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:

N0308858@ntu.ac.uk).

Abstract

Depression is a common illness in the elderly population due to a variety of factors related to

later life. If left untreated, depression can prevent recovery from other conditions, and even

cause them to worsen. Depression is a big contributory factor to suicide, a tragic reality that

seems to be common in older adults (65 or over). Psychosocial interventions may be a safer

alternative to anti-depressant medication as mental and physical health problems of older

people are entwined and manifested into complex comorbidity. Research suggests that due to

the effective marketing of anti-depressant drugs, and their cost effectiveness, psychosocial

treatments are under-utilised within the elderly population. A review was undertaken to

discover what psychosocial interventions are available to combat depression and how

effective they are in terms of treating the elderly population. Psychosocial interventions were

categorised into four sections consisting of self-help interventions, technological

breakthroughs, social interaction and befriending and clinical approaches in treating

depression. From this review it is possible to see that more research is needed to confirm such

interventions are advantageous, however, the available literature suggests potential for

improvement using such therapies.

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1. Introduction

Mental disorders are highly prevalent among older people, with depressive disorders being

among the most common (Luijendijk et al 2008; World Health Organization, 2013).

Depression is a major predictor of impaired quality of life in the elderly population (Chan et

al, 2006; Stafford et al, 2007), with research showing that even relatively minor levels of

depression are associated with a significant decrease in well-being (Chachamovich, Fleck,

Laidlaw & Power, 2008). Blazer (2003), argues that although mental disorders are not a

normal part of ageing, older adults, considered to be those over the age of 65 (Age UK 2014),

are particularly susceptible to depression, an illness which causes pre-existing medical

conditions to worsen.

The most widely used criteria for diagnosing depressive conditions are found in the American

Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV), and the World Health Organization's International Statistical

Classification of Diseases and Related Health Problems (ICD-10). Symptoms can include:

persistent sadness for a period of two weeks or longer; excessive worries; frequent

tearfulness; feeling worthless or helpless and problems with sleeping (Geriatric Mental

Health Foundation (GMHF), 2014). Later life depression has been given its own diagnosis

because it involves the above symptoms but additional factors associated with old age such

as; difficulties with concentration and the speed of mental processing (Lockwood, 2002;

Elderkin-Thompson, 2003).

With depression having such a negative impact on the quality of life and well-being amongst

the elderly population (Chan et al ,2006; Stafford, 2007; Chachamovich et al, 2008), it is

important to assess the available treatment options and find ways to improve access to those

suffering with a mental illness (Gask et al 2012).

The Mental Health Foundation suggests that most people with depression can improve their

lives with appropriate treatment (Mental Health Foundation, 2014). The GMHF (2014), argue

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that the sooner signs of sadness and loneliness are discovered and addressed, the better the

outcome for the elderly person, with less emotional and physical suffering.

1.1 costing and suicide prevention

Depression is one of the most common risk factors for suicide in the elderly population

(Conwell, Oslen, Caine & Flannery 1991; Conwell, 1995; Conwell, Duberstein & Caine

2002) and statistics from the ‘Centres for Disease Control and Prevention’, show that in 2005,

the rate of suicide in adults 65 or older was 14.7 per 100,000, compared to just 10.5 for

younger individuals (Centres for Disease Control and Prevention, 2008).

In 2012, Pittock conducted a review and explained that the current financial strain on the

Government health budget is set to worsen as the ageing population increases over the next

40 years, bringing along with it the vulnerability to mental health problems and in particular

the increase in depression. Pittock (2012), argues that current diagnostic and treatment

procedures need to be re-evaluated so that health-care systems can continue to promote health

without incurring large debts. Prevention of suicidal behaviour is a major health care target

for the United Kingdom (UK) Government, which in 2002 established a national suicide

prevention strategy for England. Figures from the Government database demonstrate that

depression costs a total of £20.2 -£23.8 billion a year and the average cost per suicide is £1.7

million for England (Department of Health UK, N.D).

Conwell et al (1991), investigated causes of suicide and found autopsy results of elderly

victims suggested depression was the most common reason. With the elderly population

expected to triple in the next 30 years (Department of Health Consultation on Preventing

Suicide in England, 2012), measures must be put into place so that depression can be

controlled in a cost effective manner, reducing rates of suicide.Thus the identification,

prevention and treatment of depression are considered pivotal for preventing suicide in later

life (NIH Consensus Conference, 1992; Pearson & Brown, 2000; Conwell et al, 2002).

Major depression can be prevented (Muñoz, Beardslee, and Leykin, 2012). More than 30

randomised trials have demonstrated that preventative interventions can reduce the incidence

of new episodes of Major Depressive Disorder by about 25% and by as much as 50% when

preventative interventions are offered (Cuijpers, Beekman and Reynolds, 2012). This is a

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promising outlook for combatting depression in older age, however, not every case can be

prevented, and therefore looking at treatment options is important (Yarnall et al, 2003).

1.2 Psychosocial interventions

Psychosocial interventions are defined as any intervention that emphasizes psychological or

social factors rather than biological factors (Ruddy and House, 2005). For example group

therapy or interactive sessions whereby a person is asked to explore the problems they are

faced with. There is a hypothesis that positive mental health can be enhanced if people

believe they have the ability to act in a way that will result in an achievement of their goals

(Blazer, 2002; Blazer 2003). As such, it is possible that psychosocial interventions can reduce

depressive symptoms in elderly people whilst increasing their self-efficacy (Javik et al, 1982;

Rybarczyk, 1999; Scogin et al, 2005).

Scogin and McElreath (1994), conducted a meta- analysis using 17 studies, and concluded

that psychosocial interventions for depressed older adults are indeed effective. Support also

comes from several other researchers (Laidlaw, 2001; Laidlaw et al, 200 and Laidlaw et al,

2008) who agree that such interventions are beneficial.

Alexopoulos (2001), suggests that cognitive behavioural therapy and problem solving therapy

are preferred psychotherapies for elderly people. Koder (1996) argues that cognitive therapy

approaches are as successful in elderly individuals as they are in younger adults. Forsman,

Nordmyr & Wahlbeck (2011), argue that development and evaluation of such methods

should be a research priority. Further support for this view comes from Reynolds et al (2012),

who believe that the efficiency of depression prevention needs to be further enhanced with

the field seeking to understand risk reductions using psychosocial strategies.

Psychosocial interventions may be a safer alternative to anti-depressant medication as elderly

people are more likely to take multiple agents, putting them at a higher risk of suffering

adverse drug reactions (ADRs), adverse drug events and drug-drug interactions (Fick et al,

2003). Katon, and Ciechanowski (2002), state that mental and physical health problems of

older people are entwined and manifested in complex co-morbidity. Research suggests that

due to the effective marketing of anti-depressant drugs, and their cost effectiveness,

psychosocial treatments are under-utilised within the elderly population (Rokke & Klenow,

1998; Reynolds & Kupfer, 1999; Laidlaw, Thompson and Gallagher-Thompson, 2004;

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Katona & Shankar, 2005). However, Reynolds and Kupfer (1999), discovered that clinicians

often prefer not to administer anti-depressant drugs to frail elderly individuals, especially

when they are taking multiple medications. Similarly there is evidence to suggest that elderly

patients are more likely to choose interventions that do not constitute using drugs and prefer

treatments such as counselling or psychotherapy (Gum et al, 2006; Hindi et al, 2011).

Likewise, behavioural activation (encouraging the individual to engage in experiences that

are likely to bring rewards) is seen as more acceptable than anti-depressant medication

(Rokke & Scogin 1995). Coupland et al (2011), conclude that the risks and benefits of

different antidepressants should be carefully evaluated when these type of drugs are

prescribed to older people.

Thompson, Gallagher & Breckenridge (1978), Scott et al (1997), Thompson et al (2001), all

conclude that a range of psychological interventions are efficacious for treating depression.

This evidence leads towards the aims and title of this research ‘Psychosocial interventions to

help treat later life depression: A literature review’.

1.3 Aims of the review

From the published literature available, studies published appear to be conducted on a much

smaller sample size compared to anti-depressant medication, and rarely in comparison to a

sample of people treated by pharmacotherapy.

A review was undertaken to discover what psychosocial interventions are available to combat

depression and how effective they are in terms of treating the elderly population. This paper

aims to further enhance current understanding, whilst informing practitioners, the National

Health Service (NHS) and patients that there are alternatives to anti-depressant medication

such as Cognitive Behavioural Therapy (CBT). This investigation forms a single document

combining reviews of various psychosocial interventions, whilst evaluating them in terms of

their effectiveness.

2. Materials and Methods

A literature search was conducted (up to the 15th July 2014), using seven databases (Psych

INFO, Embase, ASSIA, Psych ARTICLES, PubMed, Science Direct, and Web of Science)

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using the terms (Depression OR Dysthymia OR Mood or Affective) AND (Elderly OR Older

OR Later life) And (Psychosocial OR Non-pharmaceutical interventions).

First of all meta-analyses were looked at to locate relevant studies, and secondly studies with

a controlled design (randomised controlled or non -randomised control trials) were

considered for the analysis. Articles were included only if they reported treatment of people

with depression or a high level of depressive symptoms.

Participants had to be older adults (population defined as people aged 65 or over) with

depression that did not have any other mental disorder (e.g. Dementia). Studies were

considered even if the participant age range began under 65 so long as the mean age of the

participants was noticeably over 65. There was no upper age limit. Studies were excluded

from analysis if they did not include a clear definition of participants, or lacked adequate

reporting of participant data. 10 studies were excluded from this review because they used

participants with other mental illnesses such as dementia, or who had encountered life

changing events (such as having suffered a stroke).

A total of 106 studies were found for this review and psychosocial interventions were

categorised into four sections consisting of: self- help interventions (15 studies);

technological breakthroughs (19 studies); the importance of society and befriending (19

studies) and clinical approaches (53 studies).

Results

1. Self- help approaches to treat depression

Self- help methods can be an effective treatment alternative option for older adults (Cuijpers,

1997; den Boer, Wiersma and Van den Bosch , 2004; Anderson et al, 2005; Spek et al, 2007).

A self-help therapy can be described as a psychological treatment that the patient works

through independently at home (Marrs,1995) and can included a variety of formats such as

books, CD-ROMS, audio and videotapes. Self-help materials aim to improve patient

knowledge and skills in self-management whilst setting clear educational goals (Apodaca,

and Miller, 2003). A more contemporary method of self-help that is being increasingly

offered is help through the internet (Clarke et al 2002; Christensen, Griffiths and Jorm, 2004;

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Spek et al, 2007). Web-based self-help may be an effective and inexpensive alternative to

more traditional therapies (Bijl and Ravelli, 2000; Andrews, Henderson and Hall, 2001).

There is much evidence to suggest that self-help interventions are effective for people over

the age of 65 suffering from depression. For example Chew-Graham et al (2007), argue self-

help is better than normal GP care. Gellis and Kenaley (2007), explain the greatest effect for

treating old age depression with self-help methods is with supportive assisted monitoring

from the therapist to help guide the process. This is further supported by NICE (2004), who

reviewed nine randomised control trials and reported that guided self-help produces a

clinically significant reduction in depressive symptoms when compared with no intervention

(National Institute for Health and Clinical Excellence, 2004)

Fleddeurs, Bohlmeijer, Pieterse and Schreurs (2010), conducted a large scale study involving

376 participants aiming to look at the effectiveness of a self-help course on depressive

symptoms. Participants’ were asked to read a book chapter a week and using an audio CD

complete a set of mindfulness exercises. The treatment course was based on the Acceptance

and Commitment Therapy (ACT) which is a form of therapy in which people learnt to accept

their negative thought and emotions rather than trying to ignore them. The researchers noted

a greater reduction in anxiety and fatigue and an improvement in mental health in participants

who had attended the course. They concluded that a self- help course, where people learn to

accept their psychological distress is effective in reducing depression.

However, there is evidence to suggest self-help is not as effective as previously thought.

Holdsworth et al, (1996), found no significant advantage was observed by adding self-help to

the regular treatments that the GPs normally gave. It could be possible that other studies have

found similar results but have not been published due to publication bias. Holdsworth et al

(1996) believed such poor results were due to the high dropout rates reducing the power of

the study. Furthermore, Mead et al (2005), demonstrated that guided self-help did not provide

any additional benefit to patients on a waiting list for psychological therapy.

McKendree‐Smith, Floyd and Scogin (2003), argue that although there are numerous self-

help books for depression, relatively few have been empirically tested. However, they

suggest those that have been used in clinical trials have fared well, with an average effect size

roughly equivalent to the average effect size obtained in psychotherapy studies.

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To conclude, Bower, Richards and Lovell (2001), suggest that self-help treatments may have

the potential to improve the overall cost-effectiveness of mental health service provision but

the available evidence is limited in quantity and quality and more rigorous trials are required

to provide more reliable estimates of the clinical and cost-effectiveness of these treatments.

2. Technology approaches to treat depression.

Advances in technology may prove to be beneficial for inventing new treatments to help

combat depression as will be investigated in the following paragraphs. The Office For

National Statistics (OFNS, 2014), demonstrates how much power technology has by the

number of people using it. In Great Britain, 21 million households (83%) had Internet access

in 2013 and access to the Internet using a mobile phone more than doubled between 2010 and

2013, from 24% to 53%. A sizable increase in daily computer use, in the past seven years has

been found for adults aged 65 and over. In 2006, just 9% reported that they used a computer

every day, this compares to 37% in 2013. Of those aged 65 and over, 1 in 10 adults (11%)

used a tablet or portable computer to access the Internet “on the go” in 2013. This provides

huge potential to a new form of therapy that people can access at home. One of the main

benefits of online or technical treatments is that patients can be reached from a distance, with

reduced therapist interaction compared to face-to-face therapy (Bendelin et al, 2011). Climo

(2001), suggests that limitations to mobility and activity may increase the importance of the

internet for interpersonal communication, maintaining family bonds and expanding social

networks and supports claims by Williams and Whitfield (2001), who argue, there is a need

for a mental health treatment that is accessible and popular with patients

Mobile applications and internet use for seniors

Social isolation, decreased social contact, and lack of emotional support are risk factors for

depression in older adults (Wright 2000; Bradley & Popen 2003; Eastman & Iyer 2004).

Using the internet for communication may help reduce social isolation, loneliness and

depression as well as enhance social support among older adults (White et al 1999; Mcmellon

& Schiffman, 2002; Blit- Cohen & Litwin, 2004; Xie 2007; Cotten, 2009). Research on

internet usage among older adults indicates technology use can increase social support, social

contact, social connectedness, and greater satisfaction with that contact (Trocchia & Janda,

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2000; Bradley & Poppen, 2003; Mellor, Firth & Moore, 2008). It has been suggested that

older adults may develop new social activity to replace activities that have become more

difficult for them to perform and to strengthen existing ties with family through the internet

(White et al, 1999). Increased contact with social networks help individuals feel closer to

others which has positive implications for their sense of mattering and mental health (Cotten,

2009).

As the evidence from the OFNS suggests, more people are using their mobile phones to

access the internet so providing applications to help combat depression could be a new

gateway to developing future treatments. An example of this type of app derives from

Pizzagalli (2013), who created a piece of software called ‘Moodtune’. This software can be

downloaded on a mobile phone and used by anybody who feels they would benefit from the

app. It includes a selection of games that if played regularly is believed to help treat

depression. The app also gives tips of the day to enhance well-being and includes a mood log

which records how a person is feeling at different moments throughout the day. Pizzagalli

claims it could be just what an individual who has depression needs in order to recover. He

argues that many applications available do not have the science to back them up but

Moodtune is different because it works out certain parts of the brain causing them to work

overtime in order to counteract depression. He says this particular app has an edge as its only

focus is depression and after each game the science behind it can be explained to the user.

Another example of how mobile phone technology can be useful comes in the form of

another piece of software called ‘Mobilyze’. This is a smart phone that can read peoples

moods and can spot symptoms of depression and encourages them to do something about it.

By evaluating the data within the phone such as an individuals’ location, social context, mood

and activity level, it intuits if an individual is depressed and will nudge a person to call a

friend or go out for some company.

This software has been tested in a small pilot study and it was found it helped reduce

symptoms of depression. Mohr (2012), believes that the new phone offers a powerful new

level of social support for people who have depression as it intervenes to help them change

their behaviour in real time by prompting them to increase pleasurable behaviours that are

rewarding.

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A survey including 612 older adults conducted by the Third age council (C3A, 2012), found

that 97 per cent said that keeping up with technology helps them to stay socially connected.

They suggest that connecting online as well as spending face to face time with family and

friends is a way for seniors to combat depression. C3A, (2012) also argue that through the use

of social media such as Facebook, seniors can find people who share common interests.

However, there is a danger of internet addiction with seniors getting hooked on online

gambling and watching online videos (Morahan-Martin, 2005). There is concern that

spending too much time on these activities can pose health risks for the elderly (Huang, 2010)

and that seniors should also be careful when they use the Internet, to avoid being conned by

strangers. To help avoid this, Social Networks for Mature Users have been created especially

for seniors (seniorhome.net). These social networking websites are designed for individuals

with more life experience to share. For example, ‘My Boomer Place’

(www.myboomerplace.com), allows the user to create a profile here and get started

connecting with friends or making new ones, sharing photos, writing and sharing articles,

playing games, and much more. ‘Maple and Leek’ (http://www.mapleandleek.com), is

designed for those 50+, this community is one of adventure and entrepreneurial spirit.

To conclude Mohr (2012), suggests that these new approaches could offer new treatment

options to people who are unable to access traditional services or who are uncomfortable with

standard psychotherapy. This means that older adults would benefit from applications like

this because they can receive help in the comfort of their own home without a struggle.

3. The importance of society and befriending

Befriending has been defined as a relationship between two or more individuals where the

relationship is non-judgmental, mutual, and purposeful, and there is a commitment over time

(Dean and Goodlad 1998). Low levels of social capital in older adults is a risk factor for

depression (Van Der Horst and McLaren, 2005; Nyqvist et al., 2006). Holf- Lunstad et al

(2010), suggest that risk factors in older people for social isolation include minimal contact

with friends and family, low morale, lack of access to private transport and living alone.

Restricted social support, a limited social network and loneliness are associated with

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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

16

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

17

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

18

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

19

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

20

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

21

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.

22

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Late life depression- Psychosocial Treatments

Mental disorders are familiar among older adults, with depressive disorders being the most

common. Although depression is not a normal part of ageing, older adults are prone to

suffering its effects. This can be a big problem if you are experiencing depression because not

only does it impact on your quality of life and have a significant decrease in your personal

well-being, it also causes pre-existing medical conditions to become worse. There is concern

that anti-depressant medication can cause unwanted interactions with other prescription drugs

leading to possible side effects. As a result, there are alternative treatment options available

in the form of ‘psychosocial interventions’. Psychosocial interventions are treatments that

focus more on the psychological and social side of therapy rather than biology and offer a

different approach to treatment.

Self-help therapies

A self -help therapy can be described as a psychological treatment that a patient works

through independently at home. Treatment can include a variety of formats such as CD-

ROMS, audio and video tapes. An increasingly popular method of self -help is now being

offered through the internet. Research suggests that most self-help methods are more

effective with a therapist so your doctor may recommend you take a self-help course with a

professional overlooking the treatment to make sure you remain safe. A popular course

known as ‘Acceptance and Commitment Therapy’ (ACT), helps you learn to accept any

negative thoughts you might be experiencing and learn to ignore them so you can carry on

living a normal life. Evidence has concluded that learning to accept your own psychological

distress can be effective in reducing depression, but if you do choose to take part in this form

of therapy it will require some level of self-motivation in order to make sure you are getting

the most out it.

Technology interventions

Government figures show that those of us aged 65 or over are using a computer on a daily

basis and have access to portable computers or tablets. Research has suggested that 97 per

cent of people using the internet said that keeping up with technology helps them to stay

socially connected.

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This means we should look to take advantage of such interaction and look for possible

treatment methods as a result. For example, a new piece of software has been created called

‘Moodtune’ which is an application you can download which helps keep track of your daily

mood and can offer advice of how to increase your wellbeing. It also consists of a series of

games which are said to help stimulate certain parts of your brain, if played regularly to lift

symptoms of depression. Research suggests that there is enough science to back up that this

app that it actually works with its creators saying such science can be explained to you after

you have completed its tasks.

A similar piece of technology that has been created to help lift depression is in the form of a

smart phone called ‘Mobilyze’. This technology can read your mood and spot symptoms of

depression encouraging you to do something about it. By evaluating the data within the

phone such as your location, social context, mood and activity level, it intuits if you are

depressed and will nudge you to call a friend or go out for some company.

These new approaches could offer new treatment options to people who are unable to access

traditional services or who are uncomfortable with standard psychotherapy. If you do choose

to try out technological interventions, make sure you stay safe online. Online addiction is a

possibility and can pose serious health risks. However do not panic as there are special

websites made solely for the use of older adults which are safe, enjoyable and great for

meeting new people. To find out more about this websites please look at the links at the

bottom of this page.

The importance of social interaction

There is evidence to suggest that low levels of social interaction are a risk factor for older

adults meaning it is really important to remain integrated with society to avoid any risk. With

up to 40% of the elderly population feeling lonely, it is necessary to make sure older adults

are not left alone. Try to build up a strong connection to social groups if possible and

consider having a ‘Befriender’. Befriending has been offered as part of a treatment for over

70 years now and has shown to be very effective in lifting symptoms of depression. A

befriender comes to see you once or twice a week and will sit and talk to you in a non-

judgemental way and is there to be your friend. The impact of having somebody like that in

your life can be a real positive. A befriender can give purpose to your day and help broaden

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you perspectives so is well worth considering. Ask your GP or contact a local age related

charity for more advice about requesting a befriender.

Clinical approaches

Cognitive Behavioural Therapy (CBT)

CBT is a therapy that includes working closely with a therapist to try and change your

negative thought patterns responsible for your depressive symptoms. There is a lot of

research to support its effectiveness in people aged over 65 and follow up results suggest it is

a therapy that is long lasting. It can teach you new skills that can be used in future situations

to help combat the problems you may be experiencing. CBT takes place over a few weeks

and usually lasts about 10-12 sessions but is a suitable alternative for those who prefer a more

hands on approach.

Behavioural Activation (BA)

BA is a therapy that encourages you to behave in a way that brings about rewards in order to

alleviate the symptoms of depression you may be experiencing. Evidence supports this

method of intervention and suggests that BA can help you re-engage with your life and avoid

patterns of avoidance, withdrawal and inactivity. BA is a straightforward, structured

treatment that is time-efficient and relatively uncomplicated as a method for treating

depression so is worth considering if you need to enhance your level of well-being.

Problem Solving Therapy (PST)

PST aims to train you in adaptive problem solving attitudes and skills and is likely to benefit

those who wish to participate in an active psychological treatment. It consists of activity

scheduling which encourages you to monitor your daily activities and the mood associated

with them. By doing this it is hoped you will discover what activities you enjoy and promote

you to actively engage in them more often. This method of intervention is ideal because it is

time efficient and does not require you to carry out any complex skills.

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Reminiscence Therapy (RT)

RT is a therapy that is aimed particularly at older adults because it consists of re-experiencing

and reinterpreting life events in order to alleviate a sense of loss. Using prompts such as

photos, music or familiar items from the past, you are encouraged to talk about earlier

memories with others of a similar age. This is so that you can develop further friendships and

feel a sense of belonging. As a communicative psychosocial process, RT has proven to be a

valuable intervention. As treatments go, there are few side effects to RT. However you need

to be aware that as it is a memory process, some unpleasant memories could arise.

Nevertheless RT should be considered as a valuable intervention.

Recommended websites

(www.myboomerplace.com),

(http://www.mapleandleek.com),