Psychotherapies and Other Psychosocial Interventions for Depression in Late Life: Innovation Through Hybridization
Controversy continues as to which form of psychotherapy should be used with each type of depression1, 2 and under what circumstances psychotherapy may be recommended without antidepressant medication.3 The evidence base supporting empirically validated therapies, while sufficient, is limited compared to that which supports antidepressants. Nonetheless, the effect size of 0.78 for psychosocial interventions in geriatric depression compared to placebo or no intervention contrasts favorably with antidepressant medication.4 More limited but nonetheless promising are reports of psychosocial interventions modeled after disease management programs or psychoeducation which are adjuncts to medication management but are not considered psychotherapy.5-7 This process of innovation through hybridization is also apparent with the incorporation of cognitive-behavioral techniques within interpersonal therapy (IPT); redesigned to treat complicated grief or prevent recurrent episodes of affective illness.8-11
The availability of trained therapists as well as patient preference may narrow the choice of interventions to a simple few.12,13 Yet, the informed practitioner should be able to provide direction when the evidence suggests that under certain circumstances the interventions are not therapeutically equivalent. The psychotherapies and psychosocial interventions which have promise for geriatric depression5-8,10,11,14-25 are summarized in the Table. What follows is a more detailed discussion of some of the emerging, empirically proven interventions.
Interpersonal and Social Rhythm Therapy
Social rhythm therapy arises from the social zeitgeber hypothesis, which states that instability or disruptions in personal relationships and life’s daily routine destabilize circadian rhythms, triggering episodes of affective illness in vulnerable individuals.26 When added to IPT, the social rhythms component seeks to prevent future problems in the areas of grief, interpersonal disputes, role transitions, and role deficits, by stabilizing both personal and interpersonal routines. Treatment focuses on the connection between mood and the quality and regularity of social roles and relationships. The patient is asked to complete the Social Rhythm Metric, which is designed to assess and then enhance the regularity of daily routines. The patient records the time that target activities occur daily for 1 week. These activities include meal times, bedtime, getting up, going to work, engaging in hobbies, or leisure time pursuits. Each activity is assigned a score with higher values indicating greater regularity. The patient and therapist then work on identifying and managing potential precipitants of rhythm disruptions. Efforts to resolve current interpersonal issues and prevent future problems in these areas are also emphasized. Sessions last 45 minutes and occur weekly until remission of the present episode of illness, then every other week for 3 months, and then monthly. Patients with bipolar I disorder who are able to improve the regularity of social rhythms experience a reduced likelihood of recurrence.10 A unique component designed for younger patients with bipolar disorder but applicable to seniors as well is the problem area of “grief for the loss of the healthy self.” Here, the patient is helped to mourn the loss of what life might have been were it not for the illness. Although designed to reduce recurrence rates in bipolar disorder, social rhythm therapy has particular appeal for older patients with recurrent depression whose social roles, routines, and networks have diminished due to retirement, bereavement, or physical illness.
Problem-solving therapy is directive and brief, usually spanning six sessions. Written lists are generated in the therapy session and homework is prescribed. The patient is asked to specify and prioritize problems whether they are thoughts, feelings of fatigue, anxiety, depression, or interpersonal difficulties. The patient and therapist assess the circumstances surrounding the problem. The therapist urges the patient to formulate a feasible approach as well as to triage problems with less probability of change to a lower priority. Once a problem is identified and its determinants are specified, a brief list of potential solutions is generated by the patient and therapist. For each solution, a set of pros and cons are drawn up, which serve to prioritize the solutions from most to least difficult to effect. Pessimism (“it has not worked before”) and lack of motivation (“I forgot to practice”) are addressed by taking the problem-solving approach. However, the focus is kept purposefully narrow on the initial problem the patient identified to minimize a diffusion of effort. The patient is also reminded that the number of sessions set aside may be specific to the identified problem and that additional problems may be beyond the scope of the present therapy. This is not to say that genuine problems do not arise during therapy or that they never displace the identified difficulty. However, the aim is for the patient and therapist to focus the effort on realistic solutions.
In randomized controlled trials of interventions for minor depression or dysthymia in primary care settings, neither problem-solving therapy nor paroxetine were superior to placebo in helping patients achieve remission.27 Furthermore, the majority of patients who had received medication or psychotherapy and experienced remission discontinued the intervention at the end of the trial.19 However, the response rate among the placebo group was greater than expected. When coupled with the spontaneous remission rates seen in patients with minor depression in primary care, it may well be that the added but nonspecific attention given the placebo group functioned as low-dose therapy. Moreover, because of its brevity and narrow focus, problem-solving therapy shows promise of usefulness in home care settings.28
Social Support Intervention
Oxman and colleagues19 studied treatment response and naturally occurring social support among seniors randomized to one of three treatments for depression. In the placebo group, patients expressing higher levels of perceived social support experienced decreases in subthreshold depression. Neither of the active treatment groups (paroxetine or problem-solving therapy) exhibited this phenomenon, suggesting the potential value of efforts to change perceived social support in milder depressions. In a prospective study of clinically depressed older patients, Bosworth and colleagues29 found that baseline perceived social support was as important as clinical and diagnostic variables in predicting depression remission. They concluded that interventions directed at social support were likely to improve rates of depression remission beyond that achieved with conventional interventions.
Social support is most often assessed in behavioral, cognitive, or structural components reflecting such variables as frequency or kind of contact, perception of adequacy of support, and size or symmetry of the supportive network. If support influences depression through perceived adequacy, then interventions should focus on the cognitive processes. If contact affects depression directly, then interventions would focus on manipulations to increase or improve contacts. Several studies suggest that perceived emotional support has a significant impact on physical and mental health.30-32 In contrast, instrumental support is either unrelated to or negatively associated with well being.33,34
Given the same level of actual support, some people will see particular relationships as more or less adequate than others.31 For patients with low perceived support, techniques from cognitive therapy of depression offer strategies to address their interpretive bias.31 Such techniques focus on changing distorted, unrealistic perceptions of supportive relationships. In addition, perceptions of support from specific relationships tend to be distinct from perceptions of support in general.35,36 The opportunity to change perceptions is greatest when there is an expressed need during a time of stress.37
The Enhancing Recovery in Coronary Heart Disease (ENRICHD) study employed a psychosocial intervention to successfully increase social support and alleviate depression in older adults with a recent acute myocardial infarction.8 The ENRICHD social support intervention (SSI) utilizes behavioral, cognitive, and network intervention methods to improve perceived emotional support. The intervention has its origins in both cognitive-behavioral therapy14 and social cognitive theory38 in which psychosocial functioning is seen to emerge from the interplay of cognitive, behavioral, and environmental elements. In SSI terminology, the therapeutic focus highlights the patient’s behavioral repertoire, cognitive schema, and network interactions (especially among family). Among patients with chronic illness, psychosocial interventions are more likely to have positive effects on depression when they include family members.39
Thus, SSI seeks to socially activate the patient through active problem solving, alteration of counterproductive automatic thoughts, and enhanced coping skills. A major goal is the alteration of perceived emotional support through modification of the environmental, behavioral, and cognitive factors that lead to the perception of inadequate emotional support. Marital, family, and network interactions are included to identify modifiable attributes deemed most responsible for the participant’s perception of inadequate emotional support. The SSI intervention is tailored to the patient’s individual deficits in psychosocial functioning with the Social Networks in Adult Life Questionnaire. Counseling can then be mapped onto specific problems underlying the perception of inadequacy. The problem is conceptualized in terms of social behavior and beliefs so that the therapist can offer one or more specific work modules. For example, social isolation would be conceptualized as an environmental deficit requiring the social outreach and network development module. Those who have automatic thoughts that negate opportunities for supportive relationships (“They think they are better than me!”) would be offered the cognitive therapy module. Ineffective communication skills and passivity (“How do you introduce yourself to a stranger?”) would be targeted with the social communication and assertiveness module. The involvement of network members is a key therapeutic component requiring the identification of potential, but currently disengaged, sources of support and connecting them to the therapeutic process. However, when a network member attends the therapy session, the focus remains the participant’s adjustment.
Psychotherapy for Complicated Grief
Bereavement is considered complicated grief when it evolves into a set of persistent cognitions and behaviors characterized by a sense of disbelief regarding the death, anger, bitterness over the loss, recurrent waves of painful yearning for the deceased, preoccupation with the lost loved one, and intrusive thoughts related to the death.9 Avoidance of an expanding array of situations and activities which remind the person of the loss reinforces the preoccupation and truncates opportunities to recover spontaneously. Moreover, treatments for bereavement-related depression are minimally beneficial for symptoms of complicated grief.22 Although it resembles posttraumatic stress disorder (PTSD), factor analyses demonstrate that the symptoms of complicated grief load separately from both depression and anxiety. Shear and colleagues9 describe a psychotherapy which achieved superior results compared to IPT for symptoms of complicated grief. While therapy for complicated grief is similar to IPT for the bereaved, it incorporates imaginal and in vivo exposure techniques that commonly work in PTSD patients. In the introductory phase, the therapist provides information to distinguish normal bereavement from complicated grief, including a model of adaptive coping which addresses not only adjustment to the loss but also restoration of a life’s satisfactions. The model portrays optimal bereavement as a process alternating between attention to the loss and restorative behavior and entails a focus on personal life goals.
In the middle phase, the PTSD-like character of complicated grief is addressed with symptom-specific techniques. These include recounting the circumstances of the death as well as exercises to confront avoided situations. The therapist asks the patient to do a “revisiting exercise” in which the “story” of the death is related with closed eyes. At critical junctures, the therapist will ask the patient to gauge the level of distress associated with various elements of the story. The exercise is tape recorded for patient playback between sessions. The experience of listening to themselves recount the event helps patients detach from the intensity of the experience and places them in the role of therapist. The process also evokes memories not previously expressed that can be examined in the sessions. When the patient is able to complete the home playback without being overwhelmed, the homework is complete.
To reduce the distress of yearning and preoccupation with the loss and to promote a sense of ongoing connection with the deceased, the patient is asked to carry on a mock conversation. The therapist asks the patient to close his or her eyes and begin speaking to the deceased as if the person could hear and respond. The therapist then directs the patient to play the role of the lost loved one and answer over a period of 10–20 minutes. This call-and-response exercise is facilitated by having the patient complete a set of memory questions focused on positive remembrances but also inviting reminiscence of the negative ones as well.
For the restorative component, life goals are evoked from the perspective of “what would you want for yourself if the grief were not so intense?” The therapist then works with the patient to identify ways of recognizing that he or she is working toward these goals. Concrete, behaviorally operationalized plans are discussed and the therapist encourages the patient to put them into action. As in conventional IPT, role transitions and disputes are also addressed to reengage the patient in meaningful satisfying relationships. In the termination phase, the patient is reminded that intrusive thoughts and pangs of longing may briefly reappear in the future, triggered by anniversaries or intimate situations. However, they will not be so intense or disabling. The transient recurrence of symptoms does not mean the patient has failed. Rather, the return of symptoms overcome in the past only reinforces the value of the steps that were taken to cope with them. If the recurrence persists, a short course of therapy may be advised.
Family-focused Treatment for Recurrent Disorders
Miklowitz and colleagues11 describe a bipolar patient family-focused intervention which achieves superior medication adherence and reduced hospital readmission rates compared to crisis management or intensive individual therapy alone. Because the approach involves the patient, family, and practitioner in a collaborative effort at relapse prevention, it is also appealing for recurrent depression, particularly when delusions or suicidality have complicated the illness. At the outset, the therapist emphasizes that collaboration between the patient and family reinforces rather than sacrifices autonomy by preserving independence. An educational approach is used to combat stigma by informing the patient and family that depression (or mania) is part of an illness and is not a moral weakness. The therapist reinforces the importance of social stimulation, rewarding activities, physical activity, and regular sleep schedule, as well as medication, psychotherapy, and social support. For both the patient and family, the therapist provides training to enhance communication. This includes lessons in “active listening” that seeks clarification rather than closure, focused rather than global positive and negative feedback, framing requests for change in positive rather than negative language, and role playing assignments.
However, a significant amount of time is devoted to relapse prevention planning. In-session practice on brainstorming solves the problem of what to do when symptoms emerge. The therapist offers feedback but insures that solutions are selected by the patient and family. This includes devising and rehearsing a relapse prevention drill with a family-wide response plan. The plan will specify risk reduction for suicidal ideation if present, actions family and social supports should institute, an established threshold for emergency communication and intervention, and emergency contact information and backup for times when a particular professional is not available (physician, therapist, emergency room, dialing 911). In sum, the goal of preserving independence is conceived as multilateral with responses to specified threats foreordained by the patient and family through the assistance of the therapist. Although risk may not be eliminated, procedures to reduce vulnerability offer both hope and support.
There is increasing evidence that psychotherapeutic interventions from different traditions offer benefits for older persons with depressive disorders and complicated grief. The differing psychotherapies for late-life depression share common elements that are easily adapted across techniques. These include a problem-focused, here-and-now approach with distinct educational and social components. Homework may be assigned, faulty cognition confronted, and interpersonal changes suggested. For the motivated primary care practitioner, use of short-term psychotherapeutic techniques can enliven practice, lessen the need for referrals, and provide greater acceptance of mental health services for those patients who need specialty care. For mental health specialists accustomed to psychotherapy with younger patients, necessary adjustments in approach include allowances for sensory impairments and cognitive slowing, greater collaboration with the patient’s family and other care providers, and identification of improved function as well as symptom reduction as worthwhile goals. Although pharmacotherapy for depression has advanced greatly in the last decade, innovation through hybridization is leading to a similar change of pace in psychosocial interventions. PP
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Dr. Kennedy is professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, and director of the Division of Geriatric Psychiatry at Montefiore Medical Center in Bronx, NY.
Disclosure: Dr. Kennedy has received research support or honoraria from AstraZeneca, Eli Lilly inc., Forest, Janssen, and Pfizer Inc.
Please direct all correspondence to: Gary J. Kennedy, MD, Director, Department of Geriatric Psychiatry MMC, Dept. of Psychiatry, 111 East 210th Street, Klau One, Bronx, NY 10467; Tel: 718-920-4236; Fax: 718-920-6538; E-mail: email@example.com.