Life-review therapy with computer supplements for depression in the
elderly: A randomized controlled trial
Barbara Preschl, M.A.1§, Andreas Maercker, Ph.D.1, Birgit Wagner, Ph.D.2, Simon
Forstmeier, Ph.D.1, Rosa M. Baños, Ph.D.3, Mariano Alcañiz, Ph.D.4, Diana Castilla,
B.A.5, Cristina Botella, Ph.D.5
1Department of Psychopathology and Clinical Intervention, University of Zurich,
2Clinic for Psychotherapy and Psychosomatic Medicine, University Hospital Leipzig,
3Departamento Personalidad, Evaluación y Tratamientos Psicológicos, Universidad de
4LabHuman, Universidad Politécnica de Valencia, Valencia, Spain
5Departamento de Psicología Básica, Universitat Jaume I, Castellón, Spain
Department of Psychopathology and Clinical Intervention, University of Zurich
8050 ZürichSwitzerlandTel.: +41 44 635 7458
Life-review therapy has been recognized as an effective therapeutic approach for
depression in older adults. Additionally, the use of new media is becoming
increasingly common in psychological interventions. The aim of this study was to
investigate a life-review therapy in a face-to-face setting with additional
This study explored whether a six-week life-review therapy with computer
supplements from the e-mental health Butler system constitutes an effective
approach to treat depression in older adults aged 65 and over. A total of 36
participants with elevated levels of depressive symptoms were randomized to a
treatment group or a waiting-list control group and completed the post-
assessment. 14 individuals in the intervention group completed the follow-up
Analyses revealed significant changes from pre- to post-treatment or follow-up
for depression, well-being, self-esteem and obsessive reminiscence, but not for
integrative reminiscence and life-satisfaction. Depressive symptoms decreased
significantly over time until the 3-month follow-up in the intervention group
compared to the control group (pre to post: d = 1.13; pre to follow-up: d= 1.27;
group x time effect pre to post: d = 0.72). Furthermore, the therapy led to an
increase in well-being and a decrease in obsessive reminiscence among the
participants in the intervention group from pre-treatment to follow-up (well-
being: d = .70; obsessive reminiscence: d = .93). Analyses further revealed a
significant but small group x time effect regarding self-esteem (d = .19).
By and large, the results indicate that the life-review therapy in this combined
setting could be recommended for depressive older adults.
Keywords: depression, life-review, e-mental health, older adults
Since unipolar depression is among the most frequent mental disorders in old age
(Wernicke, Linden, Gilberg, & Helmchen, 2000), the development of new
psychotherapeutic methods or the adaptation of existing ones is highly relevant. Results
from the Berlin Aging study (Wernicke, Linden, Gilberg, & Helmchen, 2000), showed
the following prevalence rates for unipolar depression in older adults aged 70 or above:
unipolar depression (not otherwise specified, without major depression): 17.8%, major
depression (moderate, without psychotic symptoms): 4.2%, major depression (severe,
without psychotic symptoms): 0.5%). As shown in the Berlin Aging study and
demonstrated by others (Cole & Dendukuri, 2003), the prevalence rates for mild to
moderate depressive symptoms (unipolar) or subthreshold depression in old age are
higher than for major depressive disorder while subthreshold depression is considered
as a risk factor for developing a major depressive disorder (Beekman, et al., 2002).
In the current study, a life-review therapy with computer supplements for milder
forms of depression in the elderly was investigated. The intervention consisted of two
modules: a face-to-face life review part focusing on positive and negative past events;
and a computer part (see below: “Butler” system, Botella, et al., 2009) focusing
exclusively on positive experiences.
Webster, Bohlmeijer and Westerhof (2010) and Westerhof, Bohlmeijer and
Webster (2010) have proposed distinctions between different forms of reminiscence
interventions. The authors distinguish simple reminiscence (unstructured), life-review
(more structured and integrative, focusing on the whole life-span) and life-review
therapy (adopting life-review for the treatment of mental disorders). In the current study
we conducted a life-review therapy for the treatment of depression.
Life-review therapy focuses on the balance of positive and negative
reminiscence (in terms of emotional valence), the redefinition of negative experiences
and elaboration of memory (Maercker, 2002). Through structured questions, life-review
therapy enables the individual to focus equally on positive and negative past events,
with the aim of obtaining a coherent and balanced view of one’s past life. Traditionally,
different types of reminiscence have been distinguished (Webster, 1993, for more recent
reviews see Webster, Bohlmeijer & Westerhof, 2010; and Westerhof, Bohlmeijer &
Webster, 2010). Wong and Watt (1991) showed that some reminiscence types are more
strongly related to successful aging (increased self-understanding, personal meaning,
self-esteem and life satisfaction, p.273) than others, e.g., the integrative type, i.e. an
achievement of a “sense of self-worth, coherence, and reconciliation with regard to
one’s past” (p.273) being positively related to well-being. Based on these findings, we
aimed to investigate two different reminiscence types, integrative and obsessive
reminiscence (i.e. a failure to integrate problematic past experiences, p. 273); the latter
being related to less successful aging as compared to integrative reminiscence, which
was associated with successful aging in the study by Wong and Watt (1991). Based on
Wong and Watt`s (1991) taxonomy Mayer, Filipp, and Ferring (1996) developed the
first German reminiscence questionnaire that was used in the current study.
In a meta-analysis regarding the effectiveness of life review on late-life
depression, Bohlmeijer, Smit, & Cuijpers (2003) reported a large effect size (d = 0.84).
Following Pinquart, Duberstein and Lyness (2007), effect sizes in that context drop
when an active control group is involved. Recently, Pinquart and Forstmeier (2012)
reported a medium effect size for depression at post-treatment (g = 0.57). The effect
size increased for depressed individuals who received life-review therapy (g = 1.28).
Based on the fact that depressed individuals as well as older adults are often
unable to recall specific events, i.e. recall more general (“over general”) memories,
Serrano, Latorre, Gatz, and Montanes (2004) investigated a life-review therapy based
on a training of the retrieval of specific positive memories. The authors showed in a
randomized controlled trial that the integration of “autobiographical retrieval practice”
into life review, focusing mainly on memories for positive events, proved to be an
effective intervention tool for depressive older adults aged 65 or over. Based on these
findings, a module was integrated into the current study focusing on positive events in a
computer-guided setting (see below).
Besides depressive symptoms, life review therapy has also shown positive
effects on self-esteem (in terms of self-respect, to consider oneself a person of worth;
Gray-Little, Williams & Hancock, 1997, following Rosenberg 1979). Chiang, Lu, Chu,
Chang, and Chou (2008) showed in a randomized controlled trial that a “Life-Review
Group Program” (LRGP) positively influenced the self-esteem of elderly males (mean
age 78.13 years). In an earlier study, Haight and Dias (1992) investigated the effects of
ten different forms of reminiscence on depression and self-esteem. Results showed that
a structured (covering life from birth to present, p. 282) and evaluative form (evaluation
of feelings, p.282) of life review is more effective than other forms with regard to
depression and self-esteem. In a recent meta-analysis Pinquart and Forstmeier (2012)
reported small effect sizes regarding self-esteem at post-treatment (g = 0.20).
Furthermore, life-review therapy has shown positive effects on satisfaction with
life and/or well-being (Bohlmeijer, Roemer, Cuijpers, & Smit, 2007; Chiang, et al.,
2008). Bohleijer et al. (2007) reported a medium effect size (d = 0.54) in this context,
whereas Pinquart and Forstmeier (2012) reported small effect sizes regarding life-
satisfaction (g = 0.22) and positive well-being (g = 0.33) at post-treatment. Based on
these findings, in the current study, we further investigated the effects of our
intervention on life satisfaction (comprising 5 dimensions: zest versus apathy, resolution
and fortitude, congruence between desired and achieved goals, positive self-concept,
and mood tone; Liang, 1984, following Neugarten et al., 1961) and general well-being
(positive mood, vitality, interest in things; Bech, 1998).
As mentioned above, the life-review therapy conducted in the current study also
contained a computer intervention part, comprising two ‘depression modules’ of a
computer program (“Butler” system, Botella, et al., 2009) (as detailed below). In
general, e-health interventions targeting older adults have been recognized as a
promising approach for a variety of domains including depression, although research in
this field is still in its infancy (Preschl, Wagner, Forstmeier, & Maercker, 2011).
Moreover, therapeutic software has been used successfully as a supplement in
traditional face-to-face therapy, e.g. “Virtual Reality Exposure Therapy” (Parsons &
Rizzo, 2008), in which a computer tool (a simulation or virtual environment) can be
used in a therapeutic setting for the treatment of anxiety and specific phobias. With
regard to depression (and anxiety), a computer program containing several modules was
developed by a Spanish research team, the so-called “Butler system” (Spanish:
“Mayordomo”) (Botella, et al., 2009). This system provides various fields of application
for older adults: diagnosis and therapy (depression and anxiety) and social interaction
modules (also for healthy older adults). In the current study, two therapy modules of
this system for treating depression were used, which provide the possibility to focus on
certain events in the context of life review and autobiographical memory. The first
module contains so-called “Virtual Environments” (VE), in which the user learns
techniques to reduce negative mood and to recall and describe positive autobiographical
memories. This module provides three exercises: a mindfulness-based intervention
focusing on the recognition of one-self in the actual situation in preparation of the
further exercises, a relaxation exercise for agitated depressed individuals and a guided
exercise focusing on the recall of positively valuated episodes in one`s life. The second
module, a 3D adaptation of a book containing several chapters, is called the “Book of
Life”. By incorporating text, pictures, and Mp3 music files, the “Book of Life” can be
customized by the user. This guided tool offers several possibilities to recall and deal
with positive valuated episodes in one`s life. The “Butler system” contains touch screen
technology and was developed and tested to meet the needs of older adults (Botella, et
al., 2009). All applications are guided by a personalized icon, the so-called “butler”, or
in the case of the VE by a female voice, which describes all exercises to the user step by
step. The “Butler system” was translated into German at the University of Zurich in
cooperation with the aforementioned Spanish team, who integrated the German audio
and text files into the system. The methods section of this article provides more
information about how the depression modules of the “Butler system” were used in the
Based on these findings, we conducted a randomized controlled study
investigating a structured and time-limited (six-week) life-review therapy with
depressive older adults in a face-to-face setting with additional use of the
aforementioned depression modules of the “Butler system” (Botella, et al., 2009). To
our knowledge, this is the first randomized controlled trial to investigate a life-review
therapy in a combined e-mental health setting. The first objective of this study was to
investigate whether this combined and short-term life-review therapy leads to a
reduction in depressive symptoms. Second, we examined whether the intervention leads
to an increase in self-esteem, life satisfaction and well-being. Third, we investigated two
types of reminiscence: integrative and obsessive reminiscence.
A randomized controlled trial comparing a face-to-face life-review therapy including
computer supplements with a waiting-list control group was conducted at the University
of Zurich. Both groups received a six-week intervention; for ethical reasons, the
waiting-list control group received the same intervention after the waiting time period.
Assessments were conducted at baseline and at post-treatment, and participants in the
intervention group also participated in a 3-month follow-up session. The participants
completed the Beck Depression Inventory (BDI-II, Hautzinger, Keller, & Kühner
(2006), the Rosenberg Self-Esteem Scale (SES, (Wendt, 1979), the Life Satisfaction
Index - A (LSIA, (Wiendieck, 1970)), the Reminiscence Questionnaire (RQ, Mayer,
Filipp, & Ferring, 1996b), and the WHO-Five Well-being Index (WHO-5, Bech, 1998).
Participants were recruited between December 2009 and April 2011. The ethics
committee of the German Psychological Society (DGPs) approved the study in
December 2009. Patients were recruited through advertisements in newspapers,
supermarkets, libraries, pharmacies, general practitioners’ practices, a contact list of
individuals who were generally interested in participating in research projects, and
lectures for older adults at the University of Zurich. The contact list was prepared by a
coordinator who administered spontaneous requests from individuals who were
interested in participating in a research project or from former study participants who
were interested in further participating in research projects.
Older adults aged 65 or over who suffered from minimal (subsyndromal) to
moderate depression (BDI-II score 10-28) were included in the study. Exclusion
criteria were cognitive impairment (MMSE, Folstein, Folstein, & McHugh (1975) score
below 27), severe depression (BDI-II score above 28, SKID, (Wittchen, Zaudig, &
Fydrich, 1997)), severe vision or hearing impairment (NAB, Oswald & Fleischmann,
1995), mobility problems (unable to come to the outpatient clinic), currently receiving
psychotherapeutic treatment elsewhere (during the treatment or waiting time period, but
also between post-assessment and follow-up), indications of severe suicidal ideation
(BDI-II, SKID), or other psychiatric disorders (SKID). The baseline assessment was
conducted by the study coordinator (MA in psychology and CBT training). Study
participants were asked to fill in all further questionnaires on their own (at home or at
the University of Zurich in case they needed support). Master students were further
involved in the assessments (e.g. giving instructions to the participants). Follow-up
questionnaires were sent by mail.
Demographic characteristics of the sample are presented in Table 1. No
significant differences in baseline characteristics were noted between groups, besides
age [χ2(1) = 5.36, p < .05]. The age difference was in the direction of the intervention
group being older than the control group. The scores of the outcome measures of the
two groups did not differ significantly at baseline, with the exception of life satisfaction
(LSIA) [t(34) = -2.18, p < .05]. Life satisfaction was lower at baseline for the
intervention group compared to the control group
Participants indicated their interest in the study by contacting the study coordinator via
telephone or E-Mail. In this context, the study coordinator asked about basic
characteristics (age, mobility, currently receiving psychotherapy) and provided general
information concerning the procedure of the study and depressive symptoms.
Subsequently, a meeting was arranged to give further information and check for
inclusion and exclusion criteria. If the inclusion criteria were met, participants were
randomly assigned to either the intervention group or a waiting-list control group at the
end of the first meeting. The study coordinator used a true random number service
(http://www.random.org) to organize the randomization procedure, which was not
stratified by any participant characteristics. All participants were provided with detailed
information regarding their participation in the intervention or control group (e.g.
assessment time points, therapeutic procedure, or waiting time period for control group
participants). They were further informed about potential risks and benefits of study
participation and told that they could withdraw from the study at any time. All
information was provided in oral and written form. In addition, participants signed an
informed consent form. One week after the first meeting, the second meeting was
arranged to assess the baseline data. Participants were encouraged to telephone or e-
mail the therapist during their study participation in the case of distress or crisis.
Applicants excluded from the study were informed about other available forms of
counseling or treatment. Participants in the intervention group began with the six-week
intervention one week after the baseline assessment. For ethical reasons, the control
group also received the same therapy after a six-week waiting time period.
Figure 1 shows a flow chart of participants. Twenty individuals in the intervention
group and sixteen in the control group completed the post measurement. Furthermore,
fourteen participants in the intervention group completed the follow-up. After beginning
treatment, nobody dropped out before finishing the post-measurement, but six failed to
complete the three-month follow-up. The main reasons given for discontinuing
participation were lack of time, lack of motivation, transportation problems, or severe
illness. Participants who dropped out before starting treatment or finishing baseline
assessments were not considered in the analyses.
Depression. Severity of depressive symptoms was measured using the German version
(Hautzinger, et al., 2006) of the Beck Depression Inventory-II (BDI, Beck, Steer, &
Brown, 1996), a self-rating questionnaire with 21 items assessing specific symptoms of
depression. The internal consistency in the current sample was α = .86.
Self-esteem. Self-esteem (in terms of self-respect, to consider oneself a person of worth;
Gray-Little, Williams & Hancock, 1997) was assessed using the Rosenberg Self-Esteem
Scale (RSES, Wendt, 1979), a 10-item scale (e.g. I feel that I have a number of good
qualities. I feel I do not have much to be proud of). The internal consistency in the
current sample was α = .70.
Life Satisfaction. To assess life satisfaction, the Life Satisfaction Index A (LSIA,
Wiendieck, 1970) was used. The LSIA is an 18-item self-report scale to measure life
satisfaction especially in old age (e.g. I feel old and somewhat tired. My life could be
happier than it is now). This scale comprises five dimensions: zest versus apathy,
resolution and fortitude, congruence between desired and achieved goals, positive self-
concept, and mood tone (Liang, 1984, following Neugarten et al. 1961). The internal
consistency in the current sample was α = .76.
Well-being. General well-being (positive mood, vitality, interest in things) was
measured using the WHO-Five Well-being Index (WHO-5, Bech, 1998), a five-item
questionnaire (e.g. Over the last two weeks, I have felt calm and relaxed. Over the last
two weeks I woke up fresh and rested). The internal consistency in the current sample
was α = .89.
Reminiscence Types. In the current study, integrative (3 items, e.g. I feel that even bad
times were meaningful in my life.) and obsessive reminiscence (4 items, e.g. When
reflecting on my past life, I very often feel guilty.) was assessed using the Reminiscence
Questionnaire (RQ, Mayer, Filipp, & Ferring, 1996a), a German questionnaire that was
developed following the taxonomy of Wong and Watt (1991). Obsessive reminiscence
is an equivalent to the type “bitterness revival” described by, Webster (1993). The
internal consistency in the current sample was α = .64 for integrative reminiscence, and
α = .72 for obsessive reminiscence.
Cognitive impairment / dementia. Cognitive functioning was assessed by the Mini
Mental State Examination (MMSE, Folstein, et al., 1975). Individuals who scored
below 27 were excluded.
Suicidal ideation. Severe suicidal ideation was screened with the BDI-II and the
Structured Clinical Interview for DSM-IV (SKID, Wittchen, et al., 1997) . Individuals
who were excluded due to severe suicidal ideation were provided with support in
addition to the general information for excluded individuals, e.g. informing significant
others or other professionals (e.g. their general practitioner).
Other psychiatric disorders. To screen for other psychiatric disorders, we used the
SKID (Wittchen, et al., 1997). Diagnoses were validated by experienced clinicians who
were trained in structured clinical assessment.
Vision and hearing. Vision and hearing impairment was assessed using items 8
and 10 of the “Nuremberg Gerentopsychological Observation Scale” (NAB), an
observer-rated subscale of the Nuremberg Gerentopsychological Inventory (NAI,
Oswald & Fleischmann, 1995). A score below 3 was considered as meeting the
One male (Ph.D) and one female (M.A.) psychologist with training in psychotherapy
and cognitive behavioral therapy (CBT) participated in this study. Both therapists were
given special training in life-review therapy and in the application of the computer
modules for this study including an introduction session by the project leader
concerning the method itself (life-review therapy), a discussion of the treatment manual
and of lessons learned from a case study (approximately 5 hours). Further the
developers of the Butler system provided a detailed introduction of the system and
further presented results from a case study (approximately 5 hours). The therapists
received regular supervision by the project leader and further by external supervisors.
Therapists were allocated to patients based on time and availability.
In the context of the current study, a structured treatment manual was compiled
following Haight and Haight (2007), Maercker (2002) and Serrano et al. (2004). In
total, eight meetings were arranged with each participant. During the first two meetings
(one meeting each in the first and second week), the participants answered
questionnaires screening for inclusion criteria and answered the baseline assessment. In
the third week, the intervention group began the treatment, meeting for one session per
week for six weeks. Each session was divided into two parts: a face-to-face part (about
two thirds of the session time) and a computer part (about one third of the session time).
Each session lasted between 1 and 1.5 hours. In the first session, the patient was
provided with a list of questions focusing on negative and positive experiences of his or
her past life from childhood until old age covering the six sessions. The therapist
provided questions focusing on the computer intervention and on the face-to-face
intervention as shown in the following examples from session three “adolescence”:
Computer intervention: Describe a special moment in your life as a teenager that you
enjoyed a lot, e.g. a birthday party, or your first kiss. How did you feel in that moment?
What did that mean to you?
Face-to-face intervention: Did anyone make fun of you as a teenager or treat you
disrespectful? Do you remember such a moment? What did that mean to you? How did
you fell in that situation?
The questions were treated as suggestions; if the patient wished to add or delete
something he or she was free to do so. Furthermore, the therapist was free to adapt and
extend the questions based on the individual information the patient provided. The
therapist could, for example, ask about current or past hobbies in two different ways
based on the provided information. If the information suggested that a hobby might be a
resource, i.e. a positive experience, one could ask: “I would like to invite you to tell me
more about your hobby hiking! You told me it used to be fun to go hiking with your
family?” If the information provided indicated that a hobby could probably no longer be
carried out (e.g. due to loss of physical health), the therapist could rephrase: “I would
invite you to tell me more about the challenges that you are currently facing. You told
me that you are no longer able to go hiking? What happened and what does this mean to
Moreover, each patient was encouraged to think in each session about one
especially positive event that could be worked with in the computer part. In the face-to-
face part, the patient and the therapist focused on both negative and positive
experiences, situations and memories in the biographical past, with the particular aim of
restructuring negative ones. During the additional computer intervention, the patient
was encouraged to filter positive experiences and to describe them in detail. Therefore,
two depression modules of the “Butler system” (Botella, et al., 2009) were introduced.
During the exercises in the “Virtual environment” module, the patient was encouraged
to recall in detail a positive event and to carry out further exercises to induce positive
mood as described in the introduction section. The therapist sat next to the patient and
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provided support in particular by finding positive events, which was often difficult for
depressive patients. In the so called “Book of Life” module, the patient was encouraged
to write down this positive situation and could add photos and music if desired. Similar
to the generative document which is produced in “Dignity Therapy” (Chochinov et
al.,2005) , all participants received at the end of the final session a printed version of
their text and photographs of the Book of Life that they had developed together with the
therapist during their participationThey were encouraged to further adopt the developed
strategies (e.g. restructuring negative thoughts, focusing on positive events in their lives,
or talking to significant others about their emotions) to reduce negative mood.. There
was no check afterwards whether the participants actually followed the suggestion.
SPSS 17.0 for Windows was used for all analyses. In preliminary analyses, we
compared the intervention and the control group at baseline using t and chi-square tests.
To test hypothesis 1, analysis of covariance (ANCOVA) for repeated measures was
carried out including a between-group factor (intervention vs. control group) and a
within-group factor (pre-treatment vs. post-treatment). The main focus was basically on
the group x time interaction effect. Further, mean scores at follow-up (after 3 months)
were compared with pre-treatment mean scores (ANOVA). In addition, partial
correlations (Pearson) were calculated to examine the relationship between the
depression residual gain scores and the investigated variables.
To quantify the magnitude of differences between the two groups (intervention
versus control), we used Cohen’s d as a measure of effect size. Cohen (1992)
distinguished between small (d = .20), medium (d = .50) and large (d = .80) effect sizes.
As no participants dropped out after beginning the intervention, we did not
conduct intention-to-treat analysis.