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The future of psychotherapy research lies in the development of easy-to-use, efficient treatments that target specific characteristics and needs of patients with a given disorder. Meeting this aim will involve understanding why people seek psychotherapy and the therapeutic features that they feel are most helpful in their recovery. Identifying key features of treatment that patients feel lead to improvement may help identify the active ingredients of psychotherapy and further refine treatment. We selected 22 older adults who participated in a larger randomized trial of psychotherapy for late-life depression to participate in individual, semistructured qualitative interviews. Interviews took place at the University of California, San Francisco or in the participant's home. All participants were age 60 years or older with major depression and co-occurring executive dysfunction. Participants were asked about their depression experience, their expectations for treatment, most and least helpful aspects of treatment, effects of treatment, and recommended improvements to treatment. Data were transcribed, coded, and analyzed using NVivo (QSR International, Cambridge, MA). The most commonly noted causes for seeking treatment were depression related to interpersonal relationships, health conditions, grief/loss, finances, housing, and challenges due to executive dysfunction. Participants had few expectations about treatment and they found support, the problem-solving therapy process, and focus on interpersonal relationships to be the most helpful processes in treatment. Suggestions for psychotherapy include increasing the number of sessions, discussing problems in a more proactive way, and considering participant choice in treatment. This research demonstrates the value of mixed-methods approaches, in that qualitative approaches assist in contextualizing and interpreting quantitative data.
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Patient Perspectives on the Benets of
Psychotherapy for Late-Life Depression
Emily K. Dakin, Ph.D., Patricia Areán, Ph.D.
Objectives: The future of psychotherapy research lies in the development of easy-to-
use, efcient treatments that target specic characteristics and needs of patients
with a given disorder. Meeting this aim will involve understanding why people seek
psychotherapy and the therapeutic features that they feel are most helpful in their
recovery. Identifying key features of treatment that patients feel lead to improvement
may help identify the active ingredients of psychotherapy and further rene treat-
ment. Design: We selected 22 older adults who participated in a larger randomized
trial of psychotherapy for late-life depression to participate in individual, semi-
structured qualitative interviews. Setting: Interviews took place at the University of
California, San Francisco or in the participants home. Participants: All participants
were age 60 years or older with major depression and co-occurring executive
dysfunction. Measurements: Participants were asked about their depression expe-
rience, their expectations for treatment, most and least helpful aspects of treatment,
effects of treatment, and recommended improvements to treatment. Data were
transcribed, coded, and analyzed using NVivo (QSR International, Cambridge, MA).
Results: The most commonly noted causes for seeking treatment were depression
related to interpersonal relationships, health conditions, grief/loss, nances, housing,
and challenges due to executive dysfunction. Participants had few expectations about
treatment and they found support, the problem-solving therapy process, and focus on
interpersonal relationships to be the most helpful processes in treatment. Conclusion:
Suggestions for psychotherapy include increasing the number of sessions, discussing
problems in a more proactive way, and considering participant choice in treatment.
This research demonstrates the value of mixed-methods approaches, in that qualita-
tive approaches assist in contextualizing and interpreting quantitative data. (Am J
Geriatr Psychiatry 2013; 21:155e163)
Key Words: Psychotherapy, late-life depression, patient perspectives
An important focus for future interventions
research will be on the personalization of
interventions to maximize treatment outcomes
and make treatments more efcient and easier to
manage.
1,2
The Road Ahead report
3
issued by the
National Institute of Mental Health details how
personalized intervention development will benet
greatly from patient perspectives; the positive
and negative effects of treatment and the factors
that contribute to illness and recovery in part be
Received April 28, 2011; revised July 2, 2011; accepted July 26, 2011. From the Colorado State University, Fort Collins, CO (EKD); and
University of California, San Francisco, CA (PA). Send correspondence and reprint requests to Emily K. Dakin, Ph.D., CSU School of Social
Work, 1586 Campus Delivery, Fort Collins, CO 80523. e-mail: Emily.Dakin@colostate.edu
Ó2013 American Association for Geriatric Psychiatry
http://dx.doi.org/10.1016/j.jagp.2012.10.016
Am J Geriatr Psychiatry 21:2, February 2013 155
determined by the perspectives of people who have
experienced the illness and recovered from it.
We recently completed and published the results
from one of the largest psychotherapy trials for late-
life depression, the Collaborative Outcomes of
Psychotherapy for Executive Dysfunction Study.
4
This study found that a structured intervention,
namely problem-solving therapy (PST),
5
eventually
resulted in better treatment outcomes than a less-
structured treatment, supportive therapy (ST); both
interventions were effective in treating late-life
depression overall.
4
A unique feature of this study
was that all participants met criteria for executive
dysfunction (ED), which is impairment in the cogni-
tive capacity to plan and initiate tasks and solve
problems. People with this presentation of late-life
depression tend to have a poor response to selective
serotonin reuptake inhibitor treatment of depres-
sion,
6
and thus the results of this former study
suggest a viable treatment alternative for a pop-
ulation known to be resistant to antidepressant
medications.
Combined qualitative and quantitative methods
have broad appeal in health research due to
the ability of the two approaches to inform one
another and the breadth of knowledge and insights
that can be gained using multiple methods.
7
A
variety of qualitative mental health research studies
have revealed the value of examining patients
perspectives on mental health treatment
8e11
in
terms of uncovering specicwaysinwhichthe
treatment provided an impact. In particular, the
inclusion of qualitative research methods in clinical
research is an emerging methodologic approach
that strengthens our ability to answer central
questions about intervention effectiveness, why
treatments do or do not work from the patients
perspective, and to explore any outcomes of the
treatment not captured by current quantitative
measures. This can lead to better renement of
behavioral interventions that have historically been
difcult to widely implement because of their
complexity. With an eye toward developing a more
efcient form of psychotherapy, we elected to
conduct a qualitative analysis to determine patient
views on the following: 1) the most common issues
that caused them to select psychotherapy as
a treatment of choice; 2) expectations for how their
depression should be addressed in therapy and
whether expectations were met in their therapy
experience; 3) most and least helpful aspects of
psychotherapy; 4) any observed outcomes or effects
from therapy; and 5) recommended changes to
improve treatment.
METHODS
Participants
All participants in this study were participants in
a large randomized clinical trial of PST compared to
ST for the treatment of depression and co-occurring
executive dysfunction. To be eligible, participants
had to 1) be 60 years or older, 2) be diagnosed with
major depression (by Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition criteria), 3) have
scored 21 or worse on the Hamilton Depression Scale,
and 4) have mild executive dysfunction. Exclusionary
criteria included presence of dementia determined by
the Mini-Mental State Examination (<25). Additional
exclusionary criteria are detailed in the Arean et al.
2010 article.
4
Participants in the parent study were randomized
to receive 12 weekly sessions of PST or ST. PST
teaches patients a series of steps to solve problems
they see as causing their depression; participants use
these steps each week to solve different problems. ST
is an unstructured psychotherapy that helps patients
overcome their depression by discussing their feel-
ings and supporting patients in attempts to feel
better. Twenty-two participants volunteered and
consented to participate in this qualitative study and
were not demographically different from the original
sample (Table 1). The interviews for the qualitative
study occurred during the window of time between
completing psychotherapy and being disenrolled
from the study after the nal study assessment at
9 months.
Interviews
Three trained interviewers conducted individual,
semi-structured interviews at the University of Cal-
ifornia, San Francisco or in the participants home.
Participants were paid $15 for taking part in the
qualitative interview. We made an effort to ensure
that the wording of interview questions was under-
standable to our research participants. This article
156 Am J Geriatr Psychiatry 21:2, February 2013
Benets of Psychotherapy for Late-Life Depression
focuses on the following open-ended questions from
the interview:
What kinds of problems or difculties were you
experiencing when you rst entered treatment
through [this study]?
What were your expectations for how your
depression should be treated?
Did this program meet your expectations?
(follow-up probe if participant does not expound: Can
you tell me more about why it did/did not?)
What about this treatment was most helpful?
What was least helpful?
What effects, if any, did you notice from this
treatment?
If you could make changes to this treatment for
future patients, what changes would you
recommend?
Data Analysis
All of the interviews were digitally recorded and
a template analysis was performed on the transcribed
data. In template analysis, an initial coding structure
is developed and successively rened through
multiple iterations, until a nal template is reached.
As each new analytic template is developed, all
previously analyzed transcripts are reanalyzed using
the new template. Renements of the template cease,
and a nal template arrived upon, once the template
is rened to the point that it is judged to be inclusive
of all the thematic categories within the transcribed
data.
12
Qualitative research de-emphasizes the search for
a single, objective truthseen in quantitative
research. Instead, it posits that there can be multiple,
subjective ways of understanding reality.
13
The term
credibility in qualitative research, roughly analogous
to validityin quantitative research,
14
refers to the
extent to which the researcher has adequately
represented participantsrealities. To ensure credi-
bility of the conclusions, two coders performed all
data analysis, including the development of the
analysis template. Each transcript was independently
read and coded by both coders and then discussed to
arrive at an agreed-upon coding structure. The
qualitative data analysis software NVivo was used to
aid in the data analysis.
RESULTS
Participants
Although our inclusion criteria specied that
participants only needed to have completed one
psychotherapy session, 21 of the 22 participants in
this study had completed all 12 psychotherapy
sessions. There were no statistically signicant
demographic differences between the qualitative
subsample and the parent study sample, with the
exception of ethnicity; the qualitative subsample was
more likely to be Caucasian than the parent study
participants, although both samples were predomi-
nantly Caucasian. Please see Table 1 for demographic
data (age, education, gender, percent PST versus ST,
and percent Caucasian) for the qualitative and orig-
inal samples.
Template Analysis Coding Structure
Our initial template closely mirrored the inter-
view questions and was rened in subsequent
iterations. Codes relevant to the interview ques-
tions reported in this article are 1) reasons for
participating in research; 2) expectations for
psychotherapy (including extent that therapy met
expectations); 3) helpful and unhelpful processes
in treatment; 4) effects of treatment; and 5) rec-
ommended changes to treatment. The codes often
had sub- and even sub-subcodes. For example,
within the code effects of treatmentwas the
subcode functioning, and within this were
sub-subcodes improvements in relationships or
interpersonal functioningand more active.
Tables 2through5showcodesandpercentagesof
sample endorsing these codes. In creating our nal
analytic template, we included only those codes
that had been identied by 3 or more of the 22
participants.
TABLE 1. Demographic Data for Qualitative Sample and
Original Study Sample
Demographic
Qualitative Study
Subsample
Original Study
Sample
Mean age, years 74 73
Mean education, years 16 15
Women, % 59 60
PST, % 41 50
Caucasian, % 91 72
Note: PST: Problem-solving therapy.
Am J Geriatr Psychiatry 21:2, February 2013 157
Dakin and Areán
Participant Reasons for Participating in Research
and Prominent Problems Reported
A majority of the participants in this study had
previous mental health treatment experience, with
16 of the 22 participants describing episodic or
ongoing/long-term treatment, and many of these
having had their rst experience with mental health
treatment as a young adult. Eight participants
(36.4%) described experiences with early onset
depression (Table 2). For example, one man stated:
I recognized that I have been depressed for most of
my life and I think theres a genetic component. My
mother was depressive and immobilized at times. Her
mother, my maternal grandmother, was depressive
and bedridden off and on for periods of time in her
life. So there probably is a genetic predisposition, and
then I wasI think both from my childhood and from
my adult life.
In contrast, nine (40.9%) participants described
having late-onset depression. Describing depression
originating from circumstances in late life, one
woman stated:
I lost my brother a few years back, and normally on
the anniversary of his death, at least one of his chil-
dren call. [This past year] nothing happened, and it
just struck me all of a sudden, my entire bloodline had
disappeared from my life, and it justeI went right
down to the bottom. I couldnt understand what had
happened, I couldnt understand why I hadnt heard
from anybody, and I was going through physically
a very bad time at that point, too, so it was just aeI
crashed.
A variety of factors were described as contributing to
participantsfeelings of depression. Most frequently
cited as leading participants to seek treatment were
problems related to executive dysfunction (54.5%),
interpersonal relationships (50.0%), health (31.8%),
grief/loss (31.8%), nances (22.7%), and housing
(13.6%).
Expectations for Therapy and Extent to Which
Treatment Met Expectations
Although all 22 participants responded to the
inquiry about expectations, the most common res-
ponse, given by 12 participants (54.5%), was having
no particular expectations about the treatment
(Table 3). Eight participants, including four without
specic expectations, simply voiced a desire to feel
better or be helped. The desire for help was voiced
in several ways, including in a general way, in terms
of depression, and in terms of MCI issues. Three
participants voiced a desire for assistance with
coping or coping strategies. Individual expectations
included help getting unstuckwith tasks,
help with a writers block,help with controlling
anger, validation of relativespoor treatment of
participant, becoming reacquainted with self; and
a desire for focused/specic rather than open-ended
treatment.
Twelve participants (54.5%) felt that treatment had
met their expectations, whereas seven (31.8%) indi-
cated that their expectations were not met or were
partially met. Participants typically responded to the
question of whether treatment met their expectations
in terms of their satisfaction with treatment. Thus, for
example, it was common for participants who had
not indicated any particular expectations to say that
treatment had met their expectations, meaning that
they were satised with their treatment experience.
TABLE 2. Reasons for Participating in Research
Code
PST ST
Total (%)
Male Subjects
(n [3)
Female Subjects
(n [6)
Male Subjects
(n [6)
Female Subjects
(n [7)
ED issues 1 2 4 5 12 (54.5)
Relationship issues 2 4 3 2 11 (50.0)
Late-onset depression 0 3 3 3 9 (40.9)
Early-onset depression 2 0 3 3 8 (36.4)
Health 0 3 2 2 7 (31.8)
Grief/loss 1 4 1 1 7 (31.8)
Finances 1 1 2 1 5 (22.7)
Housing 0 2 1 0 3 (13.6)
Notes: ED: executive dysfunction; PST: problem-solving therapy; ST: supportive therapy.
158 Am J Geriatr Psychiatry 21:2, February 2013
Benets of Psychotherapy for Late-Life Depression
The assigned treatment group played a role in terms
of whether or not participants felt that treatment had
met their expectations. For example, a man in the PST
condition was very pleased with his treatment
because he was in the condition that he believed
would be most helpful to him:
Well, I knew that there were two components, that
there was a supportive function, and there was
a problem-solving function, and I knew that it was
randomly assigned, and I was hoping for the problem-
solving function because, as I said, Ive had consid-
erable insight therapy. I really dont need much
insight therapy at this point. Im very self-sufcient in
that way. I need supportive therapy, but not exclu-
sively. But what I really needed was problem-solving,
so I was pleased when I got into that section. I would
have made the best of the supportive section, but I
really had so many practical issues that I couldnt
manage, so I was very pleased when I got into that.
Three participants expressed that treatment had not
met their expectations because they had been
assigned to ST rather than PST. One woman in the ST
group believed that she had not improved and
believed that the more proactive nature of PST would
have been a better match for her:
I think that the emphasis on the supportive is just to
allow people to articulate their concerns, and some-
times getting it off your chest .helps a lot of people,
but it doesnt really help me. .I can share my
concerns, but that doesnt get rid of them. So thats
why I was hoping for the other one.
Similarly, a man in the ST condition indicated that his
expectations for treatment had not been met by the
ST condition because
I didnt feel that there was much feedback to, you
know, help me overcome the problem.
On the contrary, a woman in the ST condition had
mixed feelings about being in ST:
Subject: Well, because I felt that I wasnt in a particular
program, and I just got therapy, it didnt meet my
expectations that way. I had a very wonderful therapist
who I thought was just really great, and whom I was
able to talk to very well, and she was smart, and shed
always have little insightful things that gave me things
to think about. So I did think it was very worthwhile.
Interviewer: So it met some of your expectations.
Subject: Yeah. It exceeded my expectations (laugh) in
many ways, because she was very excellent.
Helpful and Unhelpful Processes in Treatment
Participants described a wide range of techniques
as being helpful in their therapy experience (Table 4).
Eleven participants (50.0%) indicated that none of
the techniques in therapy were unhelpful. Four
participants (18.2%) described aspects of therapy
that were unhelpful. A woman in the PST condition
stated that although therapy was helpful personally,
family problems remained unresolved. A man in the
PST condition indicated that the interventions might
have minimized the importance of spirituality to
older adults and assumed that participants would be
troubled about their age. A woman in the ST
condition suggested that talking about painful
aspects of her past in therapy had been harmful with
no particular benet. Another woman in the ST
condition had wanted to receive PST because it was
more focused on taking action, and she believed that
the ST had not helped her.
TABLE 3. Expectations for Therapy
Code
PST ST
Total (%)
Male Subjects
(n [3)
Female Subjects
(n [6)
Male Subjects
(n [6)
Female Subjects
(n [7)
No expectations
a
1 3 5 3 12 (54.5)
Feel better or be helped 1 2 2 4 8 (36.3)
Coping strategies 0 0 3 0 3 (13.6)
Expectations met
a
2 4 2 4 12 (54.5)
Expectations not met or partially met 0 1 3 3 7 (31.8)
Notes: PST: problem-solving therapy; ST: supportive therapy.
a
Participants typically responded to the question of whether treatment met their expectations in terms of their satisfaction with treatment.
Thus, for example, it was common for participants who had not indicated any particular expectations to say that treatment had met their
expectations, meaning that they were satised with their treatment experience.
Am J Geriatr Psychiatry 21:2, February 2013 159
Dakin and Areán
Effects of Psychotherapy
Improvements in functioningin terms of inter-
personal functioning and/or becoming more active
were the most commonly noted effects from treat-
ment, identied by 13 (59.1%) of the participants
(Table 5). A slight majority of participants (12, or
54.5%) noted an improvement in mood as an effect
of treatment, whereas seven (31.8%) did not endorse
an improvement in mood. Seven participants (all in
the PST condition) indicated that they had continued
to implement techniques learned in therapy after
therapy had ended, including techniques and abilities
in terms of problem solving and decision making,
completing tasks, and changed thinking patterns.
Similarly, participants commonly desired a referral to
continue treatment. In the case of PST participants,
the desire for further treatment was often based on
the wish for continued learning about the PST process
in a structured environment with expert oversight.
There was a wide range of comments among the
nine participants who discussed the impact of treat-
ment on their ED, with three participants (a man and
a woman who had received ST and a woman who
had received PST), indicating that they believed
treatment had helped their ED symptoms, one
participant, a woman in the PST condition believing
that her ED would improve with continued treat-
ment, and a man in ST condition indicating that he
was engaged in working on his memory as a result of
treatment. Another four participants (two women
receiving ST, a man receiving ST, and a woman
receiving PST) did not believe that treatment had
helped their ED; however, the woman in the PST
condition poignantly observed that her depression
had lifted so much as a result of treatment that she
had become less worried about these issues:
I know I thought when I rst came that I was having
Alzheimers or something. .But I think so much of it
had to do with how frightened I was about, you know,
feeling so bad. So I do think somehow those two
things are connected, and Im not sure I understand
how, but I feel a lot better about that. .even if I am
going to get worse, its not so important right now.
Recommended Changes to Treatment
Sixteen participants provided comments regarding
recommended changes to treatment. Three partici-
pants wished that the therapy could have lasted
longer; this included both the recommendation of
having the therapy session last longer than an hour
and the recommendation of having a greater number
of sessions. A fourth participant recommended that
the therapist talk with the participant about whether
the participant would be interested in continued
therapy beyond the 12 sessions. Two female partici-
pants indicated a desire for treatment to take place in
a group format. One participant recommended that
a therapist formally assess, before embarking on
a course of psychotherapy, whether a given partici-
pant would be likely to benet from a particular
chosen therapeutic model. Some practical recommen-
dations included a comment about the importance
TABLE 4. Helpful and Unhelpful Processes in Treatment
Code Subcode
PST ST
Total (%)
Male Subjects
(n [3)
Female Subjects
(n [6)
Male Subjects
(n [6)
Female Subjects
(n [7)
Helpful 3 6 6 6 21 (95.5)
Providing support 2 2 2 3 9 (40.9)
Explaining or assisting with the
PST process
2 6 0 0 8 (36.4)
Helping with interpersonal
relationships
2 3 0 1 6 (27.3)
Exploring options 2 1 1 0 4 (18.2)
Promoting self-awareness 0 2 1 0 3 (13.6)
Therapeutic reframing 1 1 0 1 3 (13.6)
Nothing unhelpful 1 4 3 3 11 (50.0)
Unhelpful 1 1 0 2 4 (18.2)
Notes: PST: problem-solving therapy; ST: supportive therapy.
160 Am J Geriatr Psychiatry 21:2, February 2013
Benets of Psychotherapy for Late-Life Depression
of therapists who speak non-English languages
(e.g., Spanish), and the recommendation of having
alternate locations (e.g., clients home) for therapy to
take place because of transportation difculties within
an older population.
Participants stated a variety of recommendations
about the therapeutic process and not specically
related to the type of therapy given per se. One
recommendation was that therapists explore with each
participant his or her feelings about being in therapy,
for example, whether the participant has any sense of
shame, because these feelings can impact what happens
in the therapy session. One participant suggested that
perhaps providing a same-gender therapist could make
the therapeutic experience easier for some, whereas
another participant suggested the value of trying to
match client to therapist by personality. Similarly, one
participant appreciated that her therapist was of similar
age to her. One unique recommendation was to have
two therapists for each client to provide the client with
a wider range of perspectives.
Other recommendations were specic to the PST
and ST therapeutic conditions. Recommendations for
PST included more in-depth exploration into family
issues but in combination with the skill building that
is the hallmark of PST. As quoted by one participant:
I think the supportive therapy alone, now that Ive
been through a great deal, is not sufcient. I think
there has to be a practical component, particularly
practical application, and I think its really important,
especially at the beginning, to have someone listen to
your story in a nonjudgmental, you know, appro-
priate manner and to help you exhaust your need to
tell that story, and while thats being done, you know,
toward the end of that storytelling, there has to be
a real practical application .So I think, you know,
the most effective therapy is a combination of
supportive and practical.
This opinion appeared to be mirrored by participants
in the ST condition. Two participants in the ST
condition wished that their therapy had been more
directive and less open-ended, with one indicating
that she wished that her therapy had specically
targeted her MCI symptoms. A third ST participant
stated that although he was personally happy with
the therapy that he had received, he conjectured that
other participants might prefer a more structured and
directive therapeutic approach.
DISCUSSION
We used qualitative interviews to determine patient
perspectives about their experience in two forms of
psychotherapy for depression. Our intent was to use
this information to identify what patients felt were the
most effective elements of treatment, with the goal of
creating a more targeted intervention. In addition,
patients had a near uniform host of problems they felt
TABLE 5. Effects of Psychotherapy
Code Subcode
PST ST
Total (%)
Male
Subjects
(n [3)
Female
Subjects
(n [6)
Male
Subjects
(n [6)
Female
Subjects
(n [7)
Functioning 2 5 4 2 13 (59.1)
Improvements in relationships
or interpersonal functioning
0 2 2 1 5 (22.7)
More active 1 3 3 2 9 (40.9)
Mood improved 2 4 2 4 12 (54.5)
Mood not improved or not sure if
improved
1 1 2 3 7 (31.8)
Interested in further treatment 1 3 1 3 8 (36.4)
Implementation of learned techniques
posttherapy
2 5 0 0 7 (31.8)
Positive reframing of earlier life events 0 1 1 1 3 (13.6)
Increase in knowledge about depression,
MCI or PST process
1 1 1 0 3 (13.6)
MCI 0 3 3 3 9 (40.9)
Notes: MCI: mild cognitive impairment; PST: problem-solving therapy; ST: supportive therapy.
Am J Geriatr Psychiatry 21:2, February 2013 161
Dakin and Areán
had contributed to their depression, problems that
have been documented in epidemiologic studies to be
quite common in older adults with depression.
15e18
It should be noted here that when asked about
improvements attributed to psychotherapy, 59.1% of
the participants indicted that participation in therapy
resulted in marked improvements in functioning
(social functioning or improved activity levels), and
54.5% indicated marked improvements in mood.
There is considerable interest in the psychotherapy
eld in streamlining psychotherapies into their basic
elements, including nonspecic therapeutic elements,
so they can be efciently implemented in community
practices. The results of this study suggest that to create
a more efcient psychotherapy that retains the effective
treatment ingredients, the treatment should include the
following elements. First, the therapeutic relationship
should be collaborative rather than reective; partici-
pants preferred to work toward active solutions for their
problems, rather than simply talking about them.
Second, treatment should acknowledge and integrate
patient spirituality. Third, participant recommenda-
tions included the importance of discussing shame
associated with seeking treatment as an important
engagement tool; the current cohort of older adults may
fear disclosure in therapy due to perceived stigma, and
discussing thoughts and feelings about engaging in
psychotherapy with older adult clients could address
this concern and build therapeutic rapport. Fourth,
the treatment should focus on strategies to address
problems commonly seen among older adults, for
example social functioning (e.g., behavioral activa-
tion),
19
cognitive skills (e.g., PST, memory remedia-
tion),
20
family therapy strategies, and nancial
counseling.
21
Fifth, the treatment may need to be
lengthened given the needs of the patients, particularly
if suffering from ED (e.g., both therapies were 12
sessions and may need to be extended to 24 sessions).
Finally, participant choice in treatment approach (e.g.,
type, format, and length of treatment) should be
considered given the nding that ST participants
commonly perceived that they would havebeen helped
more by PST and the various participant treatment
recommendations noted earlier.
Limitations
Although any participant who had completed one
session of therapy through the COPED study was
eligible to be interviewed for this qualitative study,
all but one of our participants had completed all 12
sessions specied by the COPED protocol. None of
the participants who dropped out of COPED and
were contacted regarding this qualitative study were
interested in being interviewed for it. Therefore, our
interviews may have overrepresented the true level
of participantssatisfaction with the therapy that they
received through the COPED study. On the other
hand, relatively few participants dropped from the
study because of dissatisfaction, so this concern may
be relatively minor.
An additional possible limitation is that our sample
was generally highly educated and Caucasian, and so
our ndings present a limited picture of the needs
and treatment experiences of older adults in general
who are experiencing depression and ED. In addi-
tion, because 16 of the 22 participants described prior
experiences with mental health services, this was
a group that was experienced with psychotherapy, so
results may not be generalizable to people without
prior mental health treatment. Further study is war-
ranted to determine to what extent these results may
be relevant for more diverse elderly populations.
CONCLUSIONS
Evaluating patient perspectives about the treat-
ments they receive could be particularly useful in the
development of efcient and focused psychother-
apies. The data from this study suggest that treat-
ments that work toward active solutions for
problems, integrate spirituality, proactively address
stigma concerns, incorporate patient choice, and
target features of depression common in late life may
provide more efcient methods for treating depres-
sion in older adults. We suggest that the integration
of behavioral activation, problem solving, and
cognitive skills training be considered in the devel-
opment of efcient treatments. Finally, this
study demonstrates the value of mixed-method
approaches; qualitative methods provide rich data
that are helpful in understanding and contextualizing
quantitative data. The data in the parent study indi-
cated that although both ST and PST were effective
interventions, PST had better treatment outcomes in
the long run. The qualitative data support and help
interpret these ndings by indicating the most
162 Am J Geriatr Psychiatry 21:2, February 2013
Benets of Psychotherapy for Late-Life Depression
benecial aspects of treatment, which could lead to
renement of PST and, potentially, a more potent
intervention.
The authors thank Terri Huh, Ph.D., Heather Lee,
Ph.D., and Stephanie Mace, M.S.W., for their contributions.
This study was supported by three National Institute of
Mental Healthefunded grants MH074717, MH074500,
and MH63982.
An earlier version of this paper was presented previ-
ously at the annual American Association of Geriatric
Psychiatry conference in Orlando, FL, March 14e17, 2008.
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Am J Geriatr Psychiatry 21:2, February 2013 163
Dakin and Areán
... In contrast to the psychodynamic/psychoanalytic studies of Leonidaki et al. [21], Palmstierna and Werbart [19] and von Below et al. [23], which mainly reported relational and intrapersonal factors as helpful, the present psychodynamic study found it was helpful for therapists to also offer advice or tips for everyday life. Practical factors were also reported for other adults [24], elderly individuals [39] and adolescents [40]. In Dakin and Arean [39], the relevance of practical orientation may partly be explained by the fact that their patients also suffered from executive dysfunctions. ...
... Practical factors were also reported for other adults [24], elderly individuals [39] and adolescents [40]. In Dakin and Arean [39], the relevance of practical orientation may partly be explained by the fact that their patients also suffered from executive dysfunctions. Nevertheless, as Bohart and Tallman [18] observe, patients tend to take from therapy what they need to get better. ...
... Such support from therapists and help with everyday issues like relationships seem to resonate with findings from studies across the human life span. For example, studies of problem solving therapy (PST) and supportive therapy (ST) in elderly individuals [39], psychodynamic therapies in adolescents [40] and adults in the present study have all reported several of the same helpful experiences among patients in three different phases of life, with great variance based on development, age and social roles. The patients in these three studies seemed to have all experienced improvement in psychotherapy to the extent that the therapy, directly or indirectly, related to and had some positive effects not only on symptoms or personal well-being but also on their relations and life outside of therapy. ...
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The patient's perspective on improvement in psychotherapy is crucial for tailoring the therapy he or she is receiving. The present study aimed at exploring the factors aiding and the patients' experiences of improvement in time-limited psychodynamic psychotherapy for depression. Semi-structured, in-depth interviews were conducted with ten adult patients who received up to 28 sessions of manualized psychodynamic psychotherapy in the Norwegian study "Mechanisms of change in psychotherapy" (the MOP study). The post-therapy interviews addressed the participants' experiences from therapy. The data were analyzed with thematic content analysis and hermeneutic interpretation. The analysis identified four helpful dimensions: "Therapist activities" comprised supporting and acknowledging, advising and offering tips for everyday life, questioning and pressuring. "Patient activities" included opening up, caring for oneself and showing agency. "Facilitators" for improvement were learning from therapy, learning to receive therapy and agreed goals. "Achievements" comprised new perspectives and understandings, increased self-awareness and mastery and changed thinking and feeling. Improvements from psychodynamic therapy seemed reliant on the degree to which the therapy could activate and be relevant to the patients' everyday life. Tailoring therapy for patients with depression should link the focus on symptoms and ways of thinking and feeling with their life circumstances.
... In a study of public psychotherapy for economically disadvantaged Chileans and Colombians, it was found that therapy could sometimes feel unfocused and unclear [50]. Two studies, one with Hmong people and one with older white Americans found that therapy was felt to ignore spirituality [49,57]. ...
... Specific to face-to-face CB models, therapy was found to help break habitual thinking or behaviours; and specific to individual face-to-face CB approaches, therapy was reported to benefit even if people had negative expectations or experiences. In a study of PST for older people, therapy was found to also have an impact on participants' memory [49]. ...
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Background: Globally, national guidelines for depression have prioritised evidence from randomised controlled trials and quantitative meta-analyses, omitting qualitative research concerning patient experience of treatments. A review of patient experience research can provide a comprehensive overview of this important form of evidence and thus enable the voices and subjectivities of those affected by depression to have an impact on the treatments and services they are offered. This review aims to seek a comprehensive understanding of patient experiences of psychological therapies for depression using a systematic and rigorous approach to review and synthesis of qualitative research. Method: PsychINFO, PsychARTICLES, MEDLINE, and CINAHL were searched for published articles using a qualitative approach to examine experiences of psychological therapies for depression. All types of psychological therapy were included irrespective of model or modes of delivery (e.g. remote or in person; group or individual). Each article was assessed following guidance provided by the Critical Appraisal Skill Programme tool. Articles were entered in full into NVIVO and themes were extracted and synthesized following inductive thematic analysis. Results: Thirty-seven studies, representing 671 patients were included. Three main themes are described; the role of therapy features and setting; therapy processes and how they impact on outcomes; and therapy outcomes (benefits and limitations). Subthemes are described within these themes and include discussion of what works and what's unhelpful; issues integrating therapy with real life; patient preferences and individual difference; challenges of undertaking therapy; influence of the therapist; benefits of therapy; limits of therapy and what happens when therapy ends. Conclusions: Findings point to the importance of common factors in psychotherapies; highlight the need to assess negative outcomes; and indicate the need for patients to be more involved in discussions and decisions about therapy, including tailoring therapy to individual needs and taking social and cultural contexts into account.
... In addition, therapists were advised to explore cognitive fusion in relation to seeking help, because discussing shame in seeking help has been suggested to be helpful when working psychotherapeutically with older people. 75 ...
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Background Generalised anxiety disorder, characterised by excessive anxiety and worry, is the most common anxiety disorder among older people. It is a condition that may persist for decades and is associated with numerous negative outcomes. Front-line treatments include pharmacological and psychological therapy, but many older people do not find these treatments effective. Guidance on managing treatment-resistant generalised anxiety disorder in older people is lacking. Objectives To assess whether or not a study to examine the clinical effectiveness and cost-effectiveness of acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder is feasible, we developed an intervention based on acceptance and commitment therapy for this population, assessed its acceptability and feasibility in an uncontrolled feasibility study and clarified key study design parameters. Design Phase 1 involved qualitative interviews to develop and optimise an intervention as well as a survey of service users and clinicians to clarify usual care. Phase 2 involved an uncontrolled feasibility study and qualitative interviews to refine the intervention. Setting Participants were recruited from general practices, Improving Access to Psychological Therapies services, Community Mental Health Teams and the community. Participants Participants were people aged ≥ 65 years with treatment-resistant generalised anxiety disorder. Intervention Participants received up to 16 one-to-one sessions of acceptance and commitment therapy, adapted for older people with treatment-resistant generalised anxiety disorder, in addition to usual care. Sessions were delivered by therapists based in primary and secondary care services, either in the clinic or at participants’ homes. Sessions were weekly for the first 14 sessions and fortnightly thereafter. Main outcome measures The co-primary outcome measures for phase 2 were acceptability (session attendance and satisfaction with therapy) and feasibility (recruitment and retention). Secondary outcome measures included additional measures of acceptability and feasibility and self-reported measures of anxiety, worry, depression and psychological flexibility. Self-reported outcomes were assessed at 0 weeks (baseline) and 20 weeks (follow-up). Health economic outcomes included intervention and resource use costs and health-related quality of life. Results Fifteen older people with treatment-resistant generalised anxiety disorder participated in phase 1 and 37 participated in phase 2. A high level of feasibility was demonstrated by a recruitment rate of 93% and a retention rate of 81%. A high level of acceptability was found with respect to session attendance (70% of participants attended ≥ 10 sessions) and satisfaction with therapy was adequate (60% of participants scored ≥ 21 out of 30 points on the Satisfaction with Therapy subscale of the Satisfaction with Therapy and Therapist Scale-Revised, although 80% of participants had not finished receiving therapy at the time of rating). Secondary outcome measures and qualitative data further supported the feasibility and acceptability of the intervention. Health economic data supported the feasibility of examining cost-effectiveness in a future randomised controlled trial. Although the study was not powered to examine clinical effectiveness, there was indicative evidence of improvements in scores for anxiety, depression and psychological flexibility. Limitations Non-specific therapeutic factors were not controlled for, and recruitment in phase 2 was limited to London. Conclusions There was evidence of high levels of feasibility and acceptability and indicative evidence of improvements in symptoms of anxiety, depression and psychological flexibility. The results of this study suggest that a larger-scale randomised controlled trial would be feasible to conduct and is warranted. Trial registration Current Controlled Trials ISRCTN12268776. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 25, No. 54. See the NIHR Journals Library website for further project information.
... There is evidence of assumptions by clinicians that older adults are resistant to discussing mental health and that issues are more likely to be hidden, requiring more time and skill to identify (Bodner et al., 2018;Frost et al., 2019). Evidence on older adult perceptions is conflicting, with some research suggesting older adults are willing to talk to mental health providers and actually prefer talking therapies to medication (Byers et al., 2012;Dakin & Areán, 2013;Gum et al., 2006;Landreville et al., 2001), whilst other research found that fewer than one in six older adults discuss depression with their GP (Age UK, 2016). ...
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Background A low number of older adults access Improving Access to Psychological Therapies (IAPT) services in England. Barriers include ageism and stigma. Routine outcome measures (ROMs) assess the effectiveness of counselling, although counsellor and service‐level barriers prevent uptake. Aims Access rates of older adults to third sector (sometimes called voluntary or community sector) counselling and psychotherapy services were explored. The extent of ROM collection on psychological distress was assessed. Methodology Data collected between 2018 and 2019 were pooled across six third sector counselling services in England, Scotland and Northern Ireland (N = 2,757). Access based on age and gender was assessed, and the chi‐square analysis was used to compare gender distribution within the age groups. Availability of pre‐ and post‐therapy ROMs was assessed, and the chi‐square analysis was used to explore the age and gender differences in completion. Findings Lower access rates in people aged 65 and over (4.4%) were found compared with IAPT (7%). Access rates decreased further as age increased. Access of people aged 50 and over (24.5%) was below the 34.6% of the population in this age category. A third of people accessing counselling in all age groups were men. Only 28.6% completed a pre‐therapy ROM, and 29.5% of those clients subsequently completed a post‐therapy ROM. Implications Mental health promotion and adapting communication during counselling may help engage older adults and men in counselling. Training on working with older people and long‐term conditions is also beneficial. Support in using ROMs can improve uptake although organisational barriers may restrict implementation in the third sector.
... Focusing on those interactional skills related to better outcome may be helpful in both training and research (van Os et al., 2019). Furthermore, including patients in the evaluation of treatments may help to enhance efficacy and to identify what is helpful, less helpful, or even harmful (Dakin and Arean, 2013). In this way, treatment manuals may be improved on the basis of systematic patient feedback. ...
Article
Toward a paradigm shift in treatment and research of mental disorders - Volume 49 Issue 13 - Falk Leichsenring, Christiane Steinert, John P.A. Ioannidis
... The treatment of depression in later life is complex, reflecting the heterogeneity of older populations and the multiple factors involved in experiences of ageing and the development of depression. There is evidence that both antidepressants (Kok, Nolen, & Heeran, 2012) and psychological therapies (Dakin & Areán, 2013;Gould, Coulson, & Howard, 2012) are effective in the general older adult population, although antidepressants appear to be preferentially offered by health professionals (Walters, Falcaro, Freemantle, King, & Ben-Shlomo, 2017). Despite the fact that many older adults report a preference for psychosocial management strategies (Gum et al., 2006), there is in general poorer uptake of all mental health services among older adults. ...
Article
Background and objectives: Late-life depression is a major societal concern, but older adults' attitudes toward its treatment remain complex. We aimed to explore older adults' views regarding depression and its treatment. Research design and methods: We undertook a systematic review and thematic synthesis of qualitative studies that explored the views of older community-dwelling adults with depression (not actively engaged in treatment), about depression and its treatment. We searched 7 databases (inception-November 2018) and 2 reviewers independently quality-appraised studies using the CASP checklist. Results: Out of 8,351 records, we included 11 studies for thematic synthesis. Depression was viewed as a normal reaction to life stressors and ageing. Consequently, older adults preferred self-management strategies (e.g., socializing, prayer) that aligned with their lived experiences and self-image. Professional interventions (e.g., antidepressants, psychological therapies) were sometimes considered necessary for more severe depression, but participants had mixed views. Willingness to try treatments was based on a balance of different judgments, including perceptions about potential harm and attitudes based on trust, familiarity, and past experiences. Societal and structural factors, including stigma, ethnicity, and ageism, also influenced treatment attitudes. Discussion and implications: Supporting older adults to self-manage milder depressive symptoms may be more acceptable than professional interventions. Assisting older adults with accessing professional help for more severe symptoms might be better achieved by integrating access to help within familiar, convenient locations to reduce stigma and increase accessibility. Discussing treatment choices using narratives that engage with older adults' lived experiences of depression may lead to greater acceptability and engagement.
Chapter
In this chapter, we review the psychotherapy treatments for managing psychiatric disorders of older adults including individual, group, and couples therapy modalities.
Article
Introduction Depression affects many adults in the UK, often resulting in referral to primary care mental health services (e.g. improving access to psychological therapies, IAPT). CBT is the main modality for depression within IAPT, with other approaches offered in a limited capacity. Arts psychotherapies are rarely provided despite their attractiveness to clients. However, the recent dropout rate of 64% within IAPT suggests that clients’ needs are not being fully met. Therefore, in order to expand clients’ choice we developed a new creative psychological therapy integrating evidence‐based approaches with arts psychotherapies. Method A three‐level approach was used: (a) thematic synthesis of client‐identified helpful factors in evidence‐based approaches for depression and in arts psychotherapies; (b) studio practice exploring Cochrane Review findings on arts psychotherapies for depression; (c) pilot workshops for clients with depression and therapists. Findings and Discussion Eight key ingredients for positive therapy outcomes were identified: encouraging active engagement, learning skills, developing relationships, expressing emotions, processing at a deeper level, gaining understanding, experimenting with different ways of being and integrating useful material. These ingredients were brought together as Arts for the Blues for clients with depression: a 12‐session evidence‐based pluralistic group psychotherapy integrating creative methods as well as talking therapy. Conclusion The evidence‐based foundation, creative content and pluralistic nature of this new approach aligned with eight client‐identified key ingredients for positive therapy outcomes make it a promising therapy option that can be adapted to individual therapy. Implications include consideration for NICE approval as an additional therapy for depression.
Article
Accessible summary What is known on the subject? • The utilization rate of psychological therapies is low in older adults with depression. • The barriers and facilitators to engaging in psychological therapies experienced by older adults with depression are unclear. What does the paper add to existing knowledge? • Personal suitability for therapy engagement, practical abilities, personal therapy preferences, and familiarity with psychological therapies are associated with psychological therapy engagement. • Psychological therapists can also impact psychological therapy engagement among older adults with depression. What are the implications for practice? • Proving the effectiveness and suitability of chosen psychological therapies is important for improving therapy engagement. • Strategies for handling functional impairments among older adults with depression are necessary for engaging this population in psychological therapies. • Although in‐home psychological therapies are accessible, barriers to handling the technologies used for delivering the therapies should be addressed. • More methods of accessing information about psychological therapies should be available to older adults in order for them to increase their knowledge on the topic. • Psychological therapists should have positive attitudes and the competence to treat depression in older adults. Abstract Introduction Although psychological therapies are preferred by older adults, the utilization rate of these therapies is significantly low in older adults with depression. Understanding the barriers and facilitators to engaging in psychological therapies experienced by older adults is important for improving utilization rates. Aim This review aimed to explore the barriers and facilitators to engaging in psychological therapies experienced by older adults with depression. Methods A systematic review of qualitative studies on psychological therapy engagement among older adults with depression. Relevant published studies and grey literature were searched. The Critical Appraisal Skills Programme tool was used to assess the quality of the included studies. The results of the included studies were synthesized using thematic synthesis. Results Personal suitability for therapy engagement, practical abilities, personal therapy preferences and familiarity with psychological therapies was associated with therapy engagement. Therapists’ competencies also affected therapy engagement. Discussion Older adult's personal health status and requirements for psychological therapy should be considered. Implications for practice Mental health practitioners should consider whether specific psychological therapies are beneficial and acceptable for older adults. Improvements are needed in older adult's familiarity with psychological therapies and the ability of therapists to address the mental problems of older adults.
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Recent innovations in the treatment and prevention of depression that build on the foundation of cognitive-behavioral therapy represent promising directions for clinical practice and research. Specifically, behavioral activation and mindfulness-based cognitive therapy have been a recent focus of attention. Behavioral activation is a brief, structured approach to treating acute depression that seeks to alleviate depression by promoting an individual's contact with sources of reward through increasing activation, improving problem solving, and decreasing avoidance and other barriers to activation. Mindfulness-based cognitive therapy is a brief group intervention that seeks to prevent depressive relapse by promoting mindful attention, acceptance, and skillful action to help individuals interrupt habitual cognitive and affective patterns associated with risk of relapse. Each approach is supported by at least two large-scale, randomized clinical trials; however, many important questions remain. We examine current research on both approaches by addressing the robustness of findings, the extension to novel populations, and the processes by which clinical benefit is achieved.
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Background: Millions of older individuals cope with physical limitations, cognitive changes, and various losses such as bereavement that are commonly associated with aging. Given increased vulnerability to various health problems during aging, work displacement might exacerbate these due to additional distress and to possible changes in medical coverage. Older Americans are of increasing interest to researchers and policymakers due to the sheer size of the Baby Boom cohort, which is approaching retirement age, and due to the general decline in job security in the U.S. labor market. Aims of the study: This research compares and contrasts the effect of involuntary job loss and retirement on the mental health of older Americans. Furthermore, it examines the impact of re-employment on the depressive symptoms. Methods: There are two fundamental empirical challenges in isolating the effect of employment status on mental health. The first is to control for unobserved heterogeneity--all latent factors that could impact mental health so as to establish the correct magnitude of the effect of employment status. The second challenge is to verify the direction of causality. First difference models are used to control for latent effects and a two-stage least squares regression is used to account for reverse causality. Results: We find that involuntary job loss worsens mental health, and re-employment recaptures the past mental health status. Retirement is found to improve mental health of older Americans. Discussion: With the use of longitudinal data from the Health and Retirement Study surveys and the adoption of proper measures to control for the possibility of reverse causality, this study provides strong evidence of elevating depressive symptoms with involuntary job displacement even after controlling for other late-life events. Women suffer from greater distress levels than men after job loss due to business closure or lay-off. However, women also exhibit better psychological well-being than men following retirement. The present study is the first to report that the re-employment of involuntary job-loss sufferers leads to a recapturing of past mental health status. Additionally, we find that re-entering the labor force is psychologically beneficial to retirees as well. Implications for health care provision: It is well established that out-of-pocket expenditures on all forms of health care for seniors with self-diagnosed depression significantly exceeds expenditures for seniors with other common ailments such as hypertension and arthritis in the U.S. Thus, our research suggests that re-employment of older Americans displaced from the labor force will be cost-effective with regard to personal mental health outcomes. Implications for health policies: That re-employment of involuntary job loss sufferers leads to a recapturing of past mental health status illuminates one potential policy trade off - increased resources dedicated to job training and placement for older U.S. workers could reap benefits with regard to reduced private and public mental health expenditures. Implications for further research: Further research could more clearly assess the degree to which the mental health benefits of employment among older Americans would warrant the expansion of job training and employment programs aimed at this group.