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Psychosocial Treatments for MajorDepression and Dysthymia inOlder Adults: A Review ofthe Research Literature Older adults represent a growing segment of the population with the highest suicide rate and an increasing needof counseling services for major depression and dysthymia. The present study examined the literature with thepurpose of identifying research addressing psychosocial treatments of depression in later life. A summary oftreatments currently supported by research as being efficacious when treating older individuals experiencingdepression or dysthymia is presented. Limitations of the findings are discussed.
Individuals over the age of 65 constitute a fast growing seg- million American adults, or approximately 6.5% of the popu- ment of the population, and recent studies suggest that their lation, in a given year. Depression continues to be a signifi- rate of depression is a significant issue (Myers & Harper, 2004; cant public health problem for older adults (Lebowitz et al., Powers, Thompson, Futterman, & Gallagher-Thompson, 1997; Serby & Yu, 2003), with statistics indicating that 1% 2002). The population of older adults in the United States is to 2% of older adults in the community (i.e., not living in growing at a fast pace and will continue to do so in the years nursing homes or other institutions) experience depression to come (Administration on Aging, 2001). The Administra- (Johnson, Weissmann, & Klerman, 1992) and as many as tion on Aging indicates that 1 in every 8 Americans is 65 50% of older adults in nursing homes display depressive years and older. Over the last 100 years, the population of symptoms (Koenig & Blazer, 1996). Similar findings were older adults has more than tripled in percentage, from 4.1% to reported by Zisook and Downs (1998), who found that 2% 12.4%, and projections indicate that this number will con- of the older adults living in the community experience a tinue to grow to as much as 20% by the year 2030 (Adminis- major depressive episode, 2% experience dysthymia, and tration on Aging, 2001). As the number of individuals age 65 0.2% experience bipolar disorders. These estimates may be and older continues to grow, counselors will increasingly be conservative because some individuals have the miscon- faced with meeting the needs of older adults and their fami- ception that it is normal for older adults to feel depressed lies (Myers & Harper, 2004; Schwiebert, Myers, & Dice, 2000).
and dismiss the symptoms as a normal part of aging (Myers The health care costs of depressive disorders are signifi- cant. Depression is prominent within the mental disorders Depression is often undiagnosed and untreated in older condition; it is 1 of the top 15 conditions that account for adults (Birrer & Vemuri, 2004; Crystal, Sambamoorthi, almost half of the growth in spending in health care since Walkup, & Akincigil, 2003; Reynolds, Alexopoulos, & Katz, 1987 (Thorpe, Florence, & Joski, 2004). Depression costs 2002). However, when a diagnosis of depression is warranted, about the same as coronary heart disease in direct and indi- treatment with medication and/or psychosocial therapy will rect costs in the United States: $43 billion annually (Birrer help the person with depression return to a happier, more & Vemuri, 2004). Major depression is widely distributed in fulfilling life (Anderson, 2001). A great body of data exists the population and is usually associated with substantial to support the notion that treatment of depression can shorten symptom severity and role impairment (Kessler et al., 2003).
the time to recovery; such data justify the use of antidepressant Kessler et al. reported that major depression affects 13 to 14 medication and several psychosocial therapies (Gotlib & Carlos P. Zalaquett, Department of Psychological and Social Foundations, Counselor Education Program, University of South
Florida; Andrea N. Stens, private practice, Fort Myers, Florida. The authors thank Michael Curtis, Herbert Exum, and Darlene
DeMarie at the University of South Florida for their helpful comments on earlier drafts of this article. Correspondence concerning
this article should be addressed to Carlos P. Zalaquett, Department of Psychological and Social Foundations, University of
South Florida, 4202 East Fowler Ave., EDU162, Tampa, FL 33620 (e-mail: [email protected]).
2006 by the American Counseling Association. All rights reserved.
Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 Treatments for Major Depression and Dysthymia in Older Adults Hammen, 2002). Efficacy studies show that late-life depression Both critics and advocates of guideline development under- can be treated with psychosocial therapy (Lebowitz et al., 1997).
stand that the time is long past when practicing without guide- Undiagnosed and untreated depression in older adults lines is acceptable to both the public who use services and the causes needless suffering for the family and for the indi- professionals who provide such services. In addition, account- vidual who could otherwise live a fruitful life. Research ability in service provision is one way for a profession to has shown that longstanding depression predicts mortal- grow in recognition. It is especially appropriate for profes- ity, whereas recovery from depression does not (Pulska, sional counseling to be able to show the public and public Pahkala, Laippala, & Kivelä, 1999). Suicide risk is signifi- policymakers that its practices are effective, efficient, and cantly elevated among individuals with mood disorders ethical. We do that in part by being knowledgeable about (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, standards of care used by other mental health professionals 2002). Suicidality is a significant risk factor for older adults and by staying abreast of evolving trends. (p. 494) (Barnow & Linden, 2000). Barnow and Linden reportedthat “suicidality is of high importance in very old age” As the population of older adults continues to increase, (p. 177) and thoughts of suicide indicate the likely pres- counselors of all specialties will need this information. For ence of depression. Compared with all age groups, older example, school counselors may be approached by a stu- adult clients have the highest suicide rate (Szanto et al., dent and his or her family asking for information about treat- 2001). Finally, comorbidity of depression with physical ment for a grandparent experiencing a depressive reaction.
illnesses and disability are also unique factors to con- Career counselors may be asked to provide a referral to an sider when treating older individuals (Katz, 1996; Rovner, older worker experiencing depressive symptomatology, and Zisselman, & Shmuely, 1996), and adaptations may be a mental health counselor may encounter an older client necessary when working with older adults because of these reporting depressive symptoms. These professionals would benefit from knowing which are the current psychosocial Counselors and other mental health professionals pro- treatments that are best supported by outcome research.
vide psychosocial treatments, defined for the purposes of In this article, we review the research literature on psy- this article as any treatment that does not involve the use of chosocial treatments for major depression and dysthymic medication or medical procedures. Pinquart and Sörensen disorder and summarize those treatments currently supported (2001) suggested that providing psychosocial therapy to by research as being efficacious when treating older indi- older adults is valuable because it decreases depression and viduals experiencing these mood disorders. For each psy- promotes general psychological well-being. Treating mood chosocial treatment, we provide a description of the treat- disorders has also been shown to decrease suicide risk ment, suggested applications, adaptations that maximize (Rivas-Vazquez et al., 2002; Szanto, Mulsant, Houck, Dew, success of therapy in older adults, and studies supporting & Reynolds, 2003). The National Institutes of Health’s (NIH) Consensus Panel on Diagnosis and Treatment of Depressionin Late Life (1992) found that there are many different treat- ments of depression in older adults that have been shown tobe safe and efficacious. Many studies have been completed Studies that addressed psychosocial treatments of the older that suggest the efficacy of some available psychosocial adult population were identified through a literature search.
therapies when applied to treatment of late life depression.
Two electronic databases, PsycINFO and MEDLINE, were These studies have been incorporated into meta-analysis used in this study. Search terms used were the following: studies, evidence-based studies, best practices models, and aged, older adult, elderly, psychosocial treatment, geriat- comparison studies (Areán & Cook, 2002; Chambless et al., ric, treatment, counseling, depression, evidence-based, and 1998; Gatz et al., 1998; Orb, Davis, Wynaden, & Davey, best practice. Criteria for inclusion in this review were (a) 2001; Pinquart & Sörensen, 2001).
age of the population studied is over 55 years; (b) article is Older adults need and will continue to need counseling either a research comparison, meta-analysis, or outcome re- services for major depression and dysthymia, and counse- view article from a peer reviewed journal; and (c) focus on lors need to be informed about current treatments for these psychosocial treatments of depression with the older adult disorders (Myers & Harper, 2004). Thus, our first interest in population. The review produced 26 articles. An effort was depression in the older adult involves a practical issue of made to include only evidence-based treatments or thera- recognizing and serving the needs of a large and growing pies. Criteria and discussion on best practices are provided population. Our second interest was to identify best prac- by a variety of sources, including Banerjee and Dickinson, tices for treating major depression and dysthymia in older (1997), Chambless et al. (1998), and Orb et al. (2001). Out- adults. The concept of evidence-based or best practice has come research available to support the psychosocial treat- gained friends and foes among counselors. However, as indi- ment was the main criterion used in our review. We used Gatz et al.’s (1998) definition of well-established or prob- Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 ably efficacious treatment: “Demonstrated efficacy com- pared to waiting list control groups qualifies an interven- Cognitive therapy has been defined as a structured therapy tion as probably efficacious, whereas being categorized as that is both time limited and directive, with emphasis on chang- well established requires superiority to a psychological pla- ing thoughts and belief systems (Beck, 1967/1972; Beck, cebo group or control treatment (or equivalence to another Rush, Shaw, & Emery, 1979). Klausner and Alexopoulos (1999) well-established treatment)” (p. 11).
stated that “the goals of cognitive-behavioral therapy are to The criteria used for diagnosing depression are derived change thoughts, improve skills, and modify emotional states from the Diagnostic and Statistical Manual of Mental Dis- that contribute to psychopathology” (p. 1198). Cognitive orders (4th ed., text rev.; DSM-IV-TR; American Psychiatric therapy can be applied in multiple ways using techniques Association [APA], 2000). The criteria in the DSM-IV-TR do from Beck’s (Beck, 1976; Beck et al., 1979) cognitive therapy not generally distinguish between adults and older adults, model, Ellis’s (Ellis, 1973; Ellis & Grieger, 1986; Ellis & although symptoms may manifest or demonstrate themselves Whiteley, 1979) rational emotive behavioral therapy model, in slightly different ways according to age, from children to or Meichenbaum’s (1977) cognitive behavioral modification the older adult (APA, 2000, see pp. 349–354).
program, all of whom are major contributors to the field of Major depressive disorder generally refers to a series of CBT. CBT is indicated to treat clients who present with per- symptoms that mainly include a sad, depressed, hopeless or sistent distorted perceptions and beliefs that lead them to see “down” mood with a noticeable loss of interest or pleasure themselves as deficient, incapable, or unlovable; to see their in previously enjoyable activities. It is diagnosed when an current environment as unsupportive and overpowering; and individual presents with a single major depressive episode, to see their future as hopeless (Beck, 1976). The goal of CBT which is not better explained by a thought disorder, and the therapists is to help their client examine and modify negative individual has never experienced a manic episode (APA, thoughts, excessive self-criticism, lack of motivation, and the 2000). A major depressive episode is diagnosed when, dur- client’s tendency to view problems as insurmountable. Some ing the same 2-week period, at least five symptoms are techniques used in CBT include challenging irrational or self- present, including depressed mood most of the day; mark- destructive thoughts, changing the way in which individuals edly diminished interest or pleasure in activities for most of process information, self-monitoring exercises, communica- the day; significant weight loss/gain or decrease/increase in tion skills, problem-solving initiatives, increasing positive appetite; insomnia or hypersomnia; psychomotor agitation self-statements and experiences, and countering mistaken or retardation; fatigue or loss of energy; feelings of worthless- belief systems (Areán & Cook, 2002; Pinquart & Sörensen, ness or excessive guilt; diminished ability to think or con- 2001). Behavioral techniques, such as problem solving and centrate; recurrent thoughts of death; or suicidal thoughts/ communication skills, can also be incorporated into the attempts (APA, 2000). Dysthymic disorder is a form of de- therapy (Areán & Cook, 2002). The intended effect of this pression that persists for years with no more than moderate therapy is to alleviate depression by developing reinforcing intensity. The disorder is not better explained by major and rewarding experiences and perceptions (Kennedy & depression; it does not occur only during the course of a psychotic disorder; and there has never been a manic epi- When used with older adults, CBT may need to be adapted sode, a mixed episode, a hypomanic episode, or a cyclothy- to meet their needs (Knight & Satre, 1999). These adapta- mic disorder. Dysthymic disorder is diagnosed when depressed tions include the assessment of client’s knowledge, attitude, mood is present nearly every day for 2 years and at least and misconceptions. The goal of the clinician is to identify two additional criteria are present including poor appetite, those who may have difficulties in assuming an active par- insomnia or hypersomnia, low energy or fatigue, low self- ticipation in the treatment and/or in accepting therapeutic esteem, poor concentration, or feelings of hopelessness suggestions. Also, clinicians can evaluate a client’s limita- tions, especially cognitive or sensory impairments, in orderto identify those who may have difficulties understanding treatment. On the basis of these assessments, clinicians couldconduct an in-depth orientation to treatment to facilitate The research literature review identified and found support clients’ participation. In addition, Kennedy and Tanenbaum for four specific individual therapies when treating older (2000) suggested using “recorded sessions for playback at adult depression. These therapies are cognitive-behavioral home, written instructions to accompany homework assign- therapy (CBT), interpersonal therapy (IPT), brief dynamic ments and a review of past material prior to progressing to therapy (BDT), and reminiscence therapy (RT). Additional the next assignment” (p. 389). The establishment of moder- therapies that received some support from research are group ate treatment goals may be needed for older adults with therapy and family therapy because they apply to older limited resources and challenging life circumstances adults. Finally, maintenance therapy is briefly addressed.
(Gallagher & Thompson, 1982). Extended treatment may be All of these therapies are reviewed in this section.
necessary to help older clients with long-term problems.
Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 Treatments for Major Depression and Dysthymia in Older Adults Finally, clients should be allowed to return to therapy if therapist works toward establishing rapport, educates the their problems reoccur or if new problems arise (Kennedy & client about how the treatment works, assumes an active role in addressing the client’s issues and focusing on pragmatic In the literature, a significant number of studies have solutions, and acknowledges that he or she is a resource for researched the efficacy of CBT with older individuals, and advice and information (Miller & Silberman, 1996). Accord- it has generally been shown to be efficacious as a treatment ing to Kennedy and Tanenbaum, the IPT therapist addresses intervention with older adults (Pinquart & Sörensen, 2001).
in a practical manner the client’s dependency needs, chronic Scogin and McElreath (1994) analyzed posttreatment scores pathologies, and the effects of significant losses; is flexible of experimental and control groups to determine the effects regarding length of sessions, telephone consultations, and of CBT in a meta-analysis of seven studies and reported an missed appointments (due to transportation, health, or fi- effect size of d = .85. Also, there is evidence that CBT com- nancial difficulties); and keeps goals at a modest level while bined with desipramine results in greater improvement than providing reassurance and support. Older adults who have desipramine alone, especially with more severely depressed limited options to engage in new interpersonal relationships clients (Thompson, Coon, Gallagher-Thompson, Sommer, may be encouraged to tolerate problematic relationships & Koin, 2001). Additional studies found that CBT was su- while working in therapy to find acceptable alternatives.
perior to usual care for depression (Campbell, 1992), wait Several studies have been completed that address efficacy list control (Rokke, Tomhave, & Jocic, 2000), pill placebo of IPT for older adults with depression, and the results are (Jarvik, Mintz, & Steuer, 1982), and no treatment (Viney, mixed (Areán & Cook, 2002; Gatz et al., 1998). Most studies Benjamin, & Preston, 1989). The findings of Areán and Cook evaluated the efficacy of IPT compared with medication (2002) and Gatz et al. (1998) support the position that cog- therapy or pill placebo, thus limiting the ability to evaluate nitive therapy and CBT are “probably efficacious” treat- IPT as a stand alone therapy (Areán & Cook, 2002). Gatz et al.
ments for depression in older adults.
(1998) reported that the “evidence with respect to interper-sonal therapy is incomplete” (p. 16). Some studies do support the efficacy of IPT. One study in particular reported that “eld- IPT has generally been described as exploratory with focus erly persons treated with IPT . . . show significant improvements on interpersonal roles and conflicts (Kennedy & Tanenbaum, in their symptoms when treated with or without concurrent 2000). It was initially outlined and defined by Klerman, psychiatric medication” (Hinrichsen, 1999, p. 952).
Weissmann, Rounsaville, and Chevron (1984), and theirtheory continues to be applicable in its original form. IPT typically emphasizes specific areas such as grief issues, role BDT is often used with older adults to address issues such as transitions and disputes, and interpersonal shortfalls (Gatz adjustment and traumatic stress disorders, grief issues, and et al., 1998). Hinrichsen (1999) provided an excellent re- self-concept during aging, using a time-limited and focused view of IPT, describing three phases of treatment that focus approach (Kennedy & Tanenbaum, 2000). Techniques typi- on two of four main problem areas: grief, interpersonal dis- cally used in BDT include exploration of unconscious pro- putes, role transition, and interpersonal deficits. During the cesses, processing of lifetime developmental issues, and fa- first phase of treatment, a review of the individual’s present- cilitating client insight with regard to making life changes; ing symptoms is completed, diagnoses are assigned, and one transference and countertransference are important factors or two problem areas are defined with goals established for to be aware of when using BDT (Gatz et al., 1998). The main continuation of therapy. The second phase of therapy involves goals of BDT are to increase awareness and insight into the working on achieving the established goals of treatment. Tech- unconscious processes leading an individual to repeat past niques used during this phase include reflection, exploration, experiences and to institute corrective experiences through encouragement, clarification, verbal and nonverbal commu- the interaction between client and therapist (Nordhus & nication, providing psychoeducation and suggestions, and Nielsen, 1999). BDT is indicated for clients who have ad- the relationship between the therapist and client. In the final justment disorders, grief, and traumatic stress disorders phase of therapy, focus is generally on termination of therapy (Kennedy & Tanenbaum, 2000). An essential adaptation of and processing the difficulties involved in ending therapy.
BDT for working with older adults includes helping the cli- Treatment goals are reviewed and changes that have been ent regain self-mastery and a positive self-perception while made are discussed, including problems that may arise after preventing the development of dependency. Limiting the termination of therapy in anticipation for better preparation number of sessions to 15 allows many clients to successfully to solve them (Hinrichsen, 1999). IPT is indicated for older complete treatment and reduces the development of un- adults who need to change their behavior in current inter- healthy dependency (Kennedy & Tanenbaum, 2000).
personal relationships. This therapy is not intended to alter Most studies that evaluated the use of BDT as a viable personality traits or delusional symptomatology (Kennedy therapy have shown it to be an efficacious treatment of de- & Tanenbaum, 2000). In working with older clients, the IPT pression in older adults (Areán & Cook, 2002; Gallagher & Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 Thompson, 1982, 1983; Gallagher-Thompson, Hanley- therapy. In conclusion, Areán and Cook maintained that “the Peterson, & Thompson, 1990; Gallagher-Thompson & Steffen, research on RT as an efficacious intervention remains in- 1994). Gatz et al. (1998) also concluded that “brief psychody- conclusive but suggests that it is potentially useful” (p. 299).
namic therapy is a probably efficacious treatment for late lifedepression” (p. 16). Areán and Cook found that “a small body of research supports BDT as an efficacious intervention for late Six articles in this review discussed family and group therapy life major depression in healthy and ambulatory elderly adults for the older adult (Baker, 1985; Ong, Martineau, Lloyd, & [and] more research is needed to compare BDT with antidepres- Robbins, 1987; Pinquart & Sörensen, 2001; Qualls, 1999, 2000; Tisher & Dean, 2000). Family and group therapy forthe older adult currently is considered a supportive treat- ment with their main focus on social functioning (Pinquart RT was developed to be used with older adults as they re- & Sörensen, 2001). These therapies have not, however, been flect on their lives in positive and negative ways (Butler, studied enough to be considered a best practice and have 1974). RT is based on Erikson’s (1950) theory of psychoso- been suggested to be less efficacious than individual thera- cial development, and use of this therapy is seen as a way of pies (Pinquart & Sörensen, 2001). Baker (1985) suggested regaining balance in an older adult struggling with his or that “personal interaction available in group therapy may her search for meaning, mastery over life, and self-esteem stimulate growth and life satisfaction for participating el- (Kettell, 2001). Life review (LR) is the main focus of RT as ders” (p. 24). Qualls (1999) indicated that many of the issues individuals work on resolving past issues in order to find brought to individual sessions involve family members, sug- meaning in the present and promote ego integrity (Gatz et gesting that a family systems approach may be indicated al., 1998; Kennedy & Tanenbaum, 2000; Pinquart & Sörensen, when working with individuals. “A family therapy frame- 2001). RT specifically tends to be less structured compared work will aid almost all clinicians working with older adults with life review therapies in general (Gatz et al., 1998). LR because it provides guidance for what to ask, where to look, therapy is indicated for older clients coping with stressful how to investigate family factors in elder well-being, and life events or the realization of their own mortality (Butler, how to intervene” (Qualls, 1999, p. 978). Tisher and Dean 1974). Techniques that are used in RT and LR therapies are (2000) also found that a systems family approach was “very homework assignments that involve finding mementos, pho- appropriate in understanding and working with the indi- tos, journals, autobiographies, and other memorabilia from vidual and family experience of the elderly stage of the life one’s life to share with the therapist in an effort to resolve cycle” (p. 100). More research is needed to determine the past issues and gain tolerance of present conflicts (Kennedy efficacy of both of these treatments for the older adult & Tanenbaum, 2000). In working with older adults, espe- cially those who are survivors of traumatizing life events(e.g., Vietnam War’s prisoners), LR therapists demonstrate a commitment to listen and understand what the client is ex- The goal of maintenance therapies is to prevent a relapse of periencing while reviewing their past. During this process depression. There are limited studies on ways to maintain clients experience myriad emotions including rage, resent- recovery from depression after initial treatments are com- ment, or distrust, all of which may affect their engagement pleted. Four studies have evaluated effective maintenance in treatment. The therapist’s listening attitude and the devel- treatments. It has been suggested that maintenance depends opment of a meaningful degree of understanding between on the client’s initial response to treatment (Dew et al., 2001).
both parties seems to play a critical role in the client’s cop- Group support has been shown to be effective in maintain- ing response to current life threatening illnesses, losses, or ing initial treatment recovery (Ong et al., 1987). Combined nursing home placement; all of which may trigger memories therapy (nortriptyline and IPT) seems to be most effective of catastrophic events (Kennedy & Tanenbaum, 2000).
for maintenance of mood after initial treatment (Miller et al., LR and RT studies “suggest that life review therapies 2001; Reynolds et al., 1999). Treatment of late life depres- may be useful in reducing depressive symptoms among older sion with nortriptyline and ITP has been shown to help cli- community and residential cognitively impaired older adults ents maintain social adjustment more than treatment with with milder levels of depressive symptoms” (Areán & Cook, either treatment alone, suggesting that combination therapy 2002, p. 299). In their meta-analysis of seven therapy out- improves not only duration but also quality of wellness come studies, Scogin and McElreath (1994) found an effect size of d = 1.05 for LR therapy. Gatz et al. (1998) also foundresults to suggest that structured LR is probably efficacious Additional Issues in Counseling the Older Adult in treating older adults with depressive symptoms, although Additional stressors for the older adult include a high inci- a word of caution was voiced regarding size of studies, com- dence of poverty and limited access to health care (Adminis- parison results, and maintenance beyond the conclusion of tration on Aging, 2001). Morgan (2001) discussed tailoring Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 Treatments for Major Depression and Dysthymia in Older Adults treatment to the older adult client who presents with group- study but may be helpful in counseling older adult depres- specific challenges, including multiple-loss issues, struggles sion. It is important for counselors to be aware of both best with side effects of multiple medications, apprehension to see practices and additional therapies offered for treating older a therapist due to fear of being labeled insane or crazy, sig- adults with depression. Also, there is a high percentage of nificant age differences between client and counselor, and older adults with depression who experience depression pro- specific cognitive and sensory impairments. It has ultimately duced by a general medical condition, by substance abuse, been found that “because therapists with special or by other comorbid disorders (e.g., anxiety disorder; Leon gerontological/geriatric training were more effective than et al., 2003). Although these conditions were not part of other therapists, the improvement of gerontological and geri- the scope of this article, counselors should gain knowl- atric training for psychotherapists and other persons who work edge about these disorders and consider adapting the avail- with older adults is recommended” (Pinquart & Sörensen, 2001, able therapies to accommodate for comorbid disorders. Many p. 230). Additional education is needed, not only for counse- older adults may not respond positively to the therapies lors but also for physicians, due to suggestions that referrals reviewed in this article, and they may require the implemen- for psychosocial therapy services by physicians tend to be tation of therapies that have not been researched in the same low (Alvidrez & Areán, 2002; Barnow & Linden, 2000).
way as the psychosocial treatments listed here.
The psychosocial treatments presented in the summary are those Our review of the research literature clearly suggests that that have been evaluated empirically. It is important to be aware older adults who have major depression and dysthymia can of the standards that best practice models promote in terms of benefit from psychosocial treatments. A summary of our find- efficacy. However, there may be limitations to using strict best ings regarding psychosocial treatments for major depres- practice models. The stringent criteria that are required for thera- sion and dysthymia in older adults is presented in Table 1.
pies to be considered a best practice may preclude many valu- The research reviewed in this article clearly shows that CBT able therapies from ever being suggested as a viable option for is the most researched of all the psychosocial treatments for treatment. As a result, many therapies may be neglected.
depression in the older adult. The outcome studies reviewed Niederehe, Street, and Lebowitz (1999) reported that suggest that CBT is probably efficacious as a treatment for the demonstration of efficacy represents simply the first step depression in older clients who are cognitively intact and in a more extended treatment development process, rather are not suicidal. A similar conclusion was reached by Gatz et than the end point, . . . [and] research will likely deal with al. (1998), observing that there is a lack of research with demonstrating efficacy for newly developed treatments (where sufficiently large samples demonstrating superiority of CBT a need for novel approaches is evident) or for the application to psychological placebo and that studies demonstrating of existing treatments to alternate indications and under- superiority to another treatment are scarce. A similar conclu- researched populations. (E. “Is There Still a Commitment to sion can be reached for BDT. The research available sug- gests that this treatment is probably efficacious for treatingmajor depression in older adults. RT also seems to be poten- Psychosocial treatments for major depression and dys- tially useful/helpful for treating older adults with major de- thymia disorders continue to be evaluated (Gotlib & pression. Issues of small samples and comparisons favoring Hammen, 2002). Many therapies were not included in this alternative treatments support this conservative conclusion Psychosocial Treatments for Major Depression and Dysthymia in Older Adults
Major Depression
Dysthymia
Maintenance
Note. CBT = cognitive-behavioral therapy; IPT = interpersonal therapy; BDT = brief dynamic therapy; RT = reminiscence therapy; ND =no data found in the research.
Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 (Gatz et al., 1998). IPT has been researched but needs addi- to receive psychotherapy. In fact, people living in poverty tional support as a useful or efficacious treatment of depres- were nearly 4 times as likely to experience chronic depres- sion as affluent people (Kessler et al., 2003). These dispari- Family and group therapy have also been researched ties suggest that increased efforts are needed to ensure ac- with incomplete evidence to support usefulness or effi- cess to appropriate treatment for all groups of older clients cacy when treating older adult depression. These results and to remove economic barriers to treatment (Crystal et al., are different from those of Gatz et al. (1998). The differ- 2003). Evidence-based treatments appear to be effective in ences may be explained by the fact that in Gatz et al.’s minority women if they are given support to overcome barri- report, they “combined individual and group therapies that ers to care. It is likely that outreach programs, transporta- were based on the same treatment approach” (p. 37), whereas tion, and child care for the intervention groups enhanced access to treatment; without this support, women were un- For dysthymia, only CBT and IPT have been shown as likely to use resources that were available to them (Wellbery, potentially useful/helpful treatments with older adults. All other therapies should be researched to determine their use- Current research of psychosocial interventions for treat- fulness for treating dysthymia in older adults. Finally, as a ing depression in older adults falls short of meeting the maintenance therapy, IPT combined with medication ap- country’s demographic characteristics and needs. Our review pears to be probably efficacious in helping older clients reveals the same limitation observed by Karel and maintain their mood improvements after the initial treat- Hinrichsen (2000): that most studies have been conducted ment. Current research for the use of CBT and group therapy with relatively healthy White older adults. Studies of the as maintenance therapies does not fully support their use- efficacy of psychosocial therapeutic interventions for treat- fulness or efficacy, and further research is needed.
ing depression in minority and frail older adults are needed The research also suggests that necessary adjustments for providing therapy for older clients are needed disregarding The emerging demographic trends in the United States the type of psychosocial treatment used. Therapists should make the study of the effect of psychosocial treatments be flexible to accommodate for any sensory and cognitive for major depression and dysthymic disorders in older impairment, for the participation of family members and adults of critical interest. The older adult population caregivers, as well as for accepting improved function and will be in greater need of mental health services in the symptom reduction as valuable therapeutic goals (Kennedy near future. As counselors, we cannot ignore these sta- tistics and are responsible for learning as much as pos- According to Mechanic and Bilder (2004), treatments for sible about the unique needs and challenges of older people affected by mental disorders have improved or be- adults. We will see older adult clients in our practices and, as come more accepted during the past decade. The rate of out- with other groups, need to become educated on the best way patient treatment for depression increased from 0.73 per 100 to provide treatment services to them. With additional knowl- persons in 1987 to 2.33 in 1997 (Olfson et al., 2002). De- edge, we can offer effective treatments and advocacy on their spite these changes, many people who need treatment for behalf. This is particularly important given the fact that many depression still do not receive it, and most treatment fails to older adults prefer psychosocial interventions over pharma- meet reasonable evidence-based standards of care. Accord- cological interventions. Unützer et al. (2003), on the basis of ing to a recent national survey, more than half of all people the results of one of the largest and most diverse cohorts of with major depression now seek treatment for the disorder, older adults with depression to date, reported that “most par- but only 1 in 5 people with depression receives adequate ticipants indicated a preference for counseling or psycho- medication and psychotherapy (Kessler et al., 2003). Ac- therapy over antidepressant medications, but only 8% had cording to Kessler et al., the fact that only 20% of people received such treatment in the past 3 months, and only 1% with major depression receive adequate treatment reinforces reported four or more sessions of counseling” (p. 505).
the need for access to mental health services and for equal With knowledge, we counselors can question why men- (parity) insurance coverage for mental as well as physical tal health providers appear to ignore the use of psychoso- ailments. Men, African Americans, Latinos, and those who cial therapy when older consumers are themselves asking preferred counseling to antidepressant medications reported for these treatments and when there is evidence that they significantly lower rates of depression care (Unützer et al., are useful in treating late life depression (Evans, 2000; 2003). In research of more than 20,966 Medicare claims Unützer et al., 2003). As stated by Myers and Harper (2004), between 1992 and 1998 (Stephen, Sambamoorthi, Walkup, “Given the current lack of counseling services to older & Akincigil, 2003), it was found that those age 75 or older, persons, combined with a paucity of outcome research with those with Hispanic ethnicity, and those without additional this population, counselors are encouraged to conduct both coverage to supplement Medicare received significantly less quantitative and qualitative studies of intervention effec- treatment; furthermore, if treated, these groups were less likely Journal of Counseling & Development ■ Spring 2006 ■ Volume 84 Treatments for Major Depression and Dysthymia in Older Adults Future research of depressive disorders in older adults Beck, A. T., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive will need to focus on the following areas. First, controlled therapy of depression. New York: Guilford Press.
trials comparing psychosocial treatments, medication, and Birrer, R. B., & Vemuri, S. P. (2004). Depression in later life: A their combination are needed to determine which treatments diagnostic and therapeutic challenge. American Family Physi- are more effective and whether combined treatment provides an additive benefit in symptom reduction. Second, analyses Butler, R. (1974). Successful aging and the role of life review. Jour- of treatments’ components are needed to identify the rela- nal of the American Geriatrics Society, 22, 529–535.
tive contributions of specific therapeutic components to Campbell, J. M. (1992). Treating depression in well older adults: symptom reduction and maintenance of improvements. Third, Use of diaries in cognitive therapy. Issues in Mental Health Nurs- follow-up studies with adequate control groups are needed to evaluate the long-term benefit of specific treatments, in- Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., cluding examining whether maintenance sessions reduce Calhoun, K. S., Crits-Christoph, P., et al. (1998). Update on relapse rates. Fourth, studies of the use of psychosocial in- empirically validated therapies, II. The Clinical Psychologist, 51, terventions in a preventative fashion are needed to reduce the chances of developing depression in later life. Fifth, Crystal, S., Sambamoorthi, U., Walkup, J. T., & Akincigil, A. (2003).
studies with diverse older adult populations are needed to Diagnosis and treatment of depression in the elderly Medicare evaluate the effectiveness of current psychosocial treatments population: Predictors, disparities, and trends. Journal of Ameri- with these populations. Finally, studies directed to deter- can Geriatrics, 51, 1718–1728.
mine effective ways of removing barriers and increase treat- Dew, M. A., Reynolds, C. F., Mulsant, B., Frank, E., Houck, P. R., ment acceptability in diverse groups are needed. The out- Mazumdar, S., et al. (2001). Initial recovery patterns may predict come of these studies will help us as counselors enhance the which maintenance therapies for depression will keep older adults services we provide to older clients. Ultimately, improved well. Journal of Affective Disorders, 65, 155–166.
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