N0308858 Project Report

Psychosocial interventions to help treat later life depression: A
literature review
Jemma Bateman
MSc Psychological Well-being and Mental Health
Psychology Division
School of Social Sciences
Nottingham Trent University
N0308858
Eva Sundin
August 2014

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Old Age Depression: An analysis of published literature investigating
psychosocial interventions as a treatment
Bateman, J.
Division of Psychology, Nottingham Trent University, Nottingham NG1 4BU, UK (e-mail:
N0308858@ntu.ac.uk).
Abstract
Depression is a common illness in the elderly population due to a variety of factors related to
later life. If left untreated, depression can prevent recovery from other conditions, and even
cause them to worsen. Depression is a big contributory factor to suicide, a tragic reality that
seems to be common in older adults (65 or over). Psychosocial interventions may be a safer
alternative to anti-depressant medication as mental and physical health problems of older
people are entwined and manifested into complex comorbidity. Research suggests that due to
the effective marketing of anti-depressant drugs, and their cost effectiveness, psychosocial
treatments are under-utilised within the elderly population. A review was undertaken to
discover what psychosocial interventions are available to combat depression and how
effective they are in terms of treating the elderly population. Psychosocial interventions were
categorised into four sections consisting of self-help interventions, technological
breakthroughs, social interaction and befriending and clinical approaches in treating
depression. From this review it is possible to see that more research is needed to confirm such
interventions are advantageous, however, the available literature suggests potential for
improvement using such therapies.

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1. Introduction
Mental disorders are highly prevalent among older people, with depressive disorders being
among the most common (Luijendijk et al 2008; World Health Organization, 2013).
Depression is a major predictor of impaired quality of life in the elderly population (Chan et
al, 2006; Stafford et al, 2007), with research showing that even relatively minor levels of
depression are associated with a significant decrease in well-being (Chachamovich, Fleck,
Laidlaw & Power, 2008). Blazer (2003), argues that although mental disorders are not a
normal part of ageing, older adults, considered to be those over the age of 65 (Age UK 2014),
are particularly susceptible to depression, an illness which causes pre-existing medical
conditions to worsen.
The most widely used criteria for diagnosing depressive conditions are found in the American
Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), and the World Health Organization's International Statistical
Classification of Diseases and Related Health Problems (ICD-10). Symptoms can include:
persistent sadness for a period of two weeks or longer; excessive worries; frequent
tearfulness; feeling worthless or helpless and problems with sleeping (Geriatric Mental
Health Foundation (GMHF), 2014). Later life depression has been given its own diagnosis
because it involves the above symptoms but additional factors associated with old age such
as; difficulties with concentration and the speed of mental processing (Lockwood, 2002;
Elderkin-Thompson, 2003).
With depression having such a negative impact on the quality of life and well-being amongst
the elderly population (Chan et al ,2006; Stafford, 2007; Chachamovich et al, 2008), it is
important to assess the available treatment options and find ways to improve access to those
suffering with a mental illness (Gask et al 2012).
The Mental Health Foundation suggests that most people with depression can improve their
lives with appropriate treatment (Mental Health Foundation, 2014). The GMHF (2014), argue

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that the sooner signs of sadness and loneliness are discovered and addressed, the better the
outcome for the elderly person, with less emotional and physical suffering.
1.1 costing and suicide prevention
Depression is one of the most common risk factors for suicide in the elderly population
(Conwell, Oslen, Caine & Flannery 1991; Conwell, 1995; Conwell, Duberstein & Caine
2002) and statistics from the ‘Centres for Disease Control and Prevention’, show that in 2005,
the rate of suicide in adults 65 or older was 14.7 per 100,000, compared to just 10.5 for
younger individuals (Centres for Disease Control and Prevention, 2008).
In 2012, Pittock conducted a review and explained that the current financial strain on the
Government health budget is set to worsen as the ageing population increases over the next
40 years, bringing along with it the vulnerability to mental health problems and in particular
the increase in depression. Pittock (2012), argues that current diagnostic and treatment
procedures need to be re-evaluated so that health-care systems can continue to promote health
without incurring large debts. Prevention of suicidal behaviour is a major health care target
for the United Kingdom (UK) Government, which in 2002 established a national suicide
prevention strategy for England. Figures from the Government database demonstrate that
depression costs a total of £20.2 -£23.8 billion a year and the average cost per suicide is £1.7
million for England (Department of Health UK, N.D).
Conwell et al (1991), investigated causes of suicide and found autopsy results of elderly
victims suggested depression was the most common reason. With the elderly population
expected to triple in the next 30 years (Department of Health Consultation on Preventing
Suicide in England, 2012), measures must be put into place so that depression can be
controlled in a cost effective manner, reducing rates of suicide.Thus the identification,
prevention and treatment of depression are considered pivotal for preventing suicide in later
life (NIH Consensus Conference, 1992; Pearson & Brown, 2000; Conwell et al, 2002).
Major depression can be prevented (Muñoz, Beardslee, and Leykin, 2012). More than 30
randomised trials have demonstrated that preventative interventions can reduce the incidence
of new episodes of Major Depressive Disorder by about 25% and by as much as 50% when
preventative interventions are offered (Cuijpers, Beekman and Reynolds, 2012). This is a

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promising outlook for combatting depression in older age, however, not every case can be
prevented, and therefore looking at treatment options is important (Yarnall et al, 2003).
1.2 Psychosocial interventions
Psychosocial interventions are defined as any intervention that emphasizes psychological or
social factors rather than biological factors (Ruddy and House, 2005). For example group
therapy or interactive sessions whereby a person is asked to explore the problems they are
faced with. There is a hypothesis that positive mental health can be enhanced if people
believe they have the ability to act in a way that will result in an achievement of their goals
(Blazer, 2002; Blazer 2003). As such, it is possible that psychosocial interventions can reduce
depressive symptoms in elderly people whilst increasing their self-efficacy (Javik et al, 1982;
Rybarczyk, 1999; Scogin et al, 2005).
Scogin and McElreath (1994), conducted a meta- analysis using 17 studies, and concluded
that psychosocial interventions for depressed older adults are indeed effective. Support also
comes from several other researchers (Laidlaw, 2001; Laidlaw et al, 200 and Laidlaw et al,
2008) who agree that such interventions are beneficial.
Alexopoulos (2001), suggests that cognitive behavioural therapy and problem solving therapy
are preferred psychotherapies for elderly people. Koder (1996) argues that cognitive therapy
approaches are as successful in elderly individuals as they are in younger adults. Forsman,
Nordmyr & Wahlbeck (2011), argue that development and evaluation of such methods
should be a research priority. Further support for this view comes from Reynolds et al (2012),
who believe that the efficiency of depression prevention needs to be further enhanced with
the field seeking to understand risk reductions using psychosocial strategies.
Psychosocial interventions may be a safer alternative to anti-depressant medication as elderly
people are more likely to take multiple agents, putting them at a higher risk of suffering
adverse drug reactions (ADRs), adverse drug events and drug-drug interactions (Fick et al,
2003). Katon, and Ciechanowski (2002), state that mental and physical health problems of
older people are entwined and manifested in complex co-morbidity. Research suggests that
due to the effective marketing of anti-depressant drugs, and their cost effectiveness,
psychosocial treatments are under-utilised within the elderly population (Rokke & Klenow,
1998; Reynolds & Kupfer, 1999; Laidlaw, Thompson and Gallagher-Thompson, 2004;

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Katona & Shankar, 2005). However, Reynolds and Kupfer (1999), discovered that clinicians
often prefer not to administer anti-depressant drugs to frail elderly individuals, especially
when they are taking multiple medications. Similarly there is evidence to suggest that elderly
patients are more likely to choose interventions that do not constitute using drugs and prefer
treatments such as counselling or psychotherapy (Gum et al, 2006; Hindi et al, 2011).
Likewise, behavioural activation (encouraging the individual to engage in experiences that
are likely to bring rewards) is seen as more acceptable than anti-depressant medication
(Rokke & Scogin 1995). Coupland et al (2011), conclude that the risks and benefits of
different antidepressants should be carefully evaluated when these type of drugs are
prescribed to older people.
Thompson, Gallagher & Breckenridge (1978), Scott et al (1997), Thompson et al (2001), all
conclude that a range of psychological interventions are efficacious for treating depression.
This evidence leads towards the aims and title of this research ‘Psychosocial interventions to
help treat later life depression: A literature review’.
1.3 Aims of the review
From the published literature available, studies published appear to be conducted on a much
smaller sample size compared to anti-depressant medication, and rarely in comparison to a
sample of people treated by pharmacotherapy.
A review was undertaken to discover what psychosocial interventions are available to combat
depression and how effective they are in terms of treating the elderly population. This paper
aims to further enhance current understanding, whilst informing practitioners, the National
Health Service (NHS) and patients that there are alternatives to anti-depressant medication
such as Cognitive Behavioural Therapy (CBT). This investigation forms a single document
combining reviews of various psychosocial interventions, whilst evaluating them in terms of
their effectiveness.
2. Materials and Methods
A literature search was conducted (up to the 15th July 2014), using seven databases (Psych
INFO, Embase, ASSIA, Psych ARTICLES, PubMed, Science Direct, and Web of Science)

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using the terms (Depression OR Dysthymia OR Mood or Affective) AND (Elderly OR Older
OR Later life) And (Psychosocial OR Non-pharmaceutical interventions).
First of all meta-analyses were looked at to locate relevant studies, and secondly studies with
a controlled design (randomised controlled or non -randomised control trials) were
considered for the analysis. Articles were included only if they reported treatment of people
with depression or a high level of depressive symptoms.
Participants had to be older adults (population defined as people aged 65 or over) with
depression that did not have any other mental disorder (e.g. Dementia). Studies were
considered even if the participant age range began under 65 so long as the mean age of the
participants was noticeably over 65. There was no upper age limit. Studies were excluded
from analysis if they did not include a clear definition of participants, or lacked adequate
reporting of participant data. 10 studies were excluded from this review because they used
participants with other mental illnesses such as dementia, or who had encountered life
changing events (such as having suffered a stroke).
A total of 106 studies were found for this review and psychosocial interventions were
categorised into four sections consisting of: self- help interventions (15 studies);
technological breakthroughs (19 studies); the importance of society and befriending (19
studies) and clinical approaches (53 studies).
Results
1. Self- help approaches to treat depression
Self- help methods can be an effective treatment alternative option for older adults (Cuijpers,
1997; den Boer, Wiersma and Van den Bosch , 2004; Anderson et al, 2005; Spek et al, 2007).
A self-help therapy can be described as a psychological treatment that the patient works
through independently at home (Marrs,1995) and can included a variety of formats such as
books, CD-ROMS, audio and videotapes. Self-help materials aim to improve patient
knowledge and skills in self-management whilst setting clear educational goals (Apodaca,
and Miller, 2003). A more contemporary method of self-help that is being increasingly
offered is help through the internet (Clarke et al 2002; Christensen, Griffiths and Jorm, 2004;

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Spek et al, 2007). Web-based self-help may be an effective and inexpensive alternative to
more traditional therapies (Bijl and Ravelli, 2000; Andrews, Henderson and Hall, 2001).
There is much evidence to suggest that self-help interventions are effective for people over
the age of 65 suffering from depression. For example Chew-Graham et al (2007), argue self-
help is better than normal GP care. Gellis and Kenaley (2007), explain the greatest effect for
treating old age depression with self-help methods is with supportive assisted monitoring
from the therapist to help guide the process. This is further supported by NICE (2004), who
reviewed nine randomised control trials and reported that guided self-help produces a
clinically significant reduction in depressive symptoms when compared with no intervention
(National Institute for Health and Clinical Excellence, 2004)
Fleddeurs, Bohlmeijer, Pieterse and Schreurs (2010), conducted a large scale study involving
376 participants aiming to look at the effectiveness of a self-help course on depressive
symptoms. Participants’ were asked to read a book chapter a week and using an audio CD
complete a set of mindfulness exercises. The treatment course was based on the Acceptance
and Commitment Therapy (ACT) which is a form of therapy in which people learnt to accept
their negative thought and emotions rather than trying to ignore them. The researchers noted
a greater reduction in anxiety and fatigue and an improvement in mental health in participants
who had attended the course. They concluded that a self- help course, where people learn to
accept their psychological distress is effective in reducing depression.
However, there is evidence to suggest self-help is not as effective as previously thought.
Holdsworth et al, (1996), found no significant advantage was observed by adding self-help to
the regular treatments that the GPs normally gave. It could be possible that other studies have
found similar results but have not been published due to publication bias. Holdsworth et al
(1996) believed such poor results were due to the high dropout rates reducing the power of
the study. Furthermore, Mead et al (2005), demonstrated that guided self-help did not provide
any additional benefit to patients on a waiting list for psychological therapy.
McKendree‐Smith, Floyd and Scogin (2003), argue that although there are numerous self-
help books for depression, relatively few have been empirically tested. However, they
suggest those that have been used in clinical trials have fared well, with an average effect size
roughly equivalent to the average effect size obtained in psychotherapy studies.

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To conclude, Bower, Richards and Lovell (2001), suggest that self-help treatments may have
the potential to improve the overall cost-effectiveness of mental health service provision but
the available evidence is limited in quantity and quality and more rigorous trials are required
to provide more reliable estimates of the clinical and cost-effectiveness of these treatments.
2. Technology approaches to treat depression.
Advances in technology may prove to be beneficial for inventing new treatments to help
combat depression as will be investigated in the following paragraphs. The Office For
National Statistics (OFNS, 2014), demonstrates how much power technology has by the
number of people using it. In Great Britain, 21 million households (83%) had Internet access
in 2013 and access to the Internet using a mobile phone more than doubled between 2010 and
2013, from 24% to 53%. A sizable increase in daily computer use, in the past seven years has
been found for adults aged 65 and over. In 2006, just 9% reported that they used a computer
every day, this compares to 37% in 2013. Of those aged 65 and over, 1 in 10 adults (11%)
used a tablet or portable computer to access the Internet “on the go” in 2013. This provides
huge potential to a new form of therapy that people can access at home. One of the main
benefits of online or technical treatments is that patients can be reached from a distance, with
reduced therapist interaction compared to face-to-face therapy (Bendelin et al, 2011). Climo
(2001), suggests that limitations to mobility and activity may increase the importance of the
internet for interpersonal communication, maintaining family bonds and expanding social
networks and supports claims by Williams and Whitfield (2001), who argue, there is a need
for a mental health treatment that is accessible and popular with patients
Mobile applications and internet use for seniors
Social isolation, decreased social contact, and lack of emotional support are risk factors for
depression in older adults (Wright 2000; Bradley & Popen 2003; Eastman & Iyer 2004).
Using the internet for communication may help reduce social isolation, loneliness and
depression as well as enhance social support among older adults (White et al 1999; Mcmellon
& Schiffman, 2002; Blit- Cohen & Litwin, 2004; Xie 2007; Cotten, 2009). Research on
internet usage among older adults indicates technology use can increase social support, social
contact, social connectedness, and greater satisfaction with that contact (Trocchia & Janda,

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2000; Bradley & Poppen, 2003; Mellor, Firth & Moore, 2008). It has been suggested that
older adults may develop new social activity to replace activities that have become more
difficult for them to perform and to strengthen existing ties with family through the internet
(White et al, 1999). Increased contact with social networks help individuals feel closer to
others which has positive implications for their sense of mattering and mental health (Cotten,
2009).
As the evidence from the OFNS suggests, more people are using their mobile phones to
access the internet so providing applications to help combat depression could be a new
gateway to developing future treatments. An example of this type of app derives from
Pizzagalli (2013), who created a piece of software called ‘Moodtune’. This software can be
downloaded on a mobile phone and used by anybody who feels they would benefit from the
app. It includes a selection of games that if played regularly is believed to help treat
depression. The app also gives tips of the day to enhance well-being and includes a mood log
which records how a person is feeling at different moments throughout the day. Pizzagalli
claims it could be just what an individual who has depression needs in order to recover. He
argues that many applications available do not have the science to back them up but
Moodtune is different because it works out certain parts of the brain causing them to work
overtime in order to counteract depression. He says this particular app has an edge as its only
focus is depression and after each game the science behind it can be explained to the user.
Another example of how mobile phone technology can be useful comes in the form of
another piece of software called ‘Mobilyze’. This is a smart phone that can read peoples
moods and can spot symptoms of depression and encourages them to do something about it.
By evaluating the data within the phone such as an individuals’ location, social context, mood
and activity level, it intuits if an individual is depressed and will nudge a person to call a
friend or go out for some company.
This software has been tested in a small pilot study and it was found it helped reduce
symptoms of depression. Mohr (2012), believes that the new phone offers a powerful new
level of social support for people who have depression as it intervenes to help them change
their behaviour in real time by prompting them to increase pleasurable behaviours that are
rewarding.

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A survey including 612 older adults conducted by the Third age council (C3A, 2012), found
that 97 per cent said that keeping up with technology helps them to stay socially connected.
They suggest that connecting online as well as spending face to face time with family and
friends is a way for seniors to combat depression. C3A, (2012) also argue that through the use
of social media such as Facebook, seniors can find people who share common interests.
However, there is a danger of internet addiction with seniors getting hooked on online
gambling and watching online videos (Morahan-Martin, 2005). There is concern that
spending too much time on these activities can pose health risks for the elderly (Huang, 2010)
and that seniors should also be careful when they use the Internet, to avoid being conned by
strangers. To help avoid this, Social Networks for Mature Users have been created especially
for seniors (seniorhome.net). These social networking websites are designed for individuals
with more life experience to share. For example, ‘My Boomer Place’
(www.myboomerplace.com), allows the user to create a profile here and get started
connecting with friends or making new ones, sharing photos, writing and sharing articles,
playing games, and much more. ‘Maple and Leek’ (http://www.mapleandleek.com), is
designed for those 50+, this community is one of adventure and entrepreneurial spirit.
To conclude Mohr (2012), suggests that these new approaches could offer new treatment
options to people who are unable to access traditional services or who are uncomfortable with
standard psychotherapy. This means that older adults would benefit from applications like
this because they can receive help in the comfort of their own home without a struggle.
3. The importance of society and befriending
Befriending has been deﬁned as a relationship between two or more individuals where the
relationship is non-judgmental, mutual, and purposeful, and there is a commitment over time
(Dean and Goodlad 1998). Low levels of social capital in older adults is a risk factor for
depression (Van Der Horst and McLaren, 2005; Nyqvist et al., 2006). Holf- Lunstad et al
(2010), suggest that risk factors in older people for social isolation include minimal contact
with friends and family, low morale, lack of access to private transport and living alone.
Restricted social support, a limited social network and loneliness are associated with

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depressive symptoms and depression (Lynch et al, 1999; Jongenelis et al, 2004; Bisschop et
al,2004; Jongenelis et al,2004; Steunenberg et al., 2006;).
Evidence suggests that social isolation amongst older people is estimated to be between seven
and seventeen percent (Victor et al, 2003; Iliffe et al, 2007; Tomaszewski and Barnes, 2008)
and that loneliness is experienced by approximately forty percent of the elderly population
(Savikko et al ,2005; Hawthorne 2006; Hawthorine 2008). Baron, Field and Schuller, (2000),
argue that a significant mental health promoting factor among older adults is the individuals’
perceived sense of trust and social support so this is what needs to be a priority when treating
somebody with depression. The development of such strategies to increase older peoples
participation in society has been an important factor in the UK governments delivery of
health and social care (Victor, Scambler and Bond, 2005; Steed et al, 2007; Marmot 2010).
Building a strong connection to a social group helps clinically depressed patients recover and
helps prevent relapse (Canadian Institute for Advanced Research, 2014). To support this
Holt-Lunstad, Smith and Layton (2010), found in their meta-analysis of 148 longitudinal
studies that there was a 50% reduction in the likelihood of mortality for individuals with
strong social relationships. Similarly Jane-Lopis, Hosman, Jenkins and Anderson (2003),
found social support to be the most effective among older adults in treating depression during
their meta-analysis. .
.
The link between loneliness and mental health means that befriending is increasingly situated
within the broader context of ‘psycho-social interventions’ alongside psychological therapies
(Grifﬁn 2010). Befrienders have been offered to older adults in the UK for over 70 years
(Salvage 1998) , and are increasingly perceived as central to healthy ageing strategies,
through the prevention of social isolation and loneliness (Godfrey, 2001; McCormick et al,
2009; Department of Health, 2010).
It has been suggested that residential care and nursing homes should be opened up to
befrienders. Neuberger (2008), conducted a study investigating the effects a befriender could
have on depression. The seven interviewees living in residential or intermediate care all
described feeling lonely despite being surrounded by other people all day. Staff were
perceived as too busy to chat and tended to do things ‘to’ rather than spend time ‘with’
residents. Befriender visits gave purpose and shape to the residents’ days, broadening their

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perspectives on life. Neuberger (2008), summarised by saying emotional befriending may be
one means of addressing loneliness and improving the psychological health of older adults.
To conclude, counter evidence for such interventions is minimal. However Richards,
Greaves and Campbell (2011), argue more well-conducted studies of the effectiveness of
social interventions for alleviating social isolation are needed to improve the evidence base.
4. Clinical approaches to treat depression
Cognitive behavioural therapy (CBT)
A possible treatment for depression in the elderly is CBT. CBT aims to alter the way an
individual thinks and the way they behave. The focus is on ‘here and now’ problems, and
therapy looks for ways to improve a persons’ state of mind (Royal College of Psychiatrists,
2014). Beck (1961), describes CBT as a working relationship between the client and
psychotherapist, where the client explores their negative automatic thoughts against reality,
and attempts to modify them.
There is much evidence to support the use of CBT as in intervention to treat depression in
elderly people (e.g. Frazer, Christensen and Gritthis, 2005; Pinquart, Duberstein and Lyness,
2008). Robust and consistent Meta –analyses and systematic reviews such as one conducted
by Laidlaw (2001), have found that CBT consistently has the largest effect size overall other
methods, and specifically it helps alleviate symptoms associated with depression (Pinquart
and Sorenson, 2001). Such evidence suggests that CBT is more effective than either
treatment as usual or waiting list control in the treatment of depression in older adults and is
as effective as antidepressant medication (Churchill et al, 2001; Leichsenring, 2001; Hensle,
Nadiga and Uhlenhuth, 2004; Mackin and Arean, 2005; Cuijpers , van Straten and Smit,
2006).
Similarly a systematic review carried out by Peng, Huang, Chen & Lu (2009), looked at 14
randomized control trials that assessed the efficacy of psychotherapy for treating depression
in elderly people and concluded that CBT was indeed effective at reducing depressive
symptoms and aiding recovery.

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Not only do meta-analyses such as these give strong evidence that CBT is an effective way of
combatting depression, many individual studies such as one by Selmii et al (1990),
demonstrate its efficacy and reliability in this age group. Selmii and colleagues (1990),
conducted a randomised control trial comparing traditional therapist led CBT, with self-help
CBT. In this study 36 volunteers with a depressive disorder were split into three groups
receiving either traditional therapist led CBT, Self -help CBT via a computer and a control
group. After six weeks of treatment, at a two month follow up there was a significant
difference between the treatment groups. Those receiving CBT treatment had improved more
than the control group who showed no effect and still displayed the depression symptoms.
Similar results have been found by Serfaty et al (2009), who created a single-blind,
randomized, control trial with a four and 10 month follow-up visit, using a total of 204 people
aged 65 years or older. From their results they concluded that CBT was an effective treatment
for fighting depression in older adults but this particular study does warrant some
consideration after it was revealed need related factors such as disease severity, functionality
and deprivation are thought to have influenced the patients recovery process. Consequently
this poses the question of the quality of evidence supplied in the literature.
To evaluate the quality of CBT evidence, Gould, Coulson and Howard (2012), argue that
more high-quality randomised control trials comparing CBT to other methods need to be
conducted before firm conclusions can be drawn about the efficacy of CBT for depression in
older people.
CBT can have potential problems with maintaining patient commitment, and dropout rates
can be a problem leading to a failure in treatment (Hauke, Gloster, Gerlach, Hamm, Deckert,
Fehm & Wittchen, 2013). However, to address this issue, Pinquart et al (2008), suggests that
interventions with 7-12 sessions would help minimise dropout rates and optimise
effectiveness.
To conclude, perhaps an alternative form of CBT that would help maintain engagement with
the therapy is Computer Cognitive Behaviour Therapy (CCBT). The National Institute for
Health and Care Excellence guidelines (NICE, 2006), explain that CCBT is therapy given
through a computer in addition to, or instead of, sessions with a therapist. The Improving
Access to Psychological Therapies (IAPT) program was created in the United Kingdom in
2006, to meet the growing need for psychotherapy. 50% of the population have access to
CCBT, and evidence suggests that increased access to CCBT could save the NHS a

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considerable amount of money (Improving Access to Psychological Therapies, 2012). The
NHS currently offers CCBT in the form of a programme called ‘Beating the Blues’ (BTB),
(Department of Health, 2007). BTB is specifically aimed at treating patients with mild to
moderate depression and/or anxiety. However, before treatment, NICE recommends that the
individual is assessed to make sure such treatments are suitable and the relevant support is in
place for when the treatment begins.
Behavioural activation (BA)
BA is a technique of encouraging the individual to engage in experiences that are likely to
bring rewards which can act as a natural anti-depressant in the condition known as ‘positive
reinforcement’ (Jacobson, Martell and Dimidjian, 2001). Pavlov (1941), describes positive
reinforcement as a conditioned response that brings about a certain type of behaviour in order
to receive a reward. Cuijpers, Van Straten & Warmerdam (2007), suggest that BA can also
help improve interactions with other people in order to improve feelings of self- worth and
control.
BA can help an elderly person suffering from depression, reengage in their life and it helps to
fight patterns of avoidance, withdrawal and inactivity (Jacobson, Martell, & Dimidjian,
2001), which may intensify depressive symptoms (Cuijpers, van Straten, Smit, 2006).
Dimidjian et al (2006) tested the efficacy of BA by comparing cognitive therapy and anti-
depressant medication, in a randomised placebo controlled design with 241 adults with
depressive disorder. It was found that BA was at least as efficacious as anti-depressant
medication and retained a greater proportion of patients long enough for them to benefit from
the treatment. Results also demonstrated that BA was more efficacious than cognitive therapy
among the more severely depressed. This is supported by Dimidjian (2006), who concluded
in his large scale treatment study that BA is more effective than cognitive therapy and on a
par with medication for treating depression.
Further support comes from Dobson et al (2008), who found that during their randomised
controlled trial of adults with depression, patients were more likely to suffer a relapse if
withdrawn from an anti-depressant drug without previous BA training. This suggests that BA
training is important in terms of treatment effectiveness.
Additional BA findings come from Soucy Chartier (2013), who reviewed behavioural
activations theoretical foundations using a systematic review of articles on low intensity

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behavioural activation interventions for depression. They concluded that based on the
literature, behavioural activation could be a viable option as a low intensity psychological
treatment for mild to moderate depression.
Spates, Pagoto & Kalata (2006), conducted a review of eight behavioural activation treatment
studies of major depressive disorder ranging from 1997 to 2006. Their study was limited in
the fact only a small number of treatment studies have been conducted testing BA’s efficacy
as a treatment for late life depression. However Spates et al (2006), still conclude that policy
makers should consider BA as an effective treatment.
The problem with BA as highlighted above is the lack of literature in this area. Shinohara, et
al (2013) and Hunot, et al, (2013), conclude that in the studies that have been published so far
concerning Behavioural Activation, there is only low to moderate quality evidence that
behavioural therapies and other psychological therapies were equally as effective. Shinohara
et al (2013) and Hunot et al (2013) call for larger studies with a bigger recruitment of
participants with an ‘improved reporting of design and fidelity to treatment’, to improve the
quality of the evidence. Spates et al (2006), argue that although these initial studies of the
efficacy of BA have had consistently positive outcomes, larger randomized trials comparing
BA to other therapeutic modalities are needed. Soucy et al (2013), suggest further research is
needed as studies on the efficacy of behavioural activation as a guided self- help treatment
are very limited to date and there are significant variations among existing studies. This point
is further supported by Spates et al (2006), who concluded that it was clear that additional
large scale trials were needed to establish confidence in this type of intervention as a front
line treatment of choice.
To conclude, these studies as Spates et al (2006) suggest, still reveal a significant and fairly
large effect size on measures of depression and it is still possible to suggest that the
behavioural activation treatment for depression, is time-efficient, cost-effective and relatively
uncomplicated as a method for treating depression ( Hopko et al, 2003). Behavioural
activation is a straightforward, structured treatment which can be an effective treatment for
depression in older adults (Lejuez, Hopko, & Hopko 2001).
Problem solving therapy (PST)
Problem-Solving Therapy (PST) is a cognitive-behavioural intervention that focuses on
training in adaptive problem-solving attitudes and skills (Bell and D’zurilla, 2009). Problem

16
solving treatment is most likely to benefit patients who have a depressive disorder of
moderate severity and who wish to participate in an active psychological treatment (Mynors-
Wallis, Gath, Day and Baker, 2000).
Bell & D’Zurilla (2009), conducted a meta-analysis that focused on training in adaptive
problem solving attitudes and skills to reduce depressive symptomatology. Using 21 samples
they found that PST was just as effective medication treatment, plus significantly more
effective than no treatment and support groups.
Dobson (2010), explains five key objectives in PST. Firstly, problem formulation to help
foster the patients understanding of their experiences so that they can create realistic
treatment goals. In the case of an elderly individual suffering from depression, this stage
would consist of them becoming aware of the behaviour that needs to be changed. The
second stage involves the patient and the therapist working collaboratively to generate
alternative solutions, enhancing the ability to make more effective decisions. Thirdly,
developing an individual’s ability to successfully carry out a solution plan, evaluate its
effectiveness and engage in self-reinforcement. The fourth stage makes sure the success of
the patient is maximised by creating a ‘toolbox’ of new skills to use in familiar situations, and
lastly the fifth stage teaches the individual to some quick problem solving techniques.
Malouff, Thorsteinsson & Schutte (2007), show support for PST by demonstrating its
effectiveness in their study. A meta-analysis consisting of 31 studies involving 2895
participants resulted in PST showing a significant effect on reducing depressive symptoms as
opposed to no treatment or a placebo control group. However a limitation of this study is that
only published studies were included in the meta-analysis. Thus, the analysis may have a
“publication bias” in that non-significant findings are less likely to be published than
significant findings.
Malouff et al (2007) supports earlier findings by Mynors-Wallis, Gath, Lloyd-Tomlinson
(1995), study investigating 91 patients with major depression who after giving participants
six sessions of PST over 12 weeks conclude PST is effective, feasible and acceptable to
patients, and as effective as antidepressant drugs, and more effective than a placebo.
Additional evidence derives from Cuijpers, Van Straten, & Warmerdam (2007), who
conducted a meta-analysis of randomized effect studies of activity scheduling. Activity
scheduling is a behavioural treatment of depression whereby patients learn how to monitor

17
their activities daily in addition to the mood associated with them. This promotes the pleasant
activities and increasing the positive interactions with the environment. 780 people were used
across sixteen studies, and concluded there were clear indications that problem solving
therapy was effective and that activity scheduling is an attractive treatment for depression.
Cuijpers et al (2007), say this is because it is uncomplicated, time efficient and does not
require the patient to carry out complex skills.
Moreover, Areán, et al (2010), conducted a study to determine whether problem-solving
therapy is an effective treatment in older patients with depression, as they believe the elderly
population in the future is likely to be resistant to antidepressant drugs. Participants were
randomly assigned to 12 weekly sessions of PST and assessed at weeks 3, 6, 9, and 12.
Results suggested that PST is effective in reducing depressive symptoms and leading to
treatment response and remission in a considerable number of older patients with major
depression. These results are supported by Alexopoulos, (2011), who conducted a similar
study and conclude that PST may be a treatment alternative in an older patient population
likely soon to be resistant to pharmacotherapy
Another example of successful PST comes from Arean et al, (1993). Using 75 adults as
participants, they provided 12 weekly sessions of group problem solving treatment. At the
end of the study it was found that significant reductions in depressive symptoms were
highlighted and participants demonstrated a sufficient positive change.
To conclude there is mixed evidence for PST as a depression treatment. Gellis, and Kenaley,
(2007) suggest then combined use of PST and antidepressant treatment has more favourable
outcomes compared with PST alone. Although there is evidence that PST can be an effective
treatment for depression, more research is needed to ascertain the conditions and subjects in
which these positive effects are realized (Cuijpers, van Straten and Warmerdam, 2007).
Reminiscence therapy
Reminiscence therapy aims to help older adults fully understand themselves, in the hope that
it will alleviate a sense of loss by re-experiencing and reinterpreting their life events (Hsieh
&Wang, 2003). RT uses prompts, such as photos, music or familiar items from the past, to
encourage the patient to talk about earlier memories (Bharucha et al, 2014). Chao et al
(2006), suggest RT allows the individual to learn how to communicate and develop

18
friendships which allows the individual to obtain a sense of identity and belonging. As a
communicative psychosocial process, reminiscence therapy has proven to be a valuable
intervention for the depressed elderly client (Haight, Michel, & Hendrix, 2000; Cully,
LaVoie, & Gfeller, 2001).
Research has shown that older people with symptoms of depression who participate in
reminiscence therapy report better self-esteem and are more positive about their social
relations than similar people who do not receive the therapy support (e.g. Pittiglio, 2000;
Hwang & Dai, 2003). They also tend to have a more favourable view of the past, are more
optimistic about the future and it can assist the elderly to cope with crisis, loss and quality of
life (Cappeliez et al 2005; Bohlmeijer et al 2007). An example of this comes from Watt and
Cappeliez (2000), who experimented with 26 older adults with moderate to severe
depression. They found that RT led to significant improvements in the symptoms of
depression at the end of the intervention.
Early support for this method of intervention is provided by Parsons (1986), who investigated
levels of depression in the elderly after group reminiscence therapy. Findings from the study
suggest that group reminiscence therapy may provide an effective form of treatment for
moderately depressed elderly people.
Furthermore in 1995, Taylor-Price studied 34 elderly depressed female patients in nursing
homes and asked them to take part in group reminiscence therapy. Results showed that the
therapy helped to increase positive feelings amongst the residents and decreased negative low
feelings. This suggests that this type of therapy is effective particularly in elderly people
living in residential care. However this study was limited to females so it cannot account for
males’ reaction to the treatment.
Similarly Chiang et al (2010), conducted an experimental study using 92 institutionalized
elderly people aged 65 years and over. After providing the reminiscence therapy, residents
displayed improved socialization and induced feelings of accomplishment.
Further support comes from Wang (2004), who used reminiscence intervention to study
elderly people living in residential care homes in Taiwan, and found similar results that group
reminiscence therapy could effectively alleviate the depressive symptoms older people

19
experience. This demonstrates that it is effective in other countries other than the typical
western style communities.
Additional support for the effectiveness of RT comes from Bohlmeijer, Smit and Cuijpers
(2003), who conclude that RT is an effective treatment for depressive symptoms in the
elderly and that it may offer a valuable alternative to psychotherapy or pharmacotherapy.
Especially in non-institutionalised elderly people who often have untreated depression it may
prove to be an effective, safe and acceptable form of treatment. However Bohlmeijer et al
(2003), suggest randomized trials with sufficient statistical power are necessary to confirm
the results of this study.
A more recent study conducted in 2011 by Zhou et al, investigated the effects of group
reminiscence therapy on depression and self-esteem of Chinese community dwelling elderly.
Eight communities were randomly selected and divided into four experimental groups and
four control groups. In conclusion, group reminiscence therapy was effective in reducing
symptoms of depression, and promoting mental health of community-dwelling elderly.
As treatments go, there are few side effects to reminiscence therapy, but there is still some
caution as not all memories are pleasant (Bharucha et al, 2014). There are still relatively few
controlled studies in this area of research, but Hsieh &Wang, (2003), say that despite
reminiscence therapy requires further testing, it should be considered as a valuable
intervention.
Discussion
The main conclusion drawn from this review is that there is still a need to investigate
psychosocial interventions further. Even though there is evidence of the effectiveness of such
interventions, the results appear to be varied so more needs to be done to provide more
accurate understanding of such methods.
From the literature reviewed, there are many points to consider in terms of their
appropriateness with older adults. Starting with self-help methods, there is limited evidence
available critiquing such methods. As Holdsworth et al (1996), found out, there was no
significant advantage from such interventions. This suggests there could be some degree of

20
publication bias where only studies with significant studies have been published. On the
matter of published studies, it is evident that not much research is concerned with late life
depression so this is something to look into (Bower, Richards and Lovell, 2001). On another
note, as demonstrated by Holdsworth et al (1996), there is a problem with drop-out rates in
such an intervention so perhaps self-help methods are only effective if people are motivated
to carry through the course. Another matter to highlight is that the self-help tools such as
books have not been empirically tested so the evidence is limited. It is possible to suggest that
more rigorous trials are required to provide more reliable estimates of the effectiveness of this
type of intervention. There are also ethical issues to consider with self-help as a lot of it is
carried out unsupervised. It would be more ideal to have a therapist present to make sure the
elderly person stays safe (Gellis and Kenaley, 2007). However taking these concerns into
account evidence from this review still shows that self-help interventions can be an effective
alternative treatment for reducing depression in those aged 65 or over.
When considering the effectiveness of technology in treating late life depression, most
evidence suggests that such methods may be beneficial as future treatment. With statistics
from OFNS showing that more of the population is becoming familiar with online and mobile
technology there is a real potential for some new treatments to be invented. Technology can
help reach those who struggle to remain mobile (Bendelin et al, 2011). Another advantage of
technology interventions that has been demonstrated in this review is that the internet allows
a person to interact with society and other family members. This is thought to be important
for maintaining a positive mental health and helps to reduce loneliness (Cotten, 2009).
However a point must be made regarding safety whilst online. There is a danger that when
older people use the internet they are at risk of being conned by strangers or incurring
unexpected costs (Huang, 2010). There is also a chance that a person who spends most of
their time online can become addicted (Morahan-Martin, 2005). The problem with
technology being used as a source for help is that it involves the person acting independently
without any supervision of a therapist to check they are remaining safe and there are no
adverse reactions as a result of being exposed to the internet. As discovered, even though
applications do not go through clinical trials meaning it is not a nationally recognised
treatment, software and apps such as ones discussed in this review could make it cheaper than
the cost of depression medication and possibly more fun to take. They offer new treatment
options to people who are unable to access traditional services or who are uncomfortable with

21
standard psychotherapy. More research is needed and larger scale implementation but this
could be the future for treatment.
Social support and befriending has been considered important in making sure older adults
stay socially connected so they don’t become lonely and feel depressed. Even though there
are arguments for more studies to be conducted to show its effectiveness, the government
should support getting older adults to interact with society and nursing homes should open up
to having befrienders visit the elderly residents they care for (Victor, Scambler and Bond,
2005; Steed et al, 2007; Marmot 2010).
Each clinical intervention discussed has been shown to be effective as an intervention.
Evidence suggests that CBT and RT are a well-established and an acceptable form of
treatment. Taking into account the limitations of sample size, BA can be concluded as a
straight forward, effective treatment for depression in older adults (Hopko et al, 2003).
Advantages of PST as an intervention are that it is uncomplicated and time efficient as a
therapy and research in this review suggests it is just as effective as medical treatment. In
relation to use in older adults, therapies such as these would be at an advantage as it allows
the individual to learn a set of new skills and change their pattern of thinking, to help solve
the current depressive symptoms and protect against future depressive episodes.
The research conducted in this literature review is important because it incorporates various
interventions and evaluates them in terms of their effectiveness, in order to offer older adults
an alternative treatment to anti-depressant medication. However, this review is limited
because it only had access to published research. It is possible that other new research is
being conducted that this review does not have permissions to yet.
To conclude it is possible to see that psychosocial interventions are still very much in their
primary stage with research only now starting to pay attention to them. Much more research
is needed to confirm such interventions are beneficial and possibly able to replace
antidepressant drugs but it is possible to see from the literature that is available at the moment
there is potential for improvement.

22
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Late life depression- Psychosocial Treatments
Mental disorders are familiar among older adults, with depressive disorders being the most
common. Although depression is not a normal part of ageing, older adults are prone to
suffering its effects. This can be a big problem if you are experiencing depression because not
only does it impact on your quality of life and have a significant decrease in your personal
well-being, it also causes pre-existing medical conditions to become worse. There is concern
that anti-depressant medication can cause unwanted interactions with other prescription drugs
leading to possible side effects. As a result, there are alternative treatment options available
in the form of ‘psychosocial interventions’. Psychosocial interventions are treatments that
focus more on the psychological and social side of therapy rather than biology and offer a
different approach to treatment.
Self-help therapies
A self -help therapy can be described as a psychological treatment that a patient works
through independently at home. Treatment can include a variety of formats such as CD-
ROMS, audio and video tapes. An increasingly popular method of self -help is now being
offered through the internet. Research suggests that most self-help methods are more
effective with a therapist so your doctor may recommend you take a self-help course with a
professional overlooking the treatment to make sure you remain safe. A popular course
known as ‘Acceptance and Commitment Therapy’ (ACT), helps you learn to accept any
negative thoughts you might be experiencing and learn to ignore them so you can carry on
living a normal life. Evidence has concluded that learning to accept your own psychological
distress can be effective in reducing depression, but if you do choose to take part in this form
of therapy it will require some level of self-motivation in order to make sure you are getting
the most out it.
Technology interventions
Government figures show that those of us aged 65 or over are using a computer on a daily
basis and have access to portable computers or tablets. Research has suggested that 97 per
cent of people using the internet said that keeping up with technology helps them to stay
socially connected.

36
This means we should look to take advantage of such interaction and look for possible
treatment methods as a result. For example, a new piece of software has been created called
‘Moodtune’ which is an application you can download which helps keep track of your daily
mood and can offer advice of how to increase your wellbeing. It also consists of a series of
games which are said to help stimulate certain parts of your brain, if played regularly to lift
symptoms of depression. Research suggests that there is enough science to back up that this
app that it actually works with its creators saying such science can be explained to you after
you have completed its tasks.
A similar piece of technology that has been created to help lift depression is in the form of a
smart phone called ‘Mobilyze’. This technology can read your mood and spot symptoms of
depression encouraging you to do something about it. By evaluating the data within the
phone such as your location, social context, mood and activity level, it intuits if you are
depressed and will nudge you to call a friend or go out for some company.
These new approaches could offer new treatment options to people who are unable to access
traditional services or who are uncomfortable with standard psychotherapy. If you do choose
to try out technological interventions, make sure you stay safe online. Online addiction is a
possibility and can pose serious health risks. However do not panic as there are special
websites made solely for the use of older adults which are safe, enjoyable and great for
meeting new people. To find out more about this websites please look at the links at the
bottom of this page.
The importance of social interaction
There is evidence to suggest that low levels of social interaction are a risk factor for older
adults meaning it is really important to remain integrated with society to avoid any risk. With
up to 40% of the elderly population feeling lonely, it is necessary to make sure older adults
are not left alone. Try to build up a strong connection to social groups if possible and
consider having a ‘Befriender’. Befriending has been offered as part of a treatment for over
70 years now and has shown to be very effective in lifting symptoms of depression. A
befriender comes to see you once or twice a week and will sit and talk to you in a non-
judgemental way and is there to be your friend. The impact of having somebody like that in
your life can be a real positive. A befriender can give purpose to your day and help broaden

37
you perspectives so is well worth considering. Ask your GP or contact a local age related
charity for more advice about requesting a befriender.
Clinical approaches
Cognitive Behavioural Therapy (CBT)
CBT is a therapy that includes working closely with a therapist to try and change your
negative thought patterns responsible for your depressive symptoms. There is a lot of
research to support its effectiveness in people aged over 65 and follow up results suggest it is
a therapy that is long lasting. It can teach you new skills that can be used in future situations
to help combat the problems you may be experiencing. CBT takes place over a few weeks
and usually lasts about 10-12 sessions but is a suitable alternative for those who prefer a more
hands on approach.
Behavioural Activation (BA)
BA is a therapy that encourages you to behave in a way that brings about rewards in order to
alleviate the symptoms of depression you may be experiencing. Evidence supports this
method of intervention and suggests that BA can help you re-engage with your life and avoid
patterns of avoidance, withdrawal and inactivity. BA is a straightforward, structured
treatment that is time-efficient and relatively uncomplicated as a method for treating
depression so is worth considering if you need to enhance your level of well-being.
Problem Solving Therapy (PST)
PST aims to train you in adaptive problem solving attitudes and skills and is likely to benefit
those who wish to participate in an active psychological treatment. It consists of activity
scheduling which encourages you to monitor your daily activities and the mood associated
with them. By doing this it is hoped you will discover what activities you enjoy and promote
you to actively engage in them more often. This method of intervention is ideal because it is
time efficient and does not require you to carry out any complex skills.

38
Reminiscence Therapy (RT)
RT is a therapy that is aimed particularly at older adults because it consists of re-experiencing
and reinterpreting life events in order to alleviate a sense of loss. Using prompts such as
photos, music or familiar items from the past, you are encouraged to talk about earlier
memories with others of a similar age. This is so that you can develop further friendships and
feel a sense of belonging. As a communicative psychosocial process, RT has proven to be a
valuable intervention. As treatments go, there are few side effects to RT. However you need
to be aware that as it is a memory process, some unpleasant memories could arise.
Nevertheless RT should be considered as a valuable intervention.
Recommended websites
(www.myboomerplace.com),
(http://www.mapleandleek.com),

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