The following case study illustrates some aspects of both the complexity and the feasibility of offering psychotherapy in combination with medications in treating an older adult with depression.
"Ms. O" is a 71-year-old widow who has suffered for the past 16 years from recurrent MDD. Her first episode of depression followed the simultaneous occurrence of her husband's sudden death and her own job loss. Ms. O, who had a significant family history of mood disorders, took antidepressant medication for a number of years under the care of a psychiatrist who saw her approximately bimonthly. During this time she was admitted repeatedly to the same psychiatric unit for suicidal ideation, with an actual suicide attempt on one occasion.
During her latest admission, a major re-evaluation of her pharmacotherapy was initiated and she received, for the first time, a form of cognitive-behavioral therapy (CBT) adapted for older adults. At first, Ms. O was skeptical about beginning a course of psychotherapy. Having taken a college psychology course in the early 1950s she thought of psychotherapy as equivalent to psychoanalysis and did not see the relevance of "talk therapy" to her condition. An explanation of the therapeutic process, however, emphasized how CBT would focus on her current thought processes with only brief forays into the distant past. The therapist's identification of specific and realistic therapeutic goals proved reassuring enough that she was willing to begin. Therapy with Ms. O involved a frank examination of her maladaptive cognitions, repeated exploration of alternative cognitions and practice in cognitive restructuring.Ms. O's natural intelligence and her strong alliance with her therapist, who continued with her through successive stages of care at the same facility, maximized her use of the process.
With the help of her therapist, Ms. O identified a connection between her suicidal ideation and feelings of anger that, because of family dynamics, had been distressing for her to experience or express. She was helped by interpretation of her self-destructive thoughts as anger turned against herself, and by correction of her cognitive distortions regarding the triggers of her anger and the power of her feelings. She was able to switch from thinking of her anger as uncontrollable and destructive to viewing it as a helpful indication of an internal need state. She was also prescribed behavioral steps to increase her assertiveness to better meet her needs.
Concurrent with her psychotherapy sessions, Ms. O received antidepressant and low-dose antipsychotic medications. After discharge from the hospital she continued her psychotherapeutic work and remained in treatment for over a year with very positive results. On a few occasions, feeling "well," Ms. O attempted to "cut back" on her psychotherapy and, on other occasions, negotiated a change in medication with her psychopharmacologist. Ironically, her resistance to psychotherapy seemed on occasion to flare up when she felt some degree of benefit, as she feared her dependency on the process. She eventually began, however, to see a palpable benefit from continuing both psychotherapy and medication. What she learned about her resistance to treatment in psychotherapy added an extra dimension to simple psychoeducation about the importance of adherence to a medication regimen. In addressing feelings about her treatment, she also gained experience in problem solving and in cognitive restructuring. These skills served her well in other areas of her life.Conclusion
Although practical barriers may on occasion make an integrated treatment impractical, the combination of psychotherapy with antidepressant medication should increasingly be recognized as a standard for effective treatment of older adults with minor or major depressions. The recent resurgence in enthusiasm for psychotherapy training among psychiatric residents as well as new geriatric specialty training programs for nurses, social workers or psychologists offer hope that an increasing number of appropriately trained psychotherapists may become available. By increasing mental health and primary care awareness of the potential value of combined treatment, practice can be brought into conformance with expert consensus recommendations, and psychotherapy co-administered with pharmacotherapy can become a standard treatment approach for depressive disorders in the later years.