The global increase in life expectancy is undeniable, with approximately 11% of the world’s population currently aged over 65. In some societies, this percentage has already surpassed 30%.
While longer life spans are a positive development, they come with implications for mental health. Depression takes central stage among individuals aged 65 and above. Age-specific psychosocial factors, such as loss of significant relationships and social isolation, likely contribute to this phenomenon.
Depression in older adults is a significant mental health concern that can have debilitating effects on an individual’s well-being and overall quality of life. While pharmacological treatments are commonly employed, in recent years psychotherapy has emerged as a valuable intervention.
Additional problems are caused by age-specific physical illnesses, representing a loss of personal resources. Nevertheless, even older adults with cognitive impairments can benefit from psychotherapy.
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A social definition of the “older patient,” based on retirement age, starts at around the age of 65. This age limit, which is also used in gerontopsychiatric settings, provides an opportunity to offer specialized care for conditions and life situations typical of older age. However, this age limit blurs the fact that condition-specific approaches are still necessary for older patients.
Additionally, the diversity among individuals in older age is greater than in any other age group, making chronological age a poor indicator of a patient’s resources, experiences, and behavior. For therapeutic action, it is crucial to overcome stereotypical views of aging and to have a nuanced understanding of the physical, psychological, and social resources and deficits of older patients.
Distinction between “young-old” and “old-old”
In line with the common distinction in gerontology between the “young-old” and the “old-old” or between the “third age” and the “fourth age,” it makes sense to differentiate between older patients (from age 65) and very old or oldest-old patients (from age 80/85). This acknowledges the fact that life expectancy for today’s 65-year-olds now averages 21 years for women and nearly 18 years for men. Furthermore, between the ages of 65 and over 100, the developmental tasks change significantly, especially due to the increasing risk of various physical, mental, and social declines.
Types of Psychotherapy for Depression in Older Adults
There are several psychotherapeutic approaches explored for their efficacy for treating depression in older adults.
Cognitive Behavioral Therapy (CBT)
CBT has shown substantial effectiveness in treating depression in older adults, with larger effect sizes compared to control groups. Cognitive Behavioral Therapy addresses dysfunctional thoughts that are often age-related, such as “change is impossible in old age” or “depression in old age is normal.”
Interpersonal Psychotherapy (IPT)
IPT is a structured, problem-oriented approach that integrates elements of psychodynamic theories and CBT. It focuses on interpersonal conflicts, social deficits, grief, role changes, or transitions that contribute to depression. Interpersonal psychotherapy is particularly well-suited for addressing challenges often encountered in later life. Studies demonstrate its effectiveness in older adults, especially when combined with antidepressants.
Psychodynamic Therapies for Elderly People
Psychodynamic therapies, rooted in Freud’s psychoanalytic theory, have also been examined in older depressive patients, with evidence mainly supporting focal therapy. Focal therapy targets specific, symptom-triggering conflicts, offering more focused treatment with shorter duration and fewer sessions.
Despite the evidence favoring CBT over psychodynamic approaches, it’s important to note that psychodynamic therapies are still effective and adaptable for patients with good cognitive performance. These insight-oriented therapies are rooted in psychoanalytic theory and have been proven effective for treatment of depression in older patients.
Reminiscence-Oriented Therapies
Reminiscence therapies are mostly used to provide counselling to older adults suffering from depression. They can also be employed as an intervention technique for patients with cognitive deficits in such conditions as Alzheimer’s disease.
According to the American Psychological Association (APA), reminiscence therapies are described as the use of positive aspects of personal life stories to enhance psychological well-being. This therapeutic method emphasizes a profound respect for the life journeys and experiences of older individuals with the goal of promoting and maintaining their mental health. Reminiscence-oriented therapies vary in terms of structure, thematic scope, and goals, making it possible for nursing professionals to administer some of these interventions.
Most of the research on reminiscence therapy has centred around the elderly population, particularly those suffering from depression. These commonly used interventions have less robust evidence. Most studies have focused on subsyndromal cases, limiting their applicability to major depression.
Web-Based Cognitive Behavioral Therapy
Online interventions have been examined and found to have significant effects on depression symptoms in older adults. Considering the restrained mobility of older patients, this approach provides a flexible and accessible means of delivering psychotherapy.
“Third-Wave” Cognitive Behavioral Therapies in Older Adults
These therapies expand upon traditional CBT and include approaches like Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), and Mindfulness-Based Cognitive Therapy (MBCT). Although less researched in older populations, these approaches have shown promising effects. Acceptance and Commitment Therapy encourages acceptance of unwanted thoughts and emotions, while Mindfulness-Based Cognitive Therapy incorporates mindfulness-based stress reduction.
While psychotherapeutic and pharmacotherapeutic approaches have robust evidence, there is a shortage of studies regarding the effectiveness of psychosocial interventions. Psychosocial interventions aim to reduce depressive symptoms, lower suicide risk, maintain social connections, and enhance self-efficacy. Recommendations categorize interventions into low-intensity (e.g., guided self-help or physical activation) and high-intensity (e.g., psychoeducation) approaches. Psychoeducation also focuses on involving the patient’s family, recognizing their increased risk for depression and need for professional support.
Psychotherapy for older adults. Historical Overview
1900–1950
The first half of the 20th century was shaped by the “climate of aging” of that time and by Sigmund Freud’s therapeutic pessimism (1905). Freud believed that age was relevant when selecting patients for psychoanalytic treatment, as he argued that individuals close to or over fifty lacked the mental flexibility required for therapy, saying, “Older people can no longer be educated.” He also believed that the material to be worked through would make the treatment duration unpredictable.
However, there were alternative views, such as Abraham (1919), who suggested that it was not the patient’s age but rather the “age of the neurosis” that should determine treatment eligibility. C.G. Jung took a more positive stance, claiming that personality can only truly develop after the reproductive phase, and he conducted therapy with older patients.
From 1960
The founding of the Boston Society for Gerontologic Psychiatry in the USA in the 1960s marked a significant step toward systematically establishing the field. The possibilities for psychotherapy with older adults began to be viewed more positively. However, deficit-oriented models still dominated, such as the concept of regression (aging seen as a return to earlier developmental stages) and the idea of “old age as a second childhood” (Kessler and Peters 2017).
In 1963, the geriatrician and gerontologist Butler published “The Life Review: An Interpretation of Reminiscence in the Aged.” Instead of viewing life review as a sign of cognitive decline, Butler described it as a functional psychological mechanism in old age, leading to the development of Life Review Therapy (LRT). However, it was not systematically expanded until the 1980s by Barbara Height (e.g., Height and Webster, 1995).
From 1970
While earlier progress was mostly limited to the USA, behavior-based gerontology and intervention gerontology emerged in Germany in the 1970s, rooted in learning theory (Lehr, 1979). The focus at this stage was on memory training, clinical rehabilitation, and counseling for caregivers and housing solutions.
From 1980
It was only in the late 1980s that a systematic focus on the topic developed (Kessler and Peters, 2017). The discussion, led by psychodynamic therapy and psychosomatics, centered on the specific transfer dynamics between older patients and typically younger therapists (Radebold, 1992), psychosomatic interactions in physical illnesses, and the effects of psychological trauma over the course of life (Heuft, 1993). Internationally, behavioral therapy for older adults began to emerge in the early 1980s, with notable works such as the treatment manual “Depression in the Elderly” by Thompson (Gallagher and Thompson, 1981) and Knight’s textbook “Psychotherapy with Older Adults” (1986).
From 1990
This trend continued in the 1990s, driven by a new “positive discourse” on aging. However, it wasn’t until the early 2000s in Germany that systematic behavioral therapy programs for depression in older adults were developed, such as those by Hautzinger (2000) and Adler (2005).
Present Day
Based on evaluation studies conducted since the 1990s, the effectiveness of psychotherapy for older adults is now well established, particularly for depression. However, most of these results have been derived primarily from studies on the “young-old.”
Psychotherapy for depression in older adults. Summary
The global increase in life expectancy is undeniable, with approximately 11% of the world’s population currently aged over 65. In some societies, this percentage has already surpassed 30%.
While longer life spans are a positive development, they come with implications for mental health. Depression takes central stage among individuals aged 65 and above. Age-specific psychosocial factors, such as loss of significant relationships and social isolation, likely contribute to this phenomenon.
Beginning with Sigmund Freud psychotherapy for older adults was considered unsuccessful. Freud was arguing that old people are less adaptable, not being able to change their mindsets. However, the recent studies proved the efficacy of various psychotherapeutic techniques, including psychodynamic psychotherapy.
Psychotherapy for older depressive patients plays a crucial role in this group, offering them a therapeutic space to explore their emotions, thoughts, and behaviours. This approach is particularly valuable when patients struggle with events such as losing friends and peers, financial matters, or while facing decisions about permanent placements, such as nursing homes.
Effective treatment for depression in older adults varies depending on symptoms severity and typically involves individual psychosocial interventions, psychotherapy, and pharmacotherapy, with the involvement of family members.