Transcript Empirical Review of Psychotherapy for Late Life Depression

Psychological Therapies with Older
People: The Evidence Base
Ken Laidlaw, PhD
Senior Lecturer in Clinical Psychology/
Clinical Lead, Older Adult Psychology
Services in Edinburgh, NHS Lothian
Increasing Access to psychotherapy
for Older People?
“The mark of a noble society is found
not in the manner in which it helps
the rich but in how it helps the poor
and the vulnerable. Not in its
virtues during good times but in its
character during hard times. Not in
how it protects the powerful, but
how it defends the vulnerable”
(Osei Darkwa, 1997, p186).
Empirical Review
• Evidence has accumulated that
suggests that psychotherapy is an
effective treatment for depression in
later life
– Freud’s position
• The most commonly used
psychotherapies for depression in later
life are Cognitive-Behaviour
Therapy (CBT), Interpersonal
Psychotherapy (IPT), and
Psychodynamic Psychotherapy (PP)
Empirical Review: CBT
Cognitive Behaviour Therapy (CBT) is an
active, directive time-limited and
structured problem-solving treatment
approach whose primary aim is
symptom reduction (Laidlaw et al.
2003).
Empirical evidence suggests that CBT is
an efficacious treatment for late life
depression.
Recommended texts: Laidlaw et al, 2003 and
Gallagher-Thompson, Steffen, &
Thompson (2008) Handbook of Cognitive
and Behavioural Therapies.
Empirical Review: IPT
Interpersonal psychotherapy (IPT) is a
short-term focussed treatment
programme for depression (Hinrichsen
& Emery, 2005).
IPT focuses on 4 main problem areas in its
treatment approach to depression, these
are: (i) grief; (ii) interpersonal disputes
(iii) role transitions and (iv)
interpersonal deficits (Karel &
Hinrichsen, 2000)
Recommended text: Hinrichsen, G. &
Clougherty, K. (2006) Interpersonal
Psychotherapy for depressed older
adults.
Empirical Review: PP
There is no one single form of
psychodynamic psychotherapy
with older people.
PP can be interpreted very broadly
although many approaches focus on
the therapeutic relationship as the
means of change and focus on
transference and countertransference
Recommended texts: Evans & Garner (2004)
and Sadavoy & Leszcz (1987) Treating the
Elderly with Psychotherapy: The Scope for
Change in Later Life
How is Psychotherapy Different with
Older People?
• Chronicity and lifetime history of
distress
• Decisions have been made and lived
with
• Physical illnesses with Psychological
Consequences
• Loss experiences and experiences of
aging
• Different value systems
• Older people don’t identify
themselves as OP, so maybe
sometimes its not different!
Sadavoy talks about the
5 cs of psychogeriatrics:
Chronicity, Complexity,
Comorbidity,
Continuity & Context
Empirical Review of CBT with Older People
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Scogin & McElreath (1994) 17 studies. Meta-analysis
Koder, Brodaty & Anstey (1996) 7 studies, Meta-analysis
Engels & Verney (1997) 17 studies, Meta-analysis
Cuijpers (1998) Cuijpers et al., (2005)
Gatz et al., (1998) APA sponsored Evidence review
Gerson et al., (1999) 45 studies, Meta-analysis
Laidlaw (2001) 9 studies, Meta-analysis
Pinquart & Sorensen (2001) 122 studies, Meta-analysis
Frazer et al., 2005 Evidence based review
Pinquart, Duberstein & Lyness (2006) 89 Studies, Meta-analysis
Scogin et al., (2005) 20 studies: Evidence based review
Wilson, Mottram, Vassilas (2008) Cochrane Review
CBT vs TAU for Late Life Depression
RCT of CBT with Older People, Laidlaw et al, 2008
Results (Intention to Treat Analyses)
– Both groups improved significantly by end of
treatment phase.
– At 6 month follow-up participants improved
on all primary outcome measures.
• Adjusting for baseline scores CBT group
performed better on BHS at 6 months
follow-up (F (1,37) = 6.12, p = .018)
• Adjusting for gender differences at
baseline, CBT participants performed
better on BHS at six months follow-up (F
(1. 37) = 5.00, p = .03).
– Age was not a factor in determining outcome.
Empirical Review: CBT For Late Life Anxiety
• A number of RCTs have been conducted with older
people with anxiety. Many of these conducted in the
US. Some criticisms re: age and health status of
participants.
• Increasing No. of substantive reviews of CBT for LLA
• Recent paper in JAMA (301(14), 1460-67) by Stanley
et al conducted in Primary Care settings comparing
CBT to EUC.
• Other recent developments in late life anxiety include
highly specialised CBT for people with executive
dysfunction (Mohlman & Gorman, 2005; Mohlman et
al., 2008).
Emergent Evidence with Older People
• There are 5 published studies looking at
CBT for depression in Parkinsons’s
disease. This is very promising as
depression especially as “Pharmacological
treatment of depression in PD remains
something of a black hole” (Burn, 2002).
• The picture for CBT for post-stroke
depression is less clear. 2 RCTs with
unclear results. The data suggests that an
augmented format for CBT may be more
successful.
• Direct psychotherapy for people with
dementia is less common and research
needs to be conducted as a national
priority – MHC Pilot
Strucutred Interventions with
Dementia Caregivers
Emerging consensus on Evidence Base: REACH
– Active interventions better than passive interventions
– CBT works best for reducing caregiver distress and
burden
– Psychoeducation improves SWB, distress only if it is
active
– Supportive approaches effects SWB only but may be
ineffective for psychological distress
– Individual interventions more effective than group
– Structured Multi-component interventions may reduce
and delay institutionalisation.
• Sources: Burgio et al., 2008; Gallagher-Thompson &
Coon, 2007; Longsden et al., 2007; Pinquart & Sorenson,
2002; Pinquart & Sorensen, 2006; Selwood et al. 2007.
Empirical Review of Psychotherapy with
Older People
• Evidence for CBT is stronger than for other forms of therapy (Frazer et
al, 2005; Gatz et al, 1998; Laidlaw 2001; Pinquart et al, 2006; Scogin et
al, 2005)
• Individual therapy appears to be superior to group (Engels & Verney,
1997; Pinquart & Sorensen, 2001; Scogin et al 2005)
• Psychotherapy seems comparable in efficacy to medication (Gerson et
al, 1999; Pinquart et al, 2006)
• Few studies have examined effect of combination treatments (Pinquart
et al 2006; Scogin et al, 2005; Wilson et al, 2008).
• The literature on psychotherapy outcome with oldest-old is insufficient
(Engels & Verney, 1997; Laidlaw, 2001; Scogin et al, 2005)
• The literature on CBT for depression comorbid with disorders more
common in later life (Dementias, Post-stroke depression, etc,) is
emerging but at very early stages
CBT and the Demographic Context
The current evidence base for CBT with Older People is reasonably strong and
mature BUT
In psychological treatment models there are very few specific frameworks to
characterize the experience of older people who develop depression/anxiety
Maybe it is time to develop more age
specific models of CBT for older people
(Laidlaw & Pachana, 2009), and consider
new targets for CBT such as attitudes to
ageing and wisdom enhancement
(Laidlaw, 2010)
Wisdom is one of the few positive
attributes associated with ageing and may
enhance outcome for chronic dep.
Application of Psychological therapy with
Older People
Researchers are turning their attention to the issue of application of
therapy with older people
Knight et al., CALTAP (Contextual
Adult Lifespan Theory
for Adapting Psychotherapy)
Laidlaw et al., CCF
(Comprehensive Conceptualization
framework – for CBT)
Knight & Laidlaw, 2009, Laidlaw, 2010 – Wisdom Enhancement: Aim is to
produce a developmentally appropriate theory for therapy with older people
A Radical Approach?
Not just talking…
• NHS Lothian OP Psychology has initiated the following
• Introduction to CBT courses (x2 with a specialist CBT-OP
course planned Oct. ’10)
– “I found it challenging, inspiring and exciting. I got a buzz from learning
new skills and gaining new perspectives.”
• The Masterclass Experience: A Truly unique, innovative and
valuing approach to training in psychological therapies
– “Fantastic to hear from such experienced and knowledgeable clinicians who aren’t too academic”
• Univ. Edinburgh has given KT funds to develop proposal for a
UK-wide training course in CBT with older people
Psychological Therapies With Older
People: A Radical Approach?
• The evidence is clear multiple forms of
Psychotherapy work as well with older people as
they work with adults of working age.
• Older People want access to psychological therapies
• Mental health in ageing can be complex and thus we
need a properly equipped workforce.
– We need to prioritise this where the need is greatest
given the demographic transition in Scotland.
• We need a radical approach to ensure that older
people have access to quality psychological care
delivered by those with the relevant expertise.