Eran Metzger, MD, Associate Director of Geropsychiatry, Hebrew SeniorLife, Boston; Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA, USA.

The management of depression among individuals with dementia can be one of the more challenging problems in geriatric practice. Depression in dementia is common regardless of the type of dementia and compounds the impairment of the underlying dementing illness. Some symptoms of dementia, including apathy, impaired concentration, and decreased food intake, may be difficult to distinguish from similar symptoms of depression. This article presents background information on the epidemiology and pathophysiology of depression in dementia followed by recommendations for a systematic approach to diagnosis. Treatment modalities including psychotherapy, pharmacotherapy, and electroconvulsive therapy are reviewed.
Key words: dementia, depression, Alzheimer’s disease, psychotherapy, psychopharmacology.

Marie Crowe, RPN, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.
Sue Luty, FRANZCP, PhD, Associate Professor, Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.

Because there are particular corollaries to the treatment of depression in older adults, which include contraindications to the use of antidepressant drugs in combination with many medications, there is a need to examine nonpharmacological forms of treatment. This paper is based on a review of the literature on nonpharmacological treatments for depression in older adults. Electroconvulsive therapy has a role in severely depressed older adults because of its rapid effectiveness in life-threatening situations while psychotherapy, either on its own or in combination with antidepressants, is effective in the treatment of mild to moderate depression.
Key words: older adults, psychotherapy, depression, electroconvulsive therapy.

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

Psychotherapy: An Introduction for a Family Physician

Betty Hum, BSc

As the Canadian population ages, depression, dementia and other mental conditions such as anxiety, alcohol abuse, bereavement, and suicide will become increasingly prevalent.¹ Traditionally, it was thought that the elderly were unsuitable candidates for psychotherapy due to the belief that they have an impaired ability for abstraction and new learning.¹ Geriatric psychotherapy has gained more attention over the years because medical comorbidities in the elderly can complicate the use of pharmacotherapy.² Moreover, psychotherapy has the added benefit of providing the elderly with skills to cope with late-life stressors, such as newly acquired disabilities or the loss of a loved one.²

Dr. Michel Silberfeld, a geriatric psychiatrist at the Baycrest Centre for Geriatric Care in Toronto, who has practiced psychoanalysis since 1982, believes that psychotherapy can be very effective in the elderly. However, he suggests that an important factor in its success is the alliance between the patient and the therapist, as some personal matters of deep importance can only be dealt with in the context of a strong attachment, fostered by frequent visits.

Studies in geriatric patients have found most psychotherapeutic modalities to be effective, not only in reducing psychopathology, but also in reducing physical needs, pain, disability, and in improving compliance with medical and psychiatric regimens.² On average, 63% of patients achieve successful outcomes with systematic psychotherapy compared to 38% of those receiving no treatment or placebo.³

OHIP covers the costs of the psychotherapy sessions, which can be provided by a psychiatrist or a trained primary care physician. Some psychologists also practice psychotherapy and their services may also be covered by other insurance benefits. Most elderly patients with psychiatric problems, however, prefer to be treated by primary care physicians.^4,5 Therefore, it is important that these health care professionals become more familiar with psychotherapeutic techniques, and know when it is appropriate to refer a patient to a psychotherapist. There are, unfortunately, very few guidelines available to help a therapist decide which technique, out of several possibilities, would be of most use on a particular patient. This article will review the current indications for the use of psychotherapeutic interventions in the elderly.

What is psychotherapy?
Psychotherapy is the treatment of abnormal behavior or a mental disorder by psychological means, usually, but not exclusively, through patient interaction with a trained therapist. A psychotherapist has expertise in interpreting the past and in supporting the patient through current difficulties, with the goal of improving the patient's sense of well-being, personal and social functioning, and personality integration.⁶

Indications for Psychotherapy in the Elderly
There are more than 250 different forms of psychotherapy, but we will focus only on those that have been most influential and are supported by research.

Individual Therapies: Standardized
Standardized therapies are focused and time-limited types of psychotherapy that are based on treatment manuals that have been developed with the goal of reducing psychopathology and improving quality of life.² A meta-analysis of 17 studies, comparing the use of a variety of brief standardized therapies, including cognitive, behavioral, supportive, interpersonal and reminiscence interventions in geriatric depression, showed that all were more efficacious than no treatment.⁷ Brief introductions to these therapies as well as their primary documented indications in the elderly are provided below.

Behavioral psychotherapy
Behavioral psychotherapy was developed from the learning theory which states that human behaviour is acquired through processes of association, reinforcement and observation.⁶ This type of therapy involves the use of these very same processes to help the patient unlearn maladaptive behaviour and to maintain or learn more favourable responses.⁶ Behavioral psychotherapy encompasses many types of therapies including systematic desensitization (flooding), aversive therapies involving punishment schedules, relaxation training, anxiety management, social skills training and token economies (systematic sets of contingencies like "star charts" that involve earning objects or symbols, as a result of certain behaviours, that are then exchanged for meaningful positive responses).⁶ Unlike psychodynamic psychotherapy, behaviour therapy is more effective in elderly patients with advanced dementia because patients do not have to verbally articulate or be motivated for change.² However, there has to be a consistent approach to a particular behaviour, which can be difficult with several health care providers being involved in a patient's care. Research has substantiated its usefulness in managing behavioral disorders in patients with dementia, like Alzheimer's, particularly in outpatient and residential care settings such as nursing homes.^8,9 Psychosocial interventions targeting caregivers of the patient with dementia not only reduces the burden on the caregiver, but also influences the quality of life of both the patient and caregivers.¹⁰

Cognitive-behavioral therapy (CBT)
Cognitive behavioral therapy is based on the theory that irrational beliefs and distorted attitudes toward the self, the environment and one's future lead to depression.⁸ This type of therapy allows an individual to identify his/her distorted and dysfunctional beliefs and thoughts, and to learn how these thoughts bring about negative feelings and behaviours.^6,8 Its superior ability to reduce symptoms of depression in elderly patients, as compared with drug therapy and placebo, has been demonstrated in several studies.^11-14 Research also suggests that CBT is beneficial in the treatment of elderly patients with depression and dementia.¹⁵ A recent meta-analysis of four randomized trials has also shown that CBT is just as effective as antidepressant medication in treating severely depressed patients (those who scored >20 on the Hamilton depression scale or > 30 on the Beck Depression Inventory scale).¹⁶ Although these studies were not conducted exclusively on the elderly (the age of the patient population ranged from 18-65 years¹⁶), CBT has also been shown to be effective in the treatment of other disorders, including anxiety disorders,^15,17 and insomnia.¹⁸ Prolonged CBT in patients ranging in age from 18-60 years, with acute stress disorder, can also prevent post-traumatic stress disorder if given early.¹⁹ With advanced dementia in the elderly, behavioural therapy becomes more useful than the cognitive behavioural model.⁶

Interpersonal psychotherapy (IPT)
Interpersonal psychotherapy was developed to deal with depression and was based on the belief that problems that people have in relating to others, causes, contributes to, or worsens depression.²¹ This form of therapy is focused on grief, role disputes, role transitions and interpersonal deficits, which are common problem areas for the elderly. Controlled treatment trials have suggested that IPT either alone or in combination with medication are as effective as pharmacotherapy, and both treatments have been shown to be more effective than placebo in acute, maintenance, and continuous treatment of late-life major depression.^21-23 However, more controlled trials are still required to demonstrate the superiority of combination therapy. Studies have also demonstrated its effectiveness in managing recurrent depression in the geriatric population.²⁴

Problem-solving therapy
Problem-solving therapy enables the elderly patient to cope with current and future difficulties, in order to reduce the possibility of developing psychopathology. This is done by improving their social problem-solving skills.²⁵ It has been found to work better than reminiscence therapy in depressed geriatric patients, and is especially helpful in individuals undergoing palliative care for terminal illnesses.^26-28

Non-standardized therapies
Non-standardized therapies, like psychodynamic psychotherapy, reminiscence therapy and group therapy, are not based on treatment manuals, as by contrast with the standardized modalities.

Psychodynamic therapy
Psychodynamic psychotherapy is based on the concept that problems arise from unresolved conflicts in early childhood, which have remained in one's subconscious mind by a process of repression.⁶ The clinician helps the patient to understand and resolve their problems by increasing awareness of their inner world, and its influence over relationships in the past and present.⁶ This tends to require a long-term relationship with the therapist and is very intensive in nature.

The type of therapy most likely to benefit a patient is dependent upon the physical health and functioning of the individual.² When the elderly patient is disabled, the goal is to focus on resolving interpersonal conflicts, reconciling personal accomplishments and disappointments, and adapting to current losses and life stressors.² Psychodynamic psychotherapy is comparable to CBT in terms of its ability to prevent recurrence of depression-related symptoms in the elderly over the course of one and two year periods.²⁹

In recent years, brief dynamic and supportive psychotherapies have emerged to deal with more focused problems that are expected to become resolved in limited periods of time. In contrast to longer-term therapies, in these brief interventions the goals are much more focused and less of an attempt is made to reconstruct the developmental origin of conflicts. The overall efficacy of these brief programs is lower than that of other psychotherapies, but much of this has been attributed to the limited number of studies conducted in this area.¹ It is thought that supportive therapy may be more familiar and comfortable for elderly patients even though both the dynamic and supportive modes are successful approaches.³⁰

Reminiscence Therapy
Reminiscence therapy was first designed specifically to treat the elderly. Therapy involves reflecting on positive and negative aspects of life experiences in order to overcome feelings of depression and despair.¹ It has been found to be more effective than no treatment in the management of depression among cognitively impaired patients in nursing homes and among elderly individuals in the community.^31,32 However, it is thought to be less effective in treating late-life depression in the outpatient setting, than problem-solving therapy.²⁶ The advantage of reminiscence therapy is being able to use it in both moderately cognitively impaired and cognitively intact individuals.¹

Group Therapy
Psychodynamic, interpersonal, supportive, cognitive-behavioral, reminiscence and expressive (e.g. music, dance, art, drama) strategies can also be used in a group therapy setting. Patients are referred to group therapy when they need the force of a group experience to motivate them and to give them a social experience, or when they need to see that they are not alone in their difficulties (as with a critical medical illness). Group therapy has been used on geriatric individuals in hospitals, residential facilities, nursing homes and outpatient environments.¹ Very few studies have been done to compare the effectiveness of the different group therapy strategies.

Conclusion
It is possible that either group or individual psychotherapy will play an increasingly important role, either alone or in combination with medication, in the treatment of psychiatric syndromes and symptoms that affect our aging population. Psychotherapy, in its multiple forms, has the capacity to deal with a broad spectrum of problems encountered in the elderly, and it has the potential for having its usefulness expanded as more controlled clinical trials are conducted.

Primary care physicians not only need to be aware of these treatment strategies as they emerge, but also need to recognize when psychotherapy is indicated. Psychotherapeutic effects on depression in the elderly have been the most extensively studied; however, various modalities of psychotherapy have also been used in the treatment of many conditions that are common in an aging population, including anxiety, insomnia and bereavement. Psychotherapy has also been shown to be successful in reducing physical needs, pain and disability, improving compliance with medical and psychiatric regimens, and in dealing with late-life stressors such as adjustment to a newly-acquired medical illness. Regrettably, given our present understanding of the indications and effectiveness of psychotherapies in the elderly, it is difficult to be highly confident in the choice of one therapy over another.

Acknowledgements
I would like to acknowledge the contribution of Dr. Silberfeld to this article. Dr. Silberfeld is a practicing geriatric psychiatrist and the Coordinator of the Competency Clinic at the Baycrest Centre for Geriatric Care.

References

1. Gallo JJ and Lebowitz BD. The Epidemiology of Common Late-Life Mental Disorders in the Community: Themes for the New Century. Psychiatric Services. 50(9):1158-1166, 1999.
2. Klausner EJ and Alexopoulos GS. The Future of Psychosocial Treatments for Elderly Patients. Psychiatric Services. 50:1198-1204, 1999.
3. Hogland P. Psychotherapy Research: New Findings and Implications for Training and Practice. J of Psychotherapy Practice and Research. 8:257-263, 1999
4. Arean PA and J Miranda. Do primary care patients accept psychological treatments? General Hospital Psychiatry. 18:22-27, 1996.
5. Gallagher-Thompson D, NJ Osgood. Suicide in Later Life. Behaviour Therapy. 28:23-41, 1997.
6. d'Ardenne P. Who should you refer for psychotherapy? The Practitioner. 238:87-90, 1994.
7. Scogin F and L McElreath. Efficacy of psychosocial treatments for geriatric depression: a quantitative review. J of Consulting and Clinical Psychology. 62:69-74, 1994.
8. Blazer DG and E W Busse. Textbook of Geriatric Psychiatry, 2nd Ed.. American Psychiatric Press, Inc., 1996, 395-412.
9. Cornelia KB. Psychosocial and Behavioral Interventions for Alzheimer's Disease Patients and Their Families. Am J Geriatr Psychiatry. 6:S41-S48, 1998.
10. McCurry SM, Logsdon RG and L Teri. Behavioural treatment of sleep disturbance in elderly dementia caregivers. Clinical Gerontologist. 17:35-50, 1996.
11. Thompson LW, Gallagher-Thompson D and JS Breckenridge. Comparative effectiveness of psychotherapies for depressed elders. J of Consulting and Clinical Psychology. 55:385-390, 1987.
12. Gallagher-Thompson D, Hanley-Peterson P and Thompson LW. Maintenance of gains versus relapse following brief psychotherapy for depression. J of Consulting and Clinical Psychology. 58:371-374, 1990.
13. Breckenridge JS, Thompson L, Greckenridge JN, et al. Behavioural group therapy with the elderly. Handbook of Behavioural Group Therapy. New York: Plenum, 1985.
14. Beutler LE, Scogin F, Kirkish P, et al: Group cognitive therapy and alprazolam in the treatment of depression in older adults. J of Consulting and clinical Psychology. 55:550-556, 1987.
15. Beck JG and MA Stanley. Anxiety disorders in the elderly: the emerging role for behaviour therapy. Behavior Therapy. 28:83-100, 1997.
16. DeRubeis RJ, Gelfand LA, Tang T and Simons AD. Medications Versus Cognitive Behaviour Therapy for Severely Depressed Outpatients: Meta-analysis of Four Randomized Comparisons. Am J Psychiatry. 156:1007-1013, 1999.
17. Stanley MA, Beck JG and JD Glassco. Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioural and supportive approaches. Behavior Therapy. 27:565-581, 1996.
18. Zeiss AM and A Steffen. Behavioural and cognitive-behavioural treatments: an overview of social learning. A Guide to Psychotherapy and Aging: Effective Clinical Interventions in a Life-Stage Context. Washington, DC: American Psychological Association, 1996.
19. Bryant RA, Sackville T, Dagn ST, Moulds M and R Guthrie. Treating Acute Stress Disorder: An Evaluation of Cognitive Behaviour Therapy and Supportive Counseling Techniques. Am J Psychiatry. 156:1780-1786, 1999.
20. Klerman GL Weissman MM, et al. Interpersonal Psychotherapy of Depression. New York: Basic Books, 1984.
21. Sloane RB, Staples FR, Schneider LS. Interpersonal therapy vs. nortriptyline for depression in the elderly. Clinical and Pharmacological Studies in Psychiatric Disorders. London: Libby, 1985.
22. Schneider LS. Efficacy of clinical treatment for mental disorders among older persons. Emerging Issues I Mental Health and Aging. Washington DC: American Psychological Association, 1995.
23. Reynolds CF, Frank E, Perel JM, et al. Combined pharmacotherapy and psychotherapy in the acute and continuation treatment of elderly patients with recurrent major depression: a preliminary report. Am J of Psychiatry. 149:1687-1692, 1992.
24. Miller MD, Wolfson L, Frank E, Cornes C, Silberman R, Ehrnepreis L, Zaltman J, Malloy J and Reynolds CF. Using Interpersonal Psychotherapy (IPT) in a combined Psychotherapy/Medication Research Protocol with Depressed Elders: A descriptive Report with Case Vignettes. J Psychother Pract Res. 7:47-55, 1998.
25. Hawton K and J Kirk. Problem solving in cognitive Behaviour Therapy for Psychiatric Patients. Oxford: Oxford University Press, 1989.
26. Arean PA, Perri MG et al. Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. J of Consulting and clinical Psychology. 61:1003-1010, 1993.
27. Mynors-Wallis LM, Gath DH, Lloyd AR et al. Randomized controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. BMJ: 310;441-445, 1995.
28. Woo BC, Mynors-Wallis LM. Problem-solving therapy in palliative care. Palliative Medicine. 11:49-54, 1997.
29. Gallagher-Thompson D, Thompson LW. Effectiveness of psychotherapy for both endogenous and non-endogenous depression in older adult outpatients. J of Gerontology. 38:707-712, 1983.
30. Hellerstein DJ, Rosenthal RN, Pinsker H, Wallner Samstag L, Muran JC and Winston A. A Randomized Prospective Study Comparing Supportive and Dynamic Therapies: Outcome and Alliance. J Psychother Pract Res. 7:261-271, 1998.
31. Fry PS. Structured and unstructured reminiscence therapy training and depression among the elderly. Clinical Gerontologist. 1:15-37, 1983.
32. Goldwasser AN, Auerbach SM and SW Harkins. Cognitive, affective and behavioural effects of reminiscence group therapy on demented elderly. International J of Aging and Human Development 10: 555-557, 1987.
33. Cook AJ. Cognitive-behavioral pain management for elderly nursing home residents. J of Gerontology. 53:P51-P59, 1998.