Welcome to Edition 257 of Institute Inbrief! Because depression in older adults is so widely unrecognised, it can be difficult to comprehend just how forcefully conditions such as deteriorating health, a sense of isolation and hopelessness, and the challenge of adjusting to new life circumstances can create a “perfect storm” pushing an already-depressed person over the edge to suicide. In this edition’s featured article, we look at how depression manifests in the elderly, and explore some of the available psychosocial and medical treatment options.
Also in this edition:
Treating NPD in the Therapy Room
Cognitive Restructuring with Anxiety
Making Your Goals More Powerful
Social Media Updates & Much More!
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Treatment Options for the Depressed Elderly
Because depression in older adults is so widely unrecognised, it can be difficult to comprehend just how forcefully conditions such as deteriorating health, a sense of isolation and hopelessness, and the challenge of adjusting to new life circumstances can create a “perfect storm” pushing an already-depressed person over the edge to suicide.
When depression is not treated in elderly white men (in the United States), the suicide rate is six times the national average. Unbelievably, 75 percent of those men will have been seen by a doctor within several months of their deaths: clearly a doctor who did not truly “see” them! Proper treatment can prevent suicide, but because it so often goes unrecognised, the (U.S.) National Institute of Mental Health considers depression in people age 65 and older to be a major public health problem (Helpguide.org, n.d.).
Moreover, the following facts alert us to the importance of treating depression in elderly people, not only for their sake or that of their families, but for that of the whole community. Here is how depression affects the quality of life for the elderly in ways apart from suicide:
Depression significantly increases the likelihood of death from physical illnesses
As noted above, depression can make impairment from a medical disorder worse, and/or impede improvement (while the converse is also true: namely, that psychological treatment can improve the success rate for a number of medical conditions)
Without treatment for depression, patients are less likely to be able to follow necessary treatment regimens or participate successfully in any rehabilitation program
Healthcare costs of older adults with depression are about 50 percent higher than those of their non-depressed peers
The depressed elderly are more likely to rate their health as only fair or poor, to turn up at the emergency department, and to have more doctor visits than non-depressed seniors
Depression generally lasts longer in seniors
Treating depression results in better outcomes for anxiety disorders, which commonly co-occur with depression
Treating depression can help people resolve substance abuse disorders (including here both alcohol and prescription drugs) that have resulted from self-medication for symptoms (Helpguide.org, n.d.)
The same range of treatment methods is available to treat depressed seniors as those that can be used with younger people with depression, but the treatments may be applied differently due to complicating factors in the typical elderly person’s situation.
In general, health professionals treat depression through “talk therapy” – for example, Cognitive Behavioural Therapy and psychotherapy – and also medical methods, such as antidepressant medication and electroconvulsive therapy (Chiu, Tam, & Chiu, 2008). Both of those treatment thrusts are helpful for the depressed elderly, but there are special considerations in the case of the older adult which guide the taking up of treatment options.
These arise partly because depression in the older adult is often the result of a difficult life situation, so the treatment plan should address that issue. Too, the treating professional must manage medical issues and complications that are less often present for younger people being treated (Smith, Robinson, & Segal, 2013).
The most common treatments for depression in the elderly include:
Cognitive Behavioural Therapy (CBT)
Antidepressant medications (lower doses may be needed and also consistent monitoring)
Electroconvulsive therapy (ECT)
Which treatment is selected depends on the cause and severity of the depression and, partly, on personal preference. Moreover, older clients with depression are more vulnerable than their younger cohorts to effects from medication, so there is general consensus that for mild and moderate depression, psychosocial approaches should be tried first, reserving medication for severe depression and/or those cases where clients do not respond to therapy (Helpguide.org, n.d.).
Different mental health and geriatric experts champion different forms of psychotherapeutic and social interventions to help older adults heal depression, but most agree that such treatments are generally effective (Beyondblue, 2009; Birrer & Vemuri, 2004; Myers & Harper, 2004), even though they have been slow to develop for elderly people because of ageist assumptions (Ardern, 1997). Certainly, some factors triggering depression, such as stressful life situations, family conflict, and the reduction or absence of social support, are not shifted by medication, but are responsive to psychological approaches.
The main factors impacting on the success of talk therapies are whether there is cognitive impairment or there are medical problems which make the therapy difficult. Behaviour patterns, personality traits, and the client’s expectations and preferences about the type of intervention used also predict a successful outcome. For older adults, therapeutic conversations are not about imposing a new lifestyle. Rather, they attempt to discover and employ adaptive strengths which the client has used successfully in the past. Useful areas of focus are those of: building self-esteem, accepting feelings (including anger and irritability), and instilling hope (Birrer & Vemuri, 2004).
The forms of therapy often named as efficacious for depressed older adults include cognitive behaviour therapy (CBT), psychotherapy, problem-solving therapy, supportive counselling, and support groups. “Talk therapy” is just as beneficial for older adults as younger ones, because seniors often have better treatment compliance, lower dropout rates, and more positive responses to psychotherapy than younger clients (Nierenberg & McColl, 1996; Smith et al, 2013; Myers & Harper, 2004).
Notwithstanding that, any counselling or therapy interventions must take into account the older adult’s sometimes impaired sensory functions, such as loss of visual and hearing capabilities, and also cater for mobility and disability issues. Obviously, for some adults with mobility problems, just getting to the sessions may be a big challenge. Let us look in greater detail at how these approaches can help.
Cognitive behaviour therapy (CBT)
The most evaluated approach, CBT has been shown in randomised studies (Zerhusen, Boyle, & Wilson, 1991; Campbell, 1992) to be more effective than occupational therapy, routine nursing care, and waiting list controls. When behavioural and psychodynamic approaches were compared, they were found to have similar efficacy and both strands of help are superior to no treatment (Morris & Morris, 1991). CBT is particularly suited to helping older clients reframe negative, limited thinking, fostering an improved ability to solve problems with compassionate self-regard and a realistic appraisal of their situation.
Psychotherapy generally helps clients to work through stressful life situations and transitions, heal from losses, and process difficult emotions. By re-visiting earlier periods of life, psychotherapy can aid in illuminating past causes of present difficulties, especially in relationships. Given its potential capacity to transform negative thinking patterns and develop coping skills, psychotherapy can assist those losing their independence to create and maintain higher-quality relationships with caregivers and members of the health team.
Specifically named “problem-solving” for its focus on solutions, this sort of therapy can help the older adult by expanding their range of possible solutions to presenting issues and reminding the client of the problem-solving resources at their command. Brief and focused, it helps sharpen coping and adaptation skills.
Supportive counselling, both individually and in groups (including religious and peer counselling ones), can help ease loneliness and the hopelessness of depression, and assist the older depressed client in finding new meaning and purpose in life. Such counselling is strongly encouraged for grief work. Whether the counselling is conducted in an institutional or a community setting does not seem to matter.
What research has shown to be almost universally effective are two overlapping strategies: group counselling and life review therapy. Both are highly effective at helping older adults to develop successful coping mechanisms for a variety of life problems and also to achieve life satisfaction despite unwanted change.
Group counselling. Group counselling, either topic-specific (dealing with topics such as, say, retirement, widowhood, or health challenges) or participant-specific (designed for, say, older men, bereaved persons, or older adults with substance abuse issues) has long been identified as the treatment of choice for most problems and challenges of later life (Myers & Harper, 2004).
Life review therapy. Because life review is “normal” in later life and necessary in order to attain ego integrity, life review has emerged as a superior intervention in nearly all settings where adults congregate either voluntarily or through institutional or group-living placements. One study reported successful results from 25 years of research when autobiography groups were used as a form of structured life review (Birren & Cochran, 2001). Results suggested that it is the sharing of stories in group settings which has positive therapeutic benefits for seniors. In a study which followed 52 participants (aged 70 to 88) over a three year period, a structured life review process was evaluated as a holistic nursing intervention.
Participants were divided into two groups, receiving either a friendly visit or a life review intervention. Those receiving the life review intervention showed significant improvement in life satisfaction and self-esteem and decreased incidence of depression, at one, two, and three years post-intervention (Haight, Michel, & Hendrix, 2000). The caveat is only that there be professional counsellors or therapists facilitating the life review, as life review can yield the unfortunate result of despair and consequent depression.
Whether for bereavement, illness, or depression, support groups connect those going through similar challenges, providing a safe place to share experiences, advice, and encouragement. As a counsellor/therapist, you can have a major role in helping older clients (or clients caring for older adults) to connect with appropriate local groups.
Integration and collaboration are needed
Regardless of which psychosocial intervention(s) you choose, clients are well served by interdisciplinary collaboration, which you can establish with the client’s general practitioner and possibly other members of the health team. Working together, you and the other members of the team will be able to refer clients and their families to resources such as senior citizen centres and nutritional programs.
Appropriate goals for your interventions include the reduction of symptoms of depression; ongoing evaluation of needs; help in accessing primary care services and other health system resources; and improvement in social and occupational skills, coping skills, everyday functioning, social integration, work performance, and quality of life (Birrer & Vemuri, 2004). Part of the interdisciplinary collaboration is recognising when psychosocial and educational interventions are insufficient and you need the medical practitioner to add medication or other treatment to therapies you have already put in place.
Medical treatment options for depression include both medication (mainly antidepressant) and also electroconvulsive therapy (ECT).
Antidepressants work to increase the level of the brain’s “messengers”, the neurotransmitters. Because many feelings, including pain and pleasure, are a result of the neurotransmitters’ function, their imbalance can bring about depression. Not all seniors are successful in alleviating symptoms of depression through antidepressants. When they don’t work for a depressed older person, it can be because the person is not taking the medication properly. Missing doses or taking more than the prescribed amount of the medication reduces its effectiveness.
Antidepressants usually begin to take effect between four and twelve weeks. However, the person who stops taking the medication simply because s/he is feeling better is inviting a relapse. Generally, people need to continue for four to six months after recovery to prevent another depressive episode (Helpguide.org, n.d.), with a total minimum time of six months to a year (GMHF, n.d.).
Electroconvulsive therapy (ECT)
The thought of ECT strikes fear into the heart of many, yet it is a safe, fast-acting, and effective treatment for severe depression of those over 60. Those who may be advised to undergo a course of it include depressed elders who have not responded to antidepressant or anti-psychotic medication. It is also used quite successfully on elder patients with delusions, psychomotor retardation, early morning awakening, or a family history of depression. It can serve those elderly populations who have severely impaired basic daily functioning, such as difficulties with eating, bathing, and grooming, and may even reverse the memory loss and confusion associated with cases of pseudo-dementia.
It is not indicated where people have brain tumours, cerebral aneurysms, recent heart attacks, or uncontrolled heart failure. Also, it is said to be an effective short-term therapy, but it has higher relapse rates over six to twelve months: both generally and also particularly for those seniors undergoing it with a history of medication resistance (Nierenberg & McColl, 1996; Birrer & Vemuri, 2004; GMHF, n.d.).
The importance of an integrated approach
There are multiple factors affecting the development of depression in older adults; thus a multidisciplinary approach works best, and the different psychosocial and medical interventions can best be thought of as synergistic rather than mutually exclusive.
A recent study found that the outcome of depression among elderly people in residential care was improved by multidisciplinary collaboration and by enhancing the clinical skills of general practitioners and care staff. Another study incorporated several strategies, including staff training, a form of life review, a regular “talk and walk” program, and a training and support group for carers.
The combined strategies not only helped the staff to improve their knowledge and self-efficacy in recognising and managing elder depression, but also helped residents to more positively adjust to their new environment (Beyondblue, 2009). More studies are needed in order to provide better evidence for integrated approaches to treating late life depression.
This article was adapted from the Mental Health Academy course “Treating Depression in Older Adults”. This course is about how to understand, recognise, and treat depression in older adults. Click here to learn more.
Click here to access the original article and a full list of references.
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Treating NPD in the Therapy Room
Benjamin (1996) asserted that therapy interventions for narcissism could be evaluated in terms of five categories of correct response: whether or not the intervention enhanced collaboration, facilitated learning about patterns, blocked maladaptive patterns, strengthened the will to give up maladaptive patterns, or facilitated new learning. In this article, we take each in turn.
Cognitive Restructuring with Anxiety
Cognitive restructuring, straight thinking or logical reanalysis is based on the belief that the way we feel, behave and respond to situations is based on the way we think. This approach attempts to modify unhelpful thought patterns and beliefs. Cognitive restructuring, also known as cognitive reframing, is a technique drawn from cognitive therapy that can help people identify, challenge and alter anxiety provoking thought patterns and beliefs.
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