Managing depression in older age: Psychological interventions

Abstract

The number of studies on psychological treatments of depression in older adults has increased considerably in the past years. Therefore, we conducted an updated meta-analysis of these studies. A total of 44 studies comparing psychotherapies to control groups, other therapies or pharmacotherapy could be included. The overall effect size indicating the difference between psychotherapy and control groups was g = 0.64 (95% CI: 0.47–0.80), which corresponds with a NNT of 3. These effects were maintained at 6 months or longer post randomization (g = 0.27; 95%CI: 0.16–0.37). Specific types of psychotherapies that were found to be effective included cognitive behavior therapy (g = 0.45; 95% CI: 0.29–0.60), life review therapy (g = 0.59; 95% CI: 0.36–0.82) and problem-solving therapy (g = 0.46; 95% CI: 0.18–0.74). Treatment compared to waiting list control groups resulted in larger effect sizes than treatments compared to care-as-usual and other control groups (p < 0.05). Studies with lower quality resulted in higher effect sizes than high-quality studies (p < 0.05). Direct comparisons between different types of psychotherapy suggested that cognitive behavior therapy and problem-solving therapy may be more effective than non-directive counseling and other psychotherapies may be less effective than other therapies. This should be considered with caution, however, because of the small number of studies. There were not enough studies to examine the long-term effects of psychotherapies and to compare psychotherapy with pharmacotherapy or combined treatments. We conclude that it is safe to assume that psychological therapies in general are effective in late-life depression, and this is especially well-established for cognitive behavior therapy and problem-solving therapy.

Introduction

It is well-established that psychological interventions are effective in the treatment of depression in adults, and that includes cognitive behavior therapy (CBT) [1], interpersonal psychotherapy (IPT) [2], behavioral activation therapy [3], problem-solving therapy (PST) [4], and possibly psychodynamic therapy [5] and non-directive counseling [6]. Whether psychological therapies are also effective in older adults has been less well-established. Depression in older adults tends to be more chronic than in their younger counterparts. And due to such a chronic nature and developmental stage that increase individual's exposure risk factors (e.g., medical condition, loss and grief, decreasing social support), psychotherapies may be less effective in older adults than in their younger counterparts.

Although several trials with different kinds of psychological treatment have focused specifically on older adults, the field is changing rapidly. In an earlier meta-analysis of these studies, we included 25 randomized trials [7], and other meta-analyses from this period included comparable numbers of studies [8], [9], [10]. Since 2010, however, 15 more randomized trials have been conducted, indicating that the field is expanding rapidly. It may be possible to examine research questions that were not answered sufficiently with meta-analyses of earlier trials. For example, several new trials have focused on life review treatments of depression, and earlier meta-analyses had to be careful in drawing definite conclusions on this type of therapy.

Since the overall meta-analyses focusing on psychological treatments in older adults from 2006 to 2008, no general meta-analyses have been conducted. Meta-analyses that were conducted since focused on specific types of therapies [11], [12], [13], [14]. We decided therefore, to conduct a new meta-analysis of trials on psychological treatments of depression in older adults. Because the number of trials has increased since the previous comprehensive meta-analysis, we focus specifically on subgroup analyses. In these subgroup analyses we can examine whether specific characteristics of the studies are associated with higher or lower effect sizes, for example different types of psychotherapy, types of control groups, recruitment methods, diagnosis, or treatment format.