Psychosocial Treatments for
Depression in the Elderly
Primary Psychiatry. 2004;11(5):48-53
• Psychotherapy can be an effective, evidence-based intervention for late-life depression.
• Of the existing psychotherapies, two are considered evidence-based according to American Psychological Association standards: cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT).
• CBT and IPT need to be adapted and modified to accommodate age-related cognitive changes and contextual challenges so that older patients may better process new information.
• More research is needed to better understand both the effects of psychotherapy on chronic, recurrent conditions and the role of these therapies in late-life depression that is resistant to medication alone.
Depression in older adults can be treated successfully with psychotherapy. This article reviews the latest information on the effectiveness of two types of psychotherapy for late-life depression, cognitive-behavioral therapy and interpersonal therapy. The reader will learn the theory, structure, and adaptations of these therapies for older adult populations. A case illustration will be briefly discussed to illustrate the application of each therapy. This article is intended to be an introduction to evidence-based psychotherapies for late-life depression and a resource for learning more about these interventions.
Since the early 1980s, several well-controlled clinical trials have demonstrated that late-life depression can be treated with psychotherapy, either alone or in combination with antidepressant medication.1 Several therapies have been studied, but the two that have been most widely investigated in this population are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). According to the American Psychological Association standards for determining a psychotherapy as evidence based,2 CBT and IPT stand out as having the most research in support of their effectiveness in treating late-life depression. Other therapies, such as problem solving therapy and brief dynamic therapy, are emerging as promising psychotherapies in the treatment of late-life depression, although there are not enough clinical trial data to truly consider these therapies evidence based when applied to older patients.1 Thus, the focus of this discussion will be on CBT and IPT.
Given the growing wealth of information on the effectiveness of psychotherapy in treating late-life depression, it is important for practitioners to truly understand the evidence for these treatments, how they should be used with older populations, and what their current limitations are. The evidence in support for each type of therapy will be presented first, followed by a discussion of the theory, the structure of the therapy, and a case example. Finally, adaptations for the treatment of older adults will be presented.
CBT for Late-Life Depression
CBT is the most extensively studied psychotherapy for treating late-life depression.3-5 Approximately 15 randomized clinical trials have been published comparing the efficacy of CBT to placebo, usual care, other brief therapies, and medication. Some studies have included 1–2-year follow-up periods to determine the permanence of treatment outcome.
Overall, CBT is an effective treatment for late-life depression. It is more effective than usual care,6 wait-list control,7 pill-placebo,8 and no treatment.9 CBT appears to be no more effective than active psychotherapies such as brief dynamic therapy.10 However, one study11 found CBT to be more effective when the goal of treatment is learning skills for coping with new life challenges and dynamic therapy to be more effective when the goal of treatment is to process affect regarding a new life change. Thus, treatment matching appears to be an important feature when deciding on the appropriateness of CBT for a depressed older adult.
The research on the comparative efficacy of CBT to medication is very limited. Only one study12 compared CBT to antidepressants in the treatment of major depressive disorder (MDD) in older adults and found that the combination of CBT and antidepressants is better than medication alone. However, this is the only study in older adults on the relative efficacy of CBT in relation to medication management.
Nearly all of the research on CBT for late-life depression has been done on healthy volunteers. The research on CBT in the medically ill and cognitively impaired is more limited. CBT is effective in treating MDD in patients with chronic obstructive pulmonary disease13 and diabetes.14 With regard to cognitive impairment, only purely behavioral interventions have been studied with this population, with promising results. However, there is no research on the efficacy of CBT in older adults with mild cognitive impairment.15
CBT is based on the premise that MDD is caused by a combination of coping skills deficits, problems with emotion regulation, and an overly negativistic view of the world and the patient’s ability to function adequately in it. Theoretically, there is little difference in how MDD is formulated for older and younger patients, except that the ability to learn new skills and material is somewhat compromised by the cognitive changes associate with aging. Thus, late-life depression, according to CBT theory, is a function of recurring psychosocial stressors that the patient has trouble resolving and a sense of helplessness over the patient’s ability to function and manage these stressors over time. The patient’s beliefs, re-engagement in positive activities, and communication skills are all a focus of therapy.
The most noted CBT manual for late-life depression was created by Thompson and colleagues.3 This manual is quite similar to other CBT manuals, with the exception of the addition of time-management strategies and therapist strategies to facilitate learning in older patients. The structure is simple: therapists meet with patients for a total of 12 sessions, 50 minutes per session. During the session, patients are taught new skills to help them regulate their depression, increase their activity levels, counter negativistic thinking, and apply these new skills in their daily life.
The stages of therapy consist of the introductory stage to socialize the patient to therapy; this includes introductory and skill-building sessions on behavioral activation to increase patient engagement in pleasant activities, cognitive strategies to challenge negative thinking, and communication skills. The initial series of sessions begins with explaining the cognitive-behavioral formulation of MDD. Patients are asked their understanding of what is causing the depression and then a history is obtained regarding their previous attempts to address it. After the patient and therapist agree on the focus of treatment and goals for change, patients begin learning skills to address their depression.
Also during this skill-building phase of treatment (usually during sessions 1–3), patients are taught methods of mood regulation. Initially, patients begin to engage in more pleasant activities. The therapist, along with patient input, ascertains what the patient’s day is typically like, whether any activities have been discontinued, and why they were discontinued. Patients are educated about balancing their lives with “have-to” and “want-to” activities, and then create a hierarchy of activities in which they would like to participate. This hierarchy is ordered from easiest to hardest to fulfill, based on patient resources and emotional readiness.
In the next few sessions, patients are taught cognitive restructuring skills to help them understand the link between thoughts, feelings, and actions. In these sessions, patients are first taught to identify events that seem to trigger depressed or negative affect. They write down their thoughts about that specific situation, in particular how they were able to cope with the situation, how their thoughts affected their mood, and how they eventually decided to handle the situation. Next, the patient is taught to weigh the evidence in support of or against the depressive thinking. This is done through constructive review of similar situations the patient has been in and the outcome of those situations. By examining the evidence for and against the negative thinking, the patient should then be able to develop a more balanced view of their problem, rather than just focusing on the negative aspects of the problem.
Near the end of treatment, patients are taught assertion skills to help them better negotiate and express their needs. Because many older adults tend to become more passive in their communication and coping style,16 it is important that they relearn how to express their needs and how to set limits on the demands for their time. Through role play, patients are taught the difference between passive, aggressive, and assertive communication.
It should be noted that between-session work is also very important in the success of CBT. Patients are encouraged to practice their new skills between sessions and are often assigned activities to engage in and problems to solve using the new skills. At times, these between-session assignments are supported by calls from the therapist to remind patients of their assignment and to check in on how the assignment is working. These support calls tend to be more frequent early in treatment to help motivate patients to engage in the between-session activity. As patients adopt the new coping skills, therapist support wanes. Finally, treatment ends with methods to prevent relapse.
Mrs. Q, a 68-year-old African American widow, sought treatment for depression. Most troubling to Mrs. Q was that she had completely disengaged from her usual activities and that she slept most of the day. Her three adult children lived with her, and she felt they were beginning to run her life. She indicated that the only solution she could think of was to move away from her home and find an apartment somewhere. What prevented her from doing so was the belief that her children would follow her to her new home and she would be left in the same situation again. Hence, Mrs. Q felt trapped by her situation.
Mrs. Q had also been very active in the church, particularly in a foster grandparent program. She indicated that she stopped attending meetings because of a new member whom she did not like and whom she had met only once. While she wanted to re-engage in the program, she reported not having enough energy to participate in the events.
Among the many goals Mrs. Q had for treatment was re-engagement in the foster grandparent program. This was a promising goal to begin with, since it allowed Mrs. Q to learn new coping skills with a problem that was not as emotionally charged as her problem with her children. Mrs. Q first created a series of small steps that she could take to re-enter the program. These steps included getting minutes from the meetings to review so she could stay involved. The next few steps involved her taking on some committee work from home, including reminding members about the meeting, updating committee lists, and organizing pot-luck dinners from home. The final step involved her attending meetings in person. Because she was still receiving newsletters from the program, the initial steps were relatively easy for her to implement, and she first began reconnecting in the program by engaging in an activity she could do from home with minimal interpersonal involvement, thus increasing her activity level. Mrs. Q worked on her negative expectations about re-engaging. Her tendency to engage in “all or nothing” thinking—that the organization would not allow her to gradually re-involve herself in the program—prevented her from calling the program and proposing that she help the program from home.
In addition, Mrs. Q was unsure how to present her plan to the program without arousing suspicions about her mental health. In response, the therapist first worked on Mrs. Q’s negative expectations using a “thought record.” Mrs. Q was instructed to think about times when other members had participated from home and identify her own thoughts at the time about those people. Once she was comfortable with a plan to engage in activities from home, she then role-played how she could present her plan to the program. By practicing what she would say not only to herself to increase her motivation but also to the foster grandparent program, Mrs. Q was able to reconnect with the program.
Subsequently, because she did not encounter any resistance from the foster program, Mrs. Q was in a better position to set limits on her children’s demands on her time. After 6 weeks of therapy, Mrs. Q’s Hamilton Rating Scale for Depression (HAM-D) score dropped from 24 to 6. By week 12, Mrs. Q was actively solving family problems and was re-connected to most of the activities she had been avoiding when she initially joined treatment.
IPT for Late-Life Depression
IPT is another effective treatment for late-life depression. Although most of the recent research has focused on IPT in combination with antidepressants for treating late-life depression,17 there are a number of earlier, small-scale studies that have found IPT to be a useful intervention in treating depression on its own.18 IPT has an advantage over CBT in that the research has tended to follow participants for ?1 year, better addressing the issue of sustainability of treatment outcome. Unfortunately, most of the research on IPT has studied this intervention in combination with medication management, and thus, the pure effect of IPT on late-life depression is relatively unknown.
IPT has not been compared to CBT in older adults; however, it has been compared favorably to pill-placebo17 and appears to be as good as antidepressant treatment.19,20 IPT looks particularly favorable when used in combination with antidepressants; in fact, IPT combined with antidepressants seems to be superior to IPT combined with pill-placebo.17 This combination of treatment is also particularly effective in the long run. In addition, IPT alone is not as effective in preventing relapse of MDD as is IPT with antidepressants.21 IPT has been found to be effective with healthy older adults, older adults with medical illness,18,22 and in particular, older adults with bereavement-related depression.17
IPT is a composite of psychodynamically-informed strategies (exploration, clarification of affect) and cognitive-behavioral strategies (behavior change techniques, reality testing of perceptions). The primary goal of treatment is to address four basic areas of conflict: unresolved grief, role transitions, interpersonal role disputes, and interpersonal deficits. Therapy is longer term than CBT and consists of an acute phase of treatment (16 weekly sessions), maintenance phase (6 monthly sessions), and relapse prevention (6 bi-monthly sessions).
In the acute phase of treatment, patients are first educated about depression as a medical illness. Patients are thus encouraged to assume a “sick role” and to take care of themselves while recovering from depression. In the initial sessions, the therapist determines which area of conflict seems most relevant to the patient—in older adults, the most common conflicts tend to be unresolved grief and role transitions.23
Unresolved grief is typified by sadness regarding loss of significant others. Role transition is generally manifested as distress regarding the end or start of a new psychosocial role. In the older adult, this may be distress concerning retirement, becoming disabled, or becoming a grandparent. Interpersonal role disputes typically manifest themselves in older people as conflicts with family or providers. Finally, interpersonal deficits are generally associated with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,24 Axis II features and problems in socializing with others.25
During the acute and maintenance phases of treatment, the therapist discusses situations regarding the area of conflict that is deemed to contribute most to depression. The therapist helps patients draw parallels between the specific events that are distressing them, helps them examine their thoughts and feelings regarding these situations, and also assigns homework for them to implement that will help resolve the conflict area. During the relapse-prevention phase, the therapist checks in on patient progress with the conflict area, and periodically assesses patients for depression, to ensure that if any recurrence of depression is imminent, the therapist can intervene promptly.
Mrs. V, an 80-year-old widow, was referred by her daughter for an evaluation. Mrs. V’s daughter was concerned that her mother was either depressed or becoming demented, as she found her once active mother not showing up for appointments with doctors, friends, and family, then claiming to forget that she had made the appointments. Mrs. V was given a thorough neurological and neuropsychological evaluation, which was negative. However, she did report significant symptoms of depression. The depression appeared to start immediately after the death of her husband 1 year prior. Although her tearfulness had subsided over time, she began withdrawing more from her social activities. She indicated that occasionally she would forget plans she made with friends and family, largely because she would fail to write the appointments down in her calendar—something she had relied on to organize her day for years. She also admitted that sometimes she used forgetfulness as an excuse not to attend an appointment. Mrs. V indicated that she wondered if her lack of energy was due to a physical ailment or if it was a normal part of grief. She stated that the death of her husband had reminded her of her schizophrenic son’s suicide 10 years prior, and that her husband had not allowed her to grieve that death or to even talk about it.
Based on the evaluation, the intake clinician felt a course of IPT focused on unresolved grief was warranted. During the treatment, Mrs. V discussed the parallels between her grief over her husband’s death and her grief over her son’s death. Mrs. V also talked about how, in her culture, emotions were something to suppress, and that while her husband had refused to talk about her son’s death, this method of grief resolution was not foreign to her. Mrs. V expressed many conflicting feelings toward her husband and how he handled death, and her son’s way of handling life. The therapist and Mrs. V agreed on assignments to help her overcome her grief-related depression. For example, Mrs. V indicated that she regretted never talking about her son’s death with her husband. The therapist suggested that Mrs. V write a letter to her spouse about her feelings. Mrs. V not only completed the letter but indicated that she had read the letter to his grave. This assignment was particularly helpful in that Mrs. V was able to express difficult feelings.
Over the course of acute phase treatment, Mrs. V was able to talk about and tolerate her feelings more openly. She also began to re-engage in social activities and to be more forthcoming about whether or not she felt like socializing. By the end of 16 weeks, Mrs. V was no longer forgetful and her HAM-D score dropped from 21 to 3. Maintenance treatment consisted of continuing to cope with her grief. Relapse prevention consisted largely of check-ups on her mood, which remained stable over the year.
Adapting Psychotherapy for Use with Older Adults
While there is no systematic research to suggest that psychotherapies must be adapted for older populations, most experts in psychotherapy with older populations believe that for older adults to benefit from psychotherapy, the interventions must be modified to accommodate age-related changes in learning, information processing, and health status. In addition, cohort-related beliefs about mental health and psychotherapy should also be considered. Thus, adaptations made to psychotherapy for older populations include time to socialize older adults to the process of psychotherapy, adjusting the pace of the psychotherapy to account for age-related changes in information processing, and allowing flexibility in the delivery of psychotherapy to overcome medical and physical barriers to care.
Socializing the Older Patient to Psychotherapy
Socialization to psychotherapy includes an initial introductory session that assesses the older person’s beliefs about psychotherapy and then orients the patient to the structure of therapy and what the patient can expect from engaging in psychotherapy. Typically, the therapist asks the older patient why they are seeking psychotherapy, what the patient’s past experience has been with psychotherapy, and how the patient envisions psychotherapy solving the presenting problem. Based on what the patient reports, the therapist then tries to correct any misconceptions and inform the patient about what can be expected from the therapy.
Mr. B, an older African American man, was referred by his primary care physician. Mr. B was very reluctant to take antidepressants and was also unsure about the benefits of psychotherapy. During the initial meeting with his psychotherapist, Mr. B went over an educational brochure about the therapies provided in the clinic. The therapist then asked him the following questions: “Have you or anyone close to you ever been in therapy before?” “If so, how long ago was the therapy and what was the experience like?” “What have you heard about psychotherapy?” “What would you like to get out of treatment?”
Mr. B reported that he himself had never been to therapy; in fact, he was very embarrassed to be seeking it. He had been brought up to believe you fix your own problems, and do not share family problems with outsiders. His only experience with therapy had been watching an old television program called “The Bob Newhart Show.” While he believed that therapy probably was not quite as bad as was depicted in this program, he did worry that by seeking help, he was as “crazy” as the characters in the program. He also thought that therapy would last years and that he would have to talk about his childhood, which he did not see as the problem at hand. He had never heard of CBT or IPT.
The therapist then educated Mr. B about psychotherapy, the present focus of the therapy, and also addressed his stigma concerns. The most problematic stigma that Mr. B seemed concerned about was his feeling weak and “crazy” for needing help. The therapist had Mr. B think about times when he has had help from others for problems that were not emotional. Mr. B discussed a time when his father, whom he respected greatly, needed help from his neighbors during a hurricane. The therapist was able to draw a parallel between his father’s use of neighborhood assistance for an environmental crisis to Mr. B’s asking for help during an emotional crisis. This appeared to allay Mr. B’s concerns enough to engage him in therapy, and he was able to successfully complete 16 sessions of psychotherapy.
Accounting for Changes in Information Processing
Older people can learn new tasks and can maintain a significant degree of mental flexibility; however, they learn differently than younger people. Specifically, the cognitive changes that affect psychotherapy are cognitive slowing, decreased fluid intelligence, and poorer working memory.26 Because of these cognitive changes, new information must be presented more slowly, must rely on crystallized intelligence (previous experiences), and must be repeated a number of times for it to be adequately processed. Thus, the delivery of psychotherapy to older populations tends to require more sessions and is structured so that new material raised in treatment is reviewed a number of times and presented through a number of modalities. In all psychotherapies, this multimodal approach to presenting information requires that providers must explain the new skill, demonstrate it in vivo, and have the patient use the skill in session. New skills are explained in the context of the patient’s previous experiences, and are either reviewed or repeated within the session and across sessions.
Mr. Y, an 80-year-old Caucasian male, had sought CBT for depression after experiencing several medical problems, which in turn, created a number of financial and interpersonal problems for his family. Particularly because of his age and numerous illnesses, the therapist found she not only had a hard time redirecting Mr. Y to the tasks on hand, but that he did not appear to understand the steps involved in CBT. One day, Mr. Y began talking about how much more valued he felt when he was younger and was working as an engineer for the Army. As he spoke about these experiences, the therapist noticed that the steps he took to solve problems in the Army were very similar to the CBT process. She then had Mr. Y use the problem-solving strategies he employed when he was younger to a current problem, which he was able to do very successfully. She then went back to the CBT forms and began showing Mr. Y the similarities between the two methods. Mr. Y was then able to understand the therapy process much more easily and to use CBT more effectively with his current problems. By drawing on Mr. Y’s previous experiences and crystallized skills, the therapist was able to successfully make progress with the patient in treatment.
The context and boundaries of psychotherapy with older adults is different than with younger and healthy adults. Because of a greater prevalence of medical illness, care giving demands, and sensory deficits, psychotherapies for older adults must be flexible with regard to the frequency of meetings, where the meetings take place, and the amount of work the therapist may do for the patient. The therapist may also be called upon to do some case-management–type work in order to facilitate patient engagement in treatment.27
Mrs. G, a 72-year-old Latin-American woman, was receiving psychotherapy for depression. She had several issues she needed to address, including the fact that her mentally ill son was about to be sent to prison and she was about to be evicted from her low-income housing, which they shared, because of it. Although she had a lawyer helping her with her son’s case, she did not have anyone helping her with her housing troubles. Thus, the therapist was faced with a very depressed older woman who was very busy with legal and housing issues, and, while she wanted psychotherapy for depression, she was too distracted by immediate crises to attend well to session material. To accommodate these concerns, the therapist constructed a session plan that allowed for Mrs. G to change the days she received therapy based on her ever-changing schedule. The therapist also agreed to come to Mrs. G’s home for sessions. Finally, the therapist began treatment with some initial case management. She spent additional time talking to the patient’s lawyer to determine if he could help with the patient’s housing problems, and then helped the patient get linked to the housing authority to ensure she had a place to stay when her low-income housing expired. By allowing for treatment flexibility and helping the patient overcome her crises, Mrs. G was then able to focus more on the content of the therapy, and by the end of treatment was symptom free.
The Choice Between IPT and CBT
There has been no research on older adults comparing CBT to IPT in terms of effectiveness or patient preference. Thus, the choice between CBT and IPT is largely driven by provider comfort with the intervention, by case formulation (bereavement versus negative life events), and by available resources. Although CBT can be used for depression as a result of loss and IPT can be used for depression as a result of learned helplessness, IPT may make more sense to the client who is coping with loss, whereas CBT may make more intuitive sense to an older adult who has specific problems to solve.
The choice between IPT and CBT may in the end be one of practicality. Because IPT is a longer intervention, some older adults may prefer a briefer intervention due to cost constraints. Providers should take heart in the knowledge that whatever the choice, both interventions are effective in treating depression in late life.
There are several state-of-the-art and evidence-based psychotherapies for treating late-life depression, each having a theoretical rationale and application to older patients. In CBT, the emphasis of treatment is on teaching older patients a set of mood regulation techniques that will assist them in modulating depressive affect in order to overcome the problems that are making them feel depressed. Because a number of skills are taught during the course of therapy offered, therapists have to be keenly aware of older adults’ differences in processing information. In IPT, the therapy essentially remains the same for older adults as it does for younger adults, with the exception of shorter sessions and the tendency for the focus of treatment to be around bereavement and role transition. Adjustments are made to allow for better information processing by allowing patients the opportunity to draw from past experiences. As can be seen from both the evidence base and case vignettes presented in this article, older adults with depression can benefit substantially from psychotherapy, particularly CBT or IPT. PP
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Dr. Areán is associate professor in the Department of Psychiatry at the University of California in San Francisco.
Disclosure: Dr. Areán is a consultant for The Lewin Group.
Funding/support: Dr. Areán is supported by grants from the National Institute of Mental Health (grant #R01 MH063982), the National Institute of Aging (grant #P30 AG015272), and the Substance Abuse and Mental Health Services Administration (grant #H79 SM54803).
Please direct all correspondence to: Patricia A. Areán, PhD, University of California, San Francisco, Department of Psychiatry, 401 Parnassus Ave, San Francisco, CA 94143-0984; Tel: 415-476-7817; Fax: 415-502-6364; E-mail: email@example.com.