Keywords

FormalPara Key Points

  • The combination of extended years of shifting roles in families as older adults gradually grow increasingly dependent on their adult children and the multiplying demands on caregivers suggests that both older adult family members and caregivers will be at increased risk for depression and anxiety.

  • When older adults are able to overcome barriers to accessing mental health services (e.g., stigma), psychological therapies are effective when used on their own or in combination with psychotropic medication in older adults who suffer from common disorders, such as depression, anxiety, dementia/cognitively impaired disorders, and personality disorders.

  • Psychological intervention for bodily distress syndrome in older adults is based on accurate assessment of the underlying psychosocial issues, which are often not evident to the patient or present in the medical record.

  • The psychological treatment of dementia/cognitively impaired disorder is specifically focused on specific targets, which include global quality of life, affective states, disruptive behavioral symptoms, functional impairment, and prevention of self-harm.

  • Numerous resources exist to help older adults and their family members clarify the necessary changes that must be made to keep the losses in their place and protect other sources of meaning and hope.

  • Psychological therapy for older adults can be delivered in a variety of ways. These include upskilling of existing primary care staff to provide psychological interventions: stepped care, collaborative care, and referral to a mental health specialist in the community.

1 Introduction

The afternoon of human life must also have a significance of its own and cannot merely be understood as a pitiful appendage to life’s morning.—Carl Jung

Between 2015 and 2050, the proportion of the world’s population over 60 years will nearly double, from 12% to 22%. Identifying and implementing effective, community-level psychological interventions for older adults are essential. To date, mental health problems of older adults have been under-identified by healthcare professionals, family members, and patients themselves. The stigma surrounding mental illness contributes to older adults’ reluctance to seek help. When older adults do seek help, there is evidence that a variety of psychosocial interventions are effective in alleviating distress for the patient and family [1].

A chapter on psychological interventions for older adults can never capture all of the salient issues for older adult patients and their family members. We have chosen to address treatments for common presentations in primary care, including depression, anxiety, and bodily distress syndrome, and secondary care, including dementia and personality disorders. We also discuss the universal experience of loss. Although we do not address preventive programs, it is important to note that there are many strategies to promote mental health well-being, including adequate housing, social support for older adults coping with illness and their caregivers, and education to prevent elder abuse, among others.

2 General Considerations

Ageism and generational values, both on the part of the service user, the practitioner and society in general, can be major barriers to a good therapeutic outcome. Ageism may be expressed as beliefs such as “too old to change,” which may prevent older adults from seeking help or getting referred for help and also reduces expectations about therapy outcomes. Patients may feel that they do not deserve psychological therapy and it should be reserved for those who are younger. However, many older adults express a preference for a talking treatment [2].

When older adults do get referred and participate in therapy, age-specific adaptations of standard therapy procedures are advisable. For example, the pace of therapy should be slower, and fonts for written material should be larger. Providing memory aids such as handouts and session summaries also can be very helpful. Accounting for unique cohort-based differences (e.g., sociohistorical environment, norms and commonly held beliefs, role expectations, illness beliefs, culture) and age-specific stressors (e.g., chronic illness and disability, loss of loved ones and, consequently, sources of support, caregiving responsibilities) is also advisable. In-home mental health services may be a valuable option for those who lack reliable transportation and/or have a medical or physical disability.

Most empirical evidence has shown some effectiveness of psychological therapies when used alone or in combination with psychotropic medication in older adults who suffer from common disorders such as depression, anxiety, dementia/cognitively impaired disorders, and personality disorders. Generally, there are two types of psychotherapies: (1) those used in adults which are modified for use in older patients, most prominent among them are cognitive behavioral therapy (CBT), problem-solving therapy (PST), dialectical behavior therapy (DBT), interpersonal therapy (IPT), and family therapy; and (2) those devised specifically for older adults which include psychosocial, behavioral, and cognitive stimulation therapies in cognitively impaired patients.

Psychological treatments can be offered to older patients and/or their caregivers with the following indications:

  • Patient preference, as an alternative treatment to medication (e.g., in the treatment of an anxiety disorder)

  • Augmenting the effect of psychotropic medication (e.g., in the treatment of a depressive disorder)

  • To avoid the use of potentially harmful medication (e.g., in managing behavioral symptoms of dementia)

  • To foster adherence to medication (e.g., in the treatment of depression)

  • To help distressed caregivers (e.g., treating a dementia caregiver experiencing depressive and anxiety symptoms)

  • To alleviate psychological problems related to aging (e.g., to help achieve contentment and acceptance of aging or to resolve disputes within a family brought on by the illness of an older family member)

  • As part of a collaborative care intervention in the treatment of depression, anxiety, and/or bodily distress syndrome

  • To provide the clinician and patient with a psychological formulation to the patient’s problems [3]

Deficits in verbal reasoning, speed of responses, and sensory function may result in difficulty understanding the complex verbal content of some psychological treatments. Therefore, evaluation for psychological treatment should include at least a brief assessment to look for possible deficits [4].

3 Interventions for Common Disorders in Primary Care

3.1 Anxiety and Depression

The combination of extended years of shifting roles in families as older adults gradually grow increasingly dependent on their adult children and the multiplying demands on caregivers suggests that both older adult family members and caregivers will be at increased risk for depression and anxiety. Symptoms of anxiety and depression are common in all countries throughout the lifespan, with up to 13.5% of older adults having depression and between 1 and 15% diagnosed with anxiety disorders [5,6,7]. How depression and anxiety manifest will vary greatly by culture.

It is important to recognize that in primary care settings, the most common mental disorders encountered are various mixtures of anxious, depressive, and somatic symptoms, and in many cases, a diagnosis of “anxious depression” will be appropriate [8]. These symptom clusters have been documented in all global populations and countries in which they have been studied and are consistently found to be more prevalent among women than among men [9].

Although there are fewer studies available for other therapies in older age groups, the available evidence suggests that, as in younger people, most therapies will have some efficacy compared with no intervention. In the treatment of late-life depression, psychotherapy may be the only available modality, if the antidepressant pharmacotherapy is poorly tolerated. An expert consensus guideline from 2001 favored cognitive behavioral therapy (CBT), problem-solving therapy, interpersonal therapy, and supportive psychotherapy over psychodynamic psychotherapy. The consensus among the experts was to recommend psychotherapy as an adjunctive treatment to pharmacotherapy, except in the case of mild depression or dysthymia, for which psychotherapy alone was seen as an alternative to medication [10, 11].

Pharmacotherapy is quite effective in the management of late-life anxiety; however, unwanted side effects can limit the use of psychotropic medication. CBT appears to be the best form of psychotherapy to manage the diagnosis and treatment issues that exist within the older population with generalized anxiety disorder [12]. Also, CBT can be used to augment psychotropic medications.

Other forms of psychotherapy for anxiety include psychoeducation, relaxation training, cognitive restructuring, and exposure to anxiety-provoking stimuli. Relaxation training, which is based on behavioral psychology, is most frequently used and is also the most well-substantiated treatment for anxiety in older adults. Work by DeBerry showed that progressive muscle relaxation and meditation relaxation techniques reduced anxiety symptoms more effectively than treatment control condition in older adults [13]. These strategies can be taught in brief individual or group sessions.

While the overall effectiveness of psychological therapies in the management of these conditions is recognized, debate continues about any differences in effectiveness between therapies, the best way to deliver psychological therapies in primary care settings, and the relative merits of psychological versus drug therapies. The overall costs of providing psychological therapies to large numbers of patients are also an important issue, particularly given the rapid growth in the aging population.

3.1.1 Stepped Care for Anxiety and Depressive Symptoms

The delivery of psychological therapy for anxiety and depression is increasingly aligned to the concept of stepped care. Stepped care delivers the simplest and most effective intervention first. If the patient fails to benefit from the initial intervention, then a more complex intervention from the next “step” is considered [14, 15].

Although a firm evidence base for a stepped care approach is lacking, it is recommended in evidence-based guidelines as the approach to take in the management of depression in a number of high-income countries. Examples of this approach have also been described in the treatment of depression and anxiety disorders in primary care in low- and middle-income countries, including India and Chile [16]. Psychological therapies lend themselves to a stepped care approach as they can be tailored to the availability of local resources.

A range of specific therapies has been assessed for the psychological management of anxiety and depression. They range from low-intensity modifications to lifestyle (e.g., exercise) and social connectedness to more specific therapies such as CBT, which require more intensive input. All psychological therapies have their effectiveness increased by a good therapeutic relationship between the health provider, the patient, and family. We describe the range of therapies below.

3.1.2 Exercise

There is good evidence for exercise as a low-intensity input treatment for mild to moderate depression. It is likely that it is also effective for the relief of symptoms of anxiety [17]. A recent meta-analysis which specifically assessed nine trials with older adult patients, suggested that, for older adults who present with clinically meaningful symptoms of depression, prescribing structured exercise tailored to individual ability will reduce depression severity [18].

3.1.3 Enhancing Social Contact (Befriending)

Befriending may also be useful in the management of mild depression in older adults [19]. There is significant literature suggesting that social support affects the onset, course, and outcome of depression and individuals with distress appreciate emotional and social support. One way of providing this support is through befriending, where a relationship between two or more individuals is initiated, supported, and monitored by an external agency. A systematic review of 24 studies showed that compared with usual care or no treatment, befriending had a modest but significant effect on depressive symptoms in both the short and long term [19].

While low-intensity interventions are effective in the management of depressive symptoms, there may be little difference between their effectiveness. In a recent randomized controlled trial, for example, while overall mood scores improved with intervention, no differential effect was observed between a physical activity intervention and social visits on mood in a group of older primary care patients with depressive symptoms [20].

3.1.4 Cognitive Behavioral Therapy (CBT)

The most commonly prescribed psychotherapies are those derived from cognitive therapies, which focus on overly negative beliefs the patient possesses that lead to low mood and low self-esteem [21]. CBT, and the associated problem-solving therapy (PST), emphasizes behavioral techniques, repetition, a slower pace, identifying a highly specified focus, and giving homework assignments for practice. For example, PST explicitly trains patients to select and solve daily problems that seemed insurmountable to them initially, with the goal of increasing their self-efficacy and overcoming feelings of helplessness, which form the core of depression. With continued rounds of problem-solving with highly specific action plans arrived at through patient-therapist collaboration, self-esteem and confidence rises, thereby countering demoralization and lowering overall depressive symptoms [22]. Planned termination takes place when 6–8 sessions are completed. In PST, the hoped-for result is that the newfound confidence in problem-solving will continue to additional problems, which, if also successfully handled, will maintain the patient’s confidence and continue to relieve depressive symptoms over the long term [11].

There is considerable literature outlining the efficacy of CBT for anxiety and depression in many different populations and different countries. WHO recommends it as a treatment for depression in adults. The evidence base for CBT is more developed than for other therapies. It seems likely this is due to a lack of research evidence rather than a lack of potential benefit from other therapies. It should also be considered that in many cases the comparator used to assess the effectiveness of a specific intervention was “treatment as usual.” This is something that is likely to vary widely across settings. Furthermore, research trials take place in a highly controlled environment that is unlikely to accurately reflect day-to-day clinical practice. In pragmatic observational studies where patients have had access to a wide range of different therapies, there is often little difference between them [23].

In the most recent meta-analysis, 23 randomized controlled trials were included. At the end of the intervention period, CBT was shown to be significantly more effective at reducing depressive symptoms (irrespective of whether rated by clinicians or participants) than treatment as usual or being on a waiting list but not than active controls. The same pattern of results was found for 6-month follow-up. Clinician-rated outcome measures resulted in larger effect sizes in favor of CBT than self-rated measures. No significant differences in efficacy were found between CBT and other treatment (pharmacotherapy and other psychotherapies) [24].

A similarly conducted meta-analysis and regression explored the effect of CBT on anxiety in community settings. Twelve studies were included. CBT was significantly more effective than treatment as usual or being on a waiting list at reducing anxiety symptoms at the end of the intervention, with the effect size being moderate, but when CBT was compared with an active control condition, the between-group difference in favor of CBT was not statistically significant, and the effect size was small. At 6- but not 3- or 12-month follow-ups, CBT was significantly more effective at reducing anxiety symptoms than an active control condition, although the effect size was again small. The review confirmed the effectiveness of CBT for anxiety disorders in older adults but was suggestive of lower efficacy in older than working-age people [25].

3.1.5 Additional Therapies

Interpersonal psychotherapy (IPT) was empirically derived from attachment theory and social psychology as a specific treatment for depression. It is a manual-based treatment that focuses on one of four specific areas: (1) grief, (2) role transition (such as retirement or ceasing to drive), (3) role disputes (e.g., with spouse, boss, or adult children), and (4) interpersonal deficit (those with more chronic trouble maintaining mutually satisfying relationships) [26]. The work of IPT is carried out in a real-world setting of patients’ current interpersonal relationships, which are explored in depth with problem-solving strategies to help make currently available relationships more satisfying and in the process reduce depressive symptoms. A monthly maintenance version is particularly useful for maintaining gains in those with chronic role disputes [27].

Reminiscence or life review therapy helps patients to either accept past negative events and resolve past conflicts or recollect past coping strategies. A number of studies involving older adult patients with depression demonstrate that those receiving reminiscence therapy showed fewer depressive symptoms, less hopelessness, and improved life satisfaction [28, 29].

3.2 Bodily Distress Syndrome

Many terms and labels have been applied to patients experiencing pain or other physical symptoms that are not fully explained by organic or structural abnormalities, including body distress syndrome (BDS), psychophysiologic disorder, medically unexplained symptoms, and chronic functional syndromes (fibromyalgia, irritable bowel syndrome, etc.). Diagnostic tests in these patients typically reveal either no abnormalities or findings that are found just as frequently in asymptomatic people. An estimated 25–30% of primary care outpatients fall into this category.

Presenting symptoms may affect almost any organ system and often more than one simultaneously. Gastrointestinal symptoms; chronic joint, limb, and spine pain; headache; and problems referable to the neurologic, ENT, cardiac, pulmonary, urologic, or gynecologic systems are common. Fortunately, in most of these patients symptoms are linked to one or more forms of psychosocial stress. Intervention directed at these issues leads to relief of symptoms, sometimes dramatically, and at other times only after months or years of psychotherapy.

Psychological intervention for BDS is based on accurate assessment of the underlying psychosocial issues, which are often not evident to the patient or present in the medical record. Therefore, it is helpful to mention the possibility of psychosocial stress as a cause of symptoms during the initial encounter with patients who lack an obvious organic etiology for their illness. Most patients accept this more readily than when stress is brought up only after extensive diagnostic testing. It is important to emphasize that physical symptoms linked to stress are just as “real” as symptoms with an organic or structural etiology and that there is no suspicion of symptoms being imaginary, self-inflicted, or due to malingering, psychosis, or psychological “weakness.”

3.2.1 The Stress Checkup

Stress checkup is a term readily accepted by patients for the process of uncovering the links between psychosocial issues and physical symptoms. In an integrated practice, the stress checkup can be initiated by a doctor and, if needed, completed by the mental health professional. The latter may also provide initial treatment and, where indicated, referral for mental health follow-ups.

The stress checkup consists of six parts as follows. This information may be gathered over multiple visits when time is limited:

  1. (a)

    Illness chronology: The stress checkup begins with acquiring a detailed chronology of the patient’s illness. Knowing when and where the symptoms began and their pattern over time is essential to recognizing links to stressful events in the patient’s life that are discovered later in the process. It is also important to look for patterns in the symptoms that don’t correspond to an organic or structural etiology, for example, a 75-year-old man with 25+ years of daily spine pain that was completely absent during his annual 2-week fly-fishing holiday.

  2. (b)

    Current stresses: Almost any source of ongoing life stress is capable of causing physical symptoms. A personal crisis, problems with a spouse or partner, difficulty with children or parents, workplace issues, financial problems, or a dilemma involving a friend or neighbor are worthy of inquiry. Another common theme in this category is a lack of self-care skills. A good question here is “Are you the kind of person who takes care of those around you but has difficulty finding time for yourself?” Corroboration of the patient’s answer to this question from a spouse/partner/friend is often helpful. Along similar lines, the question, “What do you do for enjoyment and how often?” can be revealing. For many patients with limited self-care skills, their childhood environment presented problems that prevented them from focusing on their own needs. Consequently they failed to develop self-care skills, and now, as adults, their lives lack space for personal fulfillment and recreation.

  3. (c)

    Childhood stress: Surprisingly, childhood stress can lead to symptoms years and even decades after the patient has left the family of origin. Symptoms may begin during childhood or adolescence but may also emerge for the first time in mid-life. Symptoms may be mild or severe and could persist for years or decades. Good questions to ask are the following: Were you under stress as a child? If you learned that a child you care about was growing up exactly as you did, would that make you feel sad or angry? On a scale of 1–10, 10 being worst, how much stress did you experience as a child? and Can you tell me a little more about why you chose that number for the last question? In listening to the response to the last question, be aware that the common denominator in childhood stress capable of causing physical illness in adults is treatment of the child that adversely impacts their self-esteem in a lasting way. This may result from physical, sexual, or verbal/emotional abuse. Many patients found it nearly impossible to elicit praise or support from their parents. Others were emotionally or physically neglected. Still others grew up in homes where one or both parents were physically violent with each other and/or were substance abusers. It is helpful to be aware of two significant barriers that hinder accurate assessment in this population. The first is that to survive childhood adversity, many patients suppressed their emotional reaction to their early experience and as adults are not consciously aware of the magnitude of their suffering. Consequently, they may appear to minimize the adversity of their early lives. Detailed questioning combined with empathic skills is often needed for an accurate assessment. The second significant barrier is that physical illness may arise during the process of recovering from childhood stress. Consequently, patients may be skeptical about stress causing their illness because their lives are noticeably improved in relation to the past.

  4. (d)

    Depression often presents with a somatic chief complaint. Further complicating the diagnosis, the majority of my patients denied feeling depressed though they often admitted to feeling stressed or exasperated. Other clues to depression are a vague, non-specific description of the symptoms and desperation to find relief that is out of proportion to the findings on a physical exam. Confirmation follows inquiry into early morning awakening, anhedonia, fatigue, anorexia, tearfulness, thoughts of self-harm, and loss of hope for the future.

  5. (e)

    Post-traumatic stress: The link between a terrifying or horrifying event and an unexplained illness is clear when symptoms begin soon after the trauma accompanied by typical manifestations of post-traumatic stress disorder (flashbacks, nightmares, avoidance of reminders of the trauma, emotional numbness, vigilance). More challenging, but not rare, is onset of the illness long after the trauma. In this situation, the onset of symptoms typically follows a triggering event linked to the trauma, as demonstrated below:

    A 57-year-old woman with severe, focal (3 cm diameter) right upper quadrant (RUQ) abdominal pain for 3 weeks. At age 45 she suffered a violent abduction and sexual assault by three men who left her tied to a tree in a remote area. Symptoms began the day after her first visit to a therapist to discuss PTSD symptoms, during which she vomited uncontrollably at one point.

  6. (f)

    Anxiety may also present with a somatic chief complaint. The most common clue to this etiology is that symptoms are significantly less severe, less common, or absent when the patient is in what they consider to be a safe environment. A patient who had diarrhea attacks only away from home is a typical example. Another patient experienced progressive stiffness and discomfort in the neck and shoulders the longer he was away from home. It was not surprising to learn that he worked on the night shift where he was the only person in the building and shopped for groceries at nearly vacant all-night markets. A variant of this condition is social anxiety disorder where symptoms are triggered by certain social conditions such as public speaking or being with large numbers of people. Patients often worry about embarrassing themselves or being judged by others.

3.2.2 Treatment

A useful diagnostic technique that also initiates treatment is to ask the patient, between their initial and follow-up visits, to compile a list of all the stresses in their life, both the past and present. This has value for several reasons:

  • Patients who would like to discuss their stresses over more time than is available during their appointment can work on this list instead.

  • Many patients are surprised at the number of items on the list.

  • Many will notice that their stresses tend to cluster in certain areas, such as with their spouse or in the workplace.

  • Often patients will find solutions to a few of the items, and notice this is associated with an improvement in their symptoms.

Patients who are symptomatic due to a lack of self-care skills should, ideally, set aside 2–5 h per week (best as a block) for trial and error in a search for an activity whose major purpose is enjoyment. This process may require months, often induces guilt (at first) and benefits from support by other members of the patient’s household. But once the patient acquires the ability to self-indulge on a regular basis, their symptoms often respond in a gratifying way.

Depression, PTSD, and anxiety can be managed with counseling and/or medication depending on the patient’s preference and local expertise. They are discussed elsewhere in this book. Patients with physical symptoms resulting from adversity in childhood often benefit from psychotherapy, but there are several techniques applicable in a medical setting (implemented by a behavioral health practitioner or medical clinician) that can be surprisingly beneficial.

The first step is to support greater conscious awareness of emotions about childhood maltreatment that have persisted to the present. For example, even patients who deny ongoing issues with past adversity may reconsider when asked to imagine their own child (or a child they care about) enduring the same experience, as demonstrated below:

  • A 74-year old man with a 55-year history of a variety of unexplained symptoms described being physically abused by his father as a boy in a flat, unemotional tone using few words. He appeared to be skeptical that this experience could be relevant to his illness after so many years. But after I asked him to imagine his grandson enduring the same treatment, he agreed to visit a support group for adults abused as children. He quickly recognized that he was, by far, the oldest person in the room. However, after keeping silent for the first two meetings, in the third he unburdened himself among those highly supportive survivors for nearly 45 min. His physical symptoms resolved soon after.

Another benefit of having the patient imagine a child enduring the same maltreatment is to better appreciate the magnitude of physical and mental challenges that they have overcome. This can help them overcome the poor self-esteem that is so often a long-lasting effect of having been abused. One might suggest that the patient was “born on the far side of a dangerous mountain, but climbed up and over it to become an adult.” This emphasizes their lack of culpability for their family situation as well as the credit they can take for having survived.

Once the patient has greater conscious recognition of the magnitude of their anger, fear, or grief, a helpful next step is to reduce the somatic expression of emotion (which causes symptoms) by writing about it. In effect, we are trying to convert somatic expression of emotion into verbal expression:

  • When the patient feels ready, writing a letter to the person(s) who perpetrated the maltreatment (not to be mailed, typically) can be cathartic.

  • Other patients prefer to write in a journal as ideas occur to them.

  • Another helpful exercise is to imagine a child enduring what the patient experienced and write about what they would like to communicate to such a child.

If perpetrators of childhood maltreatment are still active in the patient’s life, it can be helpful to discuss setting boundaries to limit the degree or change the nature of their interaction.

4 Interventions for Common Disorders in Secondary Care

4.1 Dementia/Cognitively Impaired Disorders

The development of psychosocial therapies for dementia/cognitively impaired disorders is complicated because these disorders are progressively deteriorating conditions which are unlikely to remit as a result of psychotherapy. The treatment is specifically focused on typical targets, which include global quality of life, affective states, disruptive behavioral symptoms, functional impairment, and prevention of self-harm.

Cognitive stimulation therapy is a psychotherapeutic technique that helps patients cope with the cognitive symptoms of dementia. Usually these symptoms can cause distress and injury in patients and increased stress in caregivers. It derives from reality-orientation therapy, which aims to continually orient patients’ attention to the current situation and surroundings by repeating who they are and where they are. Cognitive stimulation therapy focuses on improving information-processing abilities. Treatment can take place in formal groups or through training of professional or lay caregivers to administer intervention activities during the course of day-to-day activities [30].

Two manual-based psychotherapies have been modified to target the particular needs of older patients with cognitive impairment and depression. Problem-solving therapy (PST) has been modified to include in-house assistance with very practical problem-solving that can include caregivers as well. PST has been shown to improve depression and disability measurement scores. Interpersonal therapy has been modified to incorporate the caregiver into the treatment process at every level. There is a heavy emphasis on psychoeducation tailored individually to identified patients as well as caregivers concerning executive dysfunction, with a flexible use of individual or joint problem-solving sessions to seek optional coping strategies that may need to be adjusted further in the face of continued cognitive decline [27].

Another set of empirical treatments for caregivers with growing empirical support is based on the progressively lowered stress threshold (PLST) theory [31]. From this perspective, the disease process underlying dementia progressively lowers the patient’s ability to cope with stressors such as fatigue, change in routine, or physical illness. Treatment consists of educating and training caregivers in managing the patient’s environment to minimize such stressors. PLST-based training is effective in reducing problem behaviors and caregiver distress about patient’s behavior problems [32]. In dementia, the PLST approach shows great promise.

4.2 Personality Disorders

The prevalence rate of personality disorders in the older adult community is between 10% and 20%, analogous to the 13% prevalence rate among younger age groups [33, 34]. Overall, the emotionally constricted/risk-averse disorders in Cluster A (paranoid and schizoid personality disorders) and Cluster C (obsessive-compulsive, avoidant, and dependent personality disorders) are the most commonly diagnosed conditions in late life [33].

Most empirical evidence suggests that older adult patients with depression and comorbid personality disorder are generally less responsive to treatments for depression including antidepressants and psychotherapy, respond more slowly to these treatments, report more severe depressive symptoms, and are more likely to experience depressive recurrence. Older adults with a personality disorder diagnosis are also more likely to report suicidal ideation and experience more severe anxiety symptoms. They also report having less social support, worse interpersonal functioning after antidepressant treatment, are less likely to be married, and are more likely to report occupational difficulties. Older patients with personality disorder experience a lower quality of life and greater functional impairment and disability after treatment of depression [11].

Dialectical behavioral therapy (DBT) has shown to be effective in reducing suicidal ideation, improving interpersonal skills, and increasing coping skills, and coping. DBT consists of regular sessions of group therapy and additional sessions of specific training that strive to improve emotion-regulation skills and distress tolerance. The skills for delivering this therapy require intensive training and a commitment of several hours per week for at least 6 weeks.

5 Interventions for Transitions and Losses in Later Life

Whether they’re coping with a specific mental health disorder or not, all older adults are coping with a variety of transitions (e.g., retirement, moves) and losses (e.g., friends, physical decline). Four areas that deserve special attention by healthcare professionals include health, finances, social ties, and purpose/meaning. If an older adult has adequate resources in these four broad areas, aging need not be a period of depression and hopelessness. However, for most people, aging gradually involves multiple losses in each of these areas. In addition, the cultural context of the older adult strongly influences his resources and how he and his caregivers respond to losses.

An appropriate metaphor to guide responses to these losses comes from the family literature on coping with chronic illness [35]. “Finding the place for the illness and keeping it in its place” recognize that losses, whether they are illness, death of loved ones, retirement from meaningful work, physical frailty, or other losses, can change a person’s life forever. However, the patient and his family have some influence over the ultimate effects of the losses. “Keeping it in its place” suggests that losses do not have to always spill over into every area of well-being. Sources of pleasure and meaning can be protected with thoughtful planning and an understanding of the patient’s wishes.

In Being Mortal, Dr. Atul Gawande illustrates how often the wishes of the patient are missed or overlooked as caregivers, family members, and medical providers respond to inevitable changes [36]. Dr. Gawande suggests that the patient is the expert on the place of the loss in her life. Also, with help, she can often identify the areas of her life that most need protecting against the incursion of the loss. Activities like the card game Go Wish can help clarify what is most important to the patient.

One reason the patient’s preferences might be overlooked is that the losses lead to increasing dependence on others. The patient may begin to feel that she has little to contribute and may even feel like she is only a burden. She may feel increasingly isolated. As the patient faces losses, family members may need to compensate for the losses in some ways, such as driving the loved one to her doctor’s appointments or providing financial support. Thus, family members often want to participate in decisions about how to respond to changes from aging. Balancing the patient’s needs and the family’s needs can be challenging and renegotiation of roles and responsibilities can be explicit or implicit. Qualls discusses the many tasks of aging adults and their family members [37]. Some of the common areas that need restructuring include roles, authority, flexibility, closeness/distance, and responsibilities. While most patients and their families will not attend family therapy, the physician can use other resources, such as those found in Table 10.1 to help patients and their families negotiate the inevitable changes.

Table 10.1 Resources to help older adult patients
Full size table

Table 10.1 identifies some of the numerous resources on the web to help older adults clarify adaptations that must be made to keep the losses in their place and protect other sources of meaning and hope. Table 10.1 also lists resources that healthcare professionals, aging adults, and their family members could use. Encouraging patients to use these resources can create a sense of agency as the patient comes to terms with necessary transitions and simultaneously identifies what he values most about his life.

6 Methods of Therapy Delivery

Psychological interventions for older adults can be delivered in a variety of ways. These include:

  • Upskilling of existing primary care staff to provide psychological interventions

  • Stepped care, which was described earlier

  • Collaborative care, which is described below

  • Referral to a mental health specialist, who is responsible for the patient’s presenting problem and its treatment (e.g., a course of psychotherapy)

Collaborative care is a growing movement around the world that links doctors and mental health specialists, either through a traditional referral system or by immediately assisting with care in coordination with other healthcare professionals as they are in the process of seeing their patients. When a doctor detects emotional stress, a formal mental health diagnosis, or a health behavior change need, they can perform a “warm handoff” during the visit to the onsite mental health professional, which is more likely to result in patients receiving timely mental health services compared with usual referral to similar, but distant, services. Additional potential benefits of collaborative care include (1) improved sensitivity and accuracy of mental health problem identification; (2) contributions to increased screening, detection, and intervention; and (3) possibly earlier prevention of mental health and substance use issues. While more studies are needed to deepen the support for collaborative services across the full range of mental health needs, there is strong evidence from the USA and UK that such care improves outcomes for older adults with depression [38]. Two of these initiatives are described below.

IMPACT—A primary care physician and depression care manager (nurse, social worker, psychologist, family therapist) implement a shared treatment plan and consult with a psychiatrist as needed. The care manager provides education about depression, provides problem-solving therapy, and monitors depressive symptoms. A study of 1801 patients showed that IMPACT significantly reduces depressive symptoms in comparison with usual care and change persists after 1 year [39].

PROSPECT—To prevent suicide among older primary care patients by reducing suicidal ideation and depression, primary care physicians are trained to recognize depression and suicide ideation in older patients. In addition, mental health specialists are included on the treatment team. PROSPECT studies show that patients who receive this intervention had decreased severity of depression and are less likely to report suicidal ideation [40]. A study also found that patients participating in this intervention had lower mortality rates [41].

7 Conclusion

A wide range of psychological therapies falls within the term psychological interventions, including self-help support groups, low-intensity psychosocial interventions and higher-intensity psychological interventions. These interventions should be considered as a therapy option alongside other possible options (e.g., social support, lifestyle interventions, pharmacological therapy) rather than a singular approach to assisting patients and their family members. Increasing the Internet availability raises the possibility of using web-based therapy to support the management of anxiety and depression in older life. A number of studies are providing evidence that age is not a barrier to successfully treating anxiety and depression online [30, 42,43,44]. The increased availability of effective psychological interventions should provide much hope for older adults and their family members.