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
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.
Since a preliminary analysis of the sample characteristics revealed significant age
differences between the two groups, we controlled for age in the following analysis. A
dichotomous age variable was calculated by creating two groups of younger and older
participants using median split (70 years).
We hypothesized that the life-review therapy might lead to a reduction in
depressive symptoms and an increase in self-esteem, life satisfaction, well-being and
integrative reminiscence, as well as a decrease in obsessive reminiscence. As shown in
Table 2, results from the ANCOVA revealed a significant group (intervention vs.
control group) x time (pre-treatment vs. post-treatment) interaction effect for depression
(BDI-II, F 11.46, p < .01, d = 0.72), indicating that the decrease in depressive symptoms
in the intervention group was significantly larger than in the control group. Analysis did
not reveal significant effects of age as control variable (F .95, p > .05). Further, the
depression score decreased significantly in the intervention group from pre-treatment to
post-treatment compared to the control group (F 4.49, p < .05) and from pre-treatment
to the 3-month follow-up (F 18.21, p < .01). Results indicate a large effect size from
pre- to post-treatment (d = 1.13) and from pre-treatment to follow-up (d = 1.27). Figure
2 shows the course of depressive symptoms by group over time.
Further, Table 2 shows results from the ANCOVA concerning self-esteem
(SES). The analysis revealed a significant but smaller group x time effect (F 4.21, p <
.05) compared to depression and did not reveal significant effects of age as control
variable (F .34, p > .05). The effect in this case was small (d =.19) and self-esteem was
not found to increase significantly between pre-treatment and follow-up (F .19, p > .05)
but decreased to the baseline level. Moreover, results showed no significant effect of
factor (self-esteem) from pre-treatment to post-treatment (F .29, p > .05).
Results from the ANCOVA concerning well-being (WHO-5) showed no
significant interaction effect (F 2.69, p > .05), and no significant effect of factor (well-
being) from pre- to post-treatment (F .01, p > .05), , but a significant effect in the
intervention group from pre- to 3-month follow-up (F 5.39, p < .05, d= .70). Similarly,
there was no significant interaction effect (F .00, p > .05) concerning the obsessive
reminiscence (RQ), nor did this variable decrease significantly from pre- to post-
treatment in the intervention group compared to the control group (F 2.24, p > .05).
However, the obsessive reminiscence (RQ) decreased significantly in the intervention
group from pre-treatment to the 3-month follow-up (F 7.43, p < .05, d= .93). Results
concerning integrative reminiscence (RQ) did not show any significant interaction at
post-treatment (F 2.69, p > .05), effect of factor (F .09, p > .05), or from pre-treatment
to follow-up (F 4.61, p > .05).
With regard to life satisfaction (LSIA), results did not indicate a significant
interaction effect (F 1.10, p > .05), but the results showed a significant effect of factor
(F 6.52, p < .05, d =.58), indicating that the life satisfaction decreased significantly in
the control group. Furthermore, analyses revealed a significant age influence (F 4.8, p <
.05). Results did not show a significant effect from pre-treatment to follow-up (F .37, p
Table 3 shows the correlations between the depression residual gain score (BDI-
II) and self-esteem (SES), well-being (WHO-5), life satisfaction (LSIA), integrative
reminiscence (RQ) and obsessive reminiscence (RQ) at post-treatment (T1) and follow-
up (T2). The depression residual gain score was calculated as the difference between the
z-transformed BDI scores at post-treatment and baseline multiplied by the correlation
between the two scores (Heinecke, Weise, & Rief, 2010), i.e. lower values imply greater
symptom reduction. Significant medium correlations were found between self-esteem
(SES) and the depression residual gain score (BDI-II) at post-treatment (r = .70, p <
.01), between the integrative reminiscence score (RQ) and the depression residual gain
score (BDI-II) at post-treatment (r = -.48, p < .05), between the obsessive reminiscence
score (RQ) and the depression residual gain score (BDI-II) at pre-treatment (r = -.55, p
< .05), and further, between the well-being score (WHO-5) and the depression residual
gain score (BDI-II) at the 3-month follow-up (r = -.57, p < .05).
The aim of this study was to investigate a structured and time-limited (six-week) life-
review therapy in a randomized controlled trial (waiting list) with depressive older
adults in a face-to-face setting with additional use of two depression modules of the e-
mental health “Butler system” (Botella, et al., 2009). To our knowledge, this is the first
study to investigate a life-review therapy in this combined setting for depression in
First, we examined whether our intervention led to a reduction in depressive
symptoms. Our results showed that the depressive symptoms decreased significantly
over time until the 3-month follow-up in the intervention group compared to the control
group. Analysis revealed medium to large effect sizes. These findings are in line with
previous studies reporting that life-review therapy is an effective intervention to reduce
depressive symptoms in older populations (Bohlmeijer, et al., 2003; Pot, et al., 2010;
Serrano, et al., 2004).
Furthermore, the drop-out rate in our sample was low. Only one individual in the
intervention group discontinued participation after signing the informed consent but
before starting treatment. Three participants in the control group dropped out before the
post-assessment and before starting the treatment. This is in line with Bohlmeijer et al.
(2003), who reported relatively low drop-out rates in their meta-analysis.
Furthermore, we investigated whether our intervention led to an increase in
well-being and a decrease in obsessive reminiscence among the participants in the
intervention group. Results indicate that this was not the case from pre- to post-
treatment, but did occur from pre-treatment to follow-up. As mentioned above, none of
the responders received psychotherapeutic treatment elsewhere during this time period,
i.e. this result could be interpreted as a further intervention effect. Concurrently, the
depression score decreased further from post-treatment to follow-up. This may indicate
that the intervention caused further positive effects among the participants.. Pinquart
and Forstmeier (2012) reported small effect sizes regarding positive well-being at post-
treatment (g = 0.33) and follow-up (g = 0.32).One could speculate that after the end of
treatment, the individuals in the current study probably continued to practice the
strategies which they had developed during the therapeutic process, and were probably
coping better with problems arising in their lives. As mentioned above, at the end of the
final session, all participants received a printed version of their text and photographs of
the Book of Life in order to further adopt the developed strategies.
We further found a significant negative correlation between well-being and the
depression residual gain score at follow-up, indicating that a higher sense of well-being
is related to greater symptom reduction. The residual gain score was calculated such
that a negative sign indicated improvement, i.e. symptom reduction. Moreover, results
showed that individuals with higher levels of obsessive reminiscence at baseline and
integrative reminiscence at post-treatment benefited more from the intervention. Our
hypothesis that integrative reminiscence might increase during treatment failed to reach
significance. This finding is comparable to Pot et al. (2010), who did not find any
significant changes in reminiscence types after a life-review intervention. Since
different modes of reminiscence were not directly addressed in our life-review therapy
the participants were only stimulated to use this kind of remembering in general.
Furthermore, results did not show a significant change in life satisfaction. One
could speculate that life satisfaction might be recognized as a more stable construct, i.e.
is personality linked (Ryff, 1989), which would be more challenging to change during a
short-term (six-session) therapeutic intervention. One could speculate that the
investigated treatment addressed more explicitly the reduction of depressive symptoms
than the enhancement of life satisfaction. Analysis further indicated a significant but
small interaction effect concerning self-esteem and showed that higher self-esteem
scores at post-treatment were correlated with lower levels of decrease in depressive
symptoms. As self-esteem probably shows high correlational stability and a negative
concurrent correlation with depression, this result may indicate that individuals with
lower mental health problems benefited less from the intervention.
The limitations of our study include a low sample size (N = 36) and a bias due to
self-selection based on our recruitment advertising. 31% of the participants had
previous experience of psychotherapy and indicated high interest and motivation.
Further, we selected a rather homogeneous sample due to our strict exclusion criteria,
e.g. comorbidity. It is well known that depression co-occurs with other disorders
(Hautzinger, 2000). These facts may limit the generalizability of our results, and future
research should focus more on comorbidity when investigating depression in elder
A further limitation of our study was the inclusion of a waiting-list control
group. Our results indicate that the intervention was an effective treatment to decrease
depressive symptoms among depressive older adults. However, we cannot state that this
intervention was as effective, or even more effective, than treatment as usual (e.g.
standard CBT). Investigating this intervention in a randomized controlled setting with a
treatment-as-usual control group could be a valuable next step in researching life review
in this combined setting. As Pinquart and Forstmeier (2012) indicated, the effect size of
reminiscence intervention drops significantly to about 0.4 when it is compared to an
active control. Furthermore, a possible social interaction effect (e.g. interaction with
another person, looking together at the text and photos) may have contributed to the
comparably high effect sizes found in this short time intervention.
Considering these limitations, it is nevertheless noteworthy that we found
significant medium-to-high effect sizes in a rather low sample, indicating that a life-
review therapy in this combined setting could be recommended for older adults aged 65
or over. To our knowledge, this is the first randomized controlled trial in this context,
and therefore our study contributes to providing a better understanding of the effects of
life-review therapy with computer supplements on depression among older adults,
replicating previous findings on traditional face-to-face life-review interventions (see
Pinquart & Forstmeier, 2012).).
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Table 1: Sample characteristics.
Table 2: Means, standard deviations and effect sizes for depression and self-esteem by
treatment and control group.
Table 3: Correlations of the SES (self-esteem), WHO-5 (wel-lbeing), LSIA (life
satisfaction), integrative rem. (RQ) and obsessive rem. scores at pre- and post-treatment
with the BDI residual gain score at post-treatment and follow-up in the intervention and
Figure 1: Flowchart of participant progress.
Figure 2: Mean depression score over time.
The authors would like to thank Jürgen Raithel, who served as therapist in the study.
During the work on her dissertation, Barbara Preschl was a pre-doctoral fellow of the
International Max Planck Research School on the Life Course (LIFE, www.imprs-
life.mpg.de; participating institutions: MPI for Human Development, Humboldt-
Universität zu Berlin, Freie Universität Berlin, University of Michigan, University of
Virginia, University of Zurich).
Figure 1: Flowchart of participant progress.
Did not respond after enrolling
Applied to participate
Excluded (n =13) due to:
Other psychiatric disorder
High suicidality (n =2)
Low symptom severity (n =3)
No informed consent (n =1)
(n = 53)
Control group (waiting list)
Dropped out after the
2nd week, before
(n = 1)
Dropped out after the
1st or 2nd week,
(n = 3)
Figure 2: Mean depression score over time.
Note. Depression (Beck Depression Inventory, BDI-II) by group (intervention vs. control) and
time of measurement (n = 36).
Time of measurement
Mean depression score
Table 1: Sample characteristics.
Characteristics Total sample
Age, Median (SD) (in years)
Depression (BDI-II) score at
baseline M (SD)
Self-esteem (SES) score at
baseline M (SD)
Well-being (WHO-5) score at
baseline M (SD)
Life satisfaction (LSIA) score at
baseline M (SD)
Integrative Reminiscence (RQ)
score at baseline M (SD)
Obsessive Reminiscence (RQ)
score at baseline M (SD)
24.0 (66.7 %)
19.0 (52.8 %)
9.0 (25 %)
8.0 (22.2 %)
11.0 (30.5 %)
17.0 (47.2 %)
8.0 (22.3 %)
36.0 (100 %)
25.0 (65.8 %)
11 (31.4 %)
15.0 (75 %)
9.0 (45 %)
7.0 (35 %)
4.0 (20 %)
8.0 (40 %)
9.0 (45 %)
3.0 (15 %)
20.0 (100 %)
15.0 (71.4 %)
6 (31.6 %)
9.0 (56.3 %)
10.0 (62.5 %)
2.0 (12.5 %)
4.0 (25 %)
3.0 (18.8 %)
8.0 (50.1 %)
5.0 (31.1 %)
16.0 (100 %)
10.0 (58.8 %)
5 (31.3 %)
χ2(1) = 5.36, p < .05
χ2(1) = .25, ns
χ2(3) = .7, ns
χ2(5) = .44, ns
χ2(1) = .42, ns
χ2(2) = .54, ns
t(38) = .20, n.s.
t(34) = .33, n.s.
t(34) = -1.84, n.s.
t(34) = -2.18, p < .05
t(34) = -.62, n.s.
t(34) = .72, n.s.
Note. BDI-II = Beck Depression Inventory, SES = Rosenberg Self-Esteem Scale, WHO-5 = WHO-Five Well-
being Index, LSIA = Life Satisfaction Index, RQ = Reminiscence Questionnaire.
Table 2: Means, standard deviations and effect sizes for depression and self-esteem by
treatment and control group.
Group x pre-post
Pre-test Post-test Follow-up
pre to post
pre to 3-
Treatment 19.0 (6.6) 10.0 (6.3)
8.7 (4.8) 1.13 a
Control 16.5 (5.6) 15.1 (7.8) - .26 -
Treatment 21.4 (5.4) 22.4 (4.1) 21.4 (4.4)
Control 23 (3.9) 21.6 (4.4) - .49 -
Treatment 10.5 (5.8) 14.5 (4.5)
14.6 (4.0) .51
Control 14.1 (5.9) 13.1 (5.9) - .15 -
Treatment 31.4 (3.5) 31.6 (3.8) 31.4 (3.0)
Control 34.0 (3.8)
- .58 a -
Treatment 9.8 (1.5) 10.3 (1.5)
10.6 (1.9) .23
Control 10.2 (2.3) 9.4 (2.9) - -
Treatment 10.6 (2.9) 10.0 (1.7) 8.6 (2.8)
Control 9.8 (3.6) 9.8 (3.6) - 0 -
Note. Treatment group: n = 20 (n = 14 at follow-up), control group: n = 16, a significant effect; BDI-II = Beck
Depression Inventory, SES = Rosenberg Self-Esteem Scale, WHO-5 = WHO-Five Well-being Index, LSIA =
Life Satisfaction Index, RQ = Reminiscence Questionnaire.
Table 3: Correlations of the SES (self-esteem), WHO-5 (wel-lbeing), LSIA (life satisfaction), Download full-text
integrative rem. (RQ) and obsessive rem. scores at pre- and post-treatment with the BDI
residual gain score at post-treatment and follow-up in the intervention and control group.
Variable BDI residual gain score at post-treatment
BDI residual gain
score at follow-up
Intervention group Control group Intervention group
Pre Post Pre Post Follow-up
.44 .70** -.10 -.38 -.10
-.14 -.30 .02 -.45 -.57*
.09 -.17 .29 -.07 -.05
-.22 -.48* .14 .10 -.42
Obsessive Rem. (RQ)
-.55* -.38 .24 .38 .02
Note. BDI-II = Beck Depression Inventory, SES = Rosenberg Self-Esteem Scale, WHO-5 = WHO-Five Well-
being Index, LSIA = Life Satisfaction Index, RQ = Reminiscence Questionnaire; * p < .05. ** p < .01.