 2012;8(7):359–60.View ArticlePubMedGoogle Scholar
  4. Weintraub D, Moberg PJ, Duda JE, Katz IR, Stern MB. Effect of psychiatric and other nonmotor symptoms on disability in Parkinson’s disease. J Am Geriatr Soc. 2004;52(5):784–8.View ArticlePubMedGoogle Scholar
  5. Kostic VS, Pekmezovic T, Tomic A, Jecmenica-Lukic M, Stojkovic T, Spica V, Svetel M, Stefanova E, Petrovic I, Dzoljic E. Suicide and suicidal ideation in Parkinson’s disease. J Neurol Sci. 2010;289(1-2):40–3.View ArticlePubMedGoogle Scholar
  6. Hughes TA, Ross HF, Mindham RH, Spokes EG. Mortality in Parkinson’s disease and its association with dementia and depression. Acta Neurol Scand. 2004;110(2):118–23.View ArticlePubMedGoogle Scholar
  7. Orgeta V, Qazi A, Spector AE, Orrell M. Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database Syst Rev. 2014;1:CD009125.Google Scholar
  8. Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, Bentham P, Fox C, Holmes C, Katona C, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet. 2011;378(9789):403–11.View ArticlePubMedGoogle Scholar
  9. Enache D, Winblad B, Aarsland D. Depression in dementia: epidemiology, mechanisms, and treatment. Curr Opin Psychiatry. 2011;24(6):461–72.PubMedGoogle Scholar
  10. Riley RJ, Burgener S, Buckwalter KC. Anxiety and stigma in dementia: a threat to aging in place. Nurs Clin North Am. 2014;49(2):213–31.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Van der Mussele S, Bekelaar K, Le Bastard N, Vermeiren Y, Saerens J, Somers N, Marien P, Goeman J, De Deyn PP, Engelborghs S. Prevalence and associated behavioral symptoms of depression in mild cognitive impairment and dementia due to Alzheimer’s disease. Int J Geriatr Psychiatry. 2013;28(9):947–58.View ArticlePubMedGoogle Scholar
  12. Dissanayaka NN, Sellbach A, Matheson S, O’Sullivan JD, Silburn PA, Byrne GJ, Marsh R, Mellick GD. Anxiety disorders in Parkinson’s disease: prevalence and risk factors. Mov Disord. 2010;25(7):838–45.View ArticlePubMedGoogle Scholar
  13. Marsh L. Depression and Parkinson’s disease: current knowledge. Curr Neurol Neurosci Rep. 2013;13(12):409.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Djamshidian A, Friedman JH. Anxiety and depression in Parkinson’s disease. Curr Treat Options Neurol. 2014;16(4):285.View ArticlePubMedGoogle Scholar
  15. Knapskog AB, Barca ML, Engedal K. A comparison of the validity of the Cornell Scale and the MADRS in detecting depression among memory clinic patients. Dement Geriatr Cogn Disord. 2011;32(4):287–94.View ArticlePubMedGoogle Scholar
  16. Modrego PJ, Ferrandez J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study. Arch Neurol. 2004;61(8):1290–3.View ArticlePubMedGoogle Scholar
  17. Ownby RL, Crocco E, Acevedo A, John V, Loewenstein D. Depression and risk for Alzheimer disease: systematic review, meta-analysis, and metaregression analysis. Arch Gen Psychiatry. 2006;63(5):530–8.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Frisina PG, Borod JC, Foldi NS, Tenenbaum HR. Depression in Parkinson’s disease: health risks, etiology, and treatment options. Neuropsychiatr Dis Treat. 2008;4(1):81–91.PubMedPubMed CentralGoogle Scholar
  19. Davis D, J. Goldman, P. Valerie: Handbook on Clinical Practice Guidelines. In.: Canadian Medical Association; 2007.Google Scholar
  20. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implementation Sci. 2011;6:26. https://www.ncbi.nlm.nih.gov/pubmed/21426574
  21. Graham R, Mancher M, Miller-Wolman D, Greenfield S, Steinberg EH. Clinical Practice Guidelines We Can Trust. Washington: Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. National Academy of Sciences; 2011.Google Scholar
  22. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii–iv. 1-72.View ArticlePubMedGoogle Scholar
  23. Ramasubbu R, Taylor VH, Samaan Z, Sockalingham S, Li M, Patten S, Rodin G, Schaffer A, Beaulieu S, McIntyre RS, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and select comorbid medical conditions. Ann Clin Psychiatry. 2012;24(1):91–109.PubMedGoogle Scholar
  24. Ramasubbu R, Beaulieu S, Taylor VH, Schaffer A, McIntyre RS, Canadian Network for M, Anxiety Treatments Task F. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid medical conditions: diagnostic, assessment, and treatment principles. Ann Clin Psychiatry. 2012;24(1):82–90.PubMedGoogle Scholar
  25. Kerr MP, Mensah S, Besag F, de Toffol B, Ettinger A, Kanemoto K, Kanner A, Kemp S, Krishnamoorthy E, LaFrance Jr WC, et al. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy. Epilepsia. 2011;52(11):2133–8.View ArticlePubMedGoogle Scholar
  26. Wilcock J, Iliffe S, Turner S, Bryans M, O’Carroll R, Keady J, Levin E, Downs M. Concordance with clinical practice guidelines for dementia in general practice. Aging Ment Health. 2009;13(2):155–61.View ArticlePubMedGoogle Scholar
  27. Salter K, McClure JA, Mahon H, Foley N, Teasell R. Adherence to Canadian best practice recommendations for stroke care: assessment and management of poststroke depression in an Ontario rehabilitation facility. Top Stroke Rehabil. 2012;19(2):132–40.View ArticlePubMedGoogle Scholar
  28. McCluskey A, Vratsistas-Curto A, Schurr K. Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study. BMC Health Serv Res. 2013;13:323.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Bmj 2009, 339:b2535.Google Scholar
  30. Making the Case for Investing in Mental Health in Canada. In.: Mental Health Commission of Canada; 2013.Google Scholar
  31. PRESS: peer review of electronic search strategies. 2015 Guideline Explanation and Elaboration (PRESS E&E). Ottawa: Canadian Agency for Drugs and Technologies in Health; 2016. https://www.cadth.ca/sites/default/files/pdf/CP0015_PRESS_Update_Report_2016.pdf
  32. Martinez Garcia L, Sanabria AJ, Garcia Alvarez E, Trujillo-Martin MM, Etxeandia-Ikobaltzeta I, Kotzeva A, Rigau D, Louro-Gonzalez A, Barajas-Nava L, Diaz Del Campo P, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ. 2014;186(16):1211–9.View ArticlePubMedGoogle Scholar
  33. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–842.View ArticlePubMedPubMed CentralGoogle Scholar
  34. Grimes D, Gordon J, Snelgrove B, Lim-Carter I, Fon E, Martin W, Wieler M, Suchowersky O, Rajput A, Lafontaine AL, et al. Canadian guidelines on Parkinson’s disease. Can J Neurol Sci. 2012;39(4 Suppl 4):S1–30.PubMedGoogle Scholar
  35. Zesiewicz TA, Sullivan KL, Arnulf I, Chaudhuri KR, Morgan JC, Gronseth GS, Miyasaki J, Iverson DJ, Weiner WJ, Quality Standards Subcommittee of the American Academy of N. Practice parameter: treatment of nonmotor symptoms of Parkinson disease: report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2010;74(11):924–31.View ArticlePubMedGoogle Scholar
  36. Michie S, Johnston M: Changing clinical behaviour by making guidelines specific. Bmj 2004, 328(7435):343–345.View ArticlePubMedPubMed CentralGoogle Scholar
  37. Diagnosis and pharmacological management of Parkinson’s disease: A national clinical guideline. Scottish Intercollegiate Guidelines Network; 2010.Google Scholar
  38. Berardelli A, Wenning GK, Antonini A, Berg D, Bloem BR, Bonifati V, Brooks D, Burn DJ, Colosimo C, Fanciulli A, et al. EFNS/MDS-ES/ENS [corrected] recommendations for the diagnosis of Parkinson’s disease. European journal of neurology: the official journal of the European Federation of Neurological Societies. 2013;20(1):16–34.Google Scholar
  39. Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH, Van Rhoads RS. Practice Guideline for Treatment of Patients with Major Depressive Disorder 3rd Edition. American Pyschiatric Association; 2010.Google Scholar
  40. Ferreira JJ, Katzenschlager R, Bloem BR, Bonuccelli U, Burn D, Deuschl G, Dietrichs E, Fabbrini G, Friedman A, Kanovsky P, et al. Summary of the recommendations of the EFNS/MDS-ES review on therapeutic management of Parkinson’s disease. Eur J Neurol. 2013;20(1):5–15. https://www.ncbi.nlm.nih.gov/pubmed/23279439
  41. Dementia: Guidelines on Supporting People with Dementia and their carers in Health and Social Care. National Institute for Health and Clinical Excellence. National Collaborating Centre for Mental Health. Social Care Institute for Excellence National Institute for Health and Clinical Excellence. In. London: The British Psychological Society & Gaskell The Royal College of Psychiatrists; 2011.Google Scholar
  42. Development Group of the Clinical Practice Guideline on the comprehensive care of people with Alzheimer’s disease and other dementias. Clinical Practice Guideline on the comprehensive care of people with Alzheimer’s disease and other dementias. Quality Plan for the National Health System of the Ministry of Health, Social Policies and Equality Agència d’Informació, Avaluació i Qualitat en Salut of Catalonia Clinical Practice Guidelines in the Spanish National Health Service: AIAQS No 2009/07 2010. http://www.guiasalud.es/GPC/GPC_484_Alzheimer_AIAQS_comp_eng.pdf
  43. Clinical Research Center for Dementia of South Korea. Clinical practice guideline for dementia. Part I: diagnosis & evaluation. Seoul: Clinical Research Center for Dementia of South Korea; 2011. p. 117. The guideline cited is available here: http://jkma.org/src/SM/jkma-54-861-s002.pdf
  44. Ihl R, Frolich L, Winblad B, Schneider L, Burns A, Moller HJ, Disease WTFoTGfAs, other D. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of Alzheimer’s disease and other dementias. World J Biol Psychiatry. 2011;12(1):2–32. https://www.ncbi.nlm.nih.gov/pubmed/21288069
  45. Sorbi S, Hort J, Erkinjuntti T, Fladby T, Gainotti G, Gurvit H, Nacmias B, Pasquier F, Popescu BO, Rektorova I, et al. EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol. 2012;19(9):1159–79. https://www.ncbi.nlm.nih.gov/pubmed/22891773
  46. Working Group of the Clinical Practice Guideline for the Prevention and Treatment [trunc]. Clinical practice guideline for the prevention and treatment of suicidal behaviour. Madrid: Ministry of Health and Social Policy, Galician Health Technology Assessment Agency; 2012. p. 382. http://www.guiasalud.es/GPC/GPC_481_Conducta_Suicida_Avaliat_compl_en.pdf
  47. Hort J, O’Brien JT, Gainotti G, Pirttila T, Popescu BO, Rektorova I, Sorbi S, Scheltens P, Dementia ESPo. EFNS guidelines for the diagnosis and management of Alzheimer’s disease. Eur J Neurol. 2010;17(10):1236–48.View ArticlePubMedGoogle Scholar
  48. Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, et al. Adult Depression in Primary Care. Institute for Clinical Systems Improvement; 2013.Google Scholar
  49. Dua T, Barbui C, Clark N, Fleischmann A, Poznyak V, van Ommeren M, Yasamy MT, Ayuso-Mateos JL, Birbeck GL, Drummond C, et al. Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med. 2011;8(11):e1001122. https://www.ncbi.nlm.nih.gov/pubmed/22110406
  50. Gauthier S, Patterson C, Chertkow H, Gordon M, Herrmann N, Rockwood K, Rosa-Neto P, Soucy JP. Recommendations of the 4th Canadian consensus conference on the diagnosis and treatment of dementia (CCCDTD4). Can Geriatr J. 2012;15(4):120–6.PubMedPubMed CentralGoogle Scholar
  51. Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;5(2):e007047.View ArticlePubMedPubMed CentralGoogle Scholar
  52. Sauro KM, Wiebe S, Dunkley C, Janszky J, Kumlien E, Moshe S, Nakasato N, Pedley TA, Perucca E, Senties H, et al. The current state of epilepsy guidelines: A systematic review. Epilepsia. 2016;57(1):13–23.View ArticlePubMedGoogle Scholar
  53. Eccles MP, Grimshaw JM, Shekelle P, Schunemann HJ, Woolf S. Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implementation Sci. 2012;7:60.View ArticleGoogle Scholar
  54. Grosset DG, Macphee GJ, Nairn M, Guideline Development G. Diagnosis and pharmacological management of Parkinson’s disease: summary of SIGN guidelines. BMJ. 2010;340:b5614.View ArticlePubMedGoogle Scholar
  55. Goodarzi ZS, Mrklas K, Roberts DJ, Jette N, Pringsheim T, Holroyd-Leduc J. Depression case finding in Parkinson’s disease patients: a systematic review of depression screening tools. Montreal: Canadian Geriatric Society Scientific Meeting 2015; 2015.Google Scholar
  56. Dobkin RD, Menza M, Allen LA, Gara MA, Mark MH, Tiu J, Bienfait KL, Friedman J. Cognitive-behavioral therapy for depression in Parkinson’s disease: a randomized, controlled trial. Am J Psychiatry. 2011;168(10):1066–74.View ArticlePubMedPubMed CentralGoogle Scholar
  57. Troeung L, Egan SJ, Gasson N. A waitlist-controlled trial of group cognitive behavioural therapy for depression and anxiety in Parkinson’s disease. BMC Psychiatry. 2014;14:19.View ArticlePubMedPubMed CentralGoogle Scholar
  58. Goodarzi Z, Mele B, Roberts D, Holroyd-Leduc J. Depression case finding in dementia patients: a systematic review of depression screening tools. Ottawa: Canadian Conference on Dementia Meeting 2015; 2015.Google Scholar
  59. Guidance notes for registering a systematic review protocol with PROSPERO. In: PROSPERO: International prospective register of systematic reviews Centre for Reviews and Dissemination, National Institute for Health Research; 2013.Google Scholar
  60. O’Brien JT, Burns A, Group BAPDC. Clinical practice with anti-dementia drugs: a revised (second) consensus statement from the British Association for Psychopharmacology. J Psychopharmacol. 2011;25(8):997–1019. https://www.ncbi.nlm.nih.gov/pubmed/21088041
  61. Patel T, Chang F, Parkinson Society C. Parkinson’s disease guidelines for pharmacists. Can Pharm J. 2014;147(3):161–70.View ArticleGoogle Scholar
  62. Moore A, Patterson C, Lee L, Vedel I, Bergman H, Canadian Consensus Conference on the D, Treatment of D. Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia: recommendations for family physicians. Can Fam Physician. 2014;60(5):433–8.PubMedPubMed CentralGoogle Scholar
  63. Herrmann N, Lanctot KL, Hogan DB. Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer’s Res Ther. 2013;5 Suppl 1:S5. https://www.ncbi.nlm.nih.gov/pubmed/24565367
  64. Rabins PV, Blacker D, Rovner BW, Rummans T, Schneider LS, Tariot PN, Blass DM. Practice Guidelines for the Treatment of Patients With Alzheimer’s Disease and Other Dementias. American Pyschiatric Association; 2007.Google Scholar

Copyright

© The Author(s). 2016

Advertisement