Mohammed T. Abou-Saleh

446 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYpsychologists have greater expertise for accurate diagnosis, yettypically only encounter a potential patient after referral from ageneral practitioner. In addition, mental health professionalsspecializing in work with geriatric populations are still in theminority and most training programs for both psychology andmedicine do not emphasize geriatric mental heath issues. Thisonly exacerbates the factors that make recognition less likely tooccur 24,25 . In order for improvements in detection to occur, allthree areas discussed above will need to be addressed. Physicianswill need to enhance their ability to detect depressive symptomsand make quick treatment decisions during increasingly shortoffice visits. Relatives and other informal sources of referral willrequire greater education regarding depressive symptoms andencouragement to report those symptoms. Finally, a greaternumber of mental health professionals will need to obtain specifictraining in geriatric issues and increase their visibility amongpotential referral sources.Under TreatmentIdeally, if the dilemma of underdiagnosis of late-life depressioncould be resolved, under treatment would not be a problem.However, this does not appear to be the case. Researchindicates that even cases that are diagnosed are not necessarilytreated. Koenig et al. 13 reported that 34% of hospitalizedmedically ill elderly patients with a diagnosis of depression intheir charts were not treated with antidepressant medicationduring their inpatient stay or during a 45 week follow-upperiod, neither were these patients referred to psychotherapy.Only 12.4% of the sample had documented psychotherapeuticintervention in their medical charts at discharge 13 . Thus, notonly does recognition appear to be a difficulty, but undertreatmentas well. The question is why?Many practitioners assume that older adults have negativeattitudes toward psychotherapy as a treatment for depression.However, research on attitudes toward treatment in elderlysamples is not conclusive, with considerable descriptive researchsuggesting that older adults may prefer counseling over medicationtreatment for depression. Sixty-eight percent of thepreviously mentioned non-depressed community-dwelling olderadult sample agreed with a statement that professional counselingor therapy helps most depressed people feel better. Interestingly,56% of the same sample reported that they believed antidepressantmedications to be addictive, and only 4% disagreed 21 . Olderadults have also been shown to report a greater number ofpositive attitudes toward mental health professionals, and to beless concerned with stigma attached to seeking treatment fordepression relative to younger adults 26 . On the other hand, Allenet al. 22 found attitudinal barriers to treatment in a survey of bothyounger adult and older adult inpatient samples. However, in theolder sample, the pattern of preference for counseling andpsychotherapy over medication persisted, with 95% of the oldergroup agreeing that ‘‘people with depression should be offeredcounseling’’, and 46% agreeing that ‘‘people with depressionshould be treated with antidepressant tablets’’ 22 . Hence, it appearsthat interventions addressing these issues must educate practitionersto evaluate their assumptions about elderly preferences fortreatment, as well as educate older and younger adults aboutavailable treatment options.PSYCHODYNAMIC THERAPYThis type of treatment is based on psychoanalytic theory thatviews current interpersonal and emotional experience asinfluenced by early childhood experience. This experience resultsin the development of a complex inner world shaped by bothunconscious and conscious mental processes. There have been avariety of theoretical formulations developed over the years thathave utilized a psychodynamic formulation to treat depression,including classic psychoanalytic theory 27 , ego-psychology 28 , selfpsychology29 and object-relations theory 30 . Revised conceptualizationshave emphasized understanding how relationships areinternalized and transformed into a sense of self 29–32 . Becauseearly interactions with caregivers are so tied up with emotionalgratification and deprivation, the interaction with mother isviewed as a template for all subsequent relationships. Psychopathologyis theorized as related to arrests in the development ofthe self and depression is viewed as a symptom state resultingfrom unresolved intrapsychic conflict, which may be activated bylife events such as loss.There have been several indications in the geriatric depressionliterature that short-term psychodynamic therapy, particularly asconducted by Thompson, Gallagher-Thompson and colleagues33,34 , is an effective means to treat depression in oldersamples. In studies with random assignment to wait-list control,short-term psychodynamic therapy or cognitive-behavioral therapy,there were no significant differences between the types ofpsychotherapy at the end of treatment or at 12 and 24 monthfollow-ups. Additional research on depressed caregivers demonstratedan interaction between mode of therapy and length ofcaregiving, such that those who had been providing care for lessthan 44 months appeared to improve more from dynamic therapy,whereas longer-term caregivers seemed to benefit most fromCBT 35 . The authors suggested that the long-term caregiversneeded the skills learned in CBT in order to care for familymembers with more pronounced deficits and requiring morecomplicated care. These interesting results call for additionalcontrolled trials comparing different treatment modalities, continuedcomponent analysis research, and continued research thatexamines which type of treatment works best with which type ofpatient.LIFE REVIEW AND REMINISCENCE THERAPYLife review and reminiscence therapies are psychoanalyticallyorientated approaches to psychotherapy for depression. Lifereview therapy includes a review of life experiences in order torevisit and resolve old conflicts and reintegrate life experiences 36,37 .Conflicts emerge in interviews about past life experiences, in bothacknowledgment and omission. Reminiscence therapy differsfrom life review in that the focus is on enhancing self-esteemand social intimacy by recounting past experiences, rather thandirectly resolving past conflicts 2,38 . Lewis and Butler 37 suggestseveral techniques to encourage elderly clients to participate in thelife review process. Written and taped autobiographies, pilgrimagesto the place of childhood, reunions, scrapbooks andphotographs are tools that can stimulate past memories. A crucialcomponent of any life review therapy is careful, attentive listeningon the part of the therapist 36,38 .Results on empirical research of life review and reminiscencetherapies are promising, but inconsistent. Teri and McCurry 2reviewed 12 empirical studies using reminiscence techniques.Results were mixed, likely due to the range of patientpopulations (institutionalized, homebound, community-dwelling),treatment duration (1–10 sessions), type of therapy(group, individual) and diagnosis (major depression, no diagnosedpsychopathology). Also, the distinction between lifereview and reminiscence therapy has not been clearly operationallydefined, resulting in an ambiguous designation of thedifferences between the two therapies.