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Clinical Interventions for the Stress and Depression Risks of Alzheimer’s Caregivers

Clinical Interventions for the Stress and Depression Risks of Alzheimer’s Caregivers


April 1, 2013

Brent T. Mausbach, PhD


Department of Psychiatry, University of California San Diego, CA


First published in Psychiatry Weekly, Volume 8, Issue 8, April 1, 2013




Over 15 million people in the US provide unpaid care for Alzheimer’s disease (AD) patients each year.1 This unpaid care, totaling approximately 17.4 billion hours annually, represents an economic savings to society estimated at $210 billion per year.1 For the caregivers, however, who are likely to be older female family members, these responsibilities can exact a heavy toll, ranging from greater depressive symptoms and high stress to a personal financial burden, and even a higher risk of early mortality.2,3

The Toll of Dementia Caregivers

“The symptoms of AD itself are among the most significant stressors for caregivers of AD patients,” says Dr. Brent Mausbach. “Behavioral symptoms of AD are particularly distressing, especially during the mild or moderately severe phases of the disease course. For example, the AD patient might accuse the caregiver—who will often be a family member—of stealing from them, or say that their own life is no longer worth living. There are treatment programs specifically designed to help these caregivers view these occurrences not as a reflection of their personal failures as a caregiver but as a symptom of the disease.”

Although caregivers of AD patients often report positive feelings about the opportunity to help a loved one with early dementia, there remains a substantial risk of elevated levels of stress related to their caregiver responsibilities. Sixty-one percent of caregivers report very high levels of emotional stress, and 43% report very high levels of physical stress.1

Caring for Caregivers

“Because these caregivers are so wrapped up in their responsibilities, they are probably engaging in fewer personally enjoyable and relaxing activities,” says Dr. Mausbach. “There is some evidence to suggest that when one’s personal exposure to positive, enjoyable activities is restricted in a caregiver context, depressive symptoms can rise pretty drastically. So we are interested in helping caregivers get involved again in things they’ve otherwise given up—to help them reevaluate how they’re spending their time.

"We found initial evidence that not only could we reduce distress but the PEP participants also showed improvements in biomarkers associated with cardiovascular disease risk."

“In the 5-year study that we just completed (manuscript in progress), we found that caregivers who received treatment focusing on involvement in more pleasurable activities saw a significant reduction in depressive symptoms, compared with caregivers who received information brochures and supportive therapy,” continues Dr. Mausbach. “The experimental therapy was a behavioral activation program, which we called the Pleasant Events Program (PEP).”

Clinicians can help caregivers regain a better balance between their caregiver responsibilities and more therapeutic activities. “Caregivers are provided a PEP treatment manual containing worksheets to help them identify and schedule various activities, such as taking 30-minute walks, reading, or taking a coffee break with friends. The clinician would then follow up to see whether the caregiver is engaging in their selected activities, and track their mood concurrently to see if there are any improvements.

“I would say that, from a practitioner’s perspective, you don’t need really detailed training on this,” says Dr. Mausbach. “We argue that one of the greatest advantages of this type of therapy is its ease of implementation, from the perspective of both the clinician and the patient.”

There are limited relevant data, but it appears that one-fourth of caregivers receive antidepressants or other psychotropic medications.2

“About one-third of caregivers in our research program tell us they are taking an antidepressant, yet felt it was in their interest to seek additional therapy to get a handle on caregiving stress,” says Dr. Mausbach. “Antidepressants appear particularly indicated in cases where the caregiver is severely depressed and needs to show improvement prior to beginning behavioral activation. Physicians and caregivers can work together to make the personal decision of beginning antidepressants alone, or if additional therapeutic approaches might also be warranted. We feel behavioral activation is a simple, straightforward therapy that might be appropriate for caregivers, either alone or in conjunction with antidepressants.”

Reducing Cardiovascular Risks

“Caregivers are at increased risk for cardiovascular disease,” says Dr. Mausbach. “During our behavioral activation research we looked at some of the biomarkers for cardiovascular diseases to see if we could alter them by treatment with the PEP protocol. We found initial evidence that not only could we reduce distress but the PEP participants also showed improvements in Interleukin-6, a marker of inflammation associated with cardiovascular disease risk, suggesting that there is a link between treating caregiver-related stress and concurrently reducing their risk of cardiovascular disease.”

Disclosure: This work was supported by a grant from the National Institute on Aging (R01-AG031090) awarded to Dr. Mausbach.

This interview was conducted on January 30, 2013 by Lonnie Stoltzfoos


1. Alzheimer’s Association. 2012 Alzheimer’s disease facts and figures. Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association. March 2012; 8:131–168.

2. Mausbach BT, Chattillion EA, Roepke SK, Patterson TL, Grant I. A Comparison of Psychosocial Outcomes in Elderly Alzheimer Caregivers and Noncaregivers. Am J Geriatr Psychiatry. 2013;21:5-13.

3. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA. 1999;282:2215-2219.