The Future of Psychosocial Treatments for Elderly Patients
Abstract
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. Modification of available treatment strategies to address infirmity and life adversity may have a major impact on rehabilitation from psychiatric and medical disorders and may reduce utilization of nonpsychiatric health services. Most elderly patients with psychiatric problems prefer to be treated by their primary care physician. 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.
Psychosocial interventions are expected to be an increasingly important part of the geriatrician's armamentarium for treatment of psychiatric disorders. Among elderly patients, medical illnesses increase the risks of psychopharmacotherapy either directly or through potential drug interactions, and poor compliance may reduce its effectiveness. Moreover, 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). Because psychopathology worsens the outcome of medical illnesses (6) and promotes disability (7,8), recognition and treatment of geriatric psychiatric disorders may have a wide range of desirable outcomes. 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 reviews 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.
Brief standardized therapies
Brief standardized 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 with an overall mean effect size of .78 (9). The efficacy of diverse psychotherapeutic approaches may in part be explained by the presence of common elements among the various treatments. The following sections summarize studies of the use of brief standardized psychotherapies with elderly patients.
Cognitive-behavioral therapy
The goals of cognitive-behavioral therapy are to change thoughts, improve skills, and modify emotional states that contribute to psychopathology. In one study, cognitive, behavioral, and brief psychodynamic therapies were shown to reduce depressive symptoms among 70 percent of elderly patients (10). In a two-year follow-up study, 70 percent of these patients maintained treatment gains and no longer met criteria for major depression (11).
The same investigators reported that a psychoeducational intervention administered in a group format reduced depressive symptoms among elderly patients (12). In another trial, depressed older adults were randomly assigned to receive cognitive group therapy and alprazolam, cognitive group therapy and placebo, placebo alone, or alprazolam alone (13). 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 (14,15), insomnia (16), and the behavioral and mood symptoms of demented patients (17,18).
Problem-solving therapy
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 (19).
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 (20). 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 amitriptyline and were associated with greater compliance with treatment (21). 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 (22).
Interpersonal psychotherapy
Interpersonal psychotherapy, developed as a time-limited treatment for mid-life depression, focuses on grief, role disputes, role transitions, and interpersonal deficits (23). 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.
Controlled treatment trials have suggested that interpersonal psychotherapy alone or in combination with pharmacotherapy is effective in the acute, continuation, and maintenance treatment of geriatric major depression. Interpersonal psychotherapy was found to be equally as effective as nortriptyline in treatment of depressed elderly outpatients, and both treatments were more effective than placebo (24,25,26). In another study, 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 (27). Similarly, interpersonal psychotherapy was found to be effective in the treatment of depression following bereavement (28).
Unpublished data suggest that monthly sessions of maintenance interpersonal psychotherapy combined with nortriptyline at plasma levels of 80 to 120 ng/ml is more effective in preventing recurrences of geriatric major depression than interpersonal psychotherapy alone, nortriptyline alone, or placebo (Reynolds CF, personal communication, 1998). Interpersonal psychotherapy alone was found to be more effective than placebo in preventing recurrences of geriatric major depression.
Nonstandardized therapies
Psychodynamic psychotherapy
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 (29). For frail elderly patients, 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 (30).
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 (11). 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 (31).
Reminiscence therapy
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 (32,33).
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 (34). Similarly, reminiscence therapy produced a short-lived amelioration of depression among cognitively impaired nursing home residents (35). Among homebound elderly patients, the effect of reminiscence therapy on depression was comparable to friendly visits (36). Reminiscence therapy was found to be less effective than problem-solving therapy among depressed elderly outpatients (20).
These observations suggest that some elements of brief psychotherapies are more beneficial than others. Future psychosocial interventions would benefit from combining techniques with known therapeutic value to target problems relevant to elderly patients, such as coping with pain, disability, and loneliness.
Interventions for particular patient groups
Elderly patients with disabilities often develop psychopathology that influences their rehabilitation (7,8). 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 (37). Weekly cognitive-behavioral therapy group sessions appear to reduce pain and pain-related disability among patients in nursing homes (38).
In a recent study in which individual behavioral treatment was used for older African Americans with depression who were receiving medical rehabilitation, outcomes for groups treated by either a psychologist or an occupational therapist were compared with those of a no-treatment group (39). Patients in both treatment conditions became less depressed than those in the no-treatment group. Besides becoming less depressed, patients treated by occupational therapists became less functionally disabled than patients who received no treatment. These results, if confirmed in future studies, may indicate that non-mental-health professionals are able to deliver brief, standardized psychosocial interventions for frail elderly patients with depression and may lead to these services becoming available to larger numbers of patients.
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 (40). A meta-analysis of 18 studies examined the efficacy of psychosocial interventions in alleviating caregiver and family distress (41). 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.
Although most controlled studies have focused on middle-class Caucasian caregivers, one multisite study is currently examining the efficacy of several psychosocial interventions designed to enhance the quality of life of Hispanic caregivers of Alzheimer's patients (42). This study may help develop useful strategies for interventions with caregivers in this group and perhaps in other ethnic groups.
The increasing diversity of the elderly population suggests that new interventions should take into consideration cultural attitudes toward caregiving. 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.
Bereaved patients
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 (43) and increased mortality (44). Self-help groups appear to ameliorate depression, improve social adjustment, and reduce the use of psychotropic drugs among widows (45,46). The efficacy of self-help groups approximates that of brief psychodynamic psychotherapy among elderly bereaved individuals without significant prior psychopathology (47). Group psychotherapy, however, has been found to be only slightly more effective than no treatment (48).
The coming decade is expected to see the development of psychosocial interventions that will take into consideration the mourning practices of different cultures as well as the needs of frail and disabled elderly survivors. Controlled studies will need to examine the efficacy of psychotherapies in treating depressive syndromes that complicate bereavement.
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, while psychotic symptoms and aggressive behavior are observed at later stages (49,50). Research findings suggest that cognitive-behavioral therapy is beneficial in the treatment of depressed demented elderly patients (15,16).
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 (51). Focused behavioral techniques have been found to improve the quality of caregivers' sleep (52), and psychoeducation and family support appeared to facilitate patient management (53). 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 (54,55), and 17 to 37 percent have minor depression syndromes (3). Minor depression may evolve into major depression within a two-year period in 25 percent of cases (54). Moreover, minor depression is associated with high medical burden (3,5,54) and disability (56). Depression affects the prognosis of comorbid medical diseases, and leads to prolonged time to recovery, long hospital stays, increased medical complications, and mortality (6). Depressed patients in ambulatory medical settings have less severe depression, briefer episodes, and more somatic symptoms than depressed patients seen in psychiatric settings (55,57).
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 (58). When younger primary care patients are referred to mental health specialists, approximately half fail to follow through (59,60). Failure to pursue mental health consultation may be even more frequent in populations of elderly patients, who may have more negative attitudes toward mental health care than younger adults (61).
These findings suggest that mental health care for elderly patients should best be provided at the primary care site. Integration of mental health and primary care services may be promoted by capitated insurance coverage, as attention to psychiatric problems may improve the outcomes of treatment for both medical and psychiatric disorders (62,63). Savings in the care of elderly psychiatric patients may be particularly significant because these patients have a high prevalence of medical comorbidity and disability.
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 (64). Based on these findings, investigators developed a treatment that combines cognitive-behavioral techniques targeting anxiety and hopelessness with rehabilitation approaches aimed at reducing disability (65). The assumption underlying this treatment has been that its dual focus will disrupt the downward spiral of depressive symptoms and disability that interferes with recovery. This intervention was found to be more effective than reminiscence therapy in the treatment of depressed elderly patients with specific symptoms and outcomes that were resistant to pharmacotherapy.
Suicidal patients
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 (66,67). 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 (67). 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 (67,68,69). Approximately 76 percent of elderly suicide victims have psychopathology; 54 percent meet criteria for major depression, and 11 percent meet criteria for minor depression (70).
The clinical profile of depressed elderly suicide victims suggests that they would have had a favorable prognosis if their depression had been treated. Several studies have observed that depression among elderly suicide victims is of mild to moderate severity, is often a first episode, and usually occurs with no comorbid substance abuse or personality disorder (67,70). These characteristics have been associated with good response to psychotherapy or combined psychotherapy and pharmacotherapy.
Hopelessness is strongly associated with suicidal ideation (71,72). Elderly patients with severe depression are more likely to have suicidal ideation with increasing hopelessness (72). In contrast, hopelessness appears to have little effect on suicidal ideation among mildly depressed patients (72). Psychotherapeutic interventions aimed at depressive symptoms and hopelessness may be particularly effective in reducing suicide risk. However, specific studies are needed.
More than 70 percent of suicide victims see their physicians within the month before their death (67,70). A program designed to educate primary care physicians in Sweden about the diagnosis and treatment of mood disorders was able to reduce suicide rates (73). However, this effect was not maintained three years later (74).
These observations suggest that interventions delivered at the primary care site may reduce the rate of suicide. Structuring primary care practices in a way that permits on-site psychotherapeutic and psychopharmacological treatment may improve the outcome of depression and reduce suicidal ideation. 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 (74,75).
As currently organized, the typical primary care office is not equipped to take full advantage of psychosocial interventions. The paucity of studies of the economics of psychosocial interventions also casts doubt on their feasibility in primary care settings. Given that older adults are less likely to follow through with psychosocial referrals, it behooves the health care system to bring psychosocial services to primary care. If research demonstrates that psychosocial interventions incorporated in primary care reduce medical morbidity and disability and the resultant health care costs, medical insurance may find psychosocial interventions cost-effective and elect to provide reimbursement.
For example, a collaborative care model has the potential to destigmatize mental health care. In this model, mental health specialists assist physicians in the assessment of patients' psychosocial needs and provide treatment and consultation when specific clinical situations arise, such as residual psychiatric symptoms, suicidal gestures, or decline in functional status. Further, the collaborative care model may be expanded to include innovative techniques such as telephone links or computer-assisted disease management systems to assess and treat homebound or rural elders, thereby increasing the utilization of mental health services and improving the quality of life of such individuals.
Conclusions
The literature on use of psychosocial treatments for elderly patients suggests the following directions for future practice and research.
• 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. Moreover, growing numbers of old-old individuals are expected to experience stress from increasing disability and psychosocial impoverishment. Psychotherapeutic interventions have the potential to help elderly patients develop mechanisms for coping with life adversity.
• 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. Some of these therapies may be effective continuation and maintenance treatments for elderly patients who have recovered from major depression and may even enhance the efficacy of prophylactic pharmacotherapy. Because some research suggests a specific treatment effect—for example, problem-solving therapy is more effective than reminiscence therapy—it is expected that brief standardized therapies that combine the most therapeutic ingredients will be developed.
• 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. Depressive symptoms and syndromes, medical morbidity, and poor adjustment during bereavement or caregiving may be alleviated by participation in self-help groups. Brief, focused psychotherapeutic interventions may be particularly useful for individuals who develop significant psychopathology or find psychotherapy to be meaningful in enhancing adaptation.
• Increased efforts to optimize recognition and treatment of geriatric depressive and anxiety symptoms in primary care are expected. Because most elderly patients with emotional problems prefer to be treated by primary care physicians, and indeed do receive care from primary care physicians, improved recognition and treatment of psychiatric symptoms and disorders will benefit a large number of elderly patients. Amelioration of psychopathology is expected to improve the outcome of medical disorders and reduce disability.
• Integration of psychotherapeutic services in primary care practices is anticipated. However, traditional methods for educating primary care physicians about mental health issues have had limited and temporary impact on physicians' behavior and patients' outcomes. 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.
Acknowledgments
This work was supported by grants T32-MH-19132, P30-MH-49762, RO1-MH-2819, and RO1-MH-51842 from the National Institute of Mental Health and by a grant by the Damman Foundation.
The authors are affiliated with the department of psychiatry at the Joan and Sanford I. Weill Medical College of Cornell University and the New York Hospital-Cornell Medical Center, Westchester Division. Address correspondence to Dr. Klausner at 56 Doyer Avenue, White Plains, New York 10605 (e-mail, [email protected]). This paper is part of a special section on meeting the mental health needs of the growing population of elderly persons.
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