Depression Treatments for Older Adults

Introduction to Group-CBT

CBT focuses on how thoughts, feelings, and behaviors are intertwined in everyday functioning and how changes in any one domain can lead to improvement in the others. The way we view ourselves, the world around us (including other people), and our futures plays a role in how we feel and act in any given situation. CBT aims to modify the unhelpful thinking and behavioral patterns that impair one’s functioning. Making these changes can lead to healthier behaviors and improved emotion regulation. Group CBT targets current problems and symptoms and is typically delivered in group format in seven to 15 weekly sessions.

Group-CBT is recommended for the treatment of depression in older adults.

How Group-CBT can help treat depression in older adults

CBT can teach people how to differentiate between their thoughts and feelings and regulate their feelings by questioning their assumptions and beliefs. This is done through identifying and labeling the types of negative thinking patterns through the various exercises the group completes (e.g., mood log). CBT might also address behavior patterns that contribute to withdrawal and lack of enjoyment by such strategies as helping people identify activities they have enjoyed and planning to engage in them regularly.

Using Group-CBT to treat depression in older adults

Group-CBT sessions are similar to individual CBT sessions for treatment of depression in adolescents and adults, with modifications relevant to what older adults might experience. Group members are encouraged to support, question and supportively challenge one another. Treatment begins with the therapist educating the group about how thoughts, feelings, and behaviors interact with each other to influence mood and well-being. The therapist introduces the idea that there are ways to modify thinking and behavioral patterns that could have a positive benefit on emotions and behaviors.

Group members might be encouraged to complete a “mood diary” outside of sessions, noting the situation that triggered the thoughts that then influenced feelings and behaviors in the moment. The group members and therapist work together to identify common themes that influence the unhelpful thinking and behavior patterns in a particular situation.

The therapist might offer behavioral strategies such as having group members identify activities they once enjoyed (e.g., seeing their children and grandchildren) and incorporate those into a schedule of pleasant activities (e.g., “When I feel sad or stressed I am going to plan a visit to my daughter’s house”).

Patients are often encouraged to complete homework assignments to fully develop new skills and build confidence to work through stressful situations.

References and resources

Muñoz, R.F., Ippen, C.G., Rao, S., Le, H.-N., & Dwyer, E.V. (2000). Manual for group cognitive-behavioral therapy of major depression: A reality management approach: Instructor's manual. University of California, San Francisco. https://i4health.paloaltou.edu/downloads/CBT_Instructor_English.pdf (PDF, 311KB)opens in new window

Muñoz, R.F., Ippen, C.G., Rao, S., Le, H.-N., & Dwyer, E.V. (2000). Manual for group cognitive-behavioral therapy of major depression: A reality management approach: Participant manual. University of California, San Francisco. https://i4health.paloaltou.edu/downloads/CBT_Participant_English.pdf (PDF, 5.50MB)opens in new window

Introduction to IPT

IPT aims to improve the person’s relationships with others by learning strategies to effectively communicate emotions and needs as well as problem-solve within a significant relationship. Therapists using IPT emphasize a biopsychosocial explanation of depression, in that negative or distressing events people experience within their lives can exacerbate feelings of sadness and worthlessness. As relationships with others improve, the depressive symptoms may subside, and the person will hopefully experience improved functioning in multiple areas of their life. On average, older adults receive 16 to 20 weekly sessions of IPT. If considering this treatment for older adults with depression, the panel recommends augmenting with a second-generation antidepressant.

IPT is recommended for the treatment of depression in older adults.

How IPT can help treat depression in older adults

IPT conceptualizes depression as consisting of three components:

• Depression symptoms: Symptoms are seen as having both biological (e.g., sleep/wake functioning, eating patterns) and psychological (e.g., sadness; feelings of guilt) underpinnings.
• Social functioning: The way one interacts with significant others and responds to social situations. Difficulties in social interactions can lead to or exacerbate depression symptoms.
• Personality difficulties: Individual characteristics that may be consistent across situations such as difficulty with anger expression, self-esteem and communication. These characteristics can play a role in a person’s response to a social situation which in turn can increase vulnerability to developing symptoms of depression.

While IPT is not expected to have an impact on personality due to the short treatment duration, the interpersonal communication skills attained in treatment may mitigate the impact of one’s personality difficulties on their relationships. In addition, the new social skills can hopefully prevent the development of future episodes of depression by improving coping skills.

Using IPT to treat depression in older adults

Treatment begins with a comprehensive evaluation of the person’s social and emotional functioning along with educating the patient about the biopsychosocial model of depression, emphasizing that the illness does not define the person. Next, the therapist will ask questions about their relationships and how they interact within those relationships with others. This comprehensive review allows the therapist to identify and work with one of the four problems areas focusing on specific themes that are commonly noted in older adults with depression: 

• Grief (e.g., continual sadness over loss of a spouse).
• Role disputes (e.g., not wanting to receive care from their adult children).
• Role transitions (e.g., transitioning from actively working to retiring).
• Interpersonal deficits (e.g., isolation).

In the middle stages of treatment, the therapist and patient identify strategies to ameliorate the chosen problem area and improve the patient’s relationships, with the goal of reducing depressive symptoms. The therapist then reviews the interpersonal skills (specifically, perspective-taking and effective communication) that the patient has learned and emphasizes use of these skills outside of the office. The therapist might also offer “booster sessions” for the patient to help solidify the skills and possibly prevent future episodes.

References and resources

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Treatment: Interpersonal psychotherapy for depression. https://www.div12.org/treatment/interpersonal-psychotherapy-for-depression/opens in new window

Bleiberg, K.L., & Markowitz, J.C. (2008). Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders (4th ed., pp. 306-327). Guilford Press.

Hinrichsen, G.A., & Clougherty, K.F. (2006). Interpersonal psychotherapy for depressed older adults. American Psychological Association. https://dx.doi.org/10.1037/11429-000opens in new window

Weissman, M.M., Markowitz, J.C., & Klerman, G. L. (2017). The guide to interpersonal psychotherapy: Updated and expanded edition. Oxford University Press. https://www.oxfordclinicalpsych.com/view/10.1093/med-psych/9780190662592.001.0001/med-9780190662592opens in new window

Introduction to group life-review/reminiscence therapy

Group life-review/reminiscence therapy is a psychotherapy treatment where older adults craft their life stories from childhood to the present moment to help them cope with the transitions that occur later in life. Group life-review/reminiscence therapy allows older adults to review and reflect on their lives and through this reflection, ideally develop an appreciation for the past and present moments that results in a more balanced and satisfied perspective. On average, older adults receive four to 12 weekly sessions of life-review/reminiscence therapy in a group format.

Group life-review/reminiscence therapy is recommended for the treatment of depression in older adults.

How group life-review/reminiscence therapy can help treat depression in older adults

Older adults are often in a stage of life when they reflect on the life lived and whether they achieved what they desired. As people reflect on their lives and their current situations, they hope to conclude that they have lived fulfilling lives. While older adults may grieve over the loss of their loved ones or the transition from active work to retirement, such experiences are expected and typically incorporated into an overall perspective of life. But older adults with depression have difficulty integrating challenges and transitions and may develop feelings of sadness and withdraw from activities they once enjoyed.

Group life-review/reminiscence therapy is intended to help older adults cope with the changes they are experiencing as well as feel at peace with the lives they have lived. The group format of this intervention also provides an opportunity for older adults to share commonalities in the life transitions they are going through. Ideally, the process of reviewing one’s life in this format will ultimately result in reduced symptoms of depression.

Using group life-review/reminiscence therapy to treat depression in older adults

In a small group format, each group member brings items to facilitate recalling certain key memories, such as music, photo albums and figurines. Each person then shares a story or experience that ties to the memorabilia they brought in. Then the therapist helps each group member continue to tell their story by asking detailed questions. Group members are taught to view memories that illicit negative feelings with wonder and curiosity instead and to compare the past memory with who they are as a person today.

The therapist notes common themes that were mentioned in each group member’s memories and helps form a common narrative of what they might be feeling now. After further group discussion of the themes, the therapist helps group members consider alternative ways to view their memories and experiences, and how to move forward in life by accepting what happened in the past and developing a balanced, accepting story of one’s life.

References and resources

American Psychological Association, Div. 12: Society of Clinical Psychology. (n.d.). Reminiscence/life review therapy for depression. https://www.div12.org/treatment/reminiscence-life-review-therapy-for-depression/opens in new window

Birren, J.E., & Cochran, K.N. (2001). Telling the stories of life through guided autobiography groups. Johns Hopkins University Press. https://jhupbooks.press.jhu.edu/title/telling-stories-life-through-guided-autobiography-groupsopens in new window

Birren, J.E., & Deutchman, D.E. (1991). Guiding autobiography groups for older adults: Exploring the fabric of life. Johns Hopkins University Press. https://jhupbooks.press.jhu.edu/title/guiding-autobiography-groups-older-adultsopens in new window

Birren, J.E., & Feldman, L. (1997). Where to go from here: Discovering your own life’s wisdom in the second half of your life. Simon & Schuster. https://www.simonandschuster.com/books/Where-To-Go-From-Here/Linda-M-Feldman/9781476728315opens in new window

Campbell, R., & Svensson, C. (2015). Writing your legacy: The step-by-step guide to crafting your life story. Writer's Digest Books. https://guidedlifestories.com/books/guided-life-stories/opens in new window

Korte, J., Bohlmeijer, E.T., Cappeliez, P., Smit, F., & Westerhof, G.J. (2012). Life review therapy for older adults with moderate depressive symptoms: A pragmatic randomized controlled trial. Psychological Medicine, 42(6), 1163-1173. https://doi.org/10.1017/S0033291711002042opens in new window

Introduction 

Second-generation antidepressants (selective serotonin reuptake inhibitors — SSRIs, serotonin-norepinephrine reuptake inhibitors — SNRIs or norepinephrine/dopamine reuptake inhibitors — NDRIs) are recommended for older adults due to the reduced risk of side effects and safety in the event of overdose. If considering medication for older adults with depression, the panel recommends combining it with interpersonal psychotherapy.

Please see Table 4 of the full guideline document (PDF, 1.15MB)opens in new window and Appendix C of the supplement for the decision tables for more information.

What are second-generation antidepressants?

Second-generation antidepressants include SSRIs, SNRIs and NDRIs. These drugs regulate the neurotransmitters serotonin, norepinephrine and dopamine, which are involved in brain functions related to mood and behavior.

SSRIs help regulate the amount of serotonin that is active in the synapses between neurons. SNRIs address levels of both serotonin and norepinephrine. NDRIs help regulate both norepinephrine and dopamine levels.

In geropsychiatric practice, the following are commonly prescribed for the treatment of depression in older adults. Shared decision-making between the provider and patient is recommended as individual patients may have different responses to the medications or be concerned about different side effect profiles.

• bupropion (Wellbutrin): 150-450 mg daily
• duloxetine (Cymbalta): 20-120 mg daily
• escitalopram (Lexapro): 10-20 mg daily
• paroxetine (Paxil): 20-40 mg daily
• sertraline (Zoloft): 100-200 mg daily
• venlafaxine (Effexor): 150-300 mg daily

Side effects and frequency of prescriber visits

Side effects of second-generation antidepressants are generally mild to moderate that can be tolerated or managed with over-the-counter remedies (e.g., headaches, nausea, drowsiness). The second-generation antidepressant may also interact with other medications and this is carefully monitored. The prescribing provider is encouraged to have the patient start at a low dose and then slowly increase the dosage until the optimum benefit has been reached. Upon initially being prescribed medication, the patient will likely see the prescriber at least a few times within the first eight weeks to check whether they are taking the medication as prescribed, as well as to determine whether the dose is optimal and whether the patient is experiencing any adverse side effects.

Once the patient has a stable medication dosage and reports a decrease of symptoms, visits to the prescriber will likely be less frequent. It is generally recommended that medication be continued at the same dose after remission of symptoms, in order to facilitate recovery and to prevent relapse.

Note: Although the tricyclic antidepressant nortriptyline was commonly used for older adults in the past, it is now generally used only when initial treatment with SSRIs or SNRIs was ineffective or had unacceptable side effects or drug interactions.

References and resources

Substance Abuse and Mental Health Services Administration. (2011). Practitioners' guide for working with older adults with depression (HHS Publication No. SMA-11-4631). U.S. Department of Health and Human Services https://store.samhsa.gov/system/files/sma11-4631cd-dvd-practioners.pdf (PDF, 846KB)opens in new window

Wilkinson, P., & Izmeth, Z. (2012). Continuation and maintenance treatments for depression in older people. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD006727.pub2opens in new window

Before taking any medications, over-the-counter drugs, supplements or herbs, consult a health care provider for a thorough evaluation. American Psychological Association does not endorse any medications, vitamins or herbs. A qualified health care provider should make a decision based on each person's medical history and current prescriptions. The medication summaries provided do not include all of the information important for patient use and should not be used as a substitute for professional health care advice. The prescribing professional should be consulted concerning any questions that you have.