Psychotherapy and Combined Therapy for Depressive Disorders in Later Life

In 2001, a panel of experts led by George S. Alexopoulos, M.D., compiled a consensus guideline for the pharmacotherapy of depressive disorders in older patients. In contrast to typical current practice, the panel's treatment recommendations gave a prominent role to psychotherapy administered alone or in combination with antidepressant medications for several patient groups. The consensus guideline recommended psychotherapy alone as a first-line treatment choice for minor depression that failed to respond to two weeks of "education and watchful waiting" and considered psychotherapy co-administered with antidepressant medication the preferred treatment for either dysthymic disorder or unipolar nonpsychotic major depressive disorder (MDD). For unipolar psychotic MDD, medication or electroconvulsive therapy were the preferred approaches, with inclusion of co-administered medication and psychotherapy as an alternate approach. The prominent inclusion of this treatment modality, which is too often underused with older patients, prompts the following comments on psychotherapy and combined treatment in older adults with depression.

During the past two decades, after a long period of relative neglect, geriatric psychotherapy has begun to receive consistent and supportive attention in the psychiatric literature. A variety of factors, not the least of which is a tradition of ageism, had preceded the current renaissance of interest. Sigmund Freud himself at the age of 68 dismissed the adult over 50 as no longer possessing the mental elasticity to benefit from psychotherapy (Freud, 1924). Older adults themselves often resist the suggestion of psychotherapy, which they may equate with psychoanalysis--the treatment popularized during their younger adulthood and still synonymous for many with psychotherapy.

For the current cohort of older adults, the idea of psychotherapy may conjure up images of the analytic couch and apprehension that events long past will need to be unearthed and re-examined. Looking back may evoke painful memories of the Great Depression or World War II. Moreover, anyone who has worked with older patients has most likely heard the all too familiar refrain: "You can't teach an old dog new tricks," and "What's the use anyway?" Older adults can feel both damaged and deprived by time; the past has taken its toll, and the future is painfully finite. But perhaps the most powerful barrier to psychotherapy among older adults is the stigma they tend to associate with mental illness: For many, the term harks back to an era when psychiatric units were filled with acutely manic or heavily sedated psychotic patients who were confined for months or even years to a hospital or sanitarium while recovering from a nervous breakdown.

Combined Treatment

The well-known development of pharmacologic approaches to treating depression since the late 1950s has been paralleled by a lesser-known refinement of psychotherapeutic approaches that can be provided alone or co-administered with antidepressants. Following the Freudians and neo-Freudians came the forerunners of Beck and colleagues' (1979) cognitive therapy: behavior modification (Wolpe, 1969) and cognitive modification (Meichenbaum, 1972). Less widely known in the lay press but empirically robust in the psychiatric literature are such interventions as problem-solving therapy (Nezu, 1986) and interpersonal therapy (IPT) (Klerman et al., 1984). Interpersonal therapy in fact was the treatment administered in one of the landmark treatment studies of geriatric depression in the last decade.

Reynolds et al. (1999) followed a group of older adults with depression for several months of medication clinic with nortriptyline (Aventyl, Pamelor), medication clinic with placebo, monthly maintenance IPT with nortriptyline, and nortriptyline or monthly maintenance IPT with placebo followed by three years of maintenance treatment. Time to recurrence of a major depressive episode was significantly better for all three active groups than placebo. Recurrence rates over three years were 20% in the nortriptyline plus IPT group, 43% in the nortriptyline group, 64% in the IPT plus placebo group and 90% in the placebo group.

In a later study, Lenze et al. (2002) found that patients over 60 recovering from recurrent major depression who had received both nortriptyline and IPT were able to maintain better social adjustment after one year than patients receiving monotherapy of either type.

Despite the growing interest in psychotherapy for older adults, studies of efficacy of either psychotherapy alone or combined treatments for older patients are still limited in number, and more attention to the issue is needed. A meta-analysis of 17 published studies of the efficacy of various forms of psychotherapy with older patients with depression in the absence of medication found an overall mean effect size of 0.78 compared to no treatment and to placebo control groups over all levels of depression (Scogin and McElreath, 1994). A review of the literature on pharmacological and psychological treatments for older patients with depression from 1974 to 1998 produced two interesting findings: no single drug or group of antidepressant drugs was superior in terms of efficacy; and response rates to non-drug therapies such as cognitive-behavioral, behavioral and psychodynamic therapies were better than placebo and did not differ significantly from psychopharmacological treatments in their efficacy (Gerson et al., 1999). The authors pointed out that differentiating more specifically among the subtypes of depression might further refine their limited conclusions. Consistent with that suggestion, Alexopoulos et al. (2003) demonstrated the power of problem-solving therapy even when delivered without pharmacotherapy to treat major depression in older adults with executive dysfunction.

The co-administration of pharmacotherapy and psychotherapy (i.e., combined treatment) has gained acknowledgement as a superior approach for many younger adults with depression (Thase et al., 1997). One might wonder if there is any reason to suspect that combined treatment has less value in treating older patients or that psychotherapy is less effective among older than younger adults. Although a number of studies clearly demonstrate the efficacy of psychotherapy for older adults, only a few have contrasted the responsiveness of different age groups within the same study. The results from these studies suggest at least that combined treatment retains efficacy among older patients. Reynolds et al. (1996), for example, found no significant difference between elderly (mean age=67.9) and midlife (mean age=38.5) patients in responsiveness to the combination of IPT plus a tricyclic antidepressant (nortriptyline for the elderly, imipramine [Tofranil] for the midlife patients), although the midlife patients showed a more rapid recovery. In a related subsequent study, the results for patients older than 70 demonstrated a positive short-term response but noted a significantly higher long-term relapse than for younger groups (Reynolds et al., 1999).

Positive results notwithstanding, the administration of either psychotherapy or pharmacotherapy to older adults may be met with resistance from a variety of sources. The problem of nonadherence to an antidepressant regimen highlights one of the important complementary interactions of these two treatment approaches. In addition to many practical obstacles to adherence, such as the high cost of pharmaceuticals in the context of limited income and insurance coverage, psychological factors also undermine adherence. The association of psychotropic medication with mental illness and all the attendant negative connotations, the loss of control involved in the ingestion of a prescribed medication, the unavoidable confrontation of illness and/or physical decline implicit in taking "one more pill," the realization that permanent reliance on antidepressant medication may be necessary to reduce the risk of future depressive episodes, and the negative effects of depressive self-assessments on self-esteem are all significant psychological barriers to medication adherence. Combined treatment or, at a minimum, extra attention to psychoeducation about depression and its treatment can work to overcome these barriers and facilitate treatment. Psychoeducation alone, which can be provided in a primary care setting by a physician's assistant or nurse practitioner if a psychotherapist is not available or acceptable, should address the older adult's view of depression as a weakness rather than as simply an illness, the importance of medication compliance and any misconceptions about the nature of the psychotherapeutic process.

Case Study

The following case study illustrates some aspects of both the complexity and the feasibility of offering psychotherapy in combination with medications in treating an older adult with depression.

"Ms. O" is a 71-year-old widow who has suffered for the past 16 years from recurrent MDD. Her first episode of depression followed the simultaneous occurrence of her husband's sudden death and her own job loss. Ms. O, who had a significant family history of mood disorders, took antidepressant medication for a number of years under the care of a psychiatrist who saw her approximately bimonthly. During this time she was admitted repeatedly to the same psychiatric unit for suicidal ideation, with an actual suicide attempt on one occasion.

During her latest admission, a major re-evaluation of her pharmacotherapy was initiated and she received, for the first time, a form of cognitive-behavioral therapy (CBT) adapted for older adults. At first, Ms. O was skeptical about beginning a course of psychotherapy. Having taken a college psychology course in the early 1950s she thought of psychotherapy as equivalent to psychoanalysis and did not see the relevance of "talk therapy" to her condition. An explanation of the therapeutic process, however, emphasized how CBT would focus on her current thought processes with only brief forays into the distant past. The therapist's identification of specific and realistic therapeutic goals proved reassuring enough that she was willing to begin. Therapy with Ms. O involved a frank examination of her maladaptive cognitions, repeated exploration of alternative cognitions and practice in cognitive restructuring.

Ms. O's natural intelligence and her strong alliance with her therapist, who continued with her through successive stages of care at the same facility, maximized her use of the process.

With the help of her therapist, Ms. O identified a connection between her suicidal ideation and feelings of anger that, because of family dynamics, had been distressing for her to experience or express. She was helped by interpretation of her self-destructive thoughts as anger turned against herself, and by correction of her cognitive distortions regarding the triggers of her anger and the power of her feelings. She was able to switch from thinking of her anger as uncontrollable and destructive to viewing it as a helpful indication of an internal need state. She was also prescribed behavioral steps to increase her assertiveness to better meet her needs.

Concurrent with her psychotherapy sessions, Ms. O received antidepressant and low-dose antipsychotic medications. After discharge from the hospital she continued her psychotherapeutic work and remained in treatment for over a year with very positive results. On a few occasions, feeling "well," Ms. O attempted to "cut back" on her psychotherapy and, on other occasions, negotiated a change in medication with her psychopharmacologist. Ironically, her resistance to psychotherapy seemed on occasion to flare up when she felt some degree of benefit, as she feared her dependency on the process. She eventually began, however, to see a palpable benefit from continuing both psychotherapy and medication. What she learned about her resistance to treatment in psychotherapy added an extra dimension to simple psychoeducation about the importance of adherence to a medication regimen. In addressing feelings about her treatment, she also gained experience in problem solving and in cognitive restructuring. These skills served her well in other areas of her life.

Conclusion

Although practical barriers may on occasion make an integrated treatment impractical, the combination of psychotherapy with antidepressant medication should increasingly be recognized as a standard for effective treatment of older adults with minor or major depressions. The recent resurgence in enthusiasm for psychotherapy training among psychiatric residents as well as new geriatric specialty training programs for nurses, social workers or psychologists offer hope that an increasing number of appropriately trained psychotherapists may become available. By increasing mental health and primary care awareness of the potential value of combined treatment, practice can be brought into conformance with expert consensus recommendations, and psychotherapy co-administered with pharmacotherapy can become a standard treatment approach for depressive disorders in the later years.

References:

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