Humour therapy in patients with late-life depression or Alzheimer's disease: A pilot study

Abstract

Of the disabling disorders of the elderly, depression is the most common affective disorder and Alzheimer's disease (AD) the most common neurodegenerative disorder. Pharmacological treatment strategies for these disorders are often accompanied with severe side effects. Therefore non-pharmacological treatment strategies are of great importance. The aim of the present study was to investigate the impact of humour therapy on quality of life in patients with depression or AD.
Twenty patients with late-life depression and 20 patients with AD were evaluated. Ten patients in each group underwent a humour therapy group (HT) once in two weeks for 60 min in addition to standard pharmacotherapy, which was given as usual to the other group as standard therapy (ST). All patients completed a psychometric test battery at admission and before discharge from the clinic.
The quality of life scores improved both in HT and ST groups for depressive patients but not for patients with AD irrespective of the therapy group. Depressive patients receiving HT showed the highest quality of life after treatment. In addition, patients with depression in both therapy groups showed improvements in mood, depression score, and instrumental activities of daily living.
Although there was no significant effect of humour therapy comparing with standard therapy on quality of life, these findings suggest that humour therapy can provide an additional therapeutic tool. Further studies with higher frequently humour groups are required in order to investigate the impact of humour therapy in gerontopsychiatric treatment.

Full text

Humour therapy in patients with late-life depression
or Alzheimer’s disease: a pilot study
Marc Walter*, Beat Ha
¨nni, Myriam Haug, Isabelle Amrhein, Eva Krebs-Roubicek,
Franz Mu
¨ller-Spahn and Egemen Savaskan
Psychiatric University Clinics, University of Basel, Basel, Switzerland
SUMMARY
Background Of the disabling disorders of the elderly, depression is the most common affective disorder and Alzheimer’s
disease (AD) the most common neurodegenerative disorder. Pharmacological treatment strategies for these disorders are
often accompanied with severe side effects. Therefore non-pharmacological treatment strategies are of great importance. The
aim of the present study was to investigate the impact of humour therapy on quality of life in patients with depression or AD.
Methods Twenty patients with late-life depression and 20 patients with AD were evaluated. Ten patients in each group
underwent a humour therapy group (HT) once in two weeks for 60 min in addition to standard pharmacotherapy, which was
given as usual to the other group as standard therapy (ST). All patients completed a psychometric test battery at admission
and before discharge from the clinic.
Results The quality of life scores improved both in HT and ST groups for depressive patients but not for patients with AD
irrespective of the therapy group. Depressive patients receiving HT showed the highest quality of life after treatment. In
addition, patients with depression in both therapy groups showed improvements in mood, depression score, and instrumental
activities of daily living.
Conclusions Although there was no significant effect of humour therapy comparing with standard therapy on quality of
life, these findings suggest that humour therapy can provide an additional therapeutic tool. Further studies with higher
frequently humour groups are required in order to investigate the impact of humour therapy in gerontopsychiatric treatment.
Copyright #2006 John Wiley & Sons, Ltd.
key words — late life depression; Alzheimer’s disease; quality of life; psychotherapy; humour
INTRODUCTION
Alzheimer’s disease (AD) and depression are common
disorders of the elderly. The interface of AD and
depression is complex. Portella et al. (2003) indicate
that cognitive impairment seem to be a trait
characteristic of patients with late life-depression.
The diagnosis of major depression can be conducted
reliably in patients with mild and moderate levels of
cognitive impairment (Katz, 1998).
AD is progressive and irreversible, but pharmaco-
logic and non-pharmacologic therapies for cognitive
impairment and behavioural problems may enhance
the quality of life (Small et al., 1997; Chan et al.,
2001; Shulman, 2002). Quality of life before and after
psychiatric treatment is estimated more often from the
view of clinicians than from the view of the patients.
For this study, quality of life is defined as an
individual’s perception of his or her position in the
current life situation.
Several psychotherapeutic methods including
music therapy and art therapy (Bonder, 1994),
behavioural treatment (Teri, 1994), and skill training
(Ro
¨sler et al., 2002), have been described as helpful in
AD, mainly because of alleviating negative emotions.
However, these are mainly case reports describing
effects of psychosocial interventions in AD. There is
empirical evidence for the greater effectiveness of the
INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIARTY
Int J Geriatr Psychiatry (in press)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/gps.1658
*Correspondence to: Dr M. Walter, Psychiatric University Clinics,
Wilhelm Klein-Strasse 27, CH-4025 Basel, Switzerland.
E-mail: marc.walter@upkbs.ch
Copyright #2006 John Wiley & Sons, Ltd.
Received 27 March 2006
Accepted 3 July 2006

combination of pharmacologic and psychosocial
treatment over pharmacologic treatment alone in
late-life depression (Mecocci et al., 2004). In general,
it has been argued that psychotherapy intervention of
elderly patients needs more attention in further studies
(Arean et al., 2003; Rainer et al., 2003).
One psychotherapeutic intervention is the thera-
peutic use of humour (Saper, 1990). Humour can be
seen as a specific defence mechanism (Strotzka, 1956/
57), by which positive emotions operate to reduce the
undesirable negative emotions involved in a stress
situation. In general, people who have better devel-
oped humour skills and who more often include
humour and laughter in their daily lives seem better
able to cope with stressful events (McGhee and
Goldstein, 1983; Lefcourt and Martin, 1986). As a
natural stress antagonist, humour has numerous
additional salutary effects, including enhancing
cardiovascular, immune, and endocrine systems (Berk
et al., 1989; Fredrickson and Levenson, 1998; Bennett
et al., 2003).
Essential elements of the humour process are the
stimulus (humour), the emotional response (mirth),
and the resulting behaviour such as grinning, laughing,
smiling, or giggling (Fry, 1992).
There are a couple of case reports concerning
humour in the treatment of psychiatric patients
(Marcus, 1990; Richman, 1996; Minden, 2002) but
there is a lack of empirical findings so far. It was
suggested that humour plays an important role in
group therapy (Bloch et al., 1983). In a first empirical
study, Hirsch and Kranzhoff (2004) showed that
humour groups with elderly patients are feasible.
However, the effect on their well-being is not clear yet.
Indeed, there are no controlled studies investigating
the effects of humour therapy (HT) on quality of life.
Our clinical experience suggests that patients with
late-life depression and mild AD may profit from HT.
The aim of the present study was to investigate how
humour therapy affected subjective quality of life in
depressed or AD patients. Another reason for the
inclusion of these two patient groups is the fact, that
these are the main inpatient cohorts in our clinic, for
whom the effects of HT as an adjunct to the therapy
setting was to be evaluated.
PATIENTS AND METHODS
Subjects
Between February 2003 and July 2005, the study
participants were recruited through the inpatient units
of the Psychogeriatric Departments of the Psychiatric
University Clinics in Basel. As required by the
inclusion criteria of the study, they were aged 65 or
above and met the DSM-IV criteria for Dementia of
the Alzheimer Type, Major Depressive Disorder or a
combination of both (American Psychiatric Associ-
ation, 1994). Only late-onset depressed subjects were
included, that is, those who had the first episode of
depression after the age of 50 years. The patients
underwent routine medical examination, electrocar-
diographic (ECG) recording and laboratory screening,
including full blood count and thyroid function test.
Thus, we excluded patients with significant abnormal
biological findings on ECG recording or laboratory
examination, with neurological disorders other than
AD, and those with acute medical illness at time of
recruitment. The diagnosis of AD was additionally
confirmed by neuroimaging. Other exclusion criteria
were severe cognitive impairment, defined as a score
of 20 or lower on the Mini- Mental State Examination
(MMSE; Folstein et al., 1975), schizophrenia or other
psychotic disorder, substance or alcohol dependence
or abuse.
The total study sample consisted of 26 women and
14 men; the average age was 78 years (range 62–89
years). Ten patients with depression and ten patients
with AD were included in the standard therapy (ST)
group receiving psychopharmacologic medication.
Ten patients with depression and ten patients with AD
were included in the humour therapy (HT) group
receiving medication and additionally humour
therapy. Three patients with AD in the HT group
and two patients with AD in the ST group had the co-
occurring diagnosis of major depression according to
DSM-IV. Both groups did not differ concerning
sociodemographic data (age, sex) and their social
characteristics (family status, living situation) at
admission. The patients in the HT group have received
the therapy during their inpatient treatment period.
The median number of weeks of hospitalisation was
15 weeks (range 4–28 weeks). Detailed information
about subjects’ demographics and social character-
istics are provided in Table 1.
Humour therapy
The HT group comprised a group of six to eight
patients who received 1 h therapy once every two
weeks. During each session it was the moderator’s
objective from the very outset to generate an
atmosphere of mirth and serenity. Each group session
was conceived to follow a pattern of growing
involvement and participation by the patients. It goes
without saying that the individual cognitive and
Copyright #2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (in press)
DOI: 10.1002/gps
m. walter ET AL.

emotional predispositions varied and had to be taken
into account. The moderator acts as a stimulant for
humour, smiling and laughter using verbal techniques.
After an initial phase, the moderator tells or reads
humorous stories or suggestive funny anecdotes. The
aim is to trigger the patients’ reactions, observations or
comments by way of personal associations with what
she or he has just heard. Where appropriate, the
moderator intervenes with provocative or slapstick
humour. Furthermore, biographical episodes and
memories, happy ones, are addressed later on:
‘How did you spend your first pocket-money?’, ‘your
favourite dessert as a second grader?’, ‘your childhood
hobby?’, ‘the first kiss’, ‘your favourite teacher?’, etc.
As these life- topics are shared by everyone in the
group, the intrinsic sense of humour of this last part
has considerable potential for shared laughing or
smiling. Compared to other interventions (e.g. life
course review), the focus of the humour therapy is the
accentuation of an exhilaration milieu in the group and
the encouragement of everyone’s sense of humour.
Psychopharmacotherapy
All AD patients were treated with a cholinesterase
inhibitor (galantamine). Thirteen (65%) patients with
AD received a low-dose antidepressive therapy with a
serotonin re-uptake inhibitor (escitalopram) (six in ST
group, seven in HT group), and 17 (85%) patients with
AD received low-dose neuroleptics (quetiapine) (nine
in ST group, eight in HT group).
All patients with late-life depression were receiving
SSRI’s (escitalopram or mirtazapine). Four patients
with late-life depression were additionally receiving a
low-dose neuroleptic medication (three in ST group,
one in HT group). Benzodiazepines were avoided. If
the patient met response criteria that dose was
continued for the rest of the inpatient treatment. In
general, medications were not changed during the
study.
Psychometric assessment instruments
For the evaluation of depressive mood, the Geriatric
Depression Scale (GDS) was used (GDS,
Yesavage et al., 1983). Scores higher or equal than
6 in GDS were rated for depression. The Mini-Mental-
State-Examination (MMSE) was used to evaluate the
grade of dementia severity (Folstein et al., 1975).
Scores on the MMSE range from 0–30, and scores
lower then 26 indicate cognitive impairment. The
Nurses’ Observation Scale for Geriatric Patients,
NOSGER (Spiegel et al., 1991) is a 30-item
questionnaire completed by the caregiver to assess
the patient with regard to the dimensions of memory,
instrumental activities of daily living (IADLs), basic
Table 1. Baseline soziodemographic data, clinical characteristics and psychometric test results of study patients (n¼40)
Characteristics Late-life Depression (n¼20) Alzheimer’s disease (n¼20)
Humour Therapy
(HT) group (n¼10)
Standard Therapy
(ST) group (n¼10)
Humour Therapy
(HT)group (n¼10)
Standard Therapy
(ST) group (n¼10)
Age, mean (SD), y 78.5 (6.3) 72.8 (6.5) 81.9 (3.9) 80.4 (7.1)
Family status
Single — 1 (10%) 1 (10%) 1 (10%)
Married 2 (20%) 5 (50%) 4 (40%) 2 (20%)
Separated/divorced — 1 (1%) 1 (10%) —
Widowed 8 (80%) 3 (30%) 4 (40%) 7 (70%)
Living situation before admission
Alone 8 (80%) 5 (50%) 6 (60%) 8 (80%)
With partner 2 (20%) 5 (50%) 4 (40%) 2 (20%)
MMS score, mean (SD) 27.3 (2.8) 27.3 (1.9) 23.1 (3.9) 20.5 (4.1)
NOSGER score, mean (SD)
Memory 7.3 (2.0) 9.2 (2.8) 10.6 (4.5) 12.1 (4.6)
ADLs 13.4 (4.4) 13.4 (3.7) 12.7 (5.1) 14.00 (3.9)
Basic Activity of daily living 6.7 (2.6) 6.7 (1.9) 9.4 (4.8) 10.1 (3.8)
Mood 12.6 (4.5) 14.0 (5.2) 9.3 (2.2) 8.5 (1.5)
Social disturbances 10.6 (4.2) 12.6 (3.7) 11.7 (3.7) 12.1 (4.3)
Disturbing behaviour 6.1 (1.7) 7.3 (2.7) 8.4 (3.9) 8.5 (3.0)
GDS score, mean (SD) 6.7 (3.3) 7.60 (5.3) 5.3 (5.3) 2.5 (2.0)
Quality of life, ACSA, mean (SD) 3.8 (2.1) 4.3 (2.6) 4.0 (1.8) 4.8 (2.2)
ADLs ¼Instrumental Activity of daily living.
Copyright #2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (in press)
DOI: 10.1002/gps
humour therapy in patients with late-life depression or ad

ADLs, mood, social behaviour, disturbing beha-
viour, each of these dimensions consisting of five
items. The answers are scored from 1 to 5, thereby
yielding a total score for each dimension of 5–25.
Higher scores indicate more severe disturbance or
impairment.
As a measure of subjective global quality of life
(QOL) we used the Anamnestic Comparative Self
Assessment Scale (ACSA), a ten-stage anchor scale
for a global assessment of present quality of life
defined in terms of the ‘best time’ versus the ‘worst
time’ in life (Bernheim and Buyse, 1983; Bernheim,
1999). A higher quality of life will be reflected by an
improvement in the global scale score. The values
calculated for a group of healthy students (n¼43)
served as a control (Rose et al., 1998). All
questionnaires used have proven to be valid and
reliable in previous clinical studies (Walter et al.,
2002; Weber et al., 2005).
Statistical analyses
Statistical analyses were performed with SPSS/13.0
for Windows. We used the t-test for dependent
samples for comparisons across and the Mann–
Whitney-U-Test for group comparisons. The level
of significance was set at p0.05.
RESULTS
The demographic and clinical characteristics of the 40
patients with late-life depression or AD receiving HT
or ST are described in Table 1.
At admission, patients of both therapy groups (HT,
ST) tended to estimate their QOL lower than the
healthy control group (p<0.001). After treatment,
depressive patients in both therapy groups rated their
QOL significantly higher than before clinical treat-
ment (Figure 1). Patients with AD in both therapy
groups did not show a significant improvement in
QOL after treatment (Figure 1).
As shown in Figure 2, QOL improved after HT in
both patient groups but this effect did not last until the
next therapy meeting after two weeks.
After treatment, four patients (10%) of the total
study sample rated their present QOL to be impaired,
26 (65%) showed a slight improvement, and ten
patients (25%) rated their present QOL to be
significantly improved.
Whereas patients with HT did not differ signifi-
cantly from the patients in the ST in their QOL after
treatment, the patients with depression were found to
be distinctly profit from both therapy methods
(t¼5.17, df ¼19, p<0.001).
Additionally, patients with late-life depression of
both groups showed significant improvements in the
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Figure 1. Global quality of life before and after treatment
Copyright #2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (in press)
DOI: 10.1002/gps
m. walter ET AL.

depression score (t¼3.16, df ¼19, p¼0.005), mood
(t¼3.13, df ¼19, p¼0.005), and instrumental activi-
ties of daily living (t¼3.15, df ¼19, p¼0.005).
DISCUSSION
This study investigated the hypothesis that humour
group therapy may influence QOL of patients with
late-life depression or AD. Previous studies have been
demonstrated that patients with mild and moderate
AD can rate their own QOL (Fuh and Wang, 2006). In
general, individual psychopathology, social network
and self-esteem were found as major determinants of
subjective QOL in psychiatric patients (Hansson,
2006). This is the first study to our knowledge which
investigates the effect of HT on QOL in patients with
depression and AD. The main finding was the
improvement of QOL during psychiatric inpatient
treatment for depressive patients. The depressive
patients (without AD) who received HT showed the
highest quality of life after treatment. However, the
difference was not significant between both therapy
groups. Furthermore patients with AD of both therapy
groups did not significantly improve in subjective
quality of life in this pilot study.
The study was not large enough to detect a modest
treatment effect for one of each therapy group, but we
must noticed that HT is applicable in geriatric
psychiatry and that each humour group enhanced
subjective well- being of patients with depression and
AD measured by global QOL. We excluded patients
with psychosis or substance abuse, because we tried to
generate two relative homogenous groups. Although
the diagnosis of depression and AD were differen-
tiated—i.e. AD was excluded in depressed patients,
and the depression scores in AD patients were lower
than in depressed patients — an overlap between the
two patient groups may exist.
It is well known that a sense of humour predicts
higher quality of life and lower depression levels in
chronic disease (Aarstad et al., 2005). In patients with
AD, humour was generally identified as a positive
approach (Colling, 2004), but no empirical study has
investigated the association between HT and QOL.
Ong et al. (2004) suggested that stress and depressive
associations are weakened when positive emotions are
present. Especially for patients with AD and mild or
0
1
2
3
4
5
6
7
8
9
10
131197531
QOL before humour group: Depression QOL after humour group: Depression
QOL before humour group: Alzheimer's disease QOL after humour group: Alzheimer's disease
Best time in life
time in lifeWorst
time (in weeks)
Healthy
group
control
Figure 2. Global quality of life before and after humour therapy
Copyright #2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (in press)
DOI: 10.1002/gps
humour therapy in patients with late-life depression or ad

moderate cognitive deficits, it seems important that
positive emotions, e.g. in a humour group, must be
experienced weekly, or even better, daily, because
patients with AD forget these emotions much faster
than patients with depressive symptoms alone. One
reason why AD patients did not show a profit from HT
may be the low frequency of the therapy setting used
in our study. Parameters such as high therapy
frequency need to be evaluated as to whether they
have a higher impact on QOL improvement in AD.
The generalization of these results is limited as a
consequence of the low intensity of humour therapy
and the small sample size of each study group.
Furthermore the standard therapy was not controlled
for the use of pharmacologic medication. However, we
have tried to reduce the number and the type of
medication used. The study groups were very
homogeneous concerning diagnosis and psychosocial
data. Future studies with higher frequent humour
therapy and larger samples may provide better insight
in the therapeutic advantages of humour therapy in the
treatment of late-life depression and AD.
ACKNOWLEDGEMENTS
We thank Professor A. Wirz-Justice for english edit-
ing.
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KEY POINTS
Although the effects of humour therapy were not
significant, especially depressed patients have
profited.
Humour therapy can provide an additional non–
pharmacologic tool in gerontopsychiatry.
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humour therapy in patients with late-life depression or ad