Psychotherapy

Antidepressants have traditionally been regarded as a primary treatment, yet psychotherapy has been shown by several studies to be at least equally effective in treating depression in elderly persons. Psychodynamic psychotherapy, life review and reminiscence therapy, interpersonal therapy, cognitive-behavioral therapy, and group therapy are commonly used treatments of late-life depression.

Psychodynamic therapy. This therapy is rooted in psychoanalytic theory, viewing current interpersonal and emotional experience as influenced by childhood experience. According to this theory, early childhood molds a complex inner world forged by unconscious and conscious mental processes. Relationships, such as that with one's mother, are internalized and create a sense of self. A life event, such as a loss, may initiate conflict within that inner world, and unresolved conflict manifests as depressive symptoms. In therapy, these conflicts are explored and resolved.

Life review and life reminiscence therapy. These therapies are also psychodynamically oriented. Life review revisits and resolves past conflicts and reintegrates life events through a review of life experiences. Reminiscence differs from life review by focusing on social intimacy and self-esteem through past experiences, instead of directly resolving past conflicts. The process includes autobiographies, visits to childhood locations, photographs, reunions, and scrapbooks.

Interpersonal psychotherapy (IPT). This time-limited outpatient therapy focuses on four problem areas of current interpersonal issues: interpersonal disputes, role transitions, interpersonal deficits, and abnormal grief. The therapist and client decide in which direction to focus. The immediate therapeutic objective is to alleviate depressive symptoms; however, the future goal is to improve social functioning and interpersonal relationships. Role-playing, communication analysis, clarification of wants and needs, and links between affect and environmental events are some of the techniques used. Suggested adaptations of IPT to elderly patients by clinicians include flexibility of session length, focusing on long-standing role disputes, and the need to help patients with practical problems. IPT has been proven to be as effective in treating elderly patients as specific medications, with longer-lasting effects when combined with antidepressant medication.

Cognitive-behavioral therapy (CBT). The cognitive model of depression is based on the idea that, due to early learning, depressed individuals develop stable, albeit distorted, cognitive schemas that predispose them to negatively interpret life events. CBT usually consists of three components: First, the patient is pressed to increase reinforcing activities and pleasurable experiences through behavioral activation. Then, automatic dysfunctional thoughts are exposed, challenged, and substituted with more accurate cognition. Finally, the cognitive schemas driving these automatic thoughts are explored and changed to accurately fit the patient's experiences. Behavioral activation and automatic-thought modification have been shown to be effective either individually or in conjunction with each other.

Social problem-solving therapy (PST) falls within the realm of cognitive and behavioral interventions and is anchored in a model in which ineffective coping skills under stress leads to deterioration of problem-solving abilities and subsequent depression. PST approaches involve recognizing and altering maladaptive attitudes linked to ineffective problem-solving while increasing motivation to generate alternative solutions, make decisions, and assess solution utility.

Group therapy. Group therapy consists of a group of patients meeting regularly with a therapist or therapist team that leads the discussion. Some group therapy emphasizes the teaching of coping skills or social skills, while other groups may focus on supportive and expressive resolution of individual difficulties in a group setting. Older patients may prefer group therapy because it can provide a social network of support, as well as decrease the cost of care.