Treatment of depression in late life: Psychotherapeutic Interventions

Introduction

Depression affects a minority of older adults and generally as responsive to

treatment as depression in younger people
Both pharmacological and psychotherapeutic interventions alone or in
combination have demonstrated efficacy in treating depression in older
adults

Prevalence in late life: prevalence, risks and assessment

Adults over the age of 65 have relatively low rates of major depressive
disorder
Older adults report relatively high rates of depressive symptoms that do not
meet DSM-IV criteria for major depressive disorder
Those who are functionally disabled by medical illness are at highest risk for
depression
Observed outpatient 10%, inpatient 25% and nursing home 30%
For many elders, depression is a recurrence of a chronic disorder first
experienced in young adulthood
Late onset depression may result from neurological changes and may be a
precursor of dementing illness
Suicide is the most dire consequence of depression
Treatments aim to reduce symptoms and to prevent relapse, improve
functional ability, physical health status and QOL

Assessment of depression in late life

Greatest barrier to treatment is inadequate recognition of depression

Unlikely to label the experience of depression in themselves
Poor energy, loss of interest, somatic symptoms are seen as a part of being
old
Even with professionals, depression is not always accurately identified in the
older adult
Symptoms of depression can overlap with symptoms of medical illness such
as sleep disturbance, poor appetite and poor energy
Older adults with dementia frequently have comorbid depression that can be
treated however, the diagnosis can be difficult
Multidisciplinary assessment is important for the diagnosis of depression with
medical or neurological comorbidities
Geriatric Depression Scale (GDS) was developed for use with older adults
Beck Depression Inventory (BDI) and the Center for Epidemiologic StudiesDepression Scale CES-D were not designed for older adults but have reliability
and validity of data
Cornell Scale for Depression in Dementia entails an interview with both the
caregiver and the patient useful for guiding the assessment of depression in
demented older adults

Psychotherapeutic Interventions
Overview of efficacy studies

Cognitive-behavioral psychotherapies are relatively well documented in their

efficacy for treating depressed older adults, although findings are limited to
depression in relatively healthy, community dwelling adults
There may not be significant differences in the efficacy of cognitive,
behavioral, and psychodynamic therapies for treating depression in late life
Treatment gains in cognitive-behavioral psychotherapy appear enduring with
follow-up studies with 2 years maintenance
Psychotherapy may be as effective as antidepressant medication for treating
mild depression, while combined treatment is more effective for treating and
preventing relapse in severe depression
Maintenance psychotherapy may be important in combination with
medication, for prevention of relapses in older adults with recurrent major
depression
There are limits to the generalizability of these research findings as few
studies to date have examined the treatment of depression in minority elders
or in the oldest old adults
Meta-analytic studies report little difference between older and younger
adults in the efficacy of psychotherapy for the treatment of depression
Cognitive, behavioral, interpersonal, psychodynamic psychotherapy
psychosocial intervention, suggested that psychotherapies are effective
treatments for depressive symptoms in older adults
Limitations include participants were mainly healthy, well-educated, white,
community dwelling adults
Not well-addressed are treatment of depressed older adults with multiple
comorbid medical disorders and associated disabilities, neurological
disorders, and/or chronic psychiatric disorders
Many are back dated to the 1980s

Issues in psychotherapy with older adults

Common themes characterize psychotherapeutic work with older adults

Similar to therapy with younger adults
Adaptations necessary to address the older persons particular historical
experience, health problems or sensory deficits, cognitive changes, and/or
family involvement
Older adults may require more initial education about the nature of
depression
The pace of therapy may be slower than with younger adults
It helps to focus the therapy on fewer points and to repeat themes during
sessions
Visual and/or memory aids may be useful
Multi-disciplinary approach is extremely important
Need to include work or communicating with family members and the
therapist may take on a more active case management role when required

Older adults are more suited in engagement due to being more introspective,
more developed sense of their values and beliefs and have a lifetime of
relationships and coping experiences
Many concerns about ones own or parents aging and fears of death

Cognitive-behavioral psychotherapies

Background
o Cognitive and behavior therapy and/or a combination of these are welldocumented effective treatments for depression in adults
o Cognitive therapy conceptualization of depression as related to
systematic errors in thinking that maintain negative thoughts about
oneself, ones experiences and ones future that result in negative
moods and behaviors
o Helps the patient to identify, challenge and replace automatic
depressive thoughts with more realistic thoughts
o Views depression as related to a deficit in reinforcing, pleasant
activities or a deficit in related skills that allow a patient to enjoy
positive activities and avoid/cope with negative ones
o Helps a patient increase participation in pleasant activity, decrease
participation in averse activity and improve problem-solving and/or
social skills
o Underlying assumption learning occurs over the life course and that
any person has the potential for change
o Very little change is needed to use cognitive-behavioral treatments for
older people
Assess the frequency and pleasure derived from participation in
a range of activities and modify them for older adults
Empirical support
o Limited empirical data to treat older adults who are also medically ill or
frail
o 5 treatment issues
Resolve logistical problems related to the patients physical
and/or cognitive disabilities
Need to confront the patients or their familys belief that a
person with physical illness or disability will inevitably be
depressed, need to be educated
Confrontation of beliefs which can lead to excess disability such
as all or none
Using strategies to address feelings of worthlessness that can
result from role loss and decreased sense of control
Help patients cope with increased dependency and fears of
being burdensome to others
o These therapies have been shown to result in significant decreases in
depressive symptomatology and/or remission of major depression
when compared to no-treatment control groups
o 52% achieved remission after the initial treatment, one year follow up
83% were depression free and 77% after two years
Some had a relapse or recurrence but were restabilized after
intervention
o Administered in group settings was also effective and comparable to
psychodynamic group interventions

Effective for depression in older adults with dementia when

administered to both patient and caregiver
o Evidence that cognitive-behavioral therapy is most effective for older
adults with mild to moderate depression with no diagnosis of
personality disorder and a high commitment to treatment
Comment
o Appear to be effective after enduring treatments for depressed,
healthy, community-residing older adults
o Quickly raises self-efficacy
o Patients may lack motivation and/or capacity for follow-through if they
have severe physical ability losses, social support systems, cognitive
deficits, histories of trauma and/or personality disorders
o

Interpersonal psychotherapies

Background
o Studies document that most older adults have reasonably satisfactory
relationships with friends, spouses and adult children
o If social problems are present they are tied to poorer emotional wellbeing including depression
o Interpersonal psychotherapy of depression (IPT) specifically targets
interpersonally relevant problems
o IPT is well-established and empirically supported treatment for
depression by the Task Force on the Promotion and Dissemination of
Psychological Procedures of the Division of clinical Psychology of the
American Psychological Association
o Developed for use with the elderly in acute and maintenance
treatment of late life depression
Empirical support
o A number of research projects have documented its success in the
treatment of late life depression
o IPT was found to be as effective as nortriptyline (tricyclic
antidepressant)
o Less likely to drop out of the treatment than those using nortriptyline
o Older adults demonstrated a greater reduction of depressive
symptoms and better self-rated health than a control group
o In a study, 78.7% achieved full remission from major depression, more
than 80% when coupled with nortriptyline
o Also effective in the treatment of depression in the medically ill
Comment
o IPT can be readily applied to older adults and is an effective acute and
maintenance treatment for late life depression

Psychodynamic psychotherapies

Background
o Refers to a range of therapies that view psychopathology as rooted in
developmental difficulties that result in ineffective coping

Emotional insight is viewed as the primary means for therapeutic

change
o Appropriate for treating underlying issues of poor self-esteem and
cravings for nurturance
o For those with depression that base their sense of self-esteem on the
adoration of others (career success, physical beauty), psychodynamic
psychotherapies help to reestablish a sense of self-continuity that is
disrupted by aging-related stresses or losses
o Older adults are appropriate given their tendencies for increased
introspection, increased acceptance of oneself including ones faults,
the capacity to delay gratification and accept pain, and a motivation
for treatment based on a sense of limited time for change
Empirical support
o There are relatively little amounts of studies of the efficacy of
psychodynamic psychotherapy
o Psychodynamic and cognitive-behavioral group psychotherapies were
equally effective treatments for depressed older adults, although the
results were ambiguous, with some suggested benefit of the cognitivebehavioral intervention
o Women showed greater improvement and tended to take a more active
and assertive role
o Men tended to respond to the nurturing therapist and become more
dependent on the therapy relationship
Comment
o Efficacy of this therapy requires continued study for the treatment of
late life depression
o

Life review therapy

Background
o One of the few psychotherapies developed especially for use with older
adults
o Reminiscence is viewed as a normative experience later in life to
resolve, reorganize and reintegrate what is troubling or preoccupying
them
o Its a psychological process that facilitates resolution of the final
development task resolution of a sense of integrity or despair about
how one has lived ones life
o Life review may affirm a sense of self-continuity and re-establishment
of self-worth
o Not developed for the treatment of depression, an opportunity to
enhance normative growth
o Cautioned that may be hurtful because various observers have
expressed concern with patients with obsessive tendencies, low ego
strength or life histories
Empirical support
o Some studies have addressed changes in well-being and/or life
satisfaction rather than depression

o Study results appear to depend upon the population studied

Comment
o Relatively little study of life review therapy
o Does not currently have support as an effective treatment for
depression in older adults

Group psychotherapy

Background
o Take many forms from education and support around a shared life
stress to psychodynamic or interpersonal focuses on learning from
here-and-now relationships
o Group psychotherapy provides distinct ingredients for healing that
individual therapies do not including:
universality seeing that one is not alone
altruism helping others and thereby increasing feelings of
usefulness and self-esteem
socialization learning and practicing social skills
group cohesiveness feeling that one belongs to and is
accepted by a group
o Groups provide an excellent forum for older adults to learn, practice
and receive feedback on cognitive and behavioral strategies for coping
with depression
o Older adults are more:
Easy going able to be patient and comforting with others,
willing to share their experiences and able to form alliances
May be less comfortable with confrontation
o Group work may be enhanced through the use of visual aids, work
books, handouts and/or complementary creative activities
o Potential problems
Hearing and/or sight impairments not able to fully participate
People with cognitive deficits mixed in with higher functioning
adults
Termination of the group
Empirical support
o Empirical support as a treatment for depression in older adults is
limited
o Older adults with disabling illness did not show continued declines in
depression
o Depressive symptoms did decline with group intervention
o Majority of patients did not remission of depression
o People who benefited the most were those who had frequent contact
with family members, fewer physical problems and a higher baseline of
positive social behaviors
Comment
o Attractive for practical reasons
o Have a promise for a wide range of medical, psychiatric, long-term and
community settings

Memory deficits alone or severe personality disorders do not preclude

participation

Family interventions

Background
o No family therapy has addressed the usefulness for family issues or
unique problems of depressed older adults and their families
o Older adult seek mental health treatment at the request of their
families
o Recommendations include engagement and education of the family,
assessment of interpersonal difficulties and intervention
o After 15 years of research, caring for an individual with dementia or
other progressively debilitating conditions can lead to depression and
anxiety and adverse changes in social relationships
o Wide variety of interventions exist to help family caregivers contend
with the practical and emotional consequences of providing care to an
older person with frailty secondary to dementia
o Goals include:
Expanding knowledge of the older patients illness
Increasing skills related to caring for the patient
Improving the emotional and social well-being of the caregiver
o Explicit goal has been to reduce depressive symptoms
Secondary goal to help the caregiver
Empirical support
o There are no studies that have evaluated the efficacy of family therapy
in the treatment of late life depression
o Nine intervention studies that explicitly used depressive symptoms at
least once in their outcomes have used mixed-modal approaches with
mixed results
o Others demonstrated modest reductions of depressive symptoms at
the end of treatment
o Problem solving classes, behaviorally based psychoeducational classes
resulted in decreased depressive symptoms in care givers
Comment
o Working with older adults often involves working with family members
o Help family members better cope with these issues
o Existing models for younger depressed patients could likely be
modified for older person and their families

Summary and directions for future research

Psychotherapy for depression helps to address the psychological and social

factors that may precipitate and/or maintain depressive illness. Older adults
who suffer from depression are as likely to benefit from psychotherapeutic
interventions.
Studies of combined psychotherapeutic interventions may also be quite
helpful

Some older adults do not respond to the treatments

We do have fairly good evidence that depression is a treatable illness in late
life and that psychotherapy can play an important role in the treatment
Challenge is to demonstrate that psychotherapy can work to treat depressed
older adults and to help their families and medical care provides to recognize
and seek appropriate treatment for depression
Approaching such treatments should lead to improved physical and social
functioning

Questions:
1. Which depressed older adults are most likely to benefit from what types of
treatments?
2. Are there reasons to choose cognitive-behavioral versus psychodynamic
versus family psychotherapy to treat depression in a particular older person?
3. Are all psychotherapies generally equivalent with non-specific factors
contributing to healing?