Arthur J. Anderson, PhD
Managing Editor - IJPR
Hampstead Psychological Associates
Southern Development Group
Anderson, A.J. (2002) Treatment of Depression in Older Adults.
International Journal of Psychosocial Rehabilitation. 6, 69-78
This article reviews the rationale for concentrating mental health system and therapeutic resources on the treatment of depression in aging populations. Etiological factors/clinical formulation, biopsychosocial treatment strategies, and therapeutic outcome evaluation are examined and presented as rationale for a renewed concentration on treatment for both dementia and non-dementia related depression in the elderly. The authors conclude that although the older adult depressive patient has special needs and conditions that require specialized psychosocial care, they are no different than any other special needs population. A lifetime accumulation of stress, specific catastrophic events, and failing physical conditions contribute to reduced coping, but are all conducive to treatment. Accepting a normative view of older adult depression and considering it a normal function in the life cycle, is categorically flawed and thus, unethical as well. Instead, clinicians should be concentrating their efforts on expanding systems and techniques/models that have proven efficacy for these patients.
Depression in older adults has been associated with and is closely related to the aging process. The accumulation of a lifetime of depressing events, such as bereavement, painful illness, etc., coupled with the effects of physical illness, decreasing mental, and deminished physical energy place older adults at risk for depressive symptoms (Stuart-Hamilton, 2000). These etiological factors are so common among older adults that they appear to normative and a part of the normal aging process.
On the surface, a normative view of older adult depression may lead to the conclusion that we should strive to understand this obviously normative phenomena and not concentrate our efforts on treatment of depression. However, this viewpoint is only possible if one assumes a normative etiology for depression in these individuals. A more comprehensive understanding of causes and presentations of depressive conditions among the elderly, and the various therapeutic intervention strategies that can be employed, clearly demonstrates that treatment not only works, but works well for this population and can greatly enhance the lives of the elderly.
Etiology and Clinical Formulation
Although some healthy aging persons maintain very high cognitive performance levels throughout life, most older people will experience a decline in some cognitive abilities. This decline is usually not pathological, but parallels a number of common decreases in physiological function that occur in conjunction with normal aging processes. For some older persons, however, declines go beyond what may be considered normal and are relentlessly progressive, robbing them of their memories, intellect, and eventually their abilities to recognize spouses or children, maintain basic personal hygiene, or even utter comprehensible speech. These more malignant forms of cognitive deterioration are caused by a variety of neuropathological conditions and dementing diseases.
However, even the depression associated with dementia and other organic depression is often a function of decreased coping skills and thus, in some measure, amenable to treatment. The inability to cope with increasing stressors due to both medical conditions and older adult stress issues, place these patients in the same position as those who suffer from depression without organic complications (Lezak, 1994) In the majority of older adult depression cases, cognitive deterioration is not directly associated with specific organic lesions or processes, but is more defuse and psychosocially based (Stuart –Hamilton, 2000). The difficulty with treatment of these clients lies partly in the differential diagnosis and clinical formulation of the presenting symptomology of these patients.
Depression in elderly persons can often mimic the effects of dementia (Kaszniak & Christenson, 1994). Psychomotor retardation and decreased motivation can result in nondemented persons appearing to have pathophysiologically determined cognitive disturbances in both day-to-day functioning and on formal neuropsychological testing. Depression can also cause non-demented persons to over-report the severity of cognitive disturbance. Consequently, it is important to perform a careful assessment for depression when evaluating for dementia and age-related cognitive decline, and determine what coping strategies exist and ways in which coping can be modified to more fully integrate the older client to his/her environment and reduce their distress.
Depression is best assessed during an interview so that the clinician can obtain a full range of behaviour, mood, cognition and social interaction patterns. Formal mood scales (e.g., Beck, Ward, Mendelson, Mock, & Erbaugh, 1961 ; Yesavage et al., 1983) can also play an important role in assessing for depression and have the advantages of quantifying and facilitating the assessment of changes in mood over time. Sociocultural factors may cause some older persons to underreport depressive symptoms.
In many patients. depression and dementia are not mutually exclusive. Depression and dementia or age-related cognitive decline frequently coexist in the same person. Depression can also be a feature of certain subcortical dementing conditions, such as Parkinson's disease (Cummings & Benson, 1992 ; Youngjohn, Beck, Jogerst, & Cain, 1992). However, even in cases of concomitant neurological difficulties, depressive patterns and their maintaining mechanisms can often be assessed apart from the underlying neurologic difficulties and aggressively treated (Kaszniak & Christenson, 1994)..
Depression constitutes the most common emotional disorder found in older people (Butler, Lewis, & Sunderland, 1991). Estimates of the prevalence of major depressive disorder in the elderly range from 2% to 10% (Blazer, Hughes, & George, 1987), with milder forms of depression such as dysthymia and dysphoria affecting 20% to 30% of older adults (Butler et al., 1991). Moreover, the clinical significance of depression in the elderly is underscored by the consistent finding that suicide occurs more frequently in the elderly than in any other age group (Rich, Young, & Fowler, 1986).
The symptoms and conditions listed in Table 1 have been demonstrated to be associated or not associated with dementia and organic processes. As part of the American Psychological Association’s Guidelines (1998) for the treatment of dementia, this table demonstrates a wide range of variation in cognitive difficulties for the elderly that may or may not be due to organic deficits. Though it may be widely agreed that conditions due to organic functional deficits are very difficult to effectively treat, the symptoms and conditions listed under "Those less likely to become demented" may not be solely due to organic factors and are therefore seen as more conducive to psychotherapy and other psychosocial treatments (APA,1998; Arean et al, 1993; Stuart-Hamilton, 2000). These symptoms and conditions have also been associated with clinical depression (Beck, 1961)
(APA, 1998) While it may be said that a minority of patients with organically derived depressive symptoms receive little benefit from treatment, the majority of patients do not fall into the category and respond well to biopsychosocial treatment strategies (Arean, et al. 1993, Stuart-Hamilton, 2000). Once a comprehensive differential assessment of organic and psychosocial factors associated with both dementia and depression has been performed a clearer understanding of the necessary components of an effective care plan can emerge for these individuals. The major difficulty with this population lies first in the comprehensive assessment and formulation. This leads to an appropriate intervention strategy that will take all bio-psycho-social factors into account in an integrated treatment framework.The causes for depression in later life are not limited to cognitive factors but are also associated with a wide range of psychosocial stressors and negative events . Depression that merits clinical attention is long-lasting and sever enough to interfere with normal functioning. In addition to a chronically depressed mood, the patient typically lacks both mental and physical energy, has irrational feelings of worthlessness and/or guilt. They may also have preoccupations with dying and suicide. Older patients also report a greater number of physical complaints, which contributes to their depressed mood and feelings of helplessness. Bereavement is also known to cause depressive symptoms and older adults report more ‘loss’ than younger patients. In short, older adults are exposed to a higher proportion of depressing events in their lives, including bereavement, painful illness, institutionalisation, loss of income, etc., and are more likely to be at risk for both depression and/or pseudodementia (Blazer, 1997). Kasl-Godley, Gatz and Fisk’s (1998) estimate that as many as 11 percent of dementia cases actually suffer from pseudodementia and depression.
Biopsychosocial and Symptom Specific Treatment Strategies
In 1992, a consensus development panel of the (U.S.) National Institutes of Health (NIH; 1992) urged vigorous treatment of depressed elderly with somatic therapies (i.e., drugs, electroconvulsive therapy [ECT], or both). Psychosocial therapies were recommended as secondary or supplemental interventions. Members of this NIH panel noted that, in comparison with the substantial research base supportive of somatic therapies (for a review, see Gerson, Plotkin, & Jarvik, 1988), there still is little evidenced based research on the benefits of psychological treatments for depression in the elderly (Alder, 1992).
On the other hand, Stuart-Hamilton (2000) reports that there is little difference in treatment effects between younger and older patients. Kasl-Godley, Gatz and Fiske (1998) along with Tuma (1996) and Burville et al (1995) conclude that psychotherapy and associated psychosocial treatments for depression in older adults are highly effective for depressive symptomology and reduce the presentation of pseudodementia as well. They report that as many as 60 percent of depressive patients who were treated aggressively recovered; with only a 20 percent relapse rate. These high rates of recovery suggest that older patients who have been effectively assessed and identified as suffering from the effects of age related or major depression can be effectively treated with lasting effects. Given this, the central question in treating this population become what strategies work for which patients under which circumstances.
Various psychological conceptualizations have been proposed to explain and to treat depression in the elderly. These range from the developmental-existential perspective of reminiscence therapy (RT; Butler, 1974) to the social reinforcement formulation of behavior therapy (Teri & Lewinsohn, 1982). Although the research literature on psychotherapy outcome for depression in the elderly is not extensive, several controlled studies have supported the effectiveness of various psychosocial treatments, including RT (e.g., Goldwasser, Auerbach, & Harkins, 1987), psychodynamic psychotherapy (e.g., Steuer et al., 1984 ; Thompson, Gallagher, & Breckenridge, 1987), behavior therapy (e.g., Brand & Clingempeel, 1992 ; Gallagher & Thompson, 1982), and cognitive therapy (e.g., Beutler et al., 1987 ; Steuer et al., 1984). Additional research is warranted by the scope and seriousness of depression in the elderly and by limitations of the existing research base (i.e., few studies, small samples, failure to include measures specific to the nature of depression in the elderly, and an over reliance on self-reports as outcome measures). Research on psychological interventions is also needed because somatic therapies are contraindicated in the treatment of many older adults, particularly those who are medically ill and cannot tolerate the side effects of antidepressant medications or ECT (Butler et al., 1991 ; Winstead, Mielke, & O'Neill, 1990).
Because age-related psychosocial factors often contribute to the occurrence of depression in the elderly (Ruegg, Zisook, & Swendlow, 1988), successful treatment (and prevention of relapse) requires modification of those psychological factors that are etiologically related to depression in later life. Nezu and his colleagues (Nezu, 1987 ; Nezu, Nezu, & Perri, 1989) have proposed a problem-solving model of unipolar depression that may hold particular relevance for understanding and treating depression in older adults. Within this formulation, social problem-solving encompasses the processes by which people develop effective means of coping with stressful life events; deficits in problem-solving skill serve as one important vulnerability factor for depression. When deficits in problem-solving lead to ineffective coping attempts under high levels of stress (emanating either from major negative life events or from continuous daily problems), depression is likely to ensue (Nezu et al., 1989).
Many of the changes that occur in later life often constitute significant stressors. For example, declining socioeconomic status, deteriorating physical health, and the loss of loved ones can each have a powerful impact on overall mood and self-esteem (Butler et al., 1991 ; Ruegg et al., 1988). Whether such stressors precipitate a major depression may be determined, in part, by the individual's ability to cope effectively with the major and minor problems posed by these life changes (Lazarus, 1991 ; Nezu et al., 1989). Indeed, some recent research has found that depressed older adults show deficits in social problem-solving ability–deficiencies that may impair one's ability to cope with stressors related to depression (e.g., Fry, 1989).
One corollary of the conceptual model proposed by Nezu et al. (1989) suggests that problem-solving training will lead to decreases in depressive symptomatology. Two outcome studies (Nezu, 1986 ; Nezu & Perri, 1989) have provided a direct test of this hypothesis and have demonstrated the clinical effectiveness of problem-solving therapy (PST) in middle-aged adults with unipolar depression. Only one study (Hussian & Lawrence, 1981) directly tested the effectiveness of PST in depressed older adults. Hussian and Lawrence found that PST was superior to a social reinforcement approach for reducing depression in institutionalized older adults. Although the results of these studies provide initial support of the problem-solving model of depression, additional research in needed regarding the effectiveness of PST as a treatment for depression in older adults and as compared with other treatments derived from alternative conceptualizations of depression in the elderly.
Reminiscence Therapy (RT), a commonly recommended psychotherapy for older adults, in based on the premise that life review constitutes a normal developmental process brought about by increasing awareness of one's mortality (Butler, 1974). A failure to successfully integrate one's life experiences is viewed as contributing to despair and depression (Erikson, Erikson, & Kinvick, 1986). RT entails a progressive return to an awareness of past experiences, both successful and unsuccessful, so that salient life experiences may be reexamined and reintegrated. The life review process gives older people opportunities to place their accomplishments in perspective, to resolve lingering conflicts, and to find new significance and meaning in their lives, thereby relieving the despair and depression that often accompany aging (Butler et al., 1991). Support for the effectiveness of RT as a treatment for depression in older people has been found in several studies (Goldwasser et al., 1987 ; Rattenberg & Stones, 1989).Conclusions
Evaluation of Effective Treatment Strategies Arean et al (1993) evaluated the comparative rates of effectiveness between RT and PST. The comparative efficacy of the two psychotherapeutic approaches for the treatment of depression in older adults was examined in a randomized, prospective investigation. This study not only compared the effects of treatment between the two psychotherapy groups but also compared both groups against a wait listed control group. Subjects in both groups were assessed on the comprehensive battery of depression, life events, and problem solving skills scales, as well as semi-structured clinical interviews. All subjects who were included in the study met the criteria for Research Diagnostic Criteria (RDC; Spitzer. Endicott, & Robins, 1978). The 75 patients were randomly assigned to one of the three study conditions. Each treatment was implemented over 12 weekly sessions; each session lasting approximately 1.5 hours. Results showed significant improvements in depressive symptoms compared with those who received no treatment. In addition, 64 percent of of the study patients who completed treatment showed substantial improvement in their condition. These patients had improved to the point where their symptoms could now be classified as sub-clinical presentations and no longer depressed. Contrary to previous findings of differences in treatment response to cognitive, behavioural, or psychodynamic approaches, this study found significant differences between the skills oriented, cognitive approach of the PST model and the more introspective RT approach. The effectiveness of the PST approach in relieving depression may be attributed to improvements in the participants ability to cope with the major and minor stressors in their lives. Over the course of the study PST subjects made significant improvements in three of the tive component skills of the problem solving measures. The RT subjects did not show such robust improvements on these measures. Such finding support the position that ineffective coping with problem in living may contribute to the experience of depression in older adults.
Once patients are clearly identified as suffering from depression, the question of whether they can respond to treatment and whether or not they should receive treatment becomes moot. Elderly patients who suffer from depression and poor life integration skills clearly benefit from various psychosocial interventions. This appears to be independent of the presence of pseudodementia or dementia. Older adults who suffer from depression respond to treatment the tend to minimize the impact of a lifetime of accumulated stressors, and/or provide the patient with more adaptive coping mechanisms to relieve their distress. Though we may debate which interventions are most appropriate and effective, psychosocial treatment clearly relieves a wide range of depressive symptoms and increases coping skills. Treatment also has a positive impact on the symptoms associated with pseudodementia as well.
As noted throughout this essay, depression in older adults is associated with and is closely related to the aging process. A lifetime of depressing events, (bereavement, painful illness, etc, coupled with the effects of physical illness, decreasing mental, and deminished physical energy) reduces the ability of many older adults to cope with not only the impact of past events, but to solve problems in the present. This leads to greater dysfunction, poorer coping with stress, and greater levels of depression. The fact that these causal and contributing factors are so common among older adults that they appear to normative and a part of the normal aging process, may delude some clinicians into the false belief that treatment for this population is neither effective, nor desirable.
On the contrary, the research base and demographic trends make it clear that treatment for depression among older adults is both effective and beneficial not only for the individual but society as a whole. As medical treatment and improvement in preventative health continues into the 21st century, life spans continue to increase. This trend also has an impact on the vitality and creative contributions of the elderly as well. As life spans increase, people remain productive for more years and contribute to not only their own development but to their social circles and to society as well. Improving their ability to cope with multiple stressors and continue to solve problems in the face of failing health or long term debilitating medical conditions, not only serves their interest by reducing their depression, but serves society as well.
Though the older adult depressive patient has special needs and conditions that require specialized psychosocial care, they are no different than any other special needs population. A lifetime of stress, specific catastrophic events, and failing physical conditions contribute to reduced coping, but are all conducive to treatment. Thus, accepting a normative view of older adult depression and considering it a normal function in the life cycle, is categorically flawed and thus, unethical as well. Instead, clinicians should be concentrating their efforts on expanding systems and techniques/models that have proven efficacy for these patients.
In addition to direct treatment for depression, improved housing and social conditions that contribute to isolation, withdrawal and depression should be addressed and efforts made to provide the resources that will improve the quality of life for this group. Based on the evidence, it is clear that instead of finding rationale for limiting services, we should continue the struggle to determine what works, for depressed elderly patients, under a variety of circumstances to improve their connection with their community and reduce their distress to the greatest extent possible.
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