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Editorial |
Received September 25, 2002; revised, accepted October 3, 2002. From the Department of Psychiatry, University of California, San Francisco. Address correspondence to Dr. Areán, UCSF Department of Psychiatry, 401 Parnassus Avenue, San Francisco, CA 94143-0984; e-mail: pata{at}lppi.ucsf.edu
Key Words: Psychotherapies • Cognitive Therapy
When I first started working in geriatric mental health, the prominent clinical lore (begun by Freud nearly 50 years ago) was that older people could not benefit from psychotherapy because they were too mentally and cognitively inflexible to learn new information or reprocess past experiences. In fact, the most common type of therapy at the time was reminiscence therapy, which focused predominantly on helping older people rehash past events in an attempt to better understand and accept their lives. Although reminiscence is certainly an important component of geropsycho-therapy today, the use of this technique alone implied that there was not much older people could do about their situation other than accept it. It also implied that mental illness in late life was largely due to an inability to accept one's past, rather than stress related to the complications of aging. In the early 1980s, Drs. Gallagher-Thompson and Thompson demonstrated empirically that once psychotherapy had been modified to accommodate age-related changes in cognitive processing, older adults could benefit from active, problem-focused treatment and experience better psychosocial functioning and improved quality of life.1,2 Were it not for the seminal work by Drs. Gallagher-Thompson and Thompson, and, later, the work by Reynolds et al.3,4 on interpersonal therapy, psychological and behavioral treatment of late-life mental illness would still be focused on containment of symptoms, rather than on improving quality of life.
Fortunately, other psychotherapy researchers and geropsychologists have taken the lead and have begun to further enhance the research database on geropsychotherapy. Although the majority of studies currently published focus predominantly on the treatment of depressive disorders, the field is now expanding to address the role psychotherapy can play in the treatment and management of other mental illnesses. We are also learning that psychotherapy is adaptable and can "flex" to be delivered in settings other than those for specialty mental health. This special issue focuses on some of the latest developments in geropsychotherapy for a variety of mental health issues, from the treatment of depression to the management of psychosis in board-and-care facilities. Although the articles in this issue are not an exhaustive list of the work being done in the field, they are certainly representative of advances in geropsychotherapy.
Advances in Research Methods
Early geropsychotherapy studies were characterized by extremely small samples of highly selected participants who tended not to be representative of the typical older adult, largely because of restrictive exclusionary criteria imposed by the study investigators. Sometimes, studies did not even provide research diagnoses. Because of the methodological problems that plagued early geropsychotherapy research, policymakers were unable to recommend psychotherapy as a first-line intervention.5 This stance by policymakers has since changed, largely because of the improvements made to geropsychotherapy research methodology. As detailed in Areán et al.'s article,6 state-of-the-art gero-psychotherapy research methods include the use of age-appropriate psychotherapies and control conditions, less restrictive entry criteria, recruitment methods informed by social marketing strategies, and broader use of age-related treatment process and outcome measures. These advances have clarified the usefulness of psychotherapy for older adults.
Advances in Psychotherapy
High-quality research has led to substantial improvements in the actual delivery of psychotherapy to older adults.7 Developments in neuropsychological research regarding age-related changes in information-processing have resulted in adapting therapies to account for these differences. Although no one has directly evaluated whether these adaptations result in better outcomes than therapy that has not been adapted, the literature does support the idea that the adapted interventions can make significant impact on mood and functioning, countering early clinical lore about the efficacy of psychotherapy in older people. Alexopoulos et al.'s study8 is an excellent illustration of this issue. Older adults with executive dysfunction tend to be less responsive to antidepressant medication, and, thus, one would expect that older people with this cognitive presentation would be unlikely to benefit from a behavioral intervention, particularly a learning-based psychotherapy.9 However, this study demonstrated how a problem-focused and skill-building intervention can reduce symptoms of depression through mediation of cognitive deficits in older adults with treatment-refractory depression. By directly and behaviorally targeting the cognitive deficits related to poor response to antidepressant medication, patients who normally would not respond to antidepressant treatment make substantial gains in both mood and functioning.
Data from geropsychotherapy research have also informed the therapeutic frame of psychotherapy. No longer is psychotherapy relegated to the 50-minute hour in specialty mental health for healthy ambulatory and cognitively intact older people. As can be seen in this special issue, geropsychotherapy has come a long way and continues changing to become amenable to all older people, in a variety of settings. Patterson et al.10 demonstrate that problem-focused skills-training improves independent living skills in older psychotic patients living in board-and-care facilities. Stanley et al.11 demonstrate that cognitive–behavioral therapy (CBT) for generalized anxiety disorder can be adapted for delivery in the primary-care setting and still be effective in reducing anxiety symptoms. Both study interventions are unique, by psychotherapy standards, in that the interventions are not provided in the traditional mental health setting, but are delivered in settings where older adults are most likely to be served. These are not the only studies that have branched out to provide psychotherapy in non-mental health settings. Both the IMPACT12 and PROSPECT13 studies have successfully demonstrated that non-mental health professionals, such as clinical nurse-specialists, can deliver psychotherapy in medical settings. The concept that psychotherapy can only be delivered in mental health settings by mental health professionals is being strongly challenged by this recent research. These data are important to highlight, in that mental health treatment in non-mental health settings should no longer be limited to medication management, and older patients now have the option to select from a host of interventions in considering care for their mental health problems.
Advances in Geropsychotherapy for Disorders Other Than Depression
Geropsychotherapy research has traditionally focused on the acute treatment of depressive disorders.14 Now, preliminary data exist demonstrating the usefulness of psychotherapy and behavioral interventions for treating other mental illnesses and for effecting outcomes beyond symptom reduction. In addition to the Patterson et al. article, which focused on older adults with psychosis, in this issue, Mohlman et al.15 demonstrate that CBT can effectively treat generalized anxiety disorders in older adults. Grant et al.'s article16 pushes the envelope even further by demonstrating that not only can an in-home respite intervention improve mental health functioning in Alzheimer-disease caregivers, but can also affect activation of the sympatho-adrenal-medullary system. A further exciting development is the relatively recent research focus on the interactive effects of psychotherapy and medication. For example, Lynch et al.17 demonstrate that dialectical behavior therapy, when used as an augmentation treatment with selective serotonin reuptake inhibitors, can successfully overcome the vulnerabilities associated with relapse in chronically depressed elderly patients. Miller et al.'s article18 demonstrates how older patients' initial treatment focus can influence whether or not interpersonal therapy, in combination with antidepressant medication, will be effective in preventing depression relapse 3 years after acute treatment. An earlier publication in this journal, by Thompson et al.19 found that the combination of CBT and the antidepressant drug desipramine was very effective in treating moderately severe depression in older adult outpatients in the acute phase of treatment. Information such as this can help inform acute- and maintenance-phase treatments for patients with chronic recurrent depression.
Conclusions and Future Directions
In summary, data in support of psychotherapy for older adults with mental illness have grown significantly over the past 20 years. The work presented in this issue represents only a small portion of the wonderful ongoing work in this area of research. In the next 5 years, we will begin to see many more high-quality studies published that demonstrate the effectiveness of psychotherapy, either alone or in combination with medications, in the treatment of a variety of mental illnesses, as implemented in a variety of settings most likely to be encountered by older adults with mental illness.
Of pressing interest from a public health perspective is the increasing number of adults from diverse ethnic and racial backgrounds who are living into old age. According to a recent report from the Surgeon General,20 "Mental Health: Culture, Race, and Ethnicity," cultural factors influence how adults conceptualize mental illness and what avenues they use for help-seeking. Although it can be a real challenge to recruit and retain older minority adults in psychotherapy research programs,21 the time has come to make this a priority in future studies.
On a final note, methods for increasing the translation of psychotherapy to actual practice are sorely needed, not just for geropsychotherapy, but also for psychotherapy, in general. I hope that the future will support efforts to change providers' perception of what older adults can respond to and how psychotherapy should be delivered and to promote the idea that psychotherapy need not be limited to mental health professionals in mental health settings. Fortunately, advances in geropsychotherapy have challenged the belief that "old dogs can't learn new tricks." The next challenge is to demonstrate that "new tricks" can be learned anywhere, for any problem, and can be taught by anyone properly trained to teach them.
REFERENCES
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