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Editorial |
Received September 21, 2002; revised October 11, 2002; accepted October 11, 2002. From Vanderbilt University, Nashville, TN. Address correspondence to Steven D. Hollon, Ph.D., Department of Psychology, Vanderbilt University, 306 Wilson Hall, Nashville, TN 37203; e-mail: steven.d.hollon{at}vanderbilt.edu
Key Words: Psychotherapies • Depression • Generalized Anxiety Disorder
Psychotherapy research is an established science in younger adult populations, but its application to the study of elderly subjects is more novel. Special problems associated with aging, such as cognitive impairment or interpersonal loss, can complicate the treatment process, and physical disability can make it harder to access needed services. Finally, many older patients are on multiple medications, making it difficult to manage their conditions with medications alone and enhancing the potential value of psychotherapy.
What strikes me in reading the articles in this special issue is the vitality and breadth in the area. There are several excellent studies reported here, and their breadth is of interest. Interventions as diverse as problem-solving therapy (PST), dialectic behavior therapy (DBT), and interpersonal psychotherapy (IPT) all appear to be of value in the treatment of depression. Cognitive–behavior therapy (CBT) appears to be helpful in the treatment of generalized anxiety disorder, especially when enhanced for older populations, and functional adaptation skills training (FAST) appears to be of use in the treatment of older patients with chronic psychoses. This work is impressive in its vitality and rich in promise. I was particularly struck by the apparent success of pragmatic efforts to adapt existing strategies to older populations. Given the problems sometimes encountered by older patients in taking medications, this is a population that might derive special benefit from efficacious and effective psychosocial interventions.
Given my experience with younger adult populations, there are several observations I would like to make. First, the bulk of the interventions examined were relatively structured and pragmatic in nature. In most instances, the focus was on providing discrete skills that people could use to solve current life situations. This is much the same as it is in the literature with younger adults.1 In that literature, those interventions that focus on providing specific skills also tend to predominate among the empirically supported treatments. More traditional interventions might have fared better if they were more adequately tested (or at least tested more often), but it is clear that the treatments with the greatest empirical support are the newer cognitive–behavioral and interpersonal approaches similar to those represented in this special issue.
Second, these same interventions often compare favorably with medications in terms of the reduction of acute distress, at least for nonpsychotic populations. For disorders such as depression and anxiety, there is little that can be done with medications that cannot be at least matched with the empirically supported psychotherapies.2 This seems to be the case for depression and the anxiety disorders, which are both prevalent in older populations, as well as other disorders more common among the young, such as bulimia. CBT and IPT both compare favorably with medications in the treatment of depression.3 Either CBT or more purely behavioral interventions appear to be the treatments of choice for specific and social phobia, panic disorder, generalized anxiety disorder, and obsessive–compulsive disorder.2 Even hypochondriasis, long thought to be largely intractable, appears to be amenable to cognitive–behavioral interventions.4 These are disorders that can be found in elderly patients.
Third, as impressive as the evidence is supporting the newer structured interventions in terms of acute response, more impressive still is the evidence of greater breadth or stability of response than seen with medications. For example, patients treated with IPT show greater improvement in their interpersonal relationships than patients treated with medications alone; similarly, patients treated to remission with CBT are considerably less likely to relapse after treatment termination than patients treated to remission with medications.5 In fact, there is considerable evidence for an enduring effect for CBT across a number of different disorders, including depression, panic disorder, social phobia, and generalized anxiety disorder.2 It would be interesting if these effects also extend to elderly populations.
Nonetheless, despite these advances, there is still more that needs to be done.6 For example, not everyone responds to treatment. Among younger adults, only about two-thirds of depressed patients respond to any given treatment, and only about half of those patients show a full response. Other disorders can be even harder to treat. Clearly, more needs to be done with existing interventions, or new interventions need to be developed to ensure that something can be done for even the most treatment-refractory patients.
Similarly, although there are clearly a number of empirically supported treatments, these interventions are often not widely available. For example, less than one-quarter of depressed patients receive adequate treatment, and the rates are probably no higher for other disorders. Some of this undertreatment doubtless reflects lack of information or concerns about social stigma on the part of potential consumers, but a major portion clearly arises from lack of availability of suitable options. Many existing practitioners are simply not trained to provide empirically supported interventions, and many potential consumers do not have access to those few practitioners who are so trained. Rates of undertreatment are particularly high among the poor and disenfranchised, including elderly patients. Clearly, more needs to be done to increase the availability of adequate services. The kinds of interventions described in this special issue often lend themselves nicely to being exported to primary care or general-practice settings, and some might even be provided through non-traditional methods such as the Internet or mass media.6
Finally, more emphasis should be given to efforts at prevention. Several of the interventions described in this special issue have been found to reduce risk for the onset of disorders in children and adolescents.5 As impressive as these findings are, there is no reason why these efforts at prevention should not be applied to older adults. Given the increment in risk for mood and related disorders often found as people age, it might prove interesting to apply preventive strategies to elderly patients. Moreover, given the size of the cohort approaching old age, it might even prove cost-effective.6
The articles published in this special issue demonstrate just how far psychotherapy research for elderly patients has advanced. It appears to be a rich and vital endeavor that draws from the best of the work with younger adults and reshapes it to the special needs of those who are older. I look forward to even more powerful and efficient designs and a greater emphasis on the special advantages conferred by psychosocial interventions in terms of greater breadth and more enduring effects. I also look forward to efforts to make treatments more efficacious, to make efficacious treatments more accessible, and to apply those treatments in a preventive fashion.
ACKNOWLEDGMENTS
Preparation of this commentary was supported by an Independent Scientist Award from the NIMH (K02 MH01697).
REFERENCES
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