http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2015; 24(3): 168–171 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.971143
REVIEW ARTICLE
Cognitive behavioural therapy for older adults with depression: a review Rasika Jayasekara1, Nicholas Procter1, Julie Harrison2, Kerim Skelton2, Sally Hampel3, Russell Draper2, and Kate Deuter1 School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, Australia, 2Adelaide Metro Mental Health Directorate, Older Persons Mental Health Service, Central and Northern Adelaide Local Health Network, Adelaide, Australia, and 3Eastern Mental Health Service, Adelaide Metropolitan Mental Health Directorate, Adelaide, Australia
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1
Abstract
Keywords
Background: Depression is a major public health concern of global significance. The illness diminishes overall quality of life and has been associated with significant distress and disability in physical, interpersonal, and social role functioning. Over the past few decades, a consensus has evolved that cognitive behavioural therapy (CBT) can be an effective treatment for depression in older adults; however, little attention has been given to its effect on them. Aims: The purpose of this review was to examine the current use of CBT and its effect on older adults with depression. Method: A web-based literature search was performed to identify original research articles published from 2000 to 2013 using a three-step search strategy. Results: Evidence indicates that cognitive behavioural therapies are likely to be efficacious in older people when compared with treatment as usual. This is consistent with the findings of several systematic reviews and meta-analyses undertaken across a wider age range. Conclusions: Given that many older adults with depression are reluctant to accept antidepressant medication or unable to tolerate their side effects, CBT can be used as an option in treating depression in older adults.
CBT, cognitive behavioural therapy, cognitive therapy, depression, older adults
Introduction Depression is a substantive cause of disability worldwide (World Health Organization, 2012). Major depression (MD) or major depressive disorder (MDD) is a leading cause of morbidity and mortality in the elderly, with an estimated prevalence of 7% of the general elderly population and it accounts for 1.6% of total disability among over 60 year olds (Institute for Health Metrics and Evaluation, 2010). If left untreated, there is evidence of an increased risk of physical and psychological morbidity and mortality, with an associated economic and societal burden (Gould et al., 2012; Lockwood et al., 2004; Smits et al., 2008). At its worst, depression can lead to suicide, highlighted by the loss of 1 million people every year worldwide (World Health Organization, 2012). Predictions of an ageing population suggest that there will be increased demand for treatments and therapies that address the specific needs of older people. The treatments for depression among older adults include antidepressants, electroconvulsive therapy, cognitive Correspondence: Dr. Rasika Jayasekara, Senior Lecturer, School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, SA 5001, Australia. Tel: +61 8 8302 2750. Fax: +61 8 8302 2168. E-mail: [email protected]
History Received 4 September 2013 Revised 28 August 2014 Accepted 18 September 2014 Published online 29 October 2014
behavioural therapy, psychodynamic psychotherapy, rational emotive behaviour therapy, behavioural activation, reminiscence therapy, and exercise (Frazer et al., 2005; Szentagotai et al., 2008). Pharmacotherapy is an accepted and often frontline treatment for depression (Lockwood et al., 2004). Epidemiological data have found that the widespread use of antidepressants is associated with a significant decline in suicide rates in most countries with traditionally high baseline suicide rates (Rihmer & Akiskal, 2006). Approximately 50– 60% of patients are supposed to improve clinically as a consequence of antidepressant treatment (Schneider & Olin, 1995). These findings are supported by a systematic review of antidepressant versus placebo in the treatment of depression in older adults (Mottram et al., 2006). However, it is evident that older, frail depressed patients are particularly prone to side effects of antidepressants (Arroll et al., 2009; Kennedy, 2013; Schatzberg, 2007; Seitz et al., 2011) and older patients are more prone to the cardiovascular side effects of antidepressants (Pacher & Kecskemeti, 2004). The World Health Organization (2011) has recommended that if antidepressant treatment is required for older people, tricyclic antidepressants (TCA) should be avoided if possible. Therefore, older people, despite taking medication, continue to experience symptoms and/or disabling adverse effects
Cognitive behavioural therapy
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DOI: 10.3109/09638237.2014.971143
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(Bogner et al., 2009; Candy et al., 2008; Mottram et al., 2006). There is thus a growing need to consider alternative forms of treatment for depression. Since the early 1980s, several well-controlled clinical trials have demonstrated that depression in older adults can be treated with psychotherapy, either alone or in combination with antidepressant medication. Several psychological therapies have been studied, but the cognitive-behavioural therapy (CBT) has been most widely investigated in this population (Bogner et al., 2009; Candy et al., 2008; Mottram et al., 2006). CBT, a form of psychotherapy, is regarded as a non-pharmacological intervention that can provide depressed individuals with the skills with which to manage their own illness (Bogner et al., 2009; Lockwood et al., 2004; Ridgway & Williams, 2011). CBT has no known adverse side effects, unlike antidepressant medications and, has the potential to go on assisting the individual long after the symptoms subside and the therapy ceases. However, the usefulness of CBT as an intervention for older adults with depression has not been adequately evaluated. The purpose of this review paper is to examine current evidence on the effectiveness of CBT for older adults with depression.
Search strategy
Background
Reviews and meta-analyses of the voluminous literature on CBT outcome studies have concluded that CBT is a highly effective approach for the treatment of depression (Gaffan et al., 1995; Oei & Dingle, 2008; Samad et al., 2011). Most Clinical Practice Guidelines advocate the additional benefit of supporting antidepressant medication with CBT (National Institute for Clinical Excellence, 2009). Despite the wealth of evidence evaluating CBT for depression, little attention has been given to its effect on older adults. The following studies were identified as meeting the inclusion criteria and are summarized below. A Cochrane systematic review was conducted to investigate the effectiveness of psychotherapeutic treatments for depression in older people (aged 55 or over) (Wilson et al., 2008). This review was limited to RCTs and cluster randomised trials. All types of psychotherapeutic treatments were considered such as cognitive behavioural therapies, psychodynamic therapy, interpersonal therapy, and supportive therapies (Wilson et al., 2008). The review included seven small trials, involving 153 older adults that examined psychotherapeutic treatments for depression in older people. Five RCTs compared cognitive behavioural therapy with control conditions, and the results revealed that cognitive behavioural therapy was more effective than waiting list controls. Two RCTs with 57 older adults compared the effectiveness of cognitive behavioural therapy versus psychodynamic therapy. However, there is no statistically significant difference between cognitive behavioural therapy and psychodynamic therapy (Wilson et al., 2008). It is reasonable to suggest that the findings of this review have limited clinical implications due to the small number of trials and small sample size. However, the review author concluded that cognitive behavioural therapies are likely to be efficacious in older people when compared with waiting list controls (Wilson et al., 2008). The authors recommended conducting a large-scale research on this area because of the paucity of high-quality studies in this field.
CBT for depression In the 1970s, psychology underwent a cognitive revolution that led to a greater interest in the significance and relevance of cognitive processes to therapy (Grant, 2010). The increasing interest in cognition resulted in the development of various cognitive behavioural therapies (Eifert & Plaud, 1993; Grant, 2010). The theoretical structure and a basic method for CBT were outlined by Aaron Beck in a series of seminal papers published in the 1960s and then elaborated in a treatment manual for depression (Eifert et al., 1993; Eifert & Plaud, 1993). CBT is an action-oriented treatment approach that has become a widely used psychotherapy for major mental disorders. CBT methods were initially developed for depression and anxiety disorders and, later they were modified for many other conditions (Linehan et al., 1991, 1993). CBT has also been adapted for use as an adjunct to medication in the management of mental disorders (Andersson et al., 2013; Binks et al., 2006; Henschke et al., 2010; Martinez-Devesa et al., 2010; Montgomery & Jane, 2003). Although the label cognitive behavioural therapy has been applied to a variety of interventions, accordingly, it is difficult to provide a single, unambiguous definition. In a Cochrane review, CBT was classified as ‘‘well-defined’’ if it clearly demonstrated that (i) the intervention involved recipients establishing links between their thoughts, feelings, and actions with respect to the target symptom; and (ii) correction of recipients’ misconceptions, irrational beliefs, and reasoning biases was related to the target symptom. A further component of the intervention should have involved one or both the followings: (i) the recipient monitoring his or her own thoughts, feelings and behaviours with respect to the target symptom; and (ii) the promotion of alternative ways of coping with the target symptom (Jones et al., 2004, 2012).
The search strategy was limited to English language papers published from 2000 to 2013. A three-step search strategy was developed using MeSH terminology and keywords to ensure that all materials relevant to the review were captured. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then conducted. Third, the reference lists of all identified articles were searched for additional studies. All systematic reviews and randomised controlled trials (RCT) assessing the effectiveness of CBT as a treatment for older adults (aged 55 or above) with major depression when compared with standard care, specific medication, other therapies, and no intervention were considered.
Results The effectiveness of cognitive behavioural therapy for older people
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R. Jayasekara et al.
A systematic review was conducted to examine the effectiveness of psychotherapy for treating depression in older adults (aged 55 or over) (Peng et al., 2009). This systematic review was also limited to RCTs and three types of psychotherapy were included: CBT, reminiscence therapy, and general psychotherapy (GPT). This review included 14 RCTs involving 705 older adults. The primary outcome measure was the depression score, measured using a range of scales, including the 20-item Symptom Checklist (SCL-20) for depression, the Hamilton Rating Scales for Depression, the Beck Depression Inventory, and the Geriatric Depression Scale. Meta-analysis and subgroup analysis showed that psychotherapy (CBT, reminiscence therapy, or GPT) was significantly more effective than placebo/no intervention in decreasing depression scores. The review further found that psychotherapy as an adjunct to antidepressant medication did not increase effectiveness. There was no statistically significant difference between CBT and reminiscence therapy in improving depression. Although this review was published in 2009, all RCTs in cognitive behavioural therapy were published before 2004. The findings of these systematic reviews are largely consistent with other research on the effectiveness of CBT in all ages. A meta-analysis which was used to integrate the results of 89 controlled studies of treatments involving 5328 older adults receiving pharmacotherapy or psychotherapy found that psychotherapy and pharmacotherapy did not show strong differences in effect sizes (Pinquart & Sorensen, 2001). A meta-analysis of 25 studies revealed that psychological treatments have moderate to large effects on depression in older adults (standardized mean effect size d ¼ 0.72) (Cuijpers et al., 2006). In a recent systematic review, a meta-analysis showed that, compared with waiting list, group cognitive behavioural therapy is an effective intervention for reducing depressive symptoms in older adults with sub-threshold depression (Krishna et al., 2013). However, major limitations of these studies were the inclusion of non-randomised studies (Samad et al., 2011) and broadly defined interventions (e.g. psychotherapy) (Cuijpers et al., 2006; Peng et al., 2009; Wilson et al., 2008). Furthermore, studies comparing CBT or other evaluated psychotherapies against combined psychotherapy and medication for depression showed that psychotherapy delivered in conjunction with pharmacotherapy is significantly more efficacious in treating depression than is pharmacotherapy alone (Cuijpers et al., 2013; de Maat et al., 2007; Hollon et al., 2005). A systematic review of 16 trials with 932 adult patients concluded that psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone (Pampallona et al., 2004). The combination treatment of CBT and antidepressants had a lower risk of discontinuation compared with antidepressants alone (RR 0.81; 95% CI 0.65, 1.01) (National Collaborating Centre for Mental Health, 2010). The use of CBT as a treatment for older adults with depression remains uncommon despite recognition of its efficacy. Ageism, or the discrimination against people on the grounds of age alone, has been slow to gain public awareness in Western society, which has been a significant hindrance to development of expertise, research, and services
J Ment Health, 2015; 24(3): 168–171
(Hepple, 2004). In addition, potential barriers to older adults receiving CBT may include invalid beliefs that older adults are unlikely to benefit from psychotherapy (Laidlaw et al., 2008). This commonly held belief can be traced back to Freud’s assertion that older people lack the mental flexibility to change or to benefit from psychotherapy (Pinquart & Sorensen, 2001). As older people respond very positively towards CBT therapies as a treatment option for depression (Hanson & Scogin, 2008; Landreville et al., 2001), much should be done to make this more widely known in the community. Noting that many older people are unable to access CBT services, comprehensive educational campaigns directed at both professionals and older people could be considered. Some authors have suggested the core elements of less than optimal usage of CBT by older people has been created by the increasing cost of the required services (Beach et al., 2010) and insufficient numbers of trained therapists both in primary care and in specialist mental health services (Hoifodt et al., 2011). A gradually increasing awareness of, and skills in, psychotherapies among mental healthcare professionals and the consumers will probably deliver the most overall benefit.
Conclusion The key finding of this review is that cognitive behavioural therapies are likely to be efficacious in older people with depression when compared with treatment as usual. However, the small size of included studies, the varied participant demographics, and the heterogeneity of the interventions have considerable impact with regard to generalising these findings to wider clinical populations of older adults. It is widely viewed that psychological treatments derived from CBT can be used as an option in treating depression in older adults because many older people with depression are reluctant to accept antidepressant medication or unable to tolerate its side effects. Future research should be aimed at developing a broader understanding of the usefulness of CBT as an intervention for older adults with depression and encompass treatment availability, costs, and preferences.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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REVIEW ARTICLE
Cognitive behavioural therapy for older adults with depression: a review Rasika Jayasekara1, Nicholas Procter1, Julie Harrison2, Kerim Skelton2, Sally Hampel3, Russell Draper2, and Kate Deuter1 School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, Australia, 2Adelaide Metro Mental Health Directorate, Older Persons Mental Health Service, Central and Northern Adelaide Local Health Network, Adelaide, Australia, and 3Eastern Mental Health Service, Adelaide Metropolitan Mental Health Directorate, Adelaide, Australia
J Ment Health Downloaded from informahealthcare.com by University of Otago on 07/11/15 For personal use only.
1
Abstract
Keywords
Background: Depression is a major public health concern of global significance. The illness diminishes overall quality of life and has been associated with significant distress and disability in physical, interpersonal, and social role functioning. Over the past few decades, a consensus has evolved that cognitive behavioural therapy (CBT) can be an effective treatment for depression in older adults; however, little attention has been given to its effect on them. Aims: The purpose of this review was to examine the current use of CBT and its effect on older adults with depression. Method: A web-based literature search was performed to identify original research articles published from 2000 to 2013 using a three-step search strategy. Results: Evidence indicates that cognitive behavioural therapies are likely to be efficacious in older people when compared with treatment as usual. This is consistent with the findings of several systematic reviews and meta-analyses undertaken across a wider age range. Conclusions: Given that many older adults with depression are reluctant to accept antidepressant medication or unable to tolerate their side effects, CBT can be used as an option in treating depression in older adults.
CBT, cognitive behavioural therapy, cognitive therapy, depression, older adults
Introduction Depression is a substantive cause of disability worldwide (World Health Organization, 2012). Major depression (MD) or major depressive disorder (MDD) is a leading cause of morbidity and mortality in the elderly, with an estimated prevalence of 7% of the general elderly population and it accounts for 1.6% of total disability among over 60 year olds (Institute for Health Metrics and Evaluation, 2010). If left untreated, there is evidence of an increased risk of physical and psychological morbidity and mortality, with an associated economic and societal burden (Gould et al., 2012; Lockwood et al., 2004; Smits et al., 2008). At its worst, depression can lead to suicide, highlighted by the loss of 1 million people every year worldwide (World Health Organization, 2012). Predictions of an ageing population suggest that there will be increased demand for treatments and therapies that address the specific needs of older people. The treatments for depression among older adults include antidepressants, electroconvulsive therapy, cognitive Correspondence: Dr. Rasika Jayasekara, Senior Lecturer, School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, SA 5001, Australia. Tel: +61 8 8302 2750. Fax: +61 8 8302 2168. E-mail: [email protected]
History Received 4 September 2013 Revised 28 August 2014 Accepted 18 September 2014 Published online 29 October 2014
behavioural therapy, psychodynamic psychotherapy, rational emotive behaviour therapy, behavioural activation, reminiscence therapy, and exercise (Frazer et al., 2005; Szentagotai et al., 2008). Pharmacotherapy is an accepted and often frontline treatment for depression (Lockwood et al., 2004). Epidemiological data have found that the widespread use of antidepressants is associated with a significant decline in suicide rates in most countries with traditionally high baseline suicide rates (Rihmer & Akiskal, 2006). Approximately 50– 60% of patients are supposed to improve clinically as a consequence of antidepressant treatment (Schneider & Olin, 1995). These findings are supported by a systematic review of antidepressant versus placebo in the treatment of depression in older adults (Mottram et al., 2006). However, it is evident that older, frail depressed patients are particularly prone to side effects of antidepressants (Arroll et al., 2009; Kennedy, 2013; Schatzberg, 2007; Seitz et al., 2011) and older patients are more prone to the cardiovascular side effects of antidepressants (Pacher & Kecskemeti, 2004). The World Health Organization (2011) has recommended that if antidepressant treatment is required for older people, tricyclic antidepressants (TCA) should be avoided if possible. Therefore, older people, despite taking medication, continue to experience symptoms and/or disabling adverse effects
Cognitive behavioural therapy
J Ment Health Downloaded from informahealthcare.com by University of Otago on 07/11/15 For personal use only.
DOI: 10.3109/09638237.2014.971143
169
(Bogner et al., 2009; Candy et al., 2008; Mottram et al., 2006). There is thus a growing need to consider alternative forms of treatment for depression. Since the early 1980s, several well-controlled clinical trials have demonstrated that depression in older adults can be treated with psychotherapy, either alone or in combination with antidepressant medication. Several psychological therapies have been studied, but the cognitive-behavioural therapy (CBT) has been most widely investigated in this population (Bogner et al., 2009; Candy et al., 2008; Mottram et al., 2006). CBT, a form of psychotherapy, is regarded as a non-pharmacological intervention that can provide depressed individuals with the skills with which to manage their own illness (Bogner et al., 2009; Lockwood et al., 2004; Ridgway & Williams, 2011). CBT has no known adverse side effects, unlike antidepressant medications and, has the potential to go on assisting the individual long after the symptoms subside and the therapy ceases. However, the usefulness of CBT as an intervention for older adults with depression has not been adequately evaluated. The purpose of this review paper is to examine current evidence on the effectiveness of CBT for older adults with depression.
Search strategy
Background
Reviews and meta-analyses of the voluminous literature on CBT outcome studies have concluded that CBT is a highly effective approach for the treatment of depression (Gaffan et al., 1995; Oei & Dingle, 2008; Samad et al., 2011). Most Clinical Practice Guidelines advocate the additional benefit of supporting antidepressant medication with CBT (National Institute for Clinical Excellence, 2009). Despite the wealth of evidence evaluating CBT for depression, little attention has been given to its effect on older adults. The following studies were identified as meeting the inclusion criteria and are summarized below. A Cochrane systematic review was conducted to investigate the effectiveness of psychotherapeutic treatments for depression in older people (aged 55 or over) (Wilson et al., 2008). This review was limited to RCTs and cluster randomised trials. All types of psychotherapeutic treatments were considered such as cognitive behavioural therapies, psychodynamic therapy, interpersonal therapy, and supportive therapies (Wilson et al., 2008). The review included seven small trials, involving 153 older adults that examined psychotherapeutic treatments for depression in older people. Five RCTs compared cognitive behavioural therapy with control conditions, and the results revealed that cognitive behavioural therapy was more effective than waiting list controls. Two RCTs with 57 older adults compared the effectiveness of cognitive behavioural therapy versus psychodynamic therapy. However, there is no statistically significant difference between cognitive behavioural therapy and psychodynamic therapy (Wilson et al., 2008). It is reasonable to suggest that the findings of this review have limited clinical implications due to the small number of trials and small sample size. However, the review author concluded that cognitive behavioural therapies are likely to be efficacious in older people when compared with waiting list controls (Wilson et al., 2008). The authors recommended conducting a large-scale research on this area because of the paucity of high-quality studies in this field.
CBT for depression In the 1970s, psychology underwent a cognitive revolution that led to a greater interest in the significance and relevance of cognitive processes to therapy (Grant, 2010). The increasing interest in cognition resulted in the development of various cognitive behavioural therapies (Eifert & Plaud, 1993; Grant, 2010). The theoretical structure and a basic method for CBT were outlined by Aaron Beck in a series of seminal papers published in the 1960s and then elaborated in a treatment manual for depression (Eifert et al., 1993; Eifert & Plaud, 1993). CBT is an action-oriented treatment approach that has become a widely used psychotherapy for major mental disorders. CBT methods were initially developed for depression and anxiety disorders and, later they were modified for many other conditions (Linehan et al., 1991, 1993). CBT has also been adapted for use as an adjunct to medication in the management of mental disorders (Andersson et al., 2013; Binks et al., 2006; Henschke et al., 2010; Martinez-Devesa et al., 2010; Montgomery & Jane, 2003). Although the label cognitive behavioural therapy has been applied to a variety of interventions, accordingly, it is difficult to provide a single, unambiguous definition. In a Cochrane review, CBT was classified as ‘‘well-defined’’ if it clearly demonstrated that (i) the intervention involved recipients establishing links between their thoughts, feelings, and actions with respect to the target symptom; and (ii) correction of recipients’ misconceptions, irrational beliefs, and reasoning biases was related to the target symptom. A further component of the intervention should have involved one or both the followings: (i) the recipient monitoring his or her own thoughts, feelings and behaviours with respect to the target symptom; and (ii) the promotion of alternative ways of coping with the target symptom (Jones et al., 2004, 2012).
The search strategy was limited to English language papers published from 2000 to 2013. A three-step search strategy was developed using MeSH terminology and keywords to ensure that all materials relevant to the review were captured. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then conducted. Third, the reference lists of all identified articles were searched for additional studies. All systematic reviews and randomised controlled trials (RCT) assessing the effectiveness of CBT as a treatment for older adults (aged 55 or above) with major depression when compared with standard care, specific medication, other therapies, and no intervention were considered.
Results The effectiveness of cognitive behavioural therapy for older people
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A systematic review was conducted to examine the effectiveness of psychotherapy for treating depression in older adults (aged 55 or over) (Peng et al., 2009). This systematic review was also limited to RCTs and three types of psychotherapy were included: CBT, reminiscence therapy, and general psychotherapy (GPT). This review included 14 RCTs involving 705 older adults. The primary outcome measure was the depression score, measured using a range of scales, including the 20-item Symptom Checklist (SCL-20) for depression, the Hamilton Rating Scales for Depression, the Beck Depression Inventory, and the Geriatric Depression Scale. Meta-analysis and subgroup analysis showed that psychotherapy (CBT, reminiscence therapy, or GPT) was significantly more effective than placebo/no intervention in decreasing depression scores. The review further found that psychotherapy as an adjunct to antidepressant medication did not increase effectiveness. There was no statistically significant difference between CBT and reminiscence therapy in improving depression. Although this review was published in 2009, all RCTs in cognitive behavioural therapy were published before 2004. The findings of these systematic reviews are largely consistent with other research on the effectiveness of CBT in all ages. A meta-analysis which was used to integrate the results of 89 controlled studies of treatments involving 5328 older adults receiving pharmacotherapy or psychotherapy found that psychotherapy and pharmacotherapy did not show strong differences in effect sizes (Pinquart & Sorensen, 2001). A meta-analysis of 25 studies revealed that psychological treatments have moderate to large effects on depression in older adults (standardized mean effect size d ¼ 0.72) (Cuijpers et al., 2006). In a recent systematic review, a meta-analysis showed that, compared with waiting list, group cognitive behavioural therapy is an effective intervention for reducing depressive symptoms in older adults with sub-threshold depression (Krishna et al., 2013). However, major limitations of these studies were the inclusion of non-randomised studies (Samad et al., 2011) and broadly defined interventions (e.g. psychotherapy) (Cuijpers et al., 2006; Peng et al., 2009; Wilson et al., 2008). Furthermore, studies comparing CBT or other evaluated psychotherapies against combined psychotherapy and medication for depression showed that psychotherapy delivered in conjunction with pharmacotherapy is significantly more efficacious in treating depression than is pharmacotherapy alone (Cuijpers et al., 2013; de Maat et al., 2007; Hollon et al., 2005). A systematic review of 16 trials with 932 adult patients concluded that psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone (Pampallona et al., 2004). The combination treatment of CBT and antidepressants had a lower risk of discontinuation compared with antidepressants alone (RR 0.81; 95% CI 0.65, 1.01) (National Collaborating Centre for Mental Health, 2010). The use of CBT as a treatment for older adults with depression remains uncommon despite recognition of its efficacy. Ageism, or the discrimination against people on the grounds of age alone, has been slow to gain public awareness in Western society, which has been a significant hindrance to development of expertise, research, and services
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(Hepple, 2004). In addition, potential barriers to older adults receiving CBT may include invalid beliefs that older adults are unlikely to benefit from psychotherapy (Laidlaw et al., 2008). This commonly held belief can be traced back to Freud’s assertion that older people lack the mental flexibility to change or to benefit from psychotherapy (Pinquart & Sorensen, 2001). As older people respond very positively towards CBT therapies as a treatment option for depression (Hanson & Scogin, 2008; Landreville et al., 2001), much should be done to make this more widely known in the community. Noting that many older people are unable to access CBT services, comprehensive educational campaigns directed at both professionals and older people could be considered. Some authors have suggested the core elements of less than optimal usage of CBT by older people has been created by the increasing cost of the required services (Beach et al., 2010) and insufficient numbers of trained therapists both in primary care and in specialist mental health services (Hoifodt et al., 2011). A gradually increasing awareness of, and skills in, psychotherapies among mental healthcare professionals and the consumers will probably deliver the most overall benefit.
Conclusion The key finding of this review is that cognitive behavioural therapies are likely to be efficacious in older people with depression when compared with treatment as usual. However, the small size of included studies, the varied participant demographics, and the heterogeneity of the interventions have considerable impact with regard to generalising these findings to wider clinical populations of older adults. It is widely viewed that psychological treatments derived from CBT can be used as an option in treating depression in older adults because many older people with depression are reluctant to accept antidepressant medication or unable to tolerate its side effects. Future research should be aimed at developing a broader understanding of the usefulness of CBT as an intervention for older adults with depression and encompass treatment availability, costs, and preferences.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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