Mohammed T. Abou-Saleh

448 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYon a model in which ineffective coping under stress is hypothesizedto lead to a breakdown of problem-solving abilities andsubsequent depression 55,56 . Therapeutic approaches involve identifyingand modifying maladaptive beliefs or attitudes associatedwith ineffective problem-solving while increasing motivation togenerate alternative solutions, make decisions, implement solutionsand assess solution utility.Outcome studies have supported the use of cognitive andbehavioral psychotherapy in treatment of depression in elderlysamples (see reviews 1,7,33,57 ). In a study comparing cognitive,behavioral and brief psychodynamic therapy to wait-listcontrols, Thompson et al. 33 found that all of the treatmentmodalities led to comparable and clinically significant reductionsof depression. All three treatment regimens includedindividual treatment twice weekly for 4 weeks and weeklythereafter, totaling 16–20 sessions. Overall, 52% of the sampleattained complete remission after treatment, and 18% showedsignificant improvement, with some enduring depressive symptoms.These rates are comparable to treatment outcomes inyounger adult populations and response to pharmacotherapy33,58 . Follow-up research indicated that at 12 months aftertreatment 58% of the sample was depression-free, and at 24months 70% of the sample was not depressed. As in acutetreatment, there were no differences between treatment modalitiesat follow-up 34 , although in previous research with asmaller sample size depressed geriatric patients in cognitive andbehavioral therapies maintained the gains longer than thosetreated in brief psychodynamic therapy 59 . Arean et al. 60examined the efficacy of PST in a randomized controlled trialof 74 clinically depressed older adults (age 55 and over).Patients were assigned to one of three treatment conditions:problem-solving therapy (PST); reminiscence therapy (RT); or awaiting-list control. Following 12 weekly sessions, boththerapies showed significant reductions in depressive symptomsat post-treatment and at a 3 month follow-up, relative tocontrols. However, PST showed a significantly greater numberof patients, compared to RT, who were classified as improvedor in remission following treatment.Subsequent research on the same sample used in the Thompson 33study examined the role of change expectancies relative tooutcome 61 . Of those who were assigned to cognitive therapy,subjects who originally indicated that they expected a change fromcognitive and behavioral processes attained greater improvement.In addition, some elderly patients, more familiar with the ‘‘doctortakes care of patient’’ mentality pervasive in medicine, may not beaccustomed to the hard work involved on the part of the patientsfor the success of cognitive-behavioral therapy. Thompson et al. 62recommend addressing such views directly, while helping thepatient to gain insight into how his/her thoughts influence moodand how new skills can help in coping with stressful events andautomatic thoughts.GROUP INTERVENTIONSGroup therapy has been shown efficacious for depression in adultsamples 63 and in geriatric samples 64 . Non-specific treatmentfactors that may influence positive outcomes include diffusingdependence on individual therapists, as well as providing asupportive social network. In addition, with the relative dearth ofcoverage for mental health care among many insurance providers,and the relative lack of parity for mental health care in Medicare,the lower cost of group therapy may be a more appealing optionin older patient populations.Beutler and colleagues 64 tested the relative and combinedeffectiveness of alprazolam and group cognitive therapy in asample of 56 depressed older adults. Subjects were assigned to oneof four groups: alprazolam and weekly management sessions;placebo and weekly management sessions; cognitive therapy plusalprazolam; and management and cognitive therapy plus placebo.The cognitive therapy groups were held in 12 weekly 90 minsessions. Patients in group therapy showed a significant andconsistent decline in BDI scores, while those not in group therapyfailed to produce significant changes. Also, a significantly higherproportion of those in group cognitive therapy were asymptomaticat the end of follow-up (29% vs. 12%). Although the resultsindicate that the cognitive therapy group was more effective inreducing depressive symptoms than alprazolam, this drug (a typeof benzodiazepine) is not a recommended medication fordepression. However, it appears that benzodiazepines remain arelatively commonly prescribed medication in medical practice. Ina sample of depressed inpatients at a large university medicalcenter during 1993–1996, 25% of patients diagnosed withdepression by a geriatric psychiatrist were prescribed onlybenzodiazepines by their physicians 13 . Koenig et al. 13 also foundthat newer and older antidepressants were prescribed with thesame frequency, suggesting that the prescribing practices of manyphysicians do not include the newer, safer antidepressants.Despite the fact that benzodiazepines are still used in clinicalpractice for depression, a revised research project using one of thenewer antidepressants in Beutler’s design would be informativefor today’s clinicians.Steuer et al. 65 investigated cognitive-behavioral therapy (CBT)and psychodynamic group therapy in a sample of 33 depressedelders. The investigators assigned members to each condition onthe basis of time entering the study and did not include acontrol group in their study design. Both treatment groupsevidenced significant clinical improvement over 9 months oftherapy. Of the 13 subjects who dropped out of treatment beforethe end of the 9-month period, 10 showed improvements indepression on the HAM-D, with mean improvement being 34%.There were no differences between treatments on the clinicianratedHamilton Rating Scale (HAM-D), although the CBT grouphad lower scores on the self-report Beck Depression Inventory(BDI).Lynch et al. 66 have reported unpublished pilot work usingdialectical behavior therapy (DBT) skills training to treat elderlydepression. Twenty-seven participants were randomly assigned toDBT skills training plus medication or medication alone plusclinical management. All participants were on antidepressantmedication and all met criteria for MDD at baseline. DBTincluded weekly 2 h group skills training and weekly half-hourtelephone check-in calls by a therapist for 28 weeks. Approximately29% of the sample met strict criteria for a SCID-IIdiagnosis of personality disorder. Although there was a trend forDBT patients to show lower desires to please others from pre- topost-treatment relative to medication alone, there were nosignificant differences between treatments on outcome measures.Both DBT and medication alone showed significant reductions inHAM-D and BDI scores. Within-group analyses revealed that themedication alone group showed significant improvement overtime on only one variable that the DBT condition did not, namelyfear of sadness. The DBT condition showed: significant decreasesin hopelessness and in total adaptive, avoidant, detached, andemotional coping; significantly lower sociotropy/dependency;lower desires to please others; and lower autonomy scores frompre- to post-treatment.MAINTENANCE THERAPY AND RELAPSEPREVENTIONDespite the effective treatments available for depression in theelderly, it has been established that elderly patients who recover