Psychosocial interventions to help treat later life depression: A literature review Jemma Bateman MSc Psychological Well-being and Mental Health Psychology Division School of Social Sciences Nottingham Trent University N0308858 Eva Sundin August 2014
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Psychosocial interventions to help treat later life depression: A literature review
Jemma Bateman
MSc Psychological Well-being and Mental Health
Psychology Division School of Social Sciences
Nottingham Trent University
N0308858 Eva Sundin
August 2014
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Old Age Depression: An analysis of published literature investigating psychosocial interventions as a treatment
Bateman, J. Division of Psychology, Nottingham Trent University, Nottingham NG1 4BU, UK (e-mail:
depressive symptoms and depression (Lynch et al, 1999; Jongenelis et al, 2004; Bisschop et
al,2004; Jongenelis et al,2004; Steunenberg et al., 2006;).
Evidence suggests that social isolation amongst older people is estimated to be between seven
and seventeen percent (Victor et al, 2003; Iliffe et al, 2007; Tomaszewski and Barnes, 2008)
and that loneliness is experienced by approximately forty percent of the elderly population
(Savikko et al ,2005; Hawthorne 2006; Hawthorine 2008). Baron, Field and Schuller, (2000),
argue that a significant mental health promoting factor among older adults is the individuals’
perceived sense of trust and social support so this is what needs to be a priority when treating
somebody with depression. The development of such strategies to increase older peoples
participation in society has been an important factor in the UK governments delivery of
health and social care (Victor, Scambler and Bond, 2005; Steed et al, 2007; Marmot 2010).
Building a strong connection to a social group helps clinically depressed patients recover and
helps prevent relapse (Canadian Institute for Advanced Research, 2014). To support this
Holt-Lunstad, Smith and Layton (2010), found in their meta-analysis of 148 longitudinal
studies that there was a 50% reduction in the likelihood of mortality for individuals with
strong social relationships. Similarly Jane-Lopis, Hosman, Jenkins and Anderson (2003),
found social support to be the most effective among older adults in treating depression during
their meta-analysis. .
.
The link between loneliness and mental health means that befriending is increasingly situated
within the broader context of ‘psycho-social interventions’ alongside psychological therapies
(Griffin 2010). Befrienders have been offered to older adults in the UK for over 70 years
(Salvage 1998) , and are increasingly perceived as central to healthy ageing strategies,
through the prevention of social isolation and loneliness (Godfrey, 2001; McCormick et al,
2009; Department of Health, 2010).
It has been suggested that residential care and nursing homes should be opened up to
befrienders. Neuberger (2008), conducted a study investigating the effects a befriender could
have on depression. The seven interviewees living in residential or intermediate care all
described feeling lonely despite being surrounded by other people all day. Staff were
perceived as too busy to chat and tended to do things ‘to’ rather than spend time ‘with’
residents. Befriender visits gave purpose and shape to the residents’ days, broadening their
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perspectives on life. Neuberger (2008), summarised by saying emotional befriending may be
one means of addressing loneliness and improving the psychological health of older adults.
To conclude, counter evidence for such interventions is minimal. However Richards,
Greaves and Campbell (2011), argue more well-conducted studies of the effectiveness of
social interventions for alleviating social isolation are needed to improve the evidence base.
4. Clinical approaches to treat depression
Cognitive behavioural therapy (CBT)
A possible treatment for depression in the elderly is CBT. CBT aims to alter the way an
individual thinks and the way they behave. The focus is on ‘here and now’ problems, and
therapy looks for ways to improve a persons’ state of mind (Royal College of Psychiatrists,
2014). Beck (1961), describes CBT as a working relationship between the client and
psychotherapist, where the client explores their negative automatic thoughts against reality,
and attempts to modify them.
There is much evidence to support the use of CBT as in intervention to treat depression in
elderly people (e.g. Frazer, Christensen and Gritthis, 2005; Pinquart, Duberstein and Lyness,
2008). Robust and consistent Meta –analyses and systematic reviews such as one conducted
by Laidlaw (2001), have found that CBT consistently has the largest effect size overall other
methods, and specifically it helps alleviate symptoms associated with depression (Pinquart
and Sorenson, 2001). Such evidence suggests that CBT is more effective than either
treatment as usual or waiting list control in the treatment of depression in older adults and is
as effective as antidepressant medication (Churchill et al, 2001; Leichsenring, 2001; Hensle,
Nadiga and Uhlenhuth, 2004; Mackin and Arean, 2005; Cuijpers , van Straten and Smit,
2006).
Similarly a systematic review carried out by Peng, Huang, Chen & Lu (2009), looked at 14
randomized control trials that assessed the efficacy of psychotherapy for treating depression
in elderly people and concluded that CBT was indeed effective at reducing depressive
symptoms and aiding recovery.
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Not only do meta-analyses such as these give strong evidence that CBT is an effective way of
combatting depression, many individual studies such as one by Selmii et al (1990),
demonstrate its efficacy and reliability in this age group. Selmii and colleagues (1990),
conducted a randomised control trial comparing traditional therapist led CBT, with self-help
CBT. In this study 36 volunteers with a depressive disorder were split into three groups
receiving either traditional therapist led CBT, Self -help CBT via a computer and a control
group. After six weeks of treatment, at a two month follow up there was a significant
difference between the treatment groups. Those receiving CBT treatment had improved more
than the control group who showed no effect and still displayed the depression symptoms.
Similar results have been found by Serfaty et al (2009), who created a single-blind,
randomized, control trial with a four and 10 month follow-up visit, using a total of 204 people
aged 65 years or older. From their results they concluded that CBT was an effective treatment
for fighting depression in older adults but this particular study does warrant some
consideration after it was revealed need related factors such as disease severity, functionality
and deprivation are thought to have influenced the patients recovery process. Consequently
this poses the question of the quality of evidence supplied in the literature.
To evaluate the quality of CBT evidence, Gould, Coulson and Howard (2012), argue that
more high-quality randomised control trials comparing CBT to other methods need to be
conducted before firm conclusions can be drawn about the efficacy of CBT for depression in
older people.
CBT can have potential problems with maintaining patient commitment, and dropout rates
can be a problem leading to a failure in treatment (Hauke, Gloster, Gerlach, Hamm, Deckert,
Fehm & Wittchen, 2013). However, to address this issue, Pinquart et al (2008), suggests that
interventions with 7-12 sessions would help minimise dropout rates and optimise
effectiveness.
To conclude, perhaps an alternative form of CBT that would help maintain engagement with
the therapy is Computer Cognitive Behaviour Therapy (CCBT). The National Institute for
Health and Care Excellence guidelines (NICE, 2006), explain that CCBT is therapy given
through a computer in addition to, or instead of, sessions with a therapist. The Improving
Access to Psychological Therapies (IAPT) program was created in the United Kingdom in
2006, to meet the growing need for psychotherapy. 50% of the population have access to
CCBT, and evidence suggests that increased access to CCBT could save the NHS a
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considerable amount of money (Improving Access to Psychological Therapies, 2012). The
NHS currently offers CCBT in the form of a programme called ‘Beating the Blues’ (BTB),
(Department of Health, 2007). BTB is specifically aimed at treating patients with mild to
moderate depression and/or anxiety. However, before treatment, NICE recommends that the
individual is assessed to make sure such treatments are suitable and the relevant support is in
place for when the treatment begins.
Behavioural activation (BA)
BA is a technique of encouraging the individual to engage in experiences that are likely to
bring rewards which can act as a natural anti-depressant in the condition known as ‘positive
reinforcement’ (Jacobson, Martell and Dimidjian, 2001). Pavlov (1941), describes positive
reinforcement as a conditioned response that brings about a certain type of behaviour in order
to receive a reward. Cuijpers, Van Straten & Warmerdam (2007), suggest that BA can also
help improve interactions with other people in order to improve feelings of self- worth and
control.
BA can help an elderly person suffering from depression, reengage in their life and it helps to
fight patterns of avoidance, withdrawal and inactivity (Jacobson, Martell, & Dimidjian,
2001), which may intensify depressive symptoms (Cuijpers, van Straten, Smit, 2006).
Dimidjian et al (2006) tested the efficacy of BA by comparing cognitive therapy and anti-
depressant medication, in a randomised placebo controlled design with 241 adults with
depressive disorder. It was found that BA was at least as efficacious as anti-depressant
medication and retained a greater proportion of patients long enough for them to benefit from
the treatment. Results also demonstrated that BA was more efficacious than cognitive therapy
among the more severely depressed. This is supported by Dimidjian (2006), who concluded
in his large scale treatment study that BA is more effective than cognitive therapy and on a
par with medication for treating depression.
Further support comes from Dobson et al (2008), who found that during their randomised
controlled trial of adults with depression, patients were more likely to suffer a relapse if
withdrawn from an anti-depressant drug without previous BA training. This suggests that BA
training is important in terms of treatment effectiveness.
Additional BA findings come from Soucy Chartier (2013), who reviewed behavioural
activations theoretical foundations using a systematic review of articles on low intensity
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behavioural activation interventions for depression. They concluded that based on the
literature, behavioural activation could be a viable option as a low intensity psychological
treatment for mild to moderate depression.
Spates, Pagoto & Kalata (2006), conducted a review of eight behavioural activation treatment
studies of major depressive disorder ranging from 1997 to 2006. Their study was limited in
the fact only a small number of treatment studies have been conducted testing BA’s efficacy
as a treatment for late life depression. However Spates et al (2006), still conclude that policy
makers should consider BA as an effective treatment.
The problem with BA as highlighted above is the lack of literature in this area. Shinohara, et
al (2013) and Hunot, et al, (2013), conclude that in the studies that have been published so far
concerning Behavioural Activation, there is only low to moderate quality evidence that
behavioural therapies and other psychological therapies were equally as effective. Shinohara
et al (2013) and Hunot et al (2013) call for larger studies with a bigger recruitment of
participants with an ‘improved reporting of design and fidelity to treatment’, to improve the
quality of the evidence. Spates et al (2006), argue that although these initial studies of the
efficacy of BA have had consistently positive outcomes, larger randomized trials comparing
BA to other therapeutic modalities are needed. Soucy et al (2013), suggest further research is
needed as studies on the efficacy of behavioural activation as a guided self- help treatment
are very limited to date and there are significant variations among existing studies. This point
is further supported by Spates et al (2006), who concluded that it was clear that additional
large scale trials were needed to establish confidence in this type of intervention as a front
line treatment of choice.
To conclude, these studies as Spates et al (2006) suggest, still reveal a significant and fairly
large effect size on measures of depression and it is still possible to suggest that the
behavioural activation treatment for depression, is time-efficient, cost-effective and relatively
uncomplicated as a method for treating depression ( Hopko et al, 2003). Behavioural
activation is a straightforward, structured treatment which can be an effective treatment for
depression in older adults (Lejuez, Hopko, & Hopko 2001).
Problem solving therapy (PST)
Problem-Solving Therapy (PST) is a cognitive-behavioural intervention that focuses on
training in adaptive problem-solving attitudes and skills (Bell and D’zurilla, 2009). Problem
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solving treatment is most likely to benefit patients who have a depressive disorder of
moderate severity and who wish to participate in an active psychological treatment (Mynors-
Wallis, Gath, Day and Baker, 2000).
Bell & D’Zurilla (2009), conducted a meta-analysis that focused on training in adaptive
problem solving attitudes and skills to reduce depressive symptomatology. Using 21 samples
they found that PST was just as effective medication treatment, plus significantly more
effective than no treatment and support groups.
Dobson (2010), explains five key objectives in PST. Firstly, problem formulation to help
foster the patients understanding of their experiences so that they can create realistic
treatment goals. In the case of an elderly individual suffering from depression, this stage
would consist of them becoming aware of the behaviour that needs to be changed. The
second stage involves the patient and the therapist working collaboratively to generate
alternative solutions, enhancing the ability to make more effective decisions. Thirdly,
developing an individual’s ability to successfully carry out a solution plan, evaluate its
effectiveness and engage in self-reinforcement. The fourth stage makes sure the success of
the patient is maximised by creating a ‘toolbox’ of new skills to use in familiar situations, and
lastly the fifth stage teaches the individual to some quick problem solving techniques.
Malouff, Thorsteinsson & Schutte (2007), show support for PST by demonstrating its
effectiveness in their study. A meta-analysis consisting of 31 studies involving 2895
participants resulted in PST showing a significant effect on reducing depressive symptoms as
opposed to no treatment or a placebo control group. However a limitation of this study is that
only published studies were included in the meta-analysis. Thus, the analysis may have a
“publication bias” in that non-significant findings are less likely to be published than
significant findings.
Malouff et al (2007) supports earlier findings by Mynors-Wallis, Gath, Lloyd-Tomlinson
(1995), study investigating 91 patients with major depression who after giving participants
six sessions of PST over 12 weeks conclude PST is effective, feasible and acceptable to
patients, and as effective as antidepressant drugs, and more effective than a placebo.
Additional evidence derives from Cuijpers, Van Straten, & Warmerdam (2007), who
conducted a meta-analysis of randomized effect studies of activity scheduling. Activity
scheduling is a behavioural treatment of depression whereby patients learn how to monitor
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their activities daily in addition to the mood associated with them. This promotes the pleasant
activities and increasing the positive interactions with the environment. 780 people were used
across sixteen studies, and concluded there were clear indications that problem solving
therapy was effective and that activity scheduling is an attractive treatment for depression.
Cuijpers et al (2007), say this is because it is uncomplicated, time efficient and does not
require the patient to carry out complex skills.
Moreover, Areán, et al (2010), conducted a study to determine whether problem-solving
therapy is an effective treatment in older patients with depression, as they believe the elderly
population in the future is likely to be resistant to antidepressant drugs. Participants were
randomly assigned to 12 weekly sessions of PST and assessed at weeks 3, 6, 9, and 12.
Results suggested that PST is effective in reducing depressive symptoms and leading to
treatment response and remission in a considerable number of older patients with major
depression. These results are supported by Alexopoulos, (2011), who conducted a similar
study and conclude that PST may be a treatment alternative in an older patient population
likely soon to be resistant to pharmacotherapy
Another example of successful PST comes from Arean et al, (1993). Using 75 adults as
participants, they provided 12 weekly sessions of group problem solving treatment. At the
end of the study it was found that significant reductions in depressive symptoms were
highlighted and participants demonstrated a sufficient positive change.
To conclude there is mixed evidence for PST as a depression treatment. Gellis, and Kenaley,
(2007) suggest then combined use of PST and antidepressant treatment has more favourable
outcomes compared with PST alone. Although there is evidence that PST can be an effective
treatment for depression, more research is needed to ascertain the conditions and subjects in
which these positive effects are realized (Cuijpers, van Straten and Warmerdam, 2007).
Reminiscence therapy
Reminiscence therapy aims to help older adults fully understand themselves, in the hope that
it will alleviate a sense of loss by re-experiencing and reinterpreting their life events (Hsieh
&Wang, 2003). RT uses prompts, such as photos, music or familiar items from the past, to
encourage the patient to talk about earlier memories (Bharucha et al, 2014). Chao et al
(2006), suggest RT allows the individual to learn how to communicate and develop
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friendships which allows the individual to obtain a sense of identity and belonging. As a
communicative psychosocial process, reminiscence therapy has proven to be a valuable
intervention for the depressed elderly client (Haight, Michel, & Hendrix, 2000; Cully,
LaVoie, & Gfeller, 2001).
Research has shown that older people with symptoms of depression who participate in
reminiscence therapy report better self-esteem and are more positive about their social
relations than similar people who do not receive the therapy support (e.g. Pittiglio, 2000;
Hwang & Dai, 2003). They also tend to have a more favourable view of the past, are more
optimistic about the future and it can assist the elderly to cope with crisis, loss and quality of
life (Cappeliez et al 2005; Bohlmeijer et al 2007). An example of this comes from Watt and
Cappeliez (2000), who experimented with 26 older adults with moderate to severe
depression. They found that RT led to significant improvements in the symptoms of
depression at the end of the intervention.
Early support for this method of intervention is provided by Parsons (1986), who investigated
levels of depression in the elderly after group reminiscence therapy. Findings from the study
suggest that group reminiscence therapy may provide an effective form of treatment for
moderately depressed elderly people.
Furthermore in 1995, Taylor-Price studied 34 elderly depressed female patients in nursing
homes and asked them to take part in group reminiscence therapy. Results showed that the
therapy helped to increase positive feelings amongst the residents and decreased negative low
feelings. This suggests that this type of therapy is effective particularly in elderly people
living in residential care. However this study was limited to females so it cannot account for
males’ reaction to the treatment.
Similarly Chiang et al (2010), conducted an experimental study using 92 institutionalized
elderly people aged 65 years and over. After providing the reminiscence therapy, residents
displayed improved socialization and induced feelings of accomplishment.
Further support comes from Wang (2004), who used reminiscence intervention to study
elderly people living in residential care homes in Taiwan, and found similar results that group
reminiscence therapy could effectively alleviate the depressive symptoms older people
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experience. This demonstrates that it is effective in other countries other than the typical
western style communities.
Additional support for the effectiveness of RT comes from Bohlmeijer, Smit and Cuijpers
(2003), who conclude that RT is an effective treatment for depressive symptoms in the
elderly and that it may offer a valuable alternative to psychotherapy or pharmacotherapy.
Especially in non-institutionalised elderly people who often have untreated depression it may
prove to be an effective, safe and acceptable form of treatment. However Bohlmeijer et al
(2003), suggest randomized trials with sufficient statistical power are necessary to confirm
the results of this study.
A more recent study conducted in 2011 by Zhou et al, investigated the effects of group
reminiscence therapy on depression and self-esteem of Chinese community dwelling elderly.
Eight communities were randomly selected and divided into four experimental groups and
four control groups. In conclusion, group reminiscence therapy was effective in reducing
symptoms of depression, and promoting mental health of community-dwelling elderly.
As treatments go, there are few side effects to reminiscence therapy, but there is still some
caution as not all memories are pleasant (Bharucha et al, 2014). There are still relatively few
controlled studies in this area of research, but Hsieh &Wang, (2003), say that despite
reminiscence therapy requires further testing, it should be considered as a valuable
intervention.
Discussion
The main conclusion drawn from this review is that there is still a need to investigate
psychosocial interventions further. Even though there is evidence of the effectiveness of such
interventions, the results appear to be varied so more needs to be done to provide more
accurate understanding of such methods.
From the literature reviewed, there are many points to consider in terms of their
appropriateness with older adults. Starting with self-help methods, there is limited evidence
available critiquing such methods. As Holdsworth et al (1996), found out, there was no
significant advantage from such interventions. This suggests there could be some degree of
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publication bias where only studies with significant studies have been published. On the
matter of published studies, it is evident that not much research is concerned with late life
depression so this is something to look into (Bower, Richards and Lovell, 2001). On another
note, as demonstrated by Holdsworth et al (1996), there is a problem with drop-out rates in
such an intervention so perhaps self-help methods are only effective if people are motivated
to carry through the course. Another matter to highlight is that the self-help tools such as
books have not been empirically tested so the evidence is limited. It is possible to suggest that
more rigorous trials are required to provide more reliable estimates of the effectiveness of this
type of intervention. There are also ethical issues to consider with self-help as a lot of it is
carried out unsupervised. It would be more ideal to have a therapist present to make sure the
elderly person stays safe (Gellis and Kenaley, 2007). However taking these concerns into
account evidence from this review still shows that self-help interventions can be an effective
alternative treatment for reducing depression in those aged 65 or over.
When considering the effectiveness of technology in treating late life depression, most
evidence suggests that such methods may be beneficial as future treatment. With statistics
from OFNS showing that more of the population is becoming familiar with online and mobile
technology there is a real potential for some new treatments to be invented. Technology can
help reach those who struggle to remain mobile (Bendelin et al, 2011). Another advantage of
technology interventions that has been demonstrated in this review is that the internet allows
a person to interact with society and other family members. This is thought to be important
for maintaining a positive mental health and helps to reduce loneliness (Cotten, 2009).
However a point must be made regarding safety whilst online. There is a danger that when
older people use the internet they are at risk of being conned by strangers or incurring
unexpected costs (Huang, 2010). There is also a chance that a person who spends most of
their time online can become addicted (Morahan-Martin, 2005). The problem with
technology being used as a source for help is that it involves the person acting independently
without any supervision of a therapist to check they are remaining safe and there are no
adverse reactions as a result of being exposed to the internet. As discovered, even though
applications do not go through clinical trials meaning it is not a nationally recognised
treatment, software and apps such as ones discussed in this review could make it cheaper than
the cost of depression medication and possibly more fun to take. They offer new treatment
options to people who are unable to access traditional services or who are uncomfortable with
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standard psychotherapy. More research is needed and larger scale implementation but this
could be the future for treatment.
Social support and befriending has been considered important in making sure older adults
stay socially connected so they don’t become lonely and feel depressed. Even though there
are arguments for more studies to be conducted to show its effectiveness, the government
should support getting older adults to interact with society and nursing homes should open up
to having befrienders visit the elderly residents they care for (Victor, Scambler and Bond,
2005; Steed et al, 2007; Marmot 2010).
Each clinical intervention discussed has been shown to be effective as an intervention.
Evidence suggests that CBT and RT are a well-established and an acceptable form of
treatment. Taking into account the limitations of sample size, BA can be concluded as a
straight forward, effective treatment for depression in older adults (Hopko et al, 2003).
Advantages of PST as an intervention are that it is uncomplicated and time efficient as a
therapy and research in this review suggests it is just as effective as medical treatment. In
relation to use in older adults, therapies such as these would be at an advantage as it allows
the individual to learn a set of new skills and change their pattern of thinking, to help solve
the current depressive symptoms and protect against future depressive episodes.
The research conducted in this literature review is important because it incorporates various
interventions and evaluates them in terms of their effectiveness, in order to offer older adults
an alternative treatment to anti-depressant medication. However, this review is limited
because it only had access to published research. It is possible that other new research is
being conducted that this review does not have permissions to yet.
To conclude it is possible to see that psychosocial interventions are still very much in their
primary stage with research only now starting to pay attention to them. Much more research
is needed to confirm such interventions are beneficial and possibly able to replace
antidepressant drugs but it is possible to see from the literature that is available at the moment
there is potential for improvement.
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