There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients.
There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.1,2 For nonresponders or partial responders, clinicians must decide between switch strategies or augmentation with another medication or psychotherapy.3,4
Evidence-based psychotherapy has shown efficacy as monotherapeutic treatment for late-life depression. Treatment effect sizes ranging from 0.43 to 1.03 have been cited in several meta-analyses, and 2 of these reviews found that individual therapy was superior to group therapy.5-10 Psychotherapy alone may suffice for mild to moderately severe depression, particularly when it stems from obvious stressors, such as bereavement. Given the clear consensus that psychotherapy is effective in late-life depression, the decision to combine it with pharmacotherapy may be determined more by whether it is available for a given patient. Table 1 lists several potential barriers.
|• Unavailability of qualified psychotherapists|
|• Cost: lower reimbursement rates compared with those for pharmacotherapy|
|• Many solo-practice psychiatrists favor pharmacotherapy alone overcombined treatment|
|• Transportation for regular attendance, particularly in rural areas (use of the telephonemay improve consistency, but it requires intact hearing and adequate privacy)|
|• Patient refusal because of unfamiliarity with potential benefits (correlated with thelack of a college education)|
|• Poor integration of care between medication prescribers and psychotherapists|
Impact of life experiences
Compared with other cohorts of depressed patients, older patients bring varied life experiences that reflect the period of history through which they have lived. Frequently, older patients are immigrants who have witnessed great change in their lifetimes or who have been victims of trauma.
We define late life as 60 years and older. With the mean life span now approaching 80 years, and with more than 200,000 centenarians in the United States, we see a heterogeneous group of young-old (aged 60 to 75), middle-old (aged 75 to 85), and old-old (aged 85 and older); some would also be considered the frail-old.
Harry Stack Sullivan once said, "When you meet a new patient, ask them to begin to tell their story [from] a point before their problem began."11 With the current cohort of older individuals, these explorations require patience and adequate time to create a context within which the depression developed. Of course, medical history, family history, drug lists, and metabolic integrity also need to be explored, but what constitutes an overwhelmingly stressful event or an accumulation of smaller burdens that threaten to undermine coping ability lies in the eyes of the beholder. To be able to optimally help him or her, the clinician must learn as much as he or she can about the cascade of events that led to the elderly patient becoming depressed.
The case for psychotherapy
Many older patients are reluctant to take additional medications, leaving psychotherapy as the only outpatient treatment option other than electroconvulsive therapy. Combination treatment has been shown to have a modest added benefit to pharmacotherapy in the acute stages of treatment, although one study showed a remission rate of 78% for combination treatment compared with the usual remission rate of 35% to 60% for pharmacotherapy alone.12
Psychotherapy may have more enduring effects on coping skills, and it may bring about better adaptation to dysfunctional relationships, lessen hopelessness, and allow the patient to better pursue pleasurable or fulfilling activity that may protect him against a recurrence in the long term compared with pharmacotherapy alone.13,14 To paraphrase Dr Kay Jamison: "Lithium diminishes my depression, but psychotherapy heals."15
Psychotherapy often enhances compliance with antidepressant medications and, conversely, the rapid resolution of vegetative symptoms and cognitive slowing brought about by antidepressant medication often improves a patient's willingness to engage in psychotherapy. Some investigators have therefore proposed a sequenced approach to using antidepressant medication for rapid improvement of core vegetative symptoms and then adding psycho-therapy to teach more effective coping strategies to prevent recurrences.15-22
Goal of combination treatment
Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:
These factors might come together spontaneously if the depression severity is ameliorated by antidepressant medication alone, which might reinvigorate the patient's own coping strategies; however, I would argue from my experience, that this is more likely to occur in younger patients than in older patients for whom fewer options for change are typically available.
Implementation of psychotherapy
Every elderly patient deserves to have a supportive psychotherapy component integrated into his pharmacotherapy management. In interpersonal psychotherapy (IPT) parlance, many of the elderly are in some kind of role transition or are experiencing a change in social roles, such as retirement, moving, or facing declining physical ability, or they have begun to experience the deaths of peers and family members.
Role disputes can also flare when marital partners experience the proximity of retirement or caregiver strain. Even if an older patient is engaged in psychotherapy elsewhere, the treating psychiatrist who is managing phar- macotherapy should check in periodically on the stress points that were identified in the initial evaluation, screen for new stressors or further impingements on coping ability, and ask directly how helpful the patient finds the psychotherapy.
In a nationwide study linking Medicare claims to survey data, 70% of psychotherapy was provided by solo-practice psychiatrists but patients received more consistent psychotherapy if a mental health center was available to them. Patients with no college education were less likely to receive psychotherapy. The best consistency was achieved with a psychiatrist who provided the pharmacotherapy and another professional who provided the psychotherapy. These data argue for taking a more patient explanatory stance with non-college-educated patients who might otherwise benefit from psychotherapy. The same study reported that limited local availability of qualified providers was a significant barrier to obtaining psychotherapy.23
Nowhere is a combined psychotherapy/pharmacotherapy approach more critical than in the management of depression in the elderly suicidal patient. Even though a guarantee against imminent lethality may be reasonably assured, the treating psychiatrist must quickly understand the true nature of the factors that are contributing to the current risk and must engage and follow up with the patient (and concerned family members) closely enough to determine whether he is moving in a safer or riskier direction. Risk factors for suicide in depressed elders are listed in Table 2.
|• Medical illness or disability|
|• Loss of spouse|
|• Male sex|
|• White race|
|• Alcohol abuse|
|• Cognitive impairment|
|• Lack of social supports|
|• Comorbid anxiety|
Stanley is a 67-year-old immigrant who presented for help with depression, some mild cognitive deficits, and chronic headaches caused by an old traumatic injury. He works as a doorman in an apartment building and lives with his wife, who speaks little English. He has an adult college-educated son who works in the same city.
After educating Stanley about the interrelationship of chronic pain and depression, it was recommended that he take an adequate dose of antidepressant that might help relieve the severity of both. He agreed and was scheduled for weekly follow-up visits. He denied suicidality at the first visit.
Although he seemed to be making some progress, he called during the third week of treatment stating that he could no longer stand the chronic pain in his head. He explained that he could not get an appointment with his neurologist for 2 months and that he could no longer concentrate on his job. He was worried about being fired; he desperately needed the job to survive financially and had decided that his only option was to kill his wife (whom he loved dearly) and then kill himself by having them both drink caustic cleaning fluid.
These statements, of course, set off alarms and the enactment of an immediate safety plan. Stanley agreed to be seen that day and reluctantly agreed to inpatient psychiatric hospitalization although he had many misgivings based on his recollection of former abuses in his native country. He proceeded to rescind his consent to be admitted, and we considered involuntary commitment as a last resort, given his inordinate fear of "locked units." With his permission, we contacted his son who was astonished to hear of his father's desperate condition and after painting a picture of his father as stubbornly stoic, volunteered to leave work and stay with him and his mother until he was convinced his father was out of danger.
In this case, as in most cases of suicidal depression, dispensing appropriately titrated antidepressant medication is not sufficient because these medications require time to relieve depressive symptoms. We needed to understand Stanley's predicament, his temperament, chronic pain, cognitive status, cultural background, and relationship to his family and to the medical system in order to make the best treatment decision, which was not hospitalization.
Although Stanley did not request psychotherapy, providing supportive psychotherapy as part of the treatment package was essential. More time was needed for his antidepressant medication to work and psychotherapeutic intervention was used in the interim to help him find immediate coping strategies. Forging an alliance with his capable son allowed the son to take a collaborative role in providing logistical support and a cognitively intact "voice of reason." He agreed to provide close supervision once the stakes were clearly explained to him. His continued collaboration may be a protective factor against a recurrence in the long term. Combination treatment was key to Stanley's eventual successful outcome.
This case also raises the possibility of early or mild cognitive impairment, which can present with executive dysfunction (ED) manifested as poor problem-solving ability, poor judgment, poor insight, impulsivity, and difficulty in generating alternative solutions. Family members often misunderstand symptoms of ED and untrained professionals can contribute to potentially bad outcomes. A modified form of IPT for cognitive impairment is under development to systematize and integrate the approach to patients with cognitive impairment and depression.24-26
Successful treatment of depression
For the treatment of depression to succeed, many variables must fall into place. The patient must be engaged and educated sufficiently about the treatment process and the expected rate of improvement, potential side effects, and other factors. For pharmacotherapy to work, patients must be compliant for a long period before the medication's effectiveness can be judged. Compliance is improved by adequate education of the patient and family members or caregivers; simplicity of the regimen; reminder systems, such as medication organizers; and a trusted relationship with the treating physician. Psychotherapy can go a long way to reinforcing this "dual attack strategy" on depression as the "enemy" to be defeated and kept at bay long term.
In our group's work on the first maintenance therapies in late-life depression study using combined IPT and nortriptyline, we were able to achieve a remission rate of 78% in a group of elderly patients with a mean age of 68 years who had recurrent depression. It should be noted, however, that strenuous effort was applied to teach the importance of medication compliance and there were frequent follow-up visits, which would not be considered usual practice. Combination treatment was also superior to either monotherapy with nortriptyline or IPT in preventing a recurrence over 3 years of follow-up. Furthermore, when we analyzed the over-age-70 group alone, we found that only combination treatment, and not monotherapy with either antidepressant medication or psychotherapy, was protective against a recurrence.12 This last finding is intuitive if one realizes that elderly patients are more likely to be affected by disruptive events such as moves, deaths, and increasing medical burdens; thus, the addition of talking therapy can help them more easily adjust, which is something even the perfect antidepressant cannot do.
The effect of psychotherapy in combined treatment may be obscured by the relatively more powerful effect of the antidepressant medication in the short term; however, the psychotherapy effect becomes more evident in the long term, particularly when maladaptive coping strategies are successfully replaced with better coping or problem-solving strategies. Changing perspectives can reduce the propensity for demoralization and depression as well. In cognitive-behavioral therapy parlance, challenging au-tomatic negative thinking, or ceasing to catastrophize can achieve a more realistic (and more comfortable) view of life. An IPT therapist would talk about grieving the loss of former social role(s) and exploring the potential positive aspects of the new role(s). Achieving these new perspectives may be even more critical in elderly patients compared with younger patients because fewer options for changing their environment may be available to the elderly. Table 3 summarizes the potential benefits of combined therapy.
|• Better compliance with pharmacotherapy|
|• Synergistic effect on reducing depressive symptom severity|
|• A more in-depth perspective on the factors that led to depression|
|• Potential to help the patient explore new or improved social supports|
|• Potential for reducing interpersonal conflict that contributed to depression|
|• Better engagement in the therapeutic process|
|• Formation of new perspectives that are more accepting of the reality of limitationscaused by age or infirmity|
|• Maximized care for suicidal patients with multiple stressors|
|• Option of including caregivers or concerned family members to educate and guidetheir efforts to improve social support for the identified patient|
|• Better long-term protection against a recurrence with newly learned skills orchanged perspectives (also consider monthly maintenance psychotherapy)|
Depression is the usual focus for combination treatment, but patients with anxiety disorders can certainly benefit as well, not to mention those with comorbid depression and anxiety states that are typically treatment-resistant and prone to high relapse rates.22,27 There are no controlled studies of combined treatment using group psychotherapy in the elderly, although this format may be particularly useful as well as cost-effective in long-term-care settings.28
Aging inevitably brings some loss of capability or function, but successful aging has been defined as the ability to adapt, accept, and even thrive at each stage of aging.29 Those who age successfully focus on what they can still do or enjoy, even if it is limited to reminiscing about treasured memories as in reminiscence therapy, an effective therapy in its own right (particularly for individuals whose functionality dictates that they live in a long-term-care facility). Finally, there are no studies that show that adding psychotherapy to a medication regimen produces a harmful outcome.
Practicing psychiatrists may find the following take-home points helpful:
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