Evidencebased Psychotherapy With Older People

The following section reviews the empirical evidence for psychological treatments for depression and anxiety, including cognitive behaviour therapy, interpersonal therapy, and psychodynamic psychotherapy. Powers et al. (2002) and Blazer (2002) have provided comprehensive reviews of both psychological and physical treatments for late-life depression. Perhaps the most noteworthy feature of research in this area is that there is simply not enough of it to draw firm conclusions about the differential effectiveness of various psychosocial and pharmacotherapy treatments when used alone. In the sections that follow, meta-analytical evidence for the efficacy of psychotherapy with older adults is considered prior to a further examination using systematic outcome studies. Where possible, evidence for the different psychotherapeutic approaches are outlined.

Psychological Therapy for Anxiety in Older Adults

Despite an increasing awareness of the importance of anxiety disorders in older people there still remains a limited number of systematic studies examining psychotherapy for anxiety in later life (Gatz et al., 1998; Nordhus & Pallesen, 2003; Stanley & Beck, 2000; Woods & Roth, 1996). This paucity of systematic studies is all the more surprising given the evidence supporting cognitive therapy as a treatment of choice for panic disorder and phobic disorders (Laidlaw et al., 2003). There are many more papers published that comment on process issues in the treatment of late-life anxiety than those reporting on the outcome of clinical trials (Gorenstein, Papp & Kleber, 1999; Sheikh & Cassidy, 2000; Stanley & Averill, 1999; Stanley & Beck, 2000; Stanley & Novy, 2000). The systematic studies that are published investigating psychological therapy as a treatment for late-life anxiety have all evaluated cognitive behaviour therapy (CBT). This finding should come as no real surprise as interpersonal psychotherapy (IPT) was developed as a treatment for depression and has only recently started to be considered for use with other affective disorders (see Weissman, Markowitz & Klerman, 2000 for review). Psychodynamic psychotherapy has a very poor outcome for anxiety disorders. Life review is another type of psychological intervention that is unlikely to be considered as a treatment for anxiety disorders in later life.

Meta-Analytic Review of Psychological Treatment for Late-life Anxiety

To date the only meta-analytic review of the nonpharmacological treatment of anxiety disorders has been carried out by Nordhus & Pallesen (2003). For this meta-analysis, the authors identified 15 psychosocial studies looking at the treatment of anxiety disorders in older people. The selection criteria used were quite flexible in order to include enough studies to permit an adequate meta-analysis. The studies varied in quality and many used relaxation as a primary treatment approach for anxiety reduction. Some of the studies were pilot studies and some were published as proceedings of a conference. Overall, Nordhus & Pallesen (2003) calculated a mean effect size for psychosocial treatments of 0.55. Using the classification adopted for the behavioural sciences (Cohen, 1977) 0.2 is considered a small effect size, 0.5 is considered a moderate effect size and 0.8 is considered a large effect size. It was noted that effect sizes are reduced when considering psychosocial treatments with active control conditions, thus suggesting that active control conditions are probably variants on active treatment conditions (Nordhus & Pallesen, 2003). It may also reflect the type of studies included in this meta-analysis. It is useful to include as many studies as possible but broad inclusion criteria probably lead to more confusion than clarity in determining the true effectiveness of structured psychosocial treatments evaluated in systematic controlled research trials. To that end the next section of this chapter reviews four systematic psychosocial outcome studies for the treatment of anxiety disorders in older people.

Cognitive Behaviour Therapy for Late-life Anxiety

King & Barrowclough (1991) developed a series of individual case studies to evaluate CBT's effectiveness as a treatment for late-life anxiety. The study was a naturalistic one as reflects the pilot nature of interventions being evaluated. Many of the participants were prescribed medication at a stable dose during their participation in the study. Outcome was impressive as seven out of 10 patients benefited from CBT. King & Barrowclough (1991) used standard procedures for treating panic disorder such as those that would be routinely applied with younger adults; no modifications to treatment procedures were deemed necessary to accommodate the needs of older people with anxiety. King & Barrowclough (1991) note that those patients who improved after receiving cognitive therapy had previously not benefited from pharmacotherapy.

Stanley, Beck & Glassco (1996) compared cognitive behaviour therapy with non-directive supportive therapy in 48 older adults aged 55 years and over diagnosed (using DSM-IIIR Criteria) with GAD. Stanley, Beck & Glassco (1996) used group treatment approaches over a 14-week treatment period, with each session lasting 90 minutes. Cognitive behaviour therapy followed standard procedures and included homework tasks. Supportive psychotherapy (SP) consisted of non-directive group discussions of anxiety symptoms and personal experiences of anxiety. Outcome was evaluated at the end of treatment and at six-months follow-up. The mean age of the sample was 68 years and 70 % were female with a mean duration of GAD of 35.5 years. All participants were medication free during the treatment phase. Both groups reported benefiting from the psychosocial interventions. There were no statistical significant differences between the groups on standardized measures of anxiety and worry. At the end of treatment, 28 % of CBT participants compared to 54 % of SP participants were classified as treatment responders. At the six-month follow-up, 50 % of the CBT participants and 77 % of the SP participants were classified as treatment responders (figures based upon complete sample). Given the small size of this study and given some methodological issues in this study there is still need for more treatment trials of anxiety in later life.

Barrowclough et al. (2001) produced the first systematic randomized controlled trial of the effectiveness of individual cognitive-behaviour therapy (CBT) for anxiety symptoms in older adults. Cognitive-behaviour therapy was compared to supportive counselling (SC). In this study all participants were aged 55 years and over with the mean age of the sample 72 years (77 % of the sample was female). All participants met DSM-IV criteria for anxiety disorders. Overall, 225 patients were referred with only 55 satisfying eligibility criteria, all participants were prescribed medication at a stable dose, with the majority being prescribed benzodiazepines In this study, there was a six-week baseline period with no evident change in treatment scores during this period. Out of the 55 participants who entered treatment, 43 completed treatment (CBT 19; SC 24), with 39 available for three-month follow-up (CBT 16; SC 23) and 40 were available for six-month follow-up (CBT 17, SC 23). At the end of treatment, the CBT group reported lower scores on the Beck Anxiety Inventory and Geriatric Depression Scale (GDS). There were also significant differences between the treatment conditions on the Beck Depression Inventory, GDS, Hamilton Rating Scale for Anxiety (HRSA) and the State-Trait Anxiety Inventory over the course of treatment. Barrowclough et al. (2001) also reported that 71 % of CBT and 39 % of SC participants met treatment responder status for anxiety at 12 month follow-up. Responder status was defined as a 20 % reduction on two anxiety measures: BAI & HRSA. Barrowclough et al. (2001) also assessed outcome in terms of the number of participants in each group who met high endstate functioning (defined as scores less than 10 on both the BAI and the HRSA) with 41 % of CBT and 26 % of SC participants meeting high endstate function for anxiety at 12 month follow-up. Overall Barrowclough et al. (2001) concluded that CBT was superior to SC at follow-up although SC did prove its usefulness.

Stanley et al. (2003) compared the efficacy of group-based CBT with a minimal contact control condition (MCC). The MCC group received weekly telephone contact with no active intervention and both interventions lasted 15 weeks. All participants (n = 85) were aged 60 years and above and were diagnosed with GAD. The CBT participants reported significant improvements in worry, anxiety, depression and quality of life in comparison to the MCC group. At the end of treatment 45 % of the CBT group in comparison to 8 % of the MCC group met classification as treatment responders. While those participants who made gains maintained these at one-year follow-up Stanley et al. (2003) note that post-treatment anxiety scores failed to return to normative levels. Currently work by this group of researchers is still in progress.

Overall, there are insufficient evaluations to reach a conclusion on the merits of psychological treatments for anxiety disorders in late life. Nonetheless, the data presented so far would suggest some optimism about the applicability of psychological treatments, essentially cognitive-behavioural interventions, for late-life anxiety, especially if one takes account of case reports (for review see Stanley & Beck, 2000). The development of efficacious psychological approaches for late-life anxiety is particularly welcomed because anxiety is a significant cause of emotional distress for a substantial minority of older people (Kogan et al., 2000; Stanley & Averill, 1999). While there is much still to be evaluated, there are enough indications to suggest that with more high quality studies, cognitive behaviour therapy is likely to become a welcome addition to the treatment options available for late-life anxiety disorders. This is especially important as Nordhus & Pallesen (2003) comment that pharmacotherapy treatments for anxiety are traditionally seen as less desirable for use with older people.

Psychological Therapy for Late-life Depression

Psychological treatments for depression have been more systematically evaluated than the anxiety disorders (Gatz et al., 1998; Powers et al., 2002; Woods & Roth, 1996). In recognition of the larger amount of systematic research carried out for late-life depression, this section separately evaluates the evidence for cognitive-behaviour therapy, interpersonal therapy and psychodynamic psychotherapy. Meta-analytical data are considered in the evaluation of psychotherapy for late-life depression prior to an in-depth analysis of individual and group evaluations of psychosocial treatments for late-life depression.

Meta-Analytic Review of Psychological Treatment for Late-life Depression

Scogin & McElreath (1994) produced the first meta-analysis of the efficacy for psychosocial treatments in late-life depression. Scogin & McElreath (1994) included 17 studies published from 1975 to 1990. In their analyses they reported mean effect sizes for treatment versus no treatment or placebo of 0.78, similar to effect sizes of 0.73 reported by Robinson et al. (1990) in their review of psychotherapy for depression across all age ranges. Scogin & McElreath (1994) also carried out separate analyses using a subset of studies satisfying diagnostic criteria for major depressive disorder and reported an effect size of 0.76. They also calculated a mean effect size of 0.3 when comparing cognitive and behavioural therapies with other psychosocial treatments. They investigated treatment delivery methods and reported a mean effect size of 0.74 for group treatments and a mean effect size of 0.77 for individual treatments. Despite the clear superiority of psychological treatments versus no treatment, there was no evidence to support the superiority of any single treatment modality or method of treatment delivery.

Scogin & McElreath (1994) note that in their meta-analyses they used a relatively small number of studies with small sample sizes to determine their effect sizes but nonetheless state that their effect size calculations are consistent with other published studies. Laidlaw (2001,2003) considered Scogin & McElreath (1994) to have included too broad a definition of psychosocial treatments and considered this overly inclusive. In addition it is questionable whether combining markedly different treatments (psychodynamic psychotherapy and behaviour therapy) together to derive a single composite measure of effect is justifiable. Nonetheless, Scogin & McElreath (1994) produced a timely and comprehensive analysis demonstrating the efficacy of psychosocial treatments for older adults at a time when this was being questioned (Zeiss & Breckenridge, 1996).

A more focused meta-analysis was published by Koder, Brodaty & Anstey (1996) evaluating cognitive therapy for the treatment of depression in older adults. They identified seven treatment comparison studies published from 1981 to 1994. There were marked methodological differences between these studies with different recruitment sources, and different methods of treatment delivery (three out of the seven used individual rather than group treatment). Three of these seven studies favoured CT over other treatment modalities, three failed to find significant treatment differences between modalities and one study was positive for some aspects of cognitive treatment. Out of the seven studies included in the Koder, Brodaty & Anstey (1996) analyses, only four provided sufficient BDI information to permit effect size comparisons across treatment modality. Koder, Brodaty & Anstey (1996) report mean effect sizes of 0.41 in favour of cognitive therapy compared to psychodynamic psychotherapy in four studies. A mean effect size of 1.22 in favour of cognitive therapy compared to a waiting-list control group was reported in two studies. Obviously this meta-analysis merely provides indications given that such a small number of studies were included in their calculations. Koder, Brodaty & Anstey (1996) correctly concluded that although there were too few studies of sufficient scientific and methodological merit upon which a definitive conclusion could be reached over the relative efficacy of cognitive therapy over other treatment modalities, cognitive therapy is nevertheless an effective treatment procedure for late-life depression.

Engels & Verney (1997) reviewed 17 psychological outcome studies for late-life depression published from 1974 to 1992. Like the studies used by Scogin & McElreath (1994), treatments were broadly psychosocial and including cognitive therapy, behaviour therapy, psychodynamic therapy, bibliotherapy, reminiscence/life review, music therapy, physical training and anger expression. The calculation of a combined mean effect size for the range of therapies used by Engels & Verney (1997) in their analyses meets with the same objections raised in relation to the Scogin & McElreath (1994) study. The mean effect size calculated in this meta-analysis was moderate at 0.63, although lower than other reported effect sizes. On average older adults receiving psychosocial treatment for depression are better off than 74 % of older people not receiving treatment. Not all of the studies included in the analysis by Engels & Verney (1997) had control conditions but, of the 13 studies that did include a control, a mean effect size of 0.52 was reported in favour of the psychosocial treatments. Cognitive therapy and behavioural therapy were the most effective treatments with mean effect sizes of 0.78 and 0.85 respectively. A surprising result showing that combined cognitive and behavioural therapy (CBT) was less effective than either cognitive treatment or behavioural therapy alone may be explained by an idiosyncratic definition for CBT. Engels & Verney (1997) characterized studies as purely cognitive when they are probably more accurately described as cognitive-behavioural. For example, studies published by Gallagher-Thompson, Thompson and colleagues are considered to be cognitive therapy by Engels & Verney (1997) when in fact they would certainly consider their approach to be more accurately labelled CBT as they generally stress the behavioural components of treatment within a framework of cognitive strategies (Thompson and Gallagher-Thompson, personal communication).

An interesting finding by Engels & Verney (1997) is that individual therapy is more efficacious than group therapy for late-life depression with older adults. This would appear to be particularly so for cognitive and behavioural treatments. Overall in this meta-analysis, psychotherapy with older adults appears to be most efficacious when the diagnosis is major depression or depression rather than multiple complaints. Psychosocial treatments appeared equally efficacious regardless of the severity of depression. Overall, Engels & Verney (1997) report a meta-analysis that produces interesting results on variables of high importance to practising psychotherapists (for example, type of therapy, mode of delivery, severity, diagnosis, age, gender, and so forth) but the inclusion of markedly different treatments combined to produce a mean effect size is likely to confuse rather than clarify issues of differential effectiveness of psychological treatments for late-life depression.

While meta-analyses reported thus far have considered psychosocial treatments, Gerson et al. (1999) investigated the effectiveness of pharmacological and psychological treatments for depression in older people. Gerson etal. (1999) reviewed 45 studies published from 1974 to 1998. Four of these used non-drug (psychological) methods of treatment for depression in later life. All patients were diagnosed with major depressive disorder and to be included in the analyses had to report outcomes using observer-rated data as well as self-report. Gerson et al. (1999) also used stricter inclusion criteria for their analyses, such as a minimum of 15 patients in each treatment group, description of dose regime in both treatment and control groups, documentation of side-effects by self-report or questionnaire, specification of attrition rates and, lastly, statistical evaluation. Using the stricter criteria reduced the number of studies entered into the meta-analysis to 28, two of which used psychological methods of treatment.

The results of Gerson et al. 's meta-analyses were identical using either criteria (inclusive versus strict) in that pharmacological and psychological treatments for major depressive disorder in late life were equally efficacious. There were no significant differences in the relative reduction on quantitative measures of mood between treatments with a 54 % reduction in pre-post treatment scores for the drug studies and a 51 % reduction in pre-post treatment scores for the psychotherapy studies. Analyses also revealed no significant difference in attrition rates between pharmacological and psychological treatments (29.2 % and 29.4 % respectively). Gerson et al. (1999) noted that both pharmacotherapy and psychotherapy were superior to placebo. In a very well written and thoughtful conclusion Gerson etal. (1999) state

Effective psychological interventions constitute a much-needed addition to antidepressant medication for depressed older patients, particularly in light of these patients' high prevalence of medical problems, their use of multiple medications, their increased sensitivity to adverse drug effects, and the many psychological stresses to which they are exposed.

Cognitive Behaviour Therapy for Late-life Depression

Cognitive-behaviour therapy (CBT) is an active, directive time-limited and structured treatment approach whose primary aim is symptom reduction (Laidlaw et al., 2003). It can be differentiated from other forms of psychotherapy by its emphasis on the empirical investigation of the patient's thoughts, appraisals, inferences and assumptions. The most basic premise of CBT is that the way in which people feel and behave determines the way that they think and make sense of their experiences. This premise has historical roots in the writings of Greek philosophers such as Epictetus who wrote 'Men are disturbed not by things, but by the views which they take of them.'

Cognitive behavioural therapy works best when clear goals are set. An important element is the use of problem-focussed strategies for helping older people deal with their current concerns. The problem-focus orientation is important as this makes CBT particularly appropriate for use with older people dealing with current concerns (Laidlaw et al., 2004). In many instances CBT techniques are used to assist an older adult in rediscovering old tricks rather than learning new ones (Thompson, 1996).

Since 1982 there have been nine systematic outcome studies looking at CBT as a treatment for late-life depression; four of these studies use individual CBT and are the product of one research group based at Stanford University in California (Gallagher & Thompson, 1983; Gallagher-Thompson, Hanley-Peterson & Thompson, 1990; Thompson et al., 2001; Thompson, Gallagher & Breckenridge, 1987). Five other systematic evaluations have also been carried out into the efficacy of group based CBT for depression (Arean et al., 1993; Beutler et al., 1987; Kemp, Corgiat & Gill, 1991/2; Rokke, Tomhave & Jocic, 2000; Steuer et al., 1984).

Individual CBT for Late-life Depression

Gallagher & Thompson (1983) produced the first systematic evaluation of CBT for late-life depression, and assigned 30 participants to one of three possible treatment conditions: behavioural, cognitive or psychodynamic (insight-oriented) psychotherapy. Treatment consisted of 16 sessions delivered over 12 weeks. The cognitive treatment followed the approach of Beck et al. (1979) whereas the behavioural treatment component used the approach of Lewinsohn et al. (1978) and emphasized activity scheduling of pleasant activities. The insight-oriented approach was heavily influenced by traditional psychodynamic theories and emphasized the use of the therapeutic relationship as a vehicle for change (Gallagher & Thompson, 1983). All three treatment approaches were equally efficacious, despite apparent differences in treatment content and style. Gallagher & Thompson (1983) noted that participants considered to have an 'endogenous' type of depression achieved a poorer outcome at the end of therapy.

In a later study that adopted the design used in their previous study, Thompson, Gallagher & Breckenridge (1987) randomized 91 out-patients diagnosed with major depressive disorder to one of the three treatment conditions; cognitive, behavioural and insight-oriented psychotherapy. Each treatment condition was identical to that described in Gallagher & Thompson (1983). As before, participants acted as their own treatment controls by the use of a six-week delayed treatment waiting-list control condition, with time treatment consisting of 16 to 20 sessions of therapy over 16 weeks. Overall the three treatment modalities produced a significant treatment effect compared with the waiting-list control condition, with 52 % of the sample overall achieving remission of symptoms at the end of treatment. A further 12 % of participants reported substantial improvements by the end of treatment, resulting in a positive treatment response overall for 70 % of participants overall. There were no significant differences noticeable between the three treatment modalities with positive treatment responses for cognitive, behavioural and insight-oriented interventions of 62 %, 80 % and 70 % respectively.

Regarding two-year follow-up, Gallagher-Thompson, Hanley-Peterson & Thompson (1990) reported that gains made initially by patients were maintained at one year follow-up with 52 %, 58 % and 72 % of patients who received cognitive, behavioural and psycho-dynamic treatments respectively remaining depression free. Of the initial 52 % who had achieved remission in the Thompson, Gallagher & Breckenridge (1987) study, 83 % were depression free at one-year follow-up, with 53 % of these participants remaining in remission for the whole year. At two-year follow-up, 77 % of participants were still depression free. Gallagher-Thompson et al. (1990) note that gains were maintained in a population that is likely to experience an increased frequency of life events and thus the effectiveness of psychotherapy is that participants learn specific skills that are useful later in dealing with depressogenic stressors. The prognosis at two-year follow-up for those participants who did not respond to treatment was poor.

Thompson et al. (2001) randomized 100 out-patients diagnosed with major depressive disorder to one of the three treatment conditions: CBT alone, Desipramine (an antidepres-sant) medication (ADM) alone and combined CBT/ADM. In each case treatment lasted three to four months and in the CBT condition participants received 16 to 20 sessions. All participants in the three treatment conditions showed substantial improvements, with the combined CBT/ADM group reporting the greatest improvement. When the sample was split into high and low levels of depression severity, the CBT/ADM combined condition proved to be a superior treatment for depression in comparison to ADM alone but was equivalent to CBT alone (i.e CBT/ADM = CBT alone > ADM alone). However this finding was inconsistent as those participants who were on higher levels of medication and considered to be more severely depressed appeared to do best with CBT/ADM combined overall.

In summary, there are strong grounds to recommend individual CBT as an efficacious treatment for late-life depression. Cognitive-behaviour therapy alone is a good treatment alternative for those patients who cannot tolerate medication, or for those older adults who do not wish to be prescribed antidepressants. For more severe levels of depression, there is evidence that CBT in combination with adequate dosages of medication constitutes an appropriate treatment regime (Gerson et al., 1999; Thompson et al., 2001). The main criticism is that the evaluations of individual CBT have mainly been carried out on healthy, community-dwelling older adults who are mainly young-old rather than old-old. Another major criticism of CBT for late-life depression is that research has largely focused on outcome, while generally ignoring the importance of process issues (see Laidlaw et al., 2004, for a fuller discussion of this issue).

Group-based CBT for Late-life Depression

Steuer et al. (1984) reported on a treatment comparison between CBT and psychodynamic psychotherapy for late-life depression. Thirty-three participants were enrolled into the research with 20 completing treatment. Seventy-six per cent of participants were female. Steuer et al. (1984) had a nine-month treatment period and on average participants attended 37.5 sessions. Of those who completed treatment, 80 % reported improvement, with 40 % in remission of depression. Overall 27 % of those participants entering treatment achieved remission of symptoms. Give that at the end of treatment there were only 10 participants in each treatment group, Steuer et al. (1984) rightly urge caution when considering the differential effectiveness of each treatment. Cognitive-behaviour therapy was more effective than the psychodynamic treatment when using the BDI as the main criterion for measuring change. However, Steuer et al. (1984) state that for each treatment condition there were comparable numbers who achieved remission.

Beutler et al. (1987) investigated the effectiveness of alprazolam compared with group cognitive therapy. Fifty-six participants were randomly assigned to one of four treatment conditions: alprazolam and support only, CBT and alprazolam and support, placebo and support only, CBT and support and placebo. Cognitive-behaviour therapy plus alprazolam and placebo produced the largest effect sizes of all treatment combinations using BDI self-report scores of participants. Cognitive therapy plus support and placebo appeared more efficacious in comparison to cognitive therapy in combination with medication in this study. It is interesting that this study had very high attrition rates for medication groups - double that of non-medication treatment groups. This result perhaps indicates that the side effects of medication proved intolerable to patients in this trial or that this medication was not appropriate for this study. As Woods & Roth (1996) state, this study is very difficult to evaluate, especially as Alprazolam is not widely used as an antidepressant.

Kemp, Corgiat & Gill (1991/2) carried out a 12-week group cognitive therapy intervention and compared individuals with and without disabling illnesses. Fifty-one participants started treatment with 41 completing treatment. Of those completing treatment, 18 had chronic disabling illnesses that limited activities of daily living. The remaining 23 participants did not have a disabling illness although some did have chronic non-limiting medical conditions. All participants met diagnostic criteria for major depressive disorder. Both groups benefited from the intervention but the non-disabled group continued to improve at six months' follow-up whereas the disabled group maintained gains but did not improve further. As Kemp et al. (1991/2) note, these results are very encouraging as they counter the belief that older people with disabling conditions who are depressed are unlikely to benefit from psychotherapy.

Arean et al. (1993) randomized 75 participants diagnosed with major depressive disorder to one of three treatment conditions: cognitive behavioural problem-solving therapy, life review/reminiscence and a waiting-list control condition. Treatment took place over 12 weeks and each session lasted for 90 minutes. Waiting list controls received treatment after 12 weeks. Both active treatment conditions proved efficacious although problem solving appears to result in better outcome than life review/reminiscence when comparing scores on the Hamilton Rating Scale for Depression and the Geriatric Depression rating scale but not on the BDI. The waiting-list control group showed no evidence of spontaneous improvement. Arean et al. (1993) note that significantly fewer participants in the problem-solving group remained depressed (11 %) in comparison to those in the life review/reminiscence group (60 %). Notably this is one of the few psychological comparison studies to show differential effectiveness between active treatments.

Rokke, Tomhave & Jocic (2000) randomized 34 participants diagnosed with major depressive disorder to one of three treatment conditions: self-management therapy and education and support and a waiting-list control condition. Self-management therapy required participants to monitor mood and activities on a daily basis. The education and support group was provided with information about depression and therapy procedures; participants were also encouraged to talk about their problems and to offer constructive support to one another. Each treatment session lasted for 90 minutes and took place over a 10-week course. Overall, 89 % of participants registered an improvement in depression diagnostic status at the end of treatment. Rokke, Tomhave & Jocic (2000) state that 71 % of the self-management group and 62 % of the education/support group achieved clinically significant reductions in depressive symptoms. The education/support group as originally conceived by Rokke, Tomhave & Jocic (2000) was to be a psychological placebo in that it provided an attention control and expectancy for outcome control comparison to the self-management group. Rokke, Tomhave & Jocic (2000) noted that psychoeducation delivered in a supportive environment can constitute a useful and helpful treatment.

In summary, group-based CBT can take many forms and in some circumstances could be considered to constitute a different type of CBT (see Malik et al., 2003). Although there have been some suggestions that group treatments would provide a superior therapeutic supportive environment for older people, especially those living alone, this is not supported by the empirical evidence for group-based CBT (see Engels & Verney, 1997). As Karel & Hinrichsen (2000) note, some older people may feel more uncomfortable with the process of group therapy and it may not be flexible enough to meet the cognitive and emotional needs of all older participants. Despite this, Arean et al. (1993) manage to produce the only evidence of differential effectiveness between psychological treatments. This is a rare finding and suggests that older people especially respond to the common-sense approach evident in problem-solving therapy.

Interpersonal Psychotherapy for Late-life Depression

Interpersonal psychotherapy (IPT) is a short-term focussed treatment programme for depression (Weissman, Markowitz & Klerman, 2000). It recognizes that many of the stressors that may predispose an individual to develop depression are interpersonal in nature (Karel & Hinrichsen, 2000). Frank etal. (1993) developed it as a treatment for late-life depression. Sholomskas et al. (1993) state that although IPT is easily applicable with older people, there are three main considerations to take into account. The IPT therapist needs to adopt an active non-neutral stance in therapy. The IPT therapist may need to take the lead in finding solutions for the patient. And in some circumstances, the problems facing the older adults may not be amenable to resolution and a process of acceptance may be appropriate (see also Frank et al., 1993, for a fuller review).

Interpersonal psychotherapy focusses on four main problem areas in its treatment approach to depression, these are:

• interpersonal disputes (conflict with significant others);

• role transitions (changes in a significant life situation); and

• interpersonal deficits (problems with an individual initiating, maintaining or sustaining relationships).

A number of authors have argued that IPT is a form of psychotherapy particularly well suited to use with older adults (Frank et al., 1993; Hinrichsen, 1999; Karel & Hinrichsen, 2000; Miller et al., 1998; Miller & Silberman, 1996). Hinrichsen (1999) notes that as late life is a time of change and adjustment, many older people will be dealing with the loss of a spouse, many will be negotiating changes in the nature of their relationships with friends, spouses and adult children and many will be dealing with role transitions due to retirement or adjustments to functional health status, these are stressors that are very interpersonal in nature. Miller & Silberman (1996) state that IPT is relevant to late-life depression because it is a time-limited, practical and goal-oriented therapy with a focus on the 'here and now'. As described by Miller & Silberman (1996) IPT and CBT share many features in terms of their relevance as treatments for late-life depression and indeed the characterization of IPT as an appropriate treatment procedure for older adults is very similar to that specified by Morris & Morris (1991).

The main empirical evidence for IPT's efficacy as a treatment for late-life depression comes from the Maintenance in Late-Life Depression Study (MTLLD) (Frank et al., 1993; Miller et al., 1998; Reynolds et al., 1999a, 1999b). This study was designed to reduce high rates of depression relapse in late-life depression. Interpersonal psychotherapy and nor-triptyline (NT) in combination are evaluated as maintenance treatments for older adults with a high risk of recurrent major depressive disorder. The basic design (see Miller et al., 1998) is that in the acute phase of treatment participants receive combined IPT and NT, and once remission has been achieved they are randomized for a three-year follow-up of NT or placebo in combination with either IPT or medication check contact. Miller et al. (1998) report limited interim results on 127 participants and state that 81 % showed a full response to combined treatment in the acute phase of the study.

Reynolds et al. (1999a) report on the use of nortriptyline (NT) and IPT alone and in combination as a treatment for bereavement-related depression. Eighty participants were randomly assigned to one of four treatments: NT plus IPT, NT alone, placebo plus IPT, and placebo alone. The use of IPT plus NT was associated with lowest attrition rate and highest remission rate. The rate of remission for IPT plus NT was 69 %; for NT alone it was 56 %; for placebo alone it was 45 % and for IPT plus placebo the remission rate was 29 %. Although the numbers were small in this study when broken down into four groups, IPT was not superior to placebo whereas NT was.

Reynolds et al. (1999b) investigated the efficacy of maintenance nortriptyline (NT) and IPT for the prevention of recurrence of depression. Over a seven-year period, 187 participants were recruited. As with the design outlined by Miller et al. (1998), all participants received combined IPT and NT during the acute phase of depression until remission was achieved. Reynolds et al. (1999b) note that 18 % of participants failed to achieve remission and a small number of participants relapsed prior to the maintenance phase of treatment, leaving 107 participants in total who began the second phase of treatment. Participants who achieved remission were the randomly assigned to one of four treatment conditions: NT plus IPT, NT alone, placebo plus IPT, and placebo alone. The best outcome was achieved in the NT/IPT combination treatment as 80 % of participants remained depression-free. Recurrence rates of depression over three years are reported by Reynolds et al. (1999b) and are as follows: rate of recurrence for IPT plus NT was 20 %, for NT alone it was 43 %, for IPT plus placebo it was 64 %, and for placebo alone it was 90 %.

In summary, the Maintenance in Late-Life Depression Study (MTLLD) is potentially very important in evaluating the efficacy of a psychosocial treatment as a maintenance treatment for late-life depression. Although the number of studies that evaluate IPT alone is severely limited the evidence suggesting that combined medication and IPT is efficacious is potentially very exciting. The questions remain as to the efficacy of IPT in comparison with the placebo condition in the MTLLD is disappointing. Overall there are not enough studies completed at this time to properly evaluate the efficacy of IPT as a treatment for late-life depression.

Psychodynamic Psychotherapy for Late-life Depression

There is no one single form of psychodynamic psychotherapy with older people (Gatz et al., 1998; Karel & Hinrichsen, 2000; Knight, 1996) and the term can be interpreted very broadly, although any psychodynamic approach tends to focus on the therapeutic relationship and uses of transference and counter-transference (Knight, 2004). Freud's view that people over the age of 50 were uneducable has in many ways prevented psychodynamic approaches being applied for the treatment of depression in older adults. As Steuer (1982) points out, not all the early pioneers of psychodynamic theory held such ageist attitudes. In fact, the work of Eriksson recognized that there was a lot of potential for psychological growth and development in later life. Jung saw the purpose of later life as individuation or integrating previously unacknowledged or unconscious aspects of the psyche (Steuer, 1982). There are a number of commonalities amongst the various forms of psychodynamic psychotherapy, such as an emphasis on the role of unresolved developmental issues for the later developmental of psychopathology or difficulties in coping and an emphasis on the curative aspects of a corrective emotional relationship between patient and therapist (Nordhus & Neilson, 1999). In many descriptions of psychodynamic psychotherapy with older people, transference and countertransference are considered to be important (Gallagher & Thompson, 1983; Gatz et al., 1998; Karel & Hinrichsen, 2000; Nordhus & Neilson, 1999; Steuer, 1982).

A lot of the empirical support for psychodynamic psychotherapy with older people comes, surprisingly, from research carried out in CBT treatment trials as noted above (Beutler et al., 1987; Gallagher & Thompson, 1983; Steuer et al., 1984; Thompson, Gallagher & Breckenridge, 1987). In the research trials carried out by the Thompson group, the form of psychodynamic psychotherapy used in their treatment trials was broadly as effective as cognitive or behavioural treatments. Steuer et al. (1984) concluded that psychodynamic and cognitive treatments were equally efficacious for the treatment of depression in older adults. In general, the meta-analysis literature provides empirical support for the use of psychodynamic approaches for the treatment of depression in older adults as results suggest equivalence in outcome between different forms of psychological treatments (Engels & Verney, 1997; Scogin & McElreath, 1994). Of course Koder et al. (1996) did note that CBT produced small to medium effect sizes in comparison to psychodynamic psychotherapy, this analysis was based upon very small numbers of studies.

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