Research roundup: Treating depression in older adults
By Practice Research and Policy staff
Jan. 31, 2013—Changing life circumstances and increased number of chronic illnesses associated with aging contribute to depression among older adults. As the median age in the U.S. increases, more attention needs to be paid to treating depression within this demographic.
Psychologists need a variety of effective treatments for depression among this population so that care can be appropriately targeted to meet individual needs.
Recent research on different treatment approaches, along with practical implications, is outlined in this article.
Wang, D.S. (2011). Interdisciplinary methods of treatment of depression in older adults: A primer for practitioners. Activities, Adaptation & Aging, 35(1) 298-314. Doi: 10.1080/01924788.2011.625221
The author conducted a literature review of psychosocial treatments for older adults with depression including cognitive therapy, problem-solving therapy, reminiscence therapy and bibliotherapy. The purpose of this review was to provide professionals with empirical evidence about the effectiveness of these treatments and potential limitations including severity of depression and reduced physical and cognitive capabilities that accompany the aging process.
Cognitive therapy (CT) aims to help patients identify and alter dysfunctional thought patterns that contribute to depression. It has been found effective in individual treatment of older adults, but there is a lack of research to validate how successful CT is for this population in a group setting.
In problem-solving therapy (PST), the client is taught a structured method for identifying and resolving problems. Treatment time can be relatively brief and utilizes the patient’s own skills and resources. Studies have shown PST is as effective as pharmacological treatments for the general population, including older adults.
Reminiscence therapy (RT), one of the few therapeutic approaches specifically designed for treating depression in older adults, uses memorabilia to trigger discussions of past events and the feelings associated with them in order to improve mood or affect. It has been effective for patients with mild levels of cognitive impairment whose inability to recall past events may contribute to their depression. Some advantages are cost effectiveness, ease of implementation and practicality in an institutional or community setting.
Bibliotherapy uses reading to treat older adults with mild and moderate depression, drawing on the individual’s desire for growth, and works especially well with patients who have a higher level of education. Bibliotherapy is inexpensive and can be used in conjunction with other treatments such as CT to maximize learning between sessions and address other issues not primary to treatment.
Cognitive therapy, problem-solving therapy, reminiscence therapy and bibliotherapy have all been demonstrated to be effective treatments for older adults with depression; however each approach has limitations. If CT is to be effective, the sensory, cognitive and psychological changes associated with aging may require modifications to treatment. PST may not be ideal for patients who do not possess the self-sufficiency and drive required to resolve their problems.
Practitioners who use RT should be aware that deeply hidden feelings or issues uncovered through discussing memories may lead to increased symptoms of depression, requiring appropriate follow-up interventions. Limitations to be considered with bibliotherapy include reading ability, visual acuity, motivation and ability to concentrate. However, given these options for intervening with depressed older adults, practitioners have choices to help them appropriately tailor treatment.
Korte, J., Bohlmeijer, E.T., Cappeliez, P., Smit, F., & Westerhof, G. J. (2012). Life review therapy for older adults with moderate depressive symptomatology: A pragmatic randomized controlled trial. Psychological Medicine, 42(1) 1163-173. Doi: 10.1017/S0033291711002042
Life review therapy, utilizing a structured assessment of past life experiences, aims to assist patients in two ways: to help them cope with negative experiences and conflicts, and to help them find positive meaning to life.
Participants over 55 years of age with moderate depressive symptoms were recruited in collaboration with 14 Dutch mental healthcare service providers in both urban and rural settings. Each was randomly assigned to the life review therapy group (n=100) or care as usual group (n=102). The life therapy patients participated in groups of four to six for eight two-hour structured sessions.
Each session included three components: assimilation of negative past life events; claiming power over one’s life stories; and recalling specific positive memories. The results of the study indicated that life review therapy was effective in reducing moderate depressive symptoms, and these effects were maintained at three-month and nine-month follow-ups.
Overall, life review therapy was effective in treating adults 55 and older with moderate depressive symptoms. However, moderator analyses found that life review therapy was more effective for patients with higher levels of extraversion who may be more inclined to share their thoughts and feelings with others in a group intervention.
In addition, patients who demonstrated reliance on reminiscence for boredom reduction were less likely to benefit from this treatment due to an inability to find meaning in the present and set new goals for the future. Psychologists who treat older adults may be able to use these factors to better match individuals to the best care.
Alexopoulos, G. S., Raue, P. J., Kiosses, D. N., Mackin, S., Kanellopoulos, D., McCulloch, C., Areán, P. A. (2011). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. Archives of General Psychiatry, 68(1) 33-41. Doi: 10.1001/archgenpsychiatry.2010.177*
Older adults with depression and executive dysfunction are shown to be at increased risk for disability and vice versa. Studies have demonstrated that pharmacotherapy does not have a high success rate when treating these patients. This study explored whether problem-solving therapy (PST), a form of psychotherapy that focuses on developing and improving an individual’s coping abilities and their capacity for handling stressful life events, decreases disability more than supportive therapy (ST). Supportive therapy is a psychotherapeutic approach that aims to reinforce a patient’s healthy and adaptive patterns of thought and behaviors in order to reduce inner conflict that result in symptoms of depression.
Data from a randomized controlled trial (RCT) was used to compare the efficacy of PST with ST. Adults over the age of 59 with major depression and executive dysfunction were selected to participate in 12 weekly individual sessions of PST or twelve sessions of ST. Four doctorate-level clinical psychologists and four licensed social workers administered treatment.
Disability in the participants was measured by the World Health Organization Disability Assessment Schedule II (WHODAS II). Depression severity was evaluated using the Hamilton Rating Scale for Depression (HDRS). The Mini-Mental State Examination (MMSE) determined cognitive impairment. The DRS-IP, the Stroop Color-Word Test, the Wisconsin Card Sorting Test, Trails B of the Trail Making Test, and the Frontal Systems Behavior Scale, measured executive functioning.
Comparable improvements in disability in participants who received PST and ST were observed in the first six weeks of treatment. However, for those receiving PST, a more prominent reduction in disability was seen at weeks nine and 12. The advantage of PST over ST was particularly significant in patients with greater cognitive impairment and more past depressive episodes.
In older patients with significant physical disability, PST may be a promising treatment. Psychologists who offer PST may want to consider ways to sustain the effects of PST. Additionally, improving access to PST among older populations with physical limitations by providing interventions in home-based care and through telemedicine may be a practice avenue for some psychologists. Keep in mind however, there may be limitations on reimbursement related to telemedicine.
*For additional details of this study, please see, Areán, Patricia A.; Raue, Patrick; Mackin, R. Scott; Kanellopoulos, Dora; McCulloch, Charles; Alexopoulos, George S. (2010). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. The American Journal of Psychiatry, 167(11), 1391-1398. doi: 10.1176/appi.ajp.2010.09091327
Ekkers, W., Korrelboom, K., Huijbrechts, I., Smits, N., Cuijpers, P., Van der Gaag, M. (2011). Competitive memory training for treating depression and rumination in depressed older adults. Behaviour Research and Therapy, 49(1) 588-596. Doi: 10.1016/j.brat.2011.05.010
Rumination, repetitively focusing on the symptoms of distress and its possible causes and consequences, is a predictor of the beginning, the length of, and the seriousness of depression. This study is the first randomized controlled trial (RCT) completed on the efficacy of Competitive Memory Training, or COMET, for depressive rumination in older adults.
The purpose of COMET is to block negative attitudes and thought patterns and replace them with more positive ones. A total of 93 patients over the age of 65 with major depression and rumination were chosen from a mental health institute that specializes in the treatment of older patients. To meet criteria for this study, participants had to meet the criteria for a DSM-IV diagnosis of major depressive disorder. They also had to score 11 or greater on the Geriatric Depression Scale (GDS). Finally, self-reported rumination had to be present.
Participants were randomly assigned to one of two groups. In one group, the patients received seven weeks of treatment as usual (TAU) and in the second group, the patients received seven weeks of COMET in addition to TAU. COMET was administered in seven group sessions of six to eight older patients, lasting 90 minutes.
First, participants were briefed on the six components that COMET encompasses: the role of rumination in depression; an individual’s ability to combat rumination by acceptance or indifference; awareness of the frequency and severity of rumination experienced; recognizing earlier successes in letting go of rumination; earlier successes in letting go are combined with imagination, posture and facial expressions, and positive self-verbalization; and the process of letting go is generalized to other rumination themes.
TAU consisted of pharmacotherapy with or without regular psychotherapy. Patients who were assigned to the COMET group in addition to TAU exhibited less depression and rumination after treatment than those who were only given TAU, as measured by the Quick Inventory of Depressive Symptomatology (QIDS), the Geriatric Depression Scale (GDS), the Ruminative Response Scale (RRS) and the Rumination on Sadness Scale (RSS).
As the results of this study indicate, this fairly new treatment protocol, COMET, could be an efficacious tool in addition to TAU that clinicians can utilize in the treatment of older adults suffering from depression and rumination. Rumination is one of the chief cognitive aspects of depression, especially in older adults, so incorporating COMET as part of care for depression may be beneficial.
Chaves-Korell, S., Beer, J., Rendon, A., Rodriguez, N., Garr, A., Pine, C., … Malcom, E. (2012). Improving access and reducing barriers to depression treatment for Latino elders: A new dawn. Professional Psychology: Research and Practice, 43(3) 217-226. Doi: 10.1037/a0026695
Psychologists and researchers partnered with a large Latino community center to implement a practice model called Improving Mood: Providing Access to Collaborative Treatment (IMPACT) in an effort to screen and treat depression among Latino older adults, an underserved community. IMPACT is designed to treat older adults with depression by employing a team consisting of a client’s primary care physician (PCP), a depression care manager (DCM), a psychologist, a nurse and a consulting psychiatrist.
After much analysis and an exhaustive review of the literature, the authors determined that IMPACT is a feasible model for the treatment of depression in older Latino adults as long as certain cultural adaptations are made. The adaptation of IMPACT was named Un Nuevo Amanecer (UNA), A New Dawn. Five cultural modifications were made to the IMPACT model including: providing the program at a community center to improve Latino elders’ access, retention and outcomes in depression treatment; providing depression treatment materials and services in Spanish; adapting treatment materials that would address illiteracy and low literacy; decreasing the ratio of clients to DCMs; and providing culturally sensitive treatment by identifying and respecting values that are particularly important to Latinos.
The UNA project screened 344 Latino older adults. Of those, 232 were determined eligible to take part in UNA and 186 (80.2 percent) enrolled. The retention rate was 96.7 percent. In a perception of care survey, 98 percent of UNA participants either “strongly agreed” or “agreed” that UNA had been a positive experience, that UNA staff had provided them with helpful information and material, and that they would recommend the program to others.
Depression scores for 130 clients from baseline to a six-month followup on the PHQ-9 showed a decline in depression symptoms by an average of 6.39 points from 13.31 to 6.92. Over half of participants experienced a 50 percent or greater reduction in depression symptoms from baseline to six-month followup, and that increased to 63.22 percent of participants by 12-month followup. Physical functioning also improved.
The U.S. population of older adults, particularly that of Latino older adults, is expected to increase rapidly over the next few years. Yet these individuals often do not seek or utilize mental health services. Psychologists have an opportunity to ensure that quality depression treatment for Latino older adults is accessible. The UNA model is one example of successfully integrating culturally adapted practice within an established, efficacious intervention.