A higher level of awareness is associated with subsyndromal depression and anxiety, whereas lack of awareness is associated with psychosis and apathy. The level of awareness decreases as dementia progresses. Clinicians should be more alert to changes in awareness in patients with dementia because psychosocial support might help to prevent the development of affective symptoms.

This article provides a review of the literature on clinical correlates of awareness in dementia. Most inconsistencies were found with regard to an association between depression and higher levels of awareness. Dysthymia, but not major depression, is probably related to higher levels of awareness. Anxiety also appears to be related to higher levels of awareness. Apathy and psychosis are frequently present in patients with less awareness, and may share common neuropathological substrates with awareness. Furthermore, unawareness seems to be related to difficulties in daily life functioning, increased caregiver burden, and deterioration in global dementia severity. Factors that may be of influence on the inconclusive data are discussed, as are future directions of research.

BackgroundMajor depressive disorder (MDD) is projected to rank second on a list of 15 major diseases in terms of burden in 2030. The major contribution of MDD to disability and health care costs is largely due to its highly recurrent nature. Accordingly, efforts to reduce the disabling effects of this chronic condition should shift to preventing recurrence, especially in patients at high risk of recurrence. Given its high prevalence and the fact that interventions are necessary during the remitted phase, new approaches are needed to prevent relapse in depression.Methods/designThe best established effective and available psychological intervention is cognitive therapy. However, it is costly and not available for most patients. Therefore, we will compare the effectiveness and cost-effectiveness of self-management supported by online CT accompanied by SMS based tele-monitoring of depressive symptomatology, i.e. Mobile Cognitive Therapy (M-CT) versus treatment as us usual (TAU). Remitted patients (n = 268) with at least two previous depressive episodes will be recruited and randomized over (1) M-CT in addition to TAU versus (2) TAU alone, with follow-ups at 3, 12, and 24 months. Randomization will be stratified for number of previous episodes and type of treatment as usual. Primary outcome is time until relapse/recurrence over 24 months using DSM-IV-TR criteria as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). For the economic evaluation the balance between costs and health outcomes will be compared across strategies using a societal perspective.DiscussionInternet-based interventions might be helpful in empowering patients to become their own disease managers in this lifelong recurrent disorder. This is, as far as we are aware of, the first study that examines the (cost) effectiveness of an E-mental health program using SMS monitoring of symptoms with therapist support to prevent relapse in remitted recurrently depressed patients.Trial registrationNetherlands Trial Register (NTR): NTR2503