Geriatric psychiatric disorders usually occur in the context of medical illness, disability, and psychosocial impoverishment. Preliminary evidence suggests that psychotherapy can reduce not only psychopathology but also physical complaints, pain, and disability and that it can improve compliance with medical regimens. Psychotherapy has been found effective in treatment of depression related to bereavement and caregiver burden.
Psychosocial intervention models need to be developed and tested to integrate psychotherapy and other mental health services in primary care settings so that timely and appropriately targeted interventions can be provided.
Psychotherapy and other psychosocial interventions may help elderly patients cope with late-life stressors, such as loss of loved ones and increases in functional disability, which contribute to the development of psychopathology and influence its course.
Most elderly patients with psychiatric symptoms or disorders are treated by primary care physicians (1,2). Recognition of psychiatric symptoms and syndromes may be complicated by comorbid medical disorders, the attitudes of patients and physicians, and other factors (3,4,5). Therefore, studies that examine the delivery of psychotherapy in the primary care setting may offer information important for designing a sound health care system for elderly persons.
Research on psychotherapy with elderly patients is limited, although most findings suggest that psychotherapy is effective for this group of patients. This paper highlights the existing knowledge about the use of psychosocial interventions with elderly patients and discusses directions for future practice and research that may improve the care of the elderly population.
Short term psychotherapeutic approaches
Short term psychotherapies, typically based on treatment manuals, target the stressors and losses common in late life with an aim of reducing psychopathology and enhancing the quality of life. In a meta-analysis of 17 studies of cognitive, behavioral, supportive, interpersonal, reminiscence, and eclectic psychosocial interventions for late-life depression, treatment was found to be more effective than no treatment or placebo. The efficacy of diverse psychotherapeutic approaches may in part be explained by the presence of common elements among the various treatments (8).
The goals of cognitive-behavioral therapy are to change thoughts, improve skills, and modify emotional states that contribute to psychopathology. Cognitive, behavioral, and brief psychodynamic therapies were shown to reduce depressive symptoms among 70 percent of elderly patients (9). In a two-year follow-up study, 70 percent of these patients maintained treatment gains and no longer met criteria for major depression (10).
In a trial with depressed older adults were randomly assigned to receive cognitive group therapy and alprazolam, cognitive group therapy and placebo, placebo alone, or alprazolam alone. The groups who received cognitive therapy had greater improvement in depressed mood and sleep efficiency than the groups who received alprazolam alone or placebo. The gains from treatment were evident three months later. The efficacy of cognitive-behavioral therapy has also been demonstrated in the treatment of other geriatric disorders, including anxiety disorders, insomnia, and the behavioral and mood symptoms of demented patients (11, 12).
Problem-solving therapy posits that deficiencies in social problem-solving skills increase vulnerability to depression and other psychiatric symptoms. Improvement in problem-solving skills is assumed to make elderly patients better able to cope with current and future difficulties and less likely to develop psychopathology (13).
Problem-solving therapy has been found to be effective in the treatment of depression of geriatric patients and other medical patients. Elderly patients who participated in problem-solving therapy and reminiscence therapy had reduced depressive symptoms and signs, compared with those who were placed on a waiting list. However, problem-solving therapy led to greater improvement than reminiscence therapy.
In a study of depressed younger primary care patients, six sessions of problem-solving therapy were found to be as effective as compared to anti depressants and were associated with greater compliance with treatment (15). Finally, a randomized clinical trial involving terminally ill patients demonstrated that problem-solving therapy is both feasible and acceptable despite some practical difficulties with its implementation (16).
Interpersonal psychotherapy, developed as a time-limited treatment for mid-life depression, focuses on grief, role disputes, role transitions, and interpersonal deficits (17). Interpersonal psychotherapy is likely to be a meaningful treatment for patients with late-life depression, which is associated with multiple losses, role changes, social isolation, and helplessness.
Interpersonal psychotherapy combined with nortriptyline and psychoeducational support groups reduced attrition and led to remission of major depression among 79 percent of the elderly patients who completed 16 weeks of treatment. Similarly, interpersonal psychotherapy was found to be effective in the treatment of depression following bereavement.
The goals of psychodynamic psychotherapy vary depending on patients' medical health and functioning. For elderly patients who are not disabled, psychodynamic psychotherapy focuses on resolution of interpersonal conflicts, reconciliation of personal accomplishments and disappointments, and adaptation to current losses and stressors. The aim of psychodynamic psychotherapy is to facilitate mourning of lost capacities, promote acceptance of physical limitations, address fears of dependency, and promote resolution of interpersonal difficulties (18).
The effectiveness of various forms of psychodynamic psychotherapy has been compared with that of cognitive-behavioral therapy in reducing symptoms of geriatric depression. An earlier study noted that psychodynamic psychotherapy was associated with a higher relapse and recurrence rate within one year compared with cognitive and behavioral therapy. However, in a larger sample, psychodynamic psychotherapy was equally as effective as cognitive and behavioral therapies and superior to placement on a waiting list in preventing depressive recurrences over periods of one and two years (19).
Reminiscence therapy was developed as a treatment for elderly persons. Its basic assumption is that reflection on positive and negative past life experiences enables individuals to overcome feelings of depression and despair (19, 20).
Reminiscence therapy has been found to reduce depressive symptoms in nonclinical samples and among cognitively impaired nursing home residents. Reminiscence therapy was shown to be more effective than no treatment among elderly community volunteers. Similarly, reminiscence therapy produced a short-lived amelioration of depression among cognitively impaired nursing home residents (21). Among homebound elderly patients, the effect of reminiscence therapy on depression was comparable to friendly visits. Reminiscence therapy was found to be less effective than problem-solving therapy among depressed elderly outpatients (14).
Interventions for particular patient groups
Elderly patients with disabilities often develop psychopathology that influences their rehabilitation (6,7). Among nursing home residents with major or minor depression, psychosocial interventions that increased patients' control over recreational and other activities were found to enhance problem-solving skills and socialization. Weekly cognitive-behavioral therapy group sessions appear to reduce pain and pain-related disability among patients in nursing homes (22).
Family members and caregivers
Elderly patients with dementing or other psychiatric disorders are cared for principally by their families. Caregivers of elderly patients are at risk for depression, anxiety, and medical problems (23). A meta-analysis of 18 studies examined the efficacy of psychosocial interventions in alleviating caregiver and family distress (24). Interventions included psychoeducation, support, cognitive-behavioral techniques, self-help, and respite care. Both individual and respite programs reduced caregiver burden and dysphoria, but group interventions were only weakly effective.
The increasing diversity of the elderly population suggests that new interventions should take into consideration cultural attitudes toward care giving. Other factors that are expected to influence the nature of new interventions include whether the patient has a cognitive or functional disability, the duration of the patient's disability, whether the caregiver is a member of the patient's family, whether the caregiver is a child or spouse of the patient, and type of distress experienced by the caregiver, including dysphoria, anxiety, somatization, and disability.
Most studies of bereavement have focused on the death of a spouse and its effect on the surviving elder. Spousal bereavement appears to be associated with declining physical and mental health (25) and increased mortality (26). Self-help groups appear to ameliorate depression, improve social adjustment, and reduce the use of psychotropic drugs among widows (27,28). The efficacy of self-help groups approximates that of brief psychodynamic psychotherapy among elderly bereaved individuals without significant prior psychopathology (29). Group psychotherapy, however, has been found to be only slightly more effective than no treatment (30).
Cognitively impaired patients
As the number of patients with dementing disorders rises, so will the relevance of psychosocial interventions for behavioral disturbances resulting from these conditions. Depression and anxiety occur most frequently during the early stages of dementing disorders. Research findings suggest that cognitive-behavioral therapy is beneficial in the treatment of depressed demented elderly patients.
Psychosocial interventions targeting the caregivers of cognitively impaired elderly patients with dementia not only reduce caregiver burden but also influence many patient- or caregiver-related outcomes. A psychosocial intervention for spouses who were caregivers was shown to delay institutionalization of demented patients. Focused behavioral techniques have been found to improve the quality of caregivers' sleep, and psychoeducation and family support appeared to facilitate patient management. These observations suggest that development and study of psychosocial interventions appropriately targeted to problems related to caregiving can improve the care of demented patients as well as the quality of life of both patients and caregivers.
Primary care patients
Most of elderly patients with psychiatric problems are treated by primary care physicians (1, 2). Approximately 6 to 9 percent of primary care patients meet criteria for major depression (31,32), and 17 to 37 percent have minor depression syndromes.
More than 80 percent of primary care patients prefer to receive help for emotional distress from their primary care physician, while only 5 percent wish to be referred to a mental health specialist (33).
These findings suggest that mental health care for elderly patients should best be provided at the primary care site.
A direct benefit of psychosocial treatments is that they have the potential to increase compliance with medical and psychiatric regimens. Developing rapport, providing psychoeducation, and addressing the patient's concerns and misconceptions are part of psychosocial treatment regardless of orientation. Frequent follow-up offers an opportunity to monitor compliance and intervene if the patient becomes negligent or resistant to treatment.
Psychosocial interventions that are modified to target not only psychiatric symptoms but also disability may have a significant impact on the adjustment of elderly patients. A study of depressed elderly patients has shown that impairment of instrumental activities of daily living was associated with anxiety and depressive ideation (34).
The rate of suicide almost doubles in late life and reaches a rate of 22.8 per 100,000 in the population age 75 to 84 (34,35). Among adults who attempt suicide, elderly persons are most likely to die as a result of their attempt; the ratio of completed to attempted suicides increases from 1 to 200 among young women to 1 to 4 among elderly persons (35). These observations suggest that aging reduces the rate of suicide attempts but increases their lethality.
Depression is the most common psychiatric diagnosis among elderly suicide victims (34,35,36). Approximately 76 percent of elderly suicide victims have psychopathology; 54 percent meet criteria for major depression, and 11 percent meet criteria for minor depression (38).
Hopelessness is strongly associated with suicidal ideation. Elderly patients with severe depression are more likely to have suicidal ideation with increasing hopelessness. More than 70 percent of suicide victims see their physicians within the month before their death (39).
These observations suggest that interventions delivered at the primary care site may reduce the rate of suicide. Mental health professionals integrated in primary care practices may provide effective screening, as well as timely and appropriately targeted interventions and follow-up. The presence of mental health workers in the primary care office is crucial because educational methods aimed at primary care physicians have been found to have little sustained impact on either physician behavior or patient outcomes (40, 41).
Psychosocial interventions will play an increasingly important role in the treatment of psychiatric syndromes and symptoms of older adults. Increased life expectancy and the resultant medical comorbidity may complicate the use of pharmacotherapy among a large percentage of elderly patients. The goal of psychotherapies will be expanded to include reduction of disability, pain management, and adherence to medical and rehabilitation regimens. Because much of the stress experienced by elderly persons results from medical disorders and disabilities, psychotherapeutic interventions that strengthen coping mechanisms and reinforce health-promoting behaviors are expected to be a crucial part of health care. Self-help groups and counseling will play an increasing role in the care of bereaved elderly persons and in the care of caregivers of elderly patients. Brief, focused psychotherapeutic interventions may be particularly useful for individuals who develop significant psychopathology or find psychotherapy to be meaningful in enhancing adaptation. Integration of mental health professionals in primary care practices will allow the timely and appropriately targeted interventions and follow-up necessary for the treatment of psychiatric disorders, most of which are chronic. Further research on brief standardized psychotherapies is expected to provide effective and well-accepted treatments for elderly persons. This view is based on the fact that existing therapies, including interpersonal psychotherapy, problem-solving therapy, and cognitive-behavioral therapy, have been found to be beneficial in the acute treatment of geriatric depressive and anxiety disorders
Dr. A. Thirumoorthy *
Dr. R. Dhanashekarapandian *
* Associate Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore - 560029