Clinical Review

Assessment and Treatment of Late-Life Depression

Journal of Clinical Outcomes Management. 2017 March;24(3)

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Psychotherapeutic and Psychosocial Interventions

Psychotherapeutic interventions have demonstrated efficacy in the treatment of geriatric depression, including but not limited to cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), reminiscence and life review, and brief psychodynamic psychotherapy [74]. Some older adults may prefer psychotherapy to pharmacologic treatment (57% vs. 43%) [75]. Potential benefits of psychotherapy include ability to directly address psychosocial stressors that may precipitate or perpetuate depressive symptoms. In addition, psychotherapy is associated with few to no side effects and avoids drug interactions. Barriers to employing psychotherapy may include cost and access to trained psychotherapists [76]. Efficacy of several psychotherapeutic approaches in the care of older depressed adults has been examined. CBT, brief psychodynamic psychotherapy, and IPT will be briefly reviewed here.

CBT. Cognitive therapy was first described by Aaron Beck in the 1960s [77]. It is a highly structured therapy built on the premise that beliefs and assumptions an individual holds can influence emotions and behavior. CBT aims to identify maladaptive belief systems, test the validity of these cognitive distortions, and help individuals formulate more realistic cognitions [78]. Symptom improvement results from addressing these cognitive aspects as well as integration of behavioral activation and skills training to overcome maladaptive behavioral patterns [78]. CBT approaches have been applied to older adults with depression and results show acceptability [79] and efficacy in this population [80–82]. A 2008 Cochrane review ( n = 153) found CBT to be superior to waitlist controls [82].

Brief psychodynamic psychotherapy. Brief psychodynamic psychotherapy, unlike highly structured CBT, aims to alter behavior by examining how past experiences and unresolved conflicts influence current emotions and behavior. While studies on application to the treatment of geriatric depression are scarce, limited data demonstrate efficacy in treating geriatric depression [81] and no significant difference in outcomes when compared to CBT [82].

IPT. Like CBT, IPT is a structured time-limited psychotherapeutic treatment approach first developed in the late 1960s by Klerman and Weissman [83]. IPT focuses on the impact of interpersonal relationships on depressive symptoms and examines 4 domains: interpersonal conflict, interpersonal deficits, role transitions, and grief [74].

Studies have shown efficacy of IPT in reducing depressive symptoms in the elderly when compared to usual care [84]. Reynolds et al found IPT combined with nortriptyline (a tricyclic antidepressant) to be superior to either nortriptyline alone or IPT alone in preventing recurrent depressive episodes [85]. Interestingly, a similar study investigating the efficacy of IPT in combination with paroxetine (an SSRI) failed to show added benefit of IPT in preventing recurrence, suggesting that further studies are needed [86].

Psychosocial interventions are integral in the care of the elderly depressed patient. Studies have shown positive benefits of aerobic exercise on depressive symptoms [87]. Yoga, Tai Chi, and other mindfulness-based exercises can increase sense of emotional and physical wellbeing [88–90]. Spirituality, religious beliefs, and involvement with a faith group may be protective against development of mental illness while at the same time provide avenues for increased social connectedness [91]. These and other avenues for socialization should be encouraged as part of the treatment plan for older depressed patients [92]