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

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An Aging Population will Lead to Mounting Fall-Related Health-Care Costs

Brian E. Maki, PhD, PEng
Professor, Department of Surgery and Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

It is well established that falling is a common occurrence in persons aged 65 and older. Among those living independently, 30-60% will fall one or more times each year,^1-3 and the falling rate is even higher among those living in long-term or acute-care institutions.^4,5 Although the degree to which the falling rate among older adults differs from that among younger adults has not been well established, it is clear that falls in older persons are much more likely to result in serious physical and psychosocial consequences. The first part of this two-part article dealt with the fear of falling and other psychosocial correlates of falls, which has tended to be an under appreciated aspect of the problem. The now forthcoming second part, will focus on what has, historically, received the most attention-the physical consequences of falls.

Although the majority of falls do not result in serious physical injury, the societal costs associated with fall-related injuries are immense. Falls are, in fact, the leading cause of fatal injuries among seniors, accounting for twice as many deaths in this population as motor vehicle accidents.

D'Arcy L. Little, MD, CCFP
Director of Medical Education
York Community Services, Toronto, ON

Introduction
Influenza, an acute respiratory illness, causes more adults to seek medical attention than any other respiratory infection. In Canada, influenza is a seasonal disease, causing annual epidemics that affect 10-20 percent of the population and result in approximately 4,000 deaths, 70,000 hospitalizations, and 1.5 million days of lost work.¹ The elderly (people aged 65 years and older), and those with chronic cardiopulmonary disorders, diabetes and other metabolic diseases, have an increased risk of developing influenza complications. Hospitalization rates among elderly patients increase markedly during major influenza epidemics, and 90% of the deaths attributed to influenza and pneumonia are observed in this population.²

Vaccination remains the most reliable means of preventing an influenza infection and the resultant morbidity and mortality. Despite the significance of influenza, efforts to vaccinate the elderly remain suboptimal. A large study conducted in the Netherlands revealed that healthy elderly people avoid influenza vaccination because they fear the side effects, and because they believe that their general health is good and that the benefits of vaccination are, therefore, minimal.

An 'Achilles Heel' in Viral Replication Helps Researchers Develop a Universal Cure for Influenza

Nadège Chéry, PhD

When influenza attacks, it may infect anyone, regardless of his or her age. But when influenza kills, it usually takes the lives of individuals, like the elderly, who are less able to fight back.² In Canada, 6000 deaths are attributable to influenza every year³ with the highest rate of mortality occurring among people over 65 years of age.² Thus, when it comes to older individuals, both early diagnosis, and prevention are imperative. Because the influenza virus continuously changes, strategies for the prevention of flu outbreaks, although thoughtfully planned, have had limited success. Recently, however, scientists have found a "weakness" in influenza's ability to escape traditional flu therapies. This discovery has set the stage for the design of new antiviral drugs which, potentially, may constitute a cure for the flu.

What is Influenza?
Influenza is a member of the Orthomyxoviridae family,1 and causes disease by infecting the epithelial cells that compose the lining of the respiratory tract. Influenza produces symptoms similar to other viruses which infect the respiratory tract. Flu outbreaks are common among elderly persons, particularly in nursing homes.⁴ Since the immune systems of elderly people in a nursing home may be compromised,⁵ their ability to fight an influenza infection can be severely undermined.

Physiologic Vs. Ventricular Pacing--Which is More Appropriate for Your Elderly Patient?

Tawfic Nessim Abu-Zahra, BSc, MSc

Cardiac pacemakers are widely used to treat the symptoms of cerebral hypoperfusion and hemodynamic decompen-sation that are caused by bradycardia.¹ Pacemaker implantation is indicated for diseases of the sino-atrial (SA or sinus) and the atrioventricular (AV) nodes. There are two different modes of cardiac pacing, ventricular and physiologic. Ventricular pacing involves the direct stimulation of the ventricular myocardium without interaction with the atria, whereas physiologic pacing stimulates either the atria alone (atrial pacing) or both the atria and ventricles together (dual pacing).

There are many theoretical reasons why physiologic pacing should be superior to ventricular pacing. Physiologic pacing maintains the synchrony of atrial and ventricular contraction and the dominance of the sinus node by stimulating both the atria and ventricles.² Physiologic pacing may prevent the pacemaker syndrome--a collection of symptoms associated with the asynchronous contraction of the heart that occurs with ventricular pacing.² In comparison to ventricular pacemakers, however, physiologic pacemakers are more expensive, and are more difficult to monitor.³

Despite the theoretical advantages of physiologic pacemakers, this mode of pacing is not widely used.

Doctor Beware! A Patient's Retained Licence Can Cause the Loss of Yours

Tracey Tremayne-Lloyd and Lonny J. Rosen
Tremayne-Lloyd Partners
Toronto, Ontario

Physicians who treat elderly patients are well aware of how important a driver's licence is to a geriatric patient. The ability to drive represents perhaps the greatest source of independence to an elderly patient. The driver's licence ensures that he can maintain an active lifestyle, keeps up his social interaction and family ties, and that he has the ability to seek support or treatment for his ailments. All of these support systems are crucial to the health and wellbeing of an elderly patient, particularly as his health begins to fail. For this reason, it is particularly difficult for a family physician to contact her local Ministry of Transportation office and report that a patient has become medically unfit to drive. However, in most Canadian provinces, it is the physician's legal obligation to report any patient who has become unfit to drive, even when that report will result in the patient losing his driver's licence and all of its attendant benefits (especially the patient's independence). It is important to remember that while it is the Ministry, and not you the doctor, who will determine whether a patient's licence should be revoked, it is your licence to practice that may be jeopardized if you fail to make the required report.

Michael A. Gardam MSc, MD, CM, FRCPC
Medical Director, Tuberculosis Clinic
Associate Hospital Epidemiologist
University Health Network

What is a Skin Test and How is it Administered?
Tuberculin skin testing is the most established method of diagnosing tuberculosis infection, that is both active disease and asymptomatic latent infection. Different skin testing techniques have been developed over the past 70 years. The Mantoux test, however, is the standard procedure in North America. The Mantoux test involves the intradermal injection of 0.1 ml of purified protein derivative (PPD--a precipitate prepared from filtered heat-sterilized cultures of Mycobacterium tuberculosis). The only absolute contraindication to administering the test is a history of anaphylaxis induced by any of the components. Those with a history of BCG vaccination may be skin tested.

The test is usually administered in an area that is free of blood vessels, hair or edema, on the flexor surface of the forearm, but it may also be administered on the upper chest or back. The needle should be inserted just under the skin with the bevel facing up until the bevel is fully inserted. A bleb should be raised when the PPD is injected. If this is not accomplished, or the PPD leaks out onto the skin, the test should be readministered in a different site. The test must be read at 48 to 72 hours by a trained healthcare professional.

By Age 70 Men Lose Bone Mass at the Same Rate as Women

Valerie Serre, PharmD, PhD

Aging of the population is associated with the rising incidence of age-related conditions such as osteoporosis. In the US, as many as 41 million people could develop osteoporosis by 2015. Osteoporosis is a progressive microarchitectural deterioration of bone tissue, which induces skeletal fragility predisposing bone to fracture. This disease is mostly known to affect postmenopausal women. Osteoporosis in men has sparked interest because of the worrisome finding that 20% of people with osteoporosis are men. Men reach peak bone mass in their late 20s. The decline in bone mass becomes apparent in men in their 40s and by the age of 70 both men and women display an identical rate of bone loss. If left untreated, osteoporosis brings about complications such as pain, decreased quality of life, dependence, and fractures. These fractures are located mainly at the hip, vertebral wedge and wrist and are often associated with mortality. The dollar cost of this silent epidemic is enormous (over 10 billion US dollars per year in the United States), and it is likely to increase exponentially in the near future.

A Fragile Future for Men

Gradual Immunologic Decline Explains Frequency of Herpes Zoster Among the Elderly

John M Conly, MD,CCFP, FRCPC, FACP
Consultant, Infectious Diseases
Director, Infection Prevention and Control
University Health Network (Toronto General,
Toronto Western and Princess Margaret Hospitals)
Professor of Medicine, University of Toronto

Introduction
Although it is now understood that varicella-zoster virus (VZV) is the etiologic agent for both varicella and herpes zoster, it is of historical interest to note that in the early medical literature, the clinical illnesses of varicella and herpes zoster were considered separate entities. Just six decades ago it was still taught at Harvard University that these viruses were unrelated.¹ In 1943, a pediatrician named Garland suggested that zoster may be due to the reactivation of a latent varicella virus,2 but it was not until 1958 that VZV was definitively recognized as the etiologic agent for both varicella and zoster.^3,4 The VZ virus is a DNA virus and is a member of the Herpesviridae family bearing many distinct similarities to other members of this group of viruses. The virus is spread by direct contact, by droplet and airborne routes from vesicular fluid of skin lesions, or from secretions from the respiratory tract.⁵ Transplacental transmission has also been documented.

Vaccination Curtails Influenza Outbreaks, but Side Effects are Still Possible

Dr. Allison McGeer MSc, MD FRCPC
Director,
Infectious Control,
Mount Sinai Hospital,
Toronto, ON

Every year, approximately one in six Canadians are infected with influenza. Healthy adults infected with influenza miss, on average, 2-7 days of work, and have a 10-30% chance of being prescribed a course of antibiotics. Influenza causes approximately 20% of all cases of acute otitis media in children,¹ and is the most common single infectious cause of hospital admission in young children.^2-4 However, the greatest impact of influenza is seen in the elderly. Every year, nearly 1% of older adults with any chronic underlying illness require hospital admission due to influenza, and about 4000 die from influenza and its complications.⁵

Vaccination is the only effective method for the prevention of influenza. Annual vaccination is required because influenza viruses are able to mutate their antigenic coat continuously in order to evade the human immune system (see "Chasing Away the Flu Bug" on page 20 for a more detailed description of this process).