Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-079Psychotherapy ofDepression and DysthymiaThomas R. Lynch 1 and Christine M. Vitt 21Duke University Medical Center and 2 Duke University, Durham, NC, USABACKGROUNDDepression in the elderly is a treatable disorder. Althoughantidepressant medication has traditionally been considered afirst-line intervention, psychotherapy has been shown to be atleast equally effective 1–3 . The NIH Consensus DevelopmentConference on Diagnosis and Treatment of Depression in LateLife concluded that psychotherapy was an important treatmentoption for elderly depression, although not sufficient by itself 4–6 .This conclusion has been challenged in the literature, with reviewsof psychotherapy research finding a powerful effect of psychotherapyalone on depression as compared to wait-list controls 1,3,7 .Additional research on the combination of medication andpsychotherapy for elderly depression has shown promising resultsfor both acute treatment and relapse prevention 8 . Less is knownabout the treatment of dysthymic disorder, although its similaritiesto major depressive disorder suggest that aggressivetreatment is the most powerful treatment option.This chapter reviews the theoretical elements and empiricalevidence supporting the use of psychotherapy to treat elderlydepression. First, we examine special issues associated withtreating elderly depression using psychotherapy. Next, we reviewthe theoretical foundations and evidence for the use of psychotherapywith older adults, including cognitive-behavioral,psychodynamic, interpersonal and group interventions. Finally,we examine recent theoretical developments and research thathave addressed problems associated with relapse prevention,treatment-resistant depression, and co-morbid personality disorders.SPECIAL ISSUES IN PSYCHOTHERAPY WITHOLDER PATIENTSPsychotherapy is a particularly useful option for depressedpatients who cannot or will not tolerate medication, or who aredealing with stressful conditions, interpersonal difficulties, limitedlevels of social support and/or recurrent episodes of depression6,8,9 . Although it has been established that psychotherapy andmedication are effective treatments for major depression, there is asizeable literature highlighting the underdiagnosis and undertreatmentof late-life depression 10–16 . Consequently, millions ofolder persons deserving of mental health care go untreated 17 .Friedhoff 14 indicated that only 10% of older adults in need ofpsychiatric services actually receive professional care and therehas been minimal utilization of mental health services in this agegroup 16,18,19 .Under DiagnosisOlder adults are more likely to see general practitioners thanmental health professionals, essentially leaving the responsibilityfor diagnosis of late-life depression in primary care. Althoughphysicians are more likely than mental health professionals to seedepressed older adults, this does not mean that elderly patientswill purposefully present with depressive symptoms. Studies haveshown that up to 75% of older adults who complete suicide hadseen their physician in the previous month, emphasizing theimportant role general practitioners play in diagnosing clinicaldepression 20 . In a non-depressed community sample of 462 olderadults, 40% indicated they would keep depressive symptoms tothemselves and not report them to anyone 21 . Of those who wouldseek help, over half (52%) indicated they would talk to theirregular doctor. Allen et al. 22 surveyed attitudes toward treatmentsfor depression in older and younger inpatients. The older group,particularly those identified as depressed, was less likely toapproach anyone for help. In addition, the older adults had morenegative attitudes about approaching their physician than theyounger group.Hesitation to seek help for mental health problems should notbe considered unfounded. Link and colleagues 23 have identified asocial stigma associated with undergoing treatment for psychiatricdysfunction. However, treatment outcome research suggests thatgains in well-being likely outweigh any stigma associated with thedisorder. Hence, coming to an understanding of the origins ofthese attitudes may assist in developing educational interventionsaddressing the needs of this age group.This descriptive research highlights several issues of concern forthe diagnosis of depression. First, general practitioners typicallybear the responsibility for the diagnosis of depression in theirolder patients, despite the possibility that patients may not feelcomfortable about discussing depressive symptoms with others.Making this more difficult have been reports that older patientsmay not recognize that they have symptoms, or may pass offsymptoms as signs of other physical conditions 10 . Second, not allolder patients regularly see general practitioners. For these olderadults, informal resources (family, friends, religious sources) areleft with the responsibility of identifying changes in moods andthe need for professional intervention. Third, psychiatrists andPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd