Clinical Psychology Review, Vol. 20, No. 6, pp.

707–729, 2000
Published by Elsevier Science Ltd.
Printed in the USA. All rights reserved
0272-7358/00/$–see front matter

PII S0272-7358(99)00065-3

TREATMENT OF DEPRESSION IN LATE LIFE:

PSYCHOTHERAPEUTIC INTERVENTIONS
Michele J. Karel
BrocktonⲐWest Roxbury VAMC, Harvard Medical School

Gregory Hinrichsen
Hillside Hospital, North Shore-Long Island Jewish Health System

ABSTRACT. Depression affects only a minority of older adults, but is a costly illness in terms of
suffering, excess medical disability, increased use of health services, and mortality. Both pharmaco-
logical and psychotherapeutic interventions are effective for treating depression in late life. This pa-
per reviews the background and empirical support for the efficacy of various psychotherapies for
treating late life depression, including cognitive-behavioral, interpersonal, psychodynamic, life re-
view, group, and family interventions. To date, cognitive-behavioral and interpersonal psychother-
apies have most empirical support yet most studies have been conducted with relatively young,
healthy, and White elderly. Studies of the efficacy of psychotherapeutic interventions for treating de-
pression in minority and frail elderly are needed, as well as further studies of combination treat-
ments across a range of care settings. Published by Elsevier Science Ltd.

INTRODUCTION
DESPITE COMMON STEREOTYPES that depression is inevitable and unchangeable
in old age, depression affects a minority of older adults and is generally as responsive
to treatment as depression in younger people (e.g., Reynolds et al., 1996; Scogin &
McElreath, 1994). Both pharmacological and psychotherapeutic interventions, alone
or in combination, have demonstrated efficacy in treating depressive illness in older
adults (Niederehe, 1996; Schneider, 1996). However, depression in late life is com-
plex. The contribution of biology, psychology, and sociology to the genesis and ame-
lioration of depression in older adults challenges both scientists and clinicians to
think in complex ways about depression in late life. In this review we will examine
what is known about the psychological treatment of late life depression and what re-
mains poorly understood and understudied.

Correspondence should be addressed to M. Karel, Brockton/West Roxbury VAMC Psychology

Service, 940 Belmont Street, Brockton, MA 02401, USA.

707
708 M. J. Karel and G. Hinrichsen

DEPRESSION IN LATE LIFE: PREVALENCE, RISKS, AND ASSESSMENT

Prevalence and Implications of Depression in Late Life
Adults over the age of 65 have relatively low rates of major depressive disorder (one
year prevalence rate of less than 1%), based on epidemiological studies conducted in
the 1980s (Weissman, Bruce, Leaf, Florio, & Holzer, 1991). On the other hand, older
adults report relatively high rates of depressive symptoms that do not meet DSM-IV
criteria for major depressive disorder (Newmann, 1989). For example, what has been
characterized as “minor depression,” or “subsyndromal depression,” is prevalent
among older adults (8–15% in community samples), results in functional impairment,
but also responds to treatment (Koenig & Blazer, 1996). Older adults who are func-
tionally disabled by medical illness are at highest risk for depression. Successively
higher rates of clinically significant depressive symptoms have been observed in medi-
cal outpatient (10%), medical inpatient (25%), and nursing home (30%) settings, re-
spectively (Blazer, 1994). There is a fair degree of diversity in risk factors for and pre-
sentation of depression in late life (Karel, 1997). For many elders, depression is a
recurrence of a chronic disorder first experienced in young adulthood; for others, it
appears for the first time in late life. Risk factors may differ, with some evidence that
late onset depression may result from neurological changes and, for some, is a precur-
sor of dementing illness (Alexopoulos, Young, Meyers, Abrams, & Shamoian, 1988).
Depression is a costly illness for older adults, in terms of suffering, excess disability
because of medical comorbidities, increased use of health services, and mortality
(Katz, 1996). The most dire consequence of depression in late life is suicide. Of any
age group, suicide rates are highest among older White men, and suicide in older
adults is often related to underlying major depression (Conwell, 1994). The treatment
of depression in older adults aims not only to reduce symptoms of depression, but
also to prevent relapse, improve functional ability, physical health status, and “quality
of life,” as well as reduce costs of care and excess mortality (Reynolds, 1997).

Assessment of Depression in Late Life

The greatest barrier to effective treatment of depression in late life is probably inade-
quate recognition of depression in older adults, by elders themselves, their families,
and physicians. Today’s older adults are relatively unlikely to label the experience of
depression in themselves as a mental health problem and self-refer for psychiatric or
psychotherapeutic treatment (e.g., Waxman, Carner, & Klein, 1984). This may
change as more “psychologically-minded” cohorts enter old age. Older adults and
those who know them may assume that poor energy, loss of interest, and somatic
symptoms are simply a part of being old or sick (Lebowitz et al., 1997), which is an un-
fortunate and costly assumption. Depressed older adults are seen frequently in pri-
mary care medical settings, but depression in them remains underdiagnosed by medi-
cal care providers (e.g., Rapp & Davis, 1989). Early recognition of depression is
important so that treatments are provided before the condition becomes more severe
or life-threatening (Fiske, Kasl-Godley, & Gatz, 1998).
Even among mental health professionals, and among mental health professionals
with training in geriatrics, depression is not always accurately identified in the older
adult. Symptoms of depression can overlap with symptoms of medical illness, includ-
ing sleep disturbance, poor appetite, and poor energy (Lyness et al., 1996). Older
adults may be less likely to spontaneously report symptoms of depressed mood (e.g.,
 Treatment of Depression 709

Gallo, Anthony, & Muthen, 1994; Lyness et al., 1995). Older adults with dementia fre-
quently have comorbid depression that can be treated (e.g., Teri & Wagner, 1992);
yet, given potential overlap in symptoms between dementia and depression (e.g., lack
of initiative, fatigue), the diagnosis of depression in dementia can be difficult (Bene-
dict & Nacoste, 1990). Even when depression is clearly identified in an older person, it
is extremely important to rule out potential medical problems or medication side-
effects that can cause depression in older adults. Thus, multidisciplinary assessment is
frequently important for the diagnosis of depression in older people with medical or
neurological comorbidities.
Fortunately, a number of tools can aid in the assessment of depression in older
adults (Pachana, Gallagher-Thompson, & Thompson, 1994). Several self-report de-
pression scales have been shown to be reliable and valid in distinguishing depressed
from non-depressed older adults. They can be extremely helpful as screening devices.
The Geriatric Depression Scale (GDS; Yesavage et al., 1983) was developed specifically
for use with older adults. The Beck Depression Inventory (BDI; Beck, Ward, Mendel-
son, Mock, & Erbaugh, 1961) and Center for Epidemiologic Studies-Depression Scale
(CES-D; Radloff & Teri, 1986) were not developed specifically for use with older
adults, but have reliability and validity data supporting their use with more highly educated
elders (Pachana et al., 1994). The Cornell Scale for Depression in Dementia (Alexopoulos,
Abrams, Young, & Shamoian, 1988) entails an interview with both the patient and a
caregiver and is helpful for guiding the assessment of depression in demented older
adults. Several excellent review articles have been published regarding the assessment
of depression in late life (e.g., Kaszniak & Christenson, 1994; Pachana et al., 1994);
the reader is encouraged to seek out these references.

A NOTE ON BIOLOGICAL TREATMENTS

Antidepressant medications and electroconvulsive therapy (ECT) are important and
effective treatments for depression in older adults. Although this paper focuses on
psychosocial interventions, the reader should be aware of the role of biological treat-
ments which are frequently used in conjunction with psychotherapeutic treatment of
depression in late life.
Tricyclic antidepressants (TCAs, e.g., nortriptyline, imipramine), serotonin selec-
tive reuptake inhibitors (SSRIs, e.g., fluoxetine, sertraline, paroxetine), and bupro-
pion have been found to be effective treatments for major depression in older adults.
Several studies that compared TCAs to SSRIs in treating depression in older adults
found no significant difference between these classes of drugs (McCusker, Cole,
Keller, Bellavance, & Berard, 1998). Typically, during the initial phase of treatment
for depression, approximately 60% of older patients respond to antidepressant medi-
cation through remission of major depression or significant decline in symptoms on
rating-scales (Schneider, 1996). Older adults appear to respond as well as middle-
aged adults to initial antidepressant therapy although more slowly. Further, older
adults are more likely to relapse without carefully monitored continuation of treat-
ment after initial remission of symptoms (Reynolds et al., 1996). As TCAs can have nu-
merous side effects that are especially adverse in older adults (e.g., orthostatic hy-
potension which can result in falls, memory disturbance, cardiotoxicity), many
clinicians prefer prescribing the newer SSRIs which have fewer serious side effects
(Zisook & Downs, 1998). Little is known about the efficacy of antidepressant treat-
710 M. J. Karel and G. Hinrichsen

ment for the oldest and frailest elderly, although there exist some hopeful data about
response of chronically ill, depressed elders to antidepressant treatment in long-term
care settings (Katz, Simpson, Curlik, Parmalee, & Muhly, 1990).
Challenges for the effective use of medications to treat depression in older adults
include increased risk for side effects and medication interactions, and high rates of
noncompliance in many older adults with complicated medication regimens (Zisook &
Downs, 1998). For older adults who are unable to tolerate or comply with antidepres-
sant treatment, psychotherapy is a very viable treatment option.
ECT is an important treatment for depression in older adults, especially when de-
pression is life-threatening and a rapid response is needed (e.g., the person is not eat-
ing) andⲐor when medications have not been effective or cannot be tolerated. De-
pressed older adults treated with ECT generally have good short-term response to the
treatment, and with low rates of medical complications (Sackeim, 1994). Very old
adults, or those with a history of cardiac illness, may be more vulnerable to cardiovas-
cular complications (Cattan et al., 1990). It is not known if older patients are more
vulnerable to cognitive side effects of ECT (confusion immediately following treat-
ment, and anterograde and retrograde amnesia which generally recovers rapidly).
Some reviews suggest that very old adults may be more vulnerable to confusion follow-
ing treatment. One problem with ECT in all age groups is that early relapse is com-
mon. The potential role of maintenance ECT for older patients has not been studied
(See Sackeim, 1994 for a review of this literature).

PSYCHOTHERAPEUTIC INTERVENTIONS
Overview of Efficacy Studies
A small body of controlled outcome research supports the efficacy of psychotherapy
for treating depression in older adults (see excellent reviews by Futterman, Thomp-
son, Gallagher-Thompson, & Ferris, 1995; Gatz et al., 1998; Niederehe, 1994; Teri,
Curtis, Gallagher-Thompson, & Thompson 1994). A review of this literature suggests
the following: (1) Cognitive-behavioral psychotherapies, in both individual and group
formats, are relatively well-documented in their efficacy for treating depressed older
adults, although findings are limited to depression in relatively healthy, community
dwelling adults (Teri et al., 1994). (2) There may not be significant differences in the
efficacy of cognitive, behavioral, and psychodynamic therapies for treating depression
in late life (Thompson, Gallagher, & Breckenridge, 1987). (3) Treatment gains in
cognitive-behavioral psychotherapy appear enduring, with follow-up studies suggesting
maintenance of improvements over two years (Gallagher-Thompson, Hanley-Peterson, &
Thompson, 1990). (4) As appears true for all adult age groups, psychotherapy may be as
effective as antidepressant medication for treating mild depression, while combined
treatment (i.e., psychotherapy plus medication) is more effective for treating and pre-
venting relapse in severe depression (Gallagher & Thompson, 1983; Reynolds, 1997;
Thase et al., 1997; Thompson, Gallagher, Hanser, Gantz, & Steffen, 1991). (5) Main-
tenance psychotherapy which follows initial treatment and remission of the index de-
pressive episode may be important, in combination with medication, for prevention of
relapses in older adults with recurrent major depression (Reynolds, 1997). (6) 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
(e.g., 80 and over).
 Treatment of Depression 711

Meta-analytic studies report little difference between older and younger adults in
the efficacy of psychotherapy for the treatment of depression. Scogin and McElreath
(1994) conducted a meta-analysis of 17 studies of psychosocial treatments for geriatric
depression. Each of these studies compared a psychosocial intervention (e.g., cogni-
tive, behavioral, interpersonal, psychodynamic psychotherapy) either to a control
group or to a second psychosocial intervention. The analysis found an overall effect
size for treatment versus no treatment or placebo control of .78, suggesting that psy-
chotherapies are effective treatments for depressive symptoms in older adults. Fur-
ther, the authors report that this effect size was comparable to that reported (.73) in a
meta-analysis of psychotherapy for depression in adults of all ages (Robinson, Ber-
man, & Neimeyer, 1990), as well as to a review of psychotherapy efficacy in general
(.85; Smith, Glass, & Miller, 1980). On the basis of the Scogin and McElreath (1994)
analysis, psychotherapy for depression in older adults appeared to be as effective as
psychotherapy for depression in adults of any age.
Despite these favorable findings, there are real limitations to this still-small body of
research. Participants in most of these studies were relatively healthy, well-educated,
White, community dwelling adults in their 60’s and 70’s. However, many clinicians
work in medical, psychiatric, or long-term care settings where depressed older pa-
tients differ from those who participate in research studies. The psychotherapeutic
treatment of depressed older adults with multiple comorbid medical disorders and as-
sociated disabilities, neurological disorders, andⲐor chronic psychiatric disorders is
not well-addressed by the research literature to date. Further, a review of the literature
shows little research regarding psychotherapy with depressed elders since the 1980’s.
There remains much work to be done!

Issues in Psychotherapy with Older Adults

What is it like to do psychotherapy with older people? Regardless of the presenting
problem or particular type of psychotherapy, several common themes characterize
psychotherapeutic work with older adults (see Knight, 1996a; Zarit & Knight, 1996).
For the most part, psychotherapy with older adults is more similar than different to
psychotherapy with younger adults. Adaptations may be necessary to address the older
person’s particular historical experience (e.g., perceived stigma associated with mental
health care), health problems or sensory deficits, cognitive changes, andⲐor family
involvement.
Older adults may require more initial education about the nature of depression
and the purpose and process of psychotherapy (e.g., depression is a disease, not a sign
that you are “weak” or “crazy”). Adults who are old today may expect a “paternalistic”
doctor to provide a cure for their problems, and may need to be taught how to take an
active role in psychotherapy. Psychotherapy with older adults may take place in a wide
range of settings, from a private practice office, to the patient’s home (for those un-
able to travel), to bedside in a hospital or nursing home. Clinicians new to this work
need to develop flexibility in delivering care. The pace of psychotherapy may be
slower than with younger adults to accommodate to sensory andⲐor cognitive deficits.
For older adults with such limitations, it helps to focus the therapy on fewer points
and to repeat themes during sessions. Visual andⲐor memory aids may be useful (e.g.,
keep a notebook, writing down main points reviewed in the therapy session).
The psychotherapist working with older adults is more likely to communicate with
medical or other care providers, as coordination of medical and psychosocial care can
712 M. J. Karel and G. Hinrichsen

be extremely important in working with older adults. As older adults are frequently
brought in for services by family members, psychotherapy may be more likely to in-
clude work or communication with family members. The therapist may take on a
more active case management role when needs so require (e.g., to help a family ex-
plore alternative living arrangements). Given the frequent involvement of family or
other professionals when providing mental services to older adults, confidentiality is-
sues need to be attended to actively.
Despite the minor adaptations, older adults are often especially well-suited to en-
gaging in psychotherapeutic work. Compared to younger age groups, they may be rel-
atively more introspective, have a more developed sense of their values and beliefs,
and have a lifetime of relationships and coping experiences to draw upon in tackling
current problems. Psychotherapists should pay particular attention to countertrans-
ference issues that may arise in working with older adults, including dependencyⲐhelp-
lessness, concerns about one’s own or one’s parent’s aging, and fears of death.
The next sections of the paper review specific modalities for treating depression in
older adults, including cognitive-behavioral, interpersonal, psychodynamic, life re-
view, group, and family psychotherapies. For each of these therapies, we provide a
brief background about the use or development of the therapy with older adults and a
review of empirical support for the treatment.

Cognitive-Behavioral Psychotherapies
Background. Cognitive therapy and behavior therapy, and a combination of these ap-
proaches, are well-documented effective treatments for depression in adults (Beck,
Rush, Shaw, & Emery, 1979; Lewinsohn, Munoz, Youngren, & Zeiss, 1978). Cognitive
therapy for depression is based on a conceptualization of depression as related to sys-
tematic errors in thinking that maintain negative thoughts about oneself, one’s expe-
riences, and one’s future, and that result in negative moods and behaviors (Beck et al.,
1979). Psychotherapy, then, helps the patient to identify, challenge, and replace automatic,
depressive thoughts with more realistic thoughts. Cognitive therapy for treatment of
depression in adults is included in a review of “well-established” empirically supported
treatments published by the Task Force on Promotion and Dissemination of Psycho-
logical Procedures of the Division of Clinical Psychology of the American Psychological
Association (Chambless et al., 1996).
Behavior therapy views depression as related to a deficit in reinforcing, pleasant ac-
tivities or a deficit in related skills that allow an individual to enjoy positive activities
and avoidⲐcope with negative ones. Behavior therapy posits a strong relationship be-
tween activity and mood and thus aims to help the patient increase participation in
pleasant activity, decrease participation in aversive activity, and improve problem-solving
andⲐor social skills (Lewinsohn, Antonuccio, Steinmetz, & Teri, 1984). In practice,
cognitive and behavior psychotherapies are frequently combined.
These approaches are characterized by the establishment of clear and measurable
treatment goals, a collaborative alliance between patient and therapist, an active and
psychoeducational stance by the therapist, the use of “homework” between sessions, a
focus on skills training, and an assumption that people can learn and change. The un-
derlying assumptions of cognitive-behavioral therapy—that learning occurs over the life
course and that any person has the potential for change—make this approach particularly
hopeful in helping older people (Zeiss & Steffen, 1996).
Several excellent reviews describe the application and adaptation of cognitive-behavioral
 Treatment of Depression 713

therapies for treating older adults (e.g., Dick, Gallagher-Thompson, & Thompson,
1996; Gallagher-Thompson & Thompson, 1996; Zeiss & Steffen, 1996). Treatment
manuals developed for outcome research detail the process and techniques of these
interventions with older adults (e.g., Gallagher & Thompson, 1981; Yost, Beutler, Cor-
bishley, & Allender, 1986). Unfortunately, these materials are not readily available
and better vehicles for dissemination are needed. In general, very little change is
needed to use cognitive-behavioral treatments for depression with relatively healthy
older adults, besides some of the general considerations for psychotherapy work re-
viewed above. In the case of behavioral therapy, a tool used to assess the frequency
and pleasure derived from participating in a range of activities was modified to in-
clude activities commonly engaged in by older adults (Older Person’s Pleasant Events
Schedule; Teri & Lewinsohn, 1986).
Although limited empirical data exist for the use of cognitive-behavioral therapies
to treat depressed older adults who are also medically ill or frail (i.e., the older adults
who are at highest risk for depression!), clinicians have published accounts of their
own work adapting cognitive-behavioral techniques with this important population
(e.g., Grant & Casey, 1995; Rybarczyk et al., 1992). Rybarczyk et al. (1992) reviewed
five major treatment issues for depressed, chronically ill older adults being treated
with cognitive-behavioral therapy. The first issue is to resolve any logistical problems
related to the patient’s physical andⲐor cognitive disabilities. This may include some
flexibility regarding where, when, and for how long to see the patient in session. A sec-
ond issue is the frequent need to confront the patient’s or their family’s belief that a
person with physical illness or disability will inevitably be depressed; many patients need ed-
ucation about depressive illness as a problem distinct from their medical condition
and that it can be helped. The third common treatment issue is confrontation of be-
liefs that can lead to excess disability, such as “all or none” or unrealistically negative
thinking. Through both cognitive and behavioral strategies, depressed people with
changed abilities can learn to adjust their expectations of themselves and discover do-able
activities that bring pleasure. The fourth issue entails the use of cognitive and behavioral
strategies to address feelings of worthlessness that can result from role loss and de-
creased sense of control; patients can be helped to identify choices that they do have. The
fifth treatment issue is to help patients cope with increased dependency and fears of being
burdensome to others; cognitive strategies can assist patients to appreciate the contri-
butions they can still make to others.

Empirical support. Cognitive, behavioral, and cognitive-behavioral therapies for de-

pression in older adults have been shown to result in significant decreases in depressive
symtomatology andⲐor remission of major depression when compared to no-treatment
control groups or other psychotherapy modalities (see review by Teri et al., 1994).
Most of this research has been conducted by Gallagher, Thompson, and their associates
at the Palo-Alto VA, and has focused on relatively healthy, community dwelling adults in
their 60’s and 70’s. In comparing individual cognitive, behavioral, and brief psychodynamic
therapy for depression, Thompson et al. (1987) found comparable remission rates
across groups and no difference in stability of effects over two years (Gallagher-
Thompson et al., 1990). Across treatment modality, 52% of the sample achieved remis-
sion of major depression after the initial treatment (16–20 individual therapy sessions
over a 4-month period). At one- and two-year follow-ups, 83% and 77% of the patients
who initially achieved remission were depression-free, respectively; however, a minor-
ity of these patients did experience relapse or recurrence of depression in the interim
714 M. J. Karel and G. Hinrichsen

and, with brief therapeutic intervention, were restabilized. The majority of patients
who did not respond to the initial treatment remained depressed for the one- and
two-year follow-ups, despite continued treatment with medication andⲐor psychother-
apy (Gallagher-Thompson et al., 1990).
Cognitive-behavioral therapy administered in a group format is also an effective
treatment for depression in older adults, and comparable to psychodynamic group in-
tervention (Steuer et al., 1984). Further, cognitive and behavioral bibliotherapy have
been found to be effective and enduring treatments for mild and moderately de-
pressed older adults (Scogin, Jamison, & Gochneaur, 1989; Scogin, Jamison, & Davis,
1990). In comparison to a delayed-treatment control group, older adults who read at
home, over a 4-week period, books on either behavioral or cognitive therapy for de-
pression showed significant clinical improvement (66% of treatment vs 19% control).
Improvement, measured by patient- and clinician-rated depressive symptoms, en-
dured at 6- and 24-month follow-ups.
There is evidence that behavior therapy is an effective treatment for depression in
older adults with dementia when administered to the patient and caregiver (Teri,
1994). Strategies for working with families of depressed older adults are addressed further
below, and strategies for working with dementia patients are detailed in Kasl-Godley
and Gatz’s paper in this issue.
For which older adults do cognitive-behavioral interventions appear to be most ef-
fective? Little data exist to provide an answer to this question. However, there is some
evidence that cognitive-behavioral therapy is most effective for older adults with mild
to moderate depression, with no diagnosis of personality disorder, and with relatively
high commitment to treatment (as reviewed by Teri et al., 1994).

Comment. Cognitive-behavioral therapies appear to be effective and enduring treat-

ments for a significant proportion of depressed, relatively healthy, community-resid-
ing older adults. Cognitive-behavioral therapies are excellent interventions for quickly
helping to increase the sense of self-efficacy for people who are able to engage in the
treatment and learn that, through their efforts, they can effect change in their mood
and behavior. The practicing clinician may struggle with how or when to adapt these
techniques for the many older patients seen in clinical settings who do not resemble
the participants in the research studies. That is, many depressed older adults have severe
losses in physical abilities andⲐor social support systems, mild-to-moderate cognitive
deficits, histories of trauma, andⲐor histories of long-standing personality disorder.
Some of these patients may lack the motivation andⲐor capacity for follow-through
with cognitive-behavioral assignments. Others may face acute losses for which other
interventions may be more appropriate. Practicing clinicians will benefit from continued
empirical research looking at which older adults do and do not benefit from cognitive-
behavioral treatments for depression.

Interpersonal Psychotherapy
Background. From the beginning of the field of gerontology, there has been concern
about the social and familial well-being of older adults. An abundance of studies docu-
ment that most older adults have reasonably satisfactory relationships with friends,
spouses, and adult children (Antonucci, 1990; Bengtson, Rosenthal, & Burton, 1990).
However, when late life social problems are present they are tied to poorer emotional
well-being including depression (George, 1994). Studies of younger persons with de-
 Treatment of Depression 715

pression have documented that depressive illness is associated with short and longer
term disruption of interpersonal relationships (Weissman & Paykel, 1974; Coryell et
al., 1993). Ironically, it is often those very interpersonal relationships that are central
to the sustained recovery of both depressed younger (Hooley, Orley, & Teasdale,
1986) and older persons (Hinrichsen & Pollack, 1997).
A psychotherapeutic intervention that specifically targets interpersonally relevant
problems is Interpersonal Psychotherapy of Depression (IPT; Klerman, Weissman,
Rounsaville, & Chevron, 1984). IPT is a time-limited (16 weeks), manualized psycho-
therapy for the treatment of major depressive disorder. IPT is theoretically influenced
by the interpersonal school of psychiatry which emphasizes the centrality of interper-
sonal relationships for emotional well-being (Sullivan, 1953). One, or sometimes two,
interpersonal problem areas are the focus of treatment: grief (death of a loved one),
interpersonal disputes (conflicts with a significant other), role transition (change in
life circumstances), and interpersonal deficits (individuals who lack the skills to de-
velop and sustain social relationships). IPT is listed a “well established” empirically
supported treatment for depression in adults by the Task Force on Promotion and
Dissemination of Psychological Procedures of the Division of Clinical Psychology of
the American Psychological Association (Chambless et al., 1996; also see Frank &
Spanier, 1995).
IPT has been developed for use with the elderly in the acute and maintenance treat-
ment of late life depression (Frank et al., 1993). Practitioners have reported that IPT
requires little adaptation for older adults. In fact, it appears especially well-suited for
older adults in view of the increasing frequency of death of family and friends,
changes in social roles, the need to acquire new or adapt existing social skills to
changing life circumstances, and the adverse emotional impact of conflicts with signif-
icant others, especially adult children (Hinrichsen, 1997; Miller et al., 1998).

Empirical Support. Although IPT is less well-studied in the elderly than in younger
persons, a number of research projects have documented its success in the treatment
of late life depression. In a small study, IPT was found to be as effective as nortrip-
tyline (NT) in the acute treatment of major depression in older adults at six and six-
teen weeks (Sloan, Staples, & Schneider, 1985; Schneider, Sloane, Staples, & Bender,
1986). Interestingly, older adults receiving IPT were less likely to drop out of the study
than those receiving NT, presumably because of the side effects of this tricyclic antide-
pressant. A brief form of IPT, interpersonal counseling (IPC), was provided to older
persons with significant symptoms of depression when medically hospitalized. Six
months after entering the study, older patients who received IPC demonstrated a
greater reduction of depressive symptoms and better self-rated health than those who
did not receive IPC (Mossey, Knott, Higgins, & Talerico, 1996).
In the largest study of IPT and the elderly, researchers at the University of Pitts-
burgh are currently examining IPT as a maintenance treatment for recurrent major
depression (Reynolds, 1997). In the acute and continuation treatment phases of the
study older people are treated with IPT and NT. During the maintenance phase of the
study elderly patients are randomly assigned to one of the following conditions:
Monthly IPT alone, NT alone, IPT with NT, IPT with placebo, and placebo alone. Sev-
eral preliminary reports from the study demonstrate that IPT holds promise in the
treatment of late life depression.
In the acute-continuation phase of the study, 78.7% of older patients achieved full
remission from major depression (Reynolds et al., 1992). As noted, successfully
716 M. J. Karel and G. Hinrichsen

treated older adults who subsequently relapsed were given IPT and NT. Eighty per-
cent of them then achieved remission from the episode (Reynolds et al., 1994). Over
the course of one year of maintenance therapy, 80% of patients receiving NT with or
without interpersonal psychotherapy, 50% of those receiving monthly IPT with pla-
cebo, and only 20% of those receiving placebo alone were without evidence of major
depression (Reynolds, 1997). Reynolds notes, “The IPT finding (50% absence of ma-
jor depression at one year) is remarkable, considering that IPT is administered only
once monthly during the maintenance phase, while NT is continued at full-dose (Rey-
nolds, 1997, p. 237).”
On the whole, study results indicate that, in the elderly, IPT may be as effective as
antidepressant medication in the acute treatment of major depression and, when
combined with antidepressant medication, it results in high rates of remission from
an initial and subsequent episode of major depression. IPT is also effective in the
treatment of depressive symptoms in the medically ill. Finally, following an initial
course of IPT, once-a-month IPT significantly reduces rates of relapse in recurrent
major depression over one year.

Comment. In view of the many late life social stressors with which elderly contend, IPT
appears to be a useful modality for the treatment of depression in older adults—especially
those who evidence interpersonal problems tied to one or more of the four IPT problem
areas. Clinical reports indicate that IPT can be readily applied to older adults. Re-
search evidence is mounting that alone, or in combination with antidepressant medication,
IPT is an effective acute and maintenance treatment for late life depression. However,
further studies of the acute efficacy of IPT in the treatment of major depression are
needed since existing work is based on a small, nonplacebo controlled study. Also it
remains to be seen if, in the maintenance treatment of late life depression, IPT might be
as efficacious as NT if administered more than monthly. Finally, further study of factors
predicting positive response to IPT in older adults will help to guide clinical practice.

Psychodynamic Psychotherapies
Background. Psychodynamic psychotherapy here refers to a range of therapies that
view psychopathology as rooted in developmental difficulties that result in ineffective
coping. These therapies emphasize intrapsychic process as affecting an individual’s
adjustment. Emotional insight, often gained through exploration of the relationship
between the patient and the therapist, is viewed as the primary means for therapeutic
change. While most psychodynamic approaches were not developed specifically for
the treatment of depression, these therapies have been viewed as appropriate for
treating underlying issues of poor self-esteem and cravings for nurturance commonly
seen in depressed people (e.g., as reviewed by Karasu, 1990). Empirical support for
psychodynamic psychotherapeutic treatment of depression in adults remains limited
(Karasu et al., 1993).
Historically, Freud was quite pessimistic about the utility of psychoanalysis for treat-
ing adults over the age of 50 (Knight, Kelly, and Gatz, 1992). Since Freud’s time, many
psychoanalytic and adult developmental theorists have offered a greater sense of hope
for growth in later life (Erikson, 1963; Colarusso & Nemiroff, 1981; Nemiroff & Co-
larusso, 1985). Depression in some older adults is viewed by psychodynamic theorists as
a common outcome of ineffective coping with the stresses or losses of late life (e.g.,
Newton, Brauer, Gutman, & Grunes, 1986; Pollock, 1987). From a self psychology
 Treatment of Depression 717

perspective, older adults who tend to base their sense of self-esteem on the adoration
of others (e.g., through career success, physical beauty) may have a precarious sense
of self in the context of illness, retirement, or interpersonal loss and, therefore, be at
greater risk for depression (Lazarus, 1980). In this context, psychotherapy for depres-
sion in late life is viewed as a means to help to reestablish a sense of self-continuity dis-
rupted by aging-related stresses or losses (Lazarus, 1988).
Criteria for selecting patients who should benefit from psychodynamic psychotherapy
are viewed by modern clinicians as the same for older and younger patients, including
the capacities for introspection and formation of a therapeutic alliance. Older adults
may, in fact, be viewed as particularly appropriate for insight-oriented psychotherapy,
given tendencies for increased introspection, increased acceptance of oneself including
one’s faults, the capacity to delay gratification and accept pain, and a motivation for treat-
ment based on a sense of limited time for change (Newton et al., 1986; Silberschatz &
Curtis, 1991). Therefore, in the clinical and theoretical literature, psychodynamic psy-
chotherapy is described as an effective treatment and opportunity for growth for older
adults who suffer from depression in the context of aging-related threats or loss.

Empirical support. There has been relatively little study of the efficacy of psychody-
namic psychotherapy for treating depression in late life. A review of the scant empiri-
cal literature concluded that psychodynamic psychotherapy is more effective in treat-
ing depression in older adults than no treatment and roughly as effective compared to
other types of psychotherapies (Niederehe, 1994). As described above, Thompson et
al. (1987) found that brief individual psychodynamic psychotherapy was as effective in
treating depressed older adults as cognitive and behavioral individual psychotherapies
and that it had similar enduring effects after two years (Gallagher-Thompson et al.,
1990). Similarly, Steuer et al. (1984) concluded that 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
cognitive-behavioral intervention (Riskind, Beck, and Steer, 1985).
Lazarus et al. (1987) report a study of the process and outcome of brief psychody-
namic psychotherapy with eight older patients, seven of whom received diagnoses of
either adjustment disorder with depressed mood or dysthymia They found that 10–15
sessions of therapy resulted in symptomatic improvement and resolution of focal psy-
chosocial problems, although not necessarily with significant gains in insight. This
study is a good example of an attempt to understand the process of psychodynamic
psychotherapy with older adults and the challenges in measuring outcomes (i.e.,
symptom scales alone may not always be sufficient for measuring changes that therapy
aims to make). One important finding from this study was that women showed greater
improvement and tended take a more active and assertive role, while the men tended
to respond to the nurturing therapist and become more dependent on the therapy re-
lationship. This result suggests that gender differences in response to treatment for
late life depression warrant further study.

Comment. The efficacy of psychodynamic psychotherapy in the treatment of late life

depression requires continued study. However, writings by developmental theorists in
this tradition provide rich theoretical ground from which to view psychotherapeutic
work with depressed older adults. In addition, the methods of clinical study in this tra-
dition, focusing on detailed case studies and methods to measure the process of psy-
chotherapy, may be very useful for studying and communicating with other clinicians
718 M. J. Karel and G. Hinrichsen

the “what happens and why” in cognitive-behavioral, interpersonal, group, as well as

psychodynamic, therapies for treating depression in older adults.

Life Review Therapy

Background. Life review therapy is one of the few psychotherapies developed espe-
cially for use with older adults. Reminiscence is viewed by some as a normative experi-
ence in later life, “in which the older person reflects on his life in order to resolve, re-
organize, and reintegrate what is troubling or preoccupying him (Lewis & Butler,
1974, p. 165).” Life review may be understood as a psychological process that facili-
tates resolution of the final developmental task suggested by Erikson; that is, resolu-
tion of a sense of integrity or despair about how one has lived one’s life. Robert Butler
(1963) first suggested that life review therapy could facilitate this process of reminis-
cence. Life review may affirm a sense of self-continuity and re-establishment of self-
worth. “There is the opportunity to understand and accept personal foibles, to take
full responsibility for acts that caused true harm but also to differentiate between real
and neurotic guilt. The patient may demonstrate a maturing of the ability to tolerate
conflict and uncertainty when these exist within himself and in his relationships to
others (Lewis & Butler, 1974, p. 168).”
Life review therapy was not developed specifically for the treatment of depression in
older adults. It was conceptualized more as an opportunity to enhance normative
growth than as a treatment for psychopathology (Butler, 1974). It has been used in
various settings, in both individual and group formats. Methods used to facilitate the
process of remembering one’s life include: writing or taping autobiographies, making
pilgrimages to important places, attending reunions, constructing genealogies, re-
viewing scrapbooks, photo albums, or old letters, writing or verbalizing summaries of
one’s life work, and preserving ethnic identify (Lewis & Butler, 1974).
Some authors caution that life review therapy could be hurtful rather than helpful for
some older adults. As Niederehe (1994) summarized, “various observers have expressed
concern and reservation about possible negative consequences of encouraging life review
in clinically depressed patients, particularly those with obsessive tendencies, low ego
strength, or life histories unlikely to be amenable to a positive review (p. 299).” Along
these lines, several writers have noted that reminiscence can take many forms, both
positive (e.g., integrative, problem-solving) and negative (e.g., obsessive, escapist), and that
life review therapy may be used to encourage positive rather than negative reminiscence
(see discussion in Blankenship, Molinari, & Kunik, 1996).

Empirical support. Most studies of life review therapy have addressed changes in well-
being, or life-satisfaction, rather than depression. Results of research on the impact of
life review on depression are inconsistent. As Knight (1996b) reviews, study results ap-
pear to depend upon the population studied (i.e., healthy community elders versus
nursing home residents with dementia), the baseline level of depression in the study
groups, and the particular nature of the life review intervention. For example, Fry
(1983) found that a structured life review intervention helped to reduce symptoms of
depression among a highly educated sample of community-dwelling older adults with
initially high levels of depression. Haight (1988, 1992) studied the impact of life re-
view therapy with homebound elders and found neither proximal nor long-term de-
clines in depression for those treated with six sessions of a structured life review pro-
cess, while there were reports of increased life satisfaction. Participants in this study
 Treatment of Depression 719

did not have high baseline levels of depression, thus limiting the potential to measure
change. Studies of life review therapy in nursing home settings have shown mixed out-
comes. In one study, a life review group intervention was found to be effective in de-
creasing depressive symptoms in a group of women aged 65 to 74, but not in the
group aged 74 and older (Youssef, 1990). In another study, reminiscence and current
topics discussion groups were equally effective in increasing well-being on a happi-
nessⲐdepression measure (Rattenbury & Stones, 1989).

Comment. There has been relatively little study of the use of life review therapy as a
treatment for depression in late life. Given the limited research, life review therapy
alone does not currently have support as an effective treatment for depression in
older adults. However, reminiscence may be a component of psychotherapy with de-
pressed elders, even if it is not the only aim of the therapy. Further research may help
to clarify when, for whom, and what type of life review is helpful in alleviating depression.
Therapists treating depressed older adults should be aware of the potentially positive,
as well as potentially negative, uses of reminiscence in psychotherapy.

Group Psychotherapy
Background. Group psychotherapy takes many forms, from education and support
around a shared life stress (e.g., coping with cancer, bereavement) to psychodynamic
or interpersonal groups focused on learning from here-and-now relationships. Across
varying types of groups, 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 (Finkel, 1991; Yalom, 1995). The utility of
groups for treating depression in adults has been based on clinical experience moreso
than controlled empirical studies (Karasu et al., 1993).
From a clinical perspective, group therapy may be particularly appropriate for the
treatment of depression in older adults. Depressed older adults are frequently socially
isolated and struggle with feelings of uselessness and decreased self-esteem. Groups
provide a forum for such adults both to give and receive support, to feel less isolated,
and to recover a sense of self-esteem through acceptance and admiration by group
members. From a cognitive-behavioral perspective, groups provide an excellent fo-
rum for older adults to learn, practice, and receive feedback on cognitive and behav-
ioral strategies for coping with depression (see Leszcz, 1990).
Older adults generally adapt quite well to participating in group psychotherapy.
Based on clinical observations of several writers, as well as these authors, older adults
may be relatively “easy-going” in group settings, able to be patient and comforting
with others, willing to share their experiences, and able to form alliances with other
members in short periods of time (e.g., Finkel, 1991; Lakin, 1988; Phoenix, Irvine, &
Kohr, 1997). On the other hand, group therapy with older adults may require a rela-
tively active stance by the therapist, initial encouragement or respect for older adults
who wish not to share personal issues (given cohort norms that one keeps one’s prob-
lems to oneself; Finkel, 1991), and attention to issues of education level and implica-
tions for language used and pacing of the group (Phoenix et al., 1997). Further, older
adults may be less comfortable with confrontation about here-and-now interactions in
the group, perhaps given cohort norms for politeness or minding one’s own business.
720 M. J. Karel and G. Hinrichsen

Group work with older adults may be enhanced through the use of visual aids, work-
books, handouts, andⲐor complementary creative activities (MacLennan, Saul, &
Weiner, 1988; Phoenix et al., 1997). Potential problems for groups with elders include
inclusion of people with hearing impairment who are less able to participate without
amplification aids, inclusion of people with cognitive deficits with higher functioning
elders (which can arouse fears and impatience among the latter; Lakin, 1988), and
relative difficulty terminating groups when the group has become a major social outlet
(Finkel, 1991).

Empirical support. Empirical support for group psychotherapy as a treatment for de-
pression in older adults is limited. Relatively healthy, community-residing depressed
older adults appear to benefit from cognitive-behavioral, cognitive, and psychody-
namic group therapies (Beutler et al., 1987; Steuer et al., 1984). Steuer et al. (1984)
compared cognitive-behavioral and psychodynamic group treatments and found modest
but significant decreases in observer-rated and self-reported depressive symptoms for
both groups. Beutler et al. (1987) found significant declines on BDI scores for cognitive
therapy groups (group plus alprazolam, or group plus placebo) relative to control
groups (alprazolam, or placebo, without group therapy), but no significant difference
in declines in depression on the HAM-D among the four groups. Kemp, Corgiat, and
Gill (1992) demonstrated that cognitive-behavioral group psychotherapy was effective
in reducing depressive symptoms in older patients both with and without disabling
chronic illness. However, older adults with disabling illness did not show continued
declines in depression after group treatment ended as did the relatively healthy
group. In all of these studies, while depressive symptoms did decline with group inter-
vention, a majority of patients did not show “remission” of depression on the basis of
commonly used scale cut-off scores.
The efficacy of group treatment for depressed elders in inpatient and long-term
care settings has received limited research attention. Abraham, Neundorfer, and Cur-
rie (1992) compared cognitive-behavioral, visual imagery, and control (education-dis-
cussion) groups for treating depressed elderly in nursing home settings. None of the
group interventions yielded significant changes in self-reported depression on the
GDS, nor on measures of hopelessness or life satisfaction. The two treatment groups
did, however, yield improved cognition as measured by the Modified Mini Mental Sta-
tus Exam. Brand and Clingempeel (1992) studied the impact of behavioral group
therapy for depressed geriatric inpatients when added to usual treatments offered
(e.g., medications, ward activities). They found no significant difference in decrease
in average level of depressive symptoms between the two groups, but found that a
greater percentage of patients in the behavioral group therapy showed remission
based on BDI and HAM-D cut-off scores. Patients who benefited the most from group
treatment the most were those “who had frequent contact with family members, fewer
physical problems, and a higher baseline of positive social behaviors (p. 481).”

Comment. Group therapy for depressed older adults is intuitively appealing for reasons
discussed above. Group therapy is also attractive for practical reasons, given the in-
creased efficiency and lower cost of providing care in group settings. Group interventions
have promise for a wide range of medical, psychiatric, long-term care, and community
settings. Most older adults with depression may be appropriate for group interventions.
However, those with significant hearing loss, cognitive disability precluding meaningful
verbal communication (memory deficits alone do not necessarily preclude meaningful
 Treatment of Depression 721

participation in a group setting), or severe personality or psychotic disorders may not be

appropriate. Further research is needed to demonstrate the efficacy of group interven-
tions, alone or in conjunction with biological treatments, for older adults in outpatient,
long-term care, and inpatient settings.

Family Interventions
Background. In younger adults, studies have demonstrated the importance of family
relationships in the genesis and amelioration of depression (Joiner & Coyne, 1999).
Interventions programs for family members of depressed younger adults exist (Clarkin,
Haas, & Glick, 1988). Further, numerous schools of family therapy more generally focus
on problems in families constituted by younger parents and their co-residing chil-
dren. To our knowledge, however, no family therapy has substantively addressed the use-
fulness of treatments for family issues in late life or for the unique problems of depressed
older adults and their families. This stands in contrast to a large literature in social geron-
tology on the family life of older adults (Bengtson et al., 1990).
Addressing family issues is particularly important for clinicians working with older
people. Older adults often seek mental health treatment at the behest of family mem-
bers, most typically a spouse or adult child who are involved in their care. General
guidance on conducting family work with older adults has been outlined (Qualls,
1996). Also, difficulties faced by family members caring for older adults with major de-
pression have been documented (Hinrichsen, Hernandez, & Pollack, 1992), as has
the association between problems in the patient-caregiver relationship and recovery
from late life depression (Hinrichsen & Hernandez, 1993). Clinical recommendations
on how best to work with families of depressed elders have been offered (Hinrichsen &
Zweig, 1994). Recommendations include engagement and education of the family,
assessment of interpersonal difficulties, and intervention which may take the form of
psychoeducation, co-joint or family therapy with patient and family members, and in-
dividual psychotherapy for the family member.
There have been numerous studies of the problems faced by family members caring
for infirm older adults, particularly older adults with dementia. Family members in-
clude not only adult children but older spouses. After fifteen years of research, it is
well-established that caring for an individual with dementia or other progressively de-
bilitating condition can lead to depression and anxiety, and adverse changes in social
relationships (Schulz, Visintainer, & Williamson, 1990). It is worth underscoring that
diagnosable depressive disorders as well as depressive symptoms have been found to
be quite high among caregivers. Rates of major depression range from 18% to 83%
(Schulz & Williamson, 1994). Providing care to a person with dementia is formidable.
Caregiving often includes contending with behavioral (e.g., agitation), cognitive (e.g.,
memory, disorientation), and psychiatric disturbances (e.g., hallucinations, delusions,
depression) evidenced by the patient; providing increasing levels of assistance with ac-
tivities of daily living (e.g., dressing, bathing, eating) and instrumental activities of
daily living (e.g., paying bills, shopping); and maneuvering through an often frag-
mented system of health care.
A wide variety of interventions exist to help family caregivers contend with the prac-
tical and emotional consequences of providing care to an older person with frailty sec-
ondary to dementia andⲐor physical health problems (Bourgeois, Schulz, & Burgio,
1996). The goals of interventions often include one or more of the following: expand-
ing knowledge about the older patient’s illness, increasing skills related to caring for
722 M. J. Karel and G. Hinrichsen

the patient, and improving the emotional and social well-being of the caregiver. These
interventions have taken the form of support groups, individual or family counseling,
respite care, skills training, and multi-modal programs (which incorporate several ap-
proaches within one intervention). The explicit goal of a few interventions has been
reduction of depressive symptoms in the caregiver. However, many interventions of-
ten have multiple goals such as reduction of perceived burden secondary to care for
the infirm older person, delayed time to institutionalization of the patient, and im-
proved caregiver social and emotional functioning.

Empirical support. To our knowledge there are no studies that have evaluated the efficacy
of family therapy in the treatment of late life depression. As noted, family issues have
been tied to the course of major depression (Hinrichsen & Pollack, 1997) and therefore
family treatment seems especially important. While there are at least 70 reports of inter-
ventions to assist family member providing care to frail older adults (particularly those
with dementia), fewer of them have evaluated the efficacy of interventions on decreasing
depressive symptoms in caregivers.
We have identified nine intervention studies that explicitly used depressive symp-
toms as at least one outcome criterion by which to judge the success of an intervention
with family members caring for older adults with dementia, physical health problems,
or both. Studies using a multi-modal approach have had mixed success in reducing
depressive symptoms with some failing to document discernible effects (Haley,
Brown, & Levine, 1987; Mohide et al., 1990; Toseland, Labrecque, Goebel, & Whit-
ney, 1992) and others demonstrating significant albeit modest reductions of depres-
sive symptoms at the end of treatment and on follow-up (Greene & Monahan, 1989).
The best studies in this area have come from the VA Palo Alto Group. The studies
have documented that behaviorally-based psychoeducational classes or problem solv-
ing classes resulted in decreased depressive symptoms in caregivers of frail elderly
(Lovett & Gallagher, 1988). They also found that both individual and cognitive-behavioral
therapy and brief dynamic therapy resulted in successful resolution of depression in care-
givers of frail elderly (Gallagher-Thompson & Steffen 1994). Toseland and Smith
(1990) also found reductions in depressive symptoms in daughters and daughters-in-
law caring for frail elderly parents who participated in a professional counseling
group. A support group intervention developed by another research team also docu-
mented a significant decrease in depressive symptoms in dementia caregivers (Kahan,
Kemp, Staples, & Brummel-Smith, 1985). A recent study found that two behavioral
treatments taught to family caregivers to help reduce depressive symptoms evident in
their relatives with dementia, resulted in significant improvement in the patient’s de-
pression as well as depressive symptoms in the caregivers themselves (Teri, Logsdon,
Uomoto, & McCurry, 1997). Results not only provide a promising direction for future
interventions but also underscore the reciprocal nature of depression in caregiver-pa-
tient dyads.

Comment. Working with older adults often involves working with family members. Fre-
quently the clinician will be required to coordinate the older patient’s care with a family
member. Since depression often arises in an interpersonal context or has negative
ramifications on interpersonal relationships, clinical experience suggests it is productive
to help family members better cope with these issues. However, a limited body of family
therapy theory exists to guide this work and there are no research studies of late life
family therapy. Testable, family intervention programs for older adults with major de-
 Treatment of Depression 723

pression are needed. Existing models for younger depressed patients could likely be
modified for older persons and their families (Clarkin et al., 1988).
Family members of mentally or physically frail older adults, who are frequently
older themselves, often experience symptoms of distress and sometimes diagnosable
depressive disorders. Recent research suggests that brief, problem-solving, cognitive-
behavioral, and psychodynamic therapies as well as teaching caregivers how to manage
depression in their relatives, reduces depression in caregivers themselves. However,
family caregivers caring for older adults with progressively deteriorating conditions
like dementia likely need ongoing support in their efforts to care for the older patient.

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 intervention as are
younger adults. In clinical practice, psychotherapy combined with medication may be
considered the “standard for appropriate care” for treating older adults with clinically
significant depression (Niederehe, 1996, p. S74). For older adults with less severe de-
pression, or who are unable to tolerate or comply with medications, psychotherapy
alone is a viable treatment option. To date, cognitive-behavioral and interpersonal
psychotherapies have the most empirical support, relative to other psychotherapies, as
effective psychological interventions for late-life depression. Psychodynamic psycho-
therapy also appears promising but has been subject to fewer empirical investigations.
Across these therapy schools, group interventions may be particularly appropriate for
a proportion of depressed elders. Due to the clinical realities of working with de-
pressed elders and the importance of family context for many older adults, family in-
terventions for late life depression hold great promise but have received close to no
research attention.
The enormously complex task of conducting psychotherapy studies of late life de-
pression has restricted the number of investigations that have been completed. Con-
clusions about the efficacy of psychotherapeutic interventions remain restricted to the
populations of older adults who have participated in research studies to date, typically
healthy, community-residing, White adults in their 60’s and 70’s. Studies of the poten-
tial efficacy of psychotherapy in treating depression in minority elders, frail elders,
and very old elders are needed. Studies in a range of treatment settings—including
primary care, long-term care, home, and inpatient—would help clinicians to adapt
psychotherapeutic interventions across the continuum of care for older adults. Stud-
ies of psychotherapeutic interventions in a vacuum may not be as useful as studies that
aim to document the efficacy of psychotherapy in coordination with medical andⲐor
psychiatric care. In addition, studies of combined psychotherapeutic interventions
may also be quite helpful (e.g., is individual plus family psychotherapy more helpful
than individual psychotherapy alone?).
Even when research finds psychotherapy to be an effective treatment for late life de-
pression, a significant minority of older adults do not respond to the treatment (as is
true for any treatment for any illness in any age group). Which depressed older adults
are most likely to benefit from what types of treatment? Are there reasons to choose
cognitive-behavioral versus psychodynamic versus family psychotherapy to treat de-
pression in a particular older person? Or, are all psychotherapies generally equiva-
724 M. J. Karel and G. Hinrichsen

lent, with “non-specific” factors such as the therapeutic relationship contributing to

healing? Obviously, these are complicated questions that are being addressed by the
psychotherapeutic community at large during recent years (Beitman, Goldfried, &
Norcross, 1989). Future research on psychotherapy for late life depression should
continue to study predictors of treatment outcome, including the role of gender,
medical comorbidity, depression severity or “subtype” (e.g., early vs late onset), and
patient expectations. Are there adaptations to standard treatments that may help
older people who have been less likely to respond to psychotherapy? The publication of
case studies, although not a substitute for controlled outcome research, is a good way to
begin examining treatment approaches with populationsⲐsettings that have not received
previous research attention, as well as an effective way for clinicians to communicate with
each other what approaches have worked with particularly challenging cases.
Evaluations of psychotherapy efficacy tend to focus on short-term gains, for example,
the proportion of patients showing remission of depression at the conclusion of a
time-limited psychotherapeutic intervention. The longer-term impact of different psy-
chotherapeutic interventions requires continued study; that is, do rates of depression
relapse in older adults differ for different types of psychotherapy? Further, the poten-
tial role for maintenance psychotherapy needs continued study (see Reynolds, 1997).
For which older adults might ongoing psychotherapeutic contact (and what intensity
of contact?) be particularly important for preventing relapse of depression?
We still have much to learn about how best to treat depression in late life and how
to fine-tune our interventions according to individuals’ presentations and needs.
However, we do have fairly good evidence that depression is a treatable illness in late
life and that psychotherapy can play an important role in treatment. Our challenge is
not only in demonstrating that psychotherapy can work to treat depressed older
adults, but also in helping older adults, families, and medical care providers to recog-
nize and seek appropriate treatment for depression and in demonstrating to health
care insurers that supporting such treatments should lead to improved physical and
social functioning and, thus, better and less expensive overall care.

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