Psychotherapy for Late-Life Depression
George S. Alexopoulos, MD
Department of Psychiatry, Weill Medical College of Cornell University and New York Presbyterian Hospital, New York
Treating older patients with MDD presents a different set of challenges to the clinician than treating younger adults. Older patients may have more comorbid medical illnesses, take more medications, and metabolize medications more slowly than young patients. Cognitive impairment, the lack of a social support network, problems with transportation, financial constraints, and disability may be barriers to older patients receiving treatment. These clinical problems make it likely that older adults will be excluded from clinical trials, thus leading to a paucity of data-based treatment information. For this reason, a team of investigators1 convened in 2001 to address some of the clinical questions regarding the treatment of late-life depression. The team sent a written survey to 50 national experts regarding treatment options for geriatric patients, and consensus was reached by the experts on the majority of options presented. Guidelines based on the treatment strategies preferred by the experts were then developed to aid clinicians in treating older patients with depression.
The consensus was that the treatment for dysythmic disorder or persistent minor depression should consist of an antidepressant combined with psychotherapy, or possibly either an antidepressant or psychotherapy alone (AV 1).1,2 The preferred treatment strategy for unipolar nonpsychotic major depression of any severity was an antidepressant plus psychotherapy, although ECT was also considered for severe depression unresponsive to antidepressants.2 The SSRIs were considered the preferred antidepressant class; for an update on pharmacotherapy, please see “Pharmacotherapy for Late-Life Depression.” The preferred psychotherapies were CBT, supportive psychotherapy, PST, and IPT. In addition, the Expert Consensus Guidelines affirmed that psychosocial interventions such as family counseling and visiting nurse services are integral components of treatment programs for patients with late-life depression, along with careful screening and treatment for comorbid medical conditions that might contribute to or even cause patients’ depression.
Indications for Psychotherapy as Treatment for Late-Life Depression
Although the treatment guidelines call for both an antidepressant and psychotherapy when treating late-life depression, they do suggest that mild depression may be treated with psychotherapy alone.2 In fact, geriatric patients may find psychotherapy more acceptable than medication.3,4 In a study5 of depressed elderly patients with COPD, 72% of patients refused treatment with antidepressants, and only 50% of those who agreed to antidepressant treatment completed the trial.
Psychotherapy may be preferable to antidepressants for some geriatric patients for several reasons. Depressed older patients taking medications for comorbid medical illnesses are at risk for drug-drug interactions with antidepressants, or they may experience adverse side effects from the antidepressants themselves. Additionally, executive dysfunction is common among the depressed elderly6,7 and has been found to predict poor antidepressant response and early relapse, as well as recurrence of depression.8,9 Executive dysfunction also contributes to behavioral competence that may interfere with adherence to an antidepressant treatment regimen.
Psychotherapy is as effective for older adults as it is for younger adults.10 Its efficacy in late-life depression is comparable to that of pharmacotherapy (AV 2).11 Although controlled studies are needed, psychotherapeutic interventions might be more beneficial than antidepressants in older patients with minor depression or dysthymia.11
Update on Evidence for Preferred Psychotherapies
The guidelines1 recommend CBT, supportive psychotherapy, PST, and IPT as the preferred psychotherapeutic techniques for treating older patients with depression. These preferences were supported by a 2002 review12 of the literature on psychotherapy for geriatric depression, which reported that CBT, PST, and the combination of an antidepressant and IPT were efficacious in the acute treatment of geriatric depression, with CBT and IPT combined with an antidepressant having the largest evidence base. In 2006, Cuijpers and colleagues13 conducted a meta-analysis of randomized controlled trials of psychotherapy for depression in older adults and found no significant differences in efficacy between CBT and other types of psychotherapy.
Since the publication of the guidelines, a type of problem-solving psychotherapy has been developed for patients with depression and executive dysfunction. The goal of this therapy is to maximize the patient’s ability to adapt to their environment and to change the patient’s “ecosystem” in a way that facilitates the patient’s adaptation. This therapy relies on the principles of PST, a derivative of CBT, to impart to depressed older patients a step-wise technique for problem solving that aims to increase patient functioning, enhance self-esteem, and instill hope.14,15 Specifically, patients are taught how to identify problems and define them concretely, set goals, generate solutions, evaluate these solutions, implement the best solution, and then verify the effectiveness of the solution. These problem-solving skills have been adapted to directly address symptoms of depressed patients with executive dysfunction, such as lack of energy, psychomotor retardation, and reduced insight.15,16 In addition, therapists make changes in patients’ physical environments to accommodate disabilities and instruct patients’ caregivers on how to help with tasks that the patients themselves are unable to perform. Maximizing patients’ problem-solving skills and creating a favorable ecosystem reduces their experience of stress and may facilitate their recovery from depression.
Indications for Combined Antidepressant and Psychotherapy Treatment
The treatment guidelines1 favored antidepressant pharmacotherapy combined with psychotherapy in the treatment of late-life major depression of any severity. In the 2002 review,12 preliminary data suggested that combining an antidepressant with IPT or possibly CBT was more efficacious than monotherapy in the acute treatment of late-life major depression. Combination therapy was also viewed as the most efficacious maintenance treatment for older patients with recurrent major depression. Hollon and colleagues17 reviewed the literature published from 1980 until 2004 for both younger and older adults and determined that, although both therapies are effective, each may have certain advantages, ie, medication may have a more rapid effect, but psychotherapies appear to better reduce the risk of recurrence (AV 3).17–20 Both of these advantages were maintained with combination treatment, which also appeared to enhance the likelihood of treatment response. Combination therapy appeared to be superior to either monotherapy for response and remission in patients with chronic or severe depression. A more recent meta-analysis21 compared psychotherapy alone with psychotherapy combined with pharmacotherapy (for both younger and older adults with depression), and concluded that combination treatment was more effective. The advantage of combination therapy over monotherapy in this meta-analysis21 trended higher in studies of older adults.
For Clinical Use
- Psychotherapy is efficacious for treating MDD in older adults and may especially help with medication adherence and relapse prevention
- Consensus guidelines recommend an antidepressant plus psychotherapy for the treatment of unipolar nonpsychotic geriatric depression, and recent evidence has supported this recommendation
- Certain psychotherapies, such as CBT, IPT, and PST, have the most evidence of efficacy in treating depression in older adults, but additional controlled trials are needed to determine which types of psychotherapy work best for which patients
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CBT = cognitive-behavioral therapy, COPD = chronic obstructive pulmonary disease, ECT = electroconvulsive therapy, IPT = interpersonal therapy, MDD = major depressive disorder, PST = problem-solving therapy, SSRI = selective serotonin reuptake inhibitor
- Alexopoulos GS, Katz IR, Reynolds CF 3rd, et al, for the Expert Consensus Panel for Pharmacotherapy of Depressive Disorders in Older Patients. The expert consensus guideline series: pharmacotherapy of depressive disorders in older patients. Postgrad Med. 2001;Spec No Pharmacotherapy:1–86.
- Alexopoulos GS, Katz IR, Reynolds CF 3rd, et al. Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines. J Psychiatr Pract. 2001;7(6):361–376.
- Landreville P, Landry J, Baillargeon L, et al. Older adults' acceptance of psychological and pharmacological treatments for depression. J Gerontol B Psychol Sci Soc Sci. 2001;56(5):P285–P291.
- Hanson AE, Scogin F. Older adults' acceptance of psychological, pharmacological, and combination treatments for geriatric depression. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):P245–P248.
- Yohannes AM, Connolly JJ, Baldwin RC. A feasibility study of antidepressant drug therapy in depressed elderly patients with chronic obstructive pulmonary disease. Int J Geriatr Psychiatry. 2001;16(5):451–454.
- Lockwood KA, Alexopoulos GS, van Gorp WG. Executive dysfunction in geriatric depression. Am J Psychiatry. 2002;1597:1119–1126.
- Lockwood KA, Alexopoulos GS, Kakuma T, et al. Subtypes of cognitive impairment in depressed older adults. Am J Geriatr Psychiatry. 2000;8(3):201–208.
- Potter GG, Kittinger JD, Wagner HR, et al. Prefrontal neuropsychological predictors of treatment remission in late-life depression. Neuropsychopharmacology. 2004;29(12):2266–2271.
- Alexopoulos GS, Kiosses DN, Heo M, et al. Executive dysfunction and the course of geriatric depression. Biol Psychiatry. 2005;58(3):204–210.
- Cuijpers P, van Straten A, Smit F, et al. Is psychotherapy for depression equally effective in younger and older adults? a meta-regression analysis. Int Psychogeriatr. 2009;21(1):16–24.
- Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry. 2006;163(9):1493–1501.
- Aréan PA, Cook BL. Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry. 2002;52(3):293–303.
- Cuijpers P, van Straten A, Smit F. Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. Int J Geriatr Psychiatry. 2006;21(12):1139–1149.
- Alexopoulos GS, Raue PJ, Sirey JA, et al. Developing an intervention for depressed, chronically medically ill elders: a model from COPD. Int J Geriatr Psychiatry. 2008;23(5):447–453.
- Alexopoulos GS, Raue PJ, Kanellopoulos D, et al. Problem solving therapy for the depression-executive dysfunction syndrome of late life. Int J Geriatr Psychiatry. 2008;23(8)782–788.
- Alexopoulos GS, Kiosses DN, Klimstra S, et al. Clinical presentation of the "depression-executive dysfunction syndrome" of late life. Am J Geriatr Psychiatry. 2002;10(1):98–106.
- Hollon SD, Jarrett RB, Nierenberg AA, et al. Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry. 2005;66(4):455–468.
- Paykel E, Scott J, Teasdale J, et al. Prevention of relapse in residual depression by cognitive therapy: a controlled trial. Arch Gen Psychiatry. 1999;56(9):829–835.
- Teasdale JD, Segal ZV, Williams JMG, et al. Prevention of relapse/recurrence in major depression by mindfullness-based cognitive therapy. J Consult Clin Psychol. 2000;68(4):615–623.
- Fava GA, Rafanelli C, Grandi S, et al. Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings. Arch Gen Psychiatry. 1998;55(9):816–820.
- Cuijpers P, van Straten A, Warmerdam L, et al. Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Depress Anxiety. 2009;26(3):279–288.