Psychological Therapies with Older People: The Evidence Base

1. Psychological Therapies with Older People: The Evidence Base Ken Laidlaw, PhD Senior Lecturer in Clinical Psychology/ Clinical Lead, Older Adult Psychology Services in Edinburgh, NHS Lothian

2. Increasing Access to psychotherapy for Older People? “The mark of a noble society is found not in the manner in which it helps the rich but in how it helps the poor and the vulnerable. Not in its virtues during good times but in its character during hard times. Not in how it protects the powerful, but how it defends the vulnerable” (Osei Darkwa, 1997, p186).

3. Empirical Review • Evidence has accumulated that suggests that psychotherapy is an effective treatment for depression in later life • Freud’s position • The most commonly used psychotherapies for depression in later life are Cognitive-Behaviour Therapy (CBT), Interpersonal Psychotherapy (IPT), and Psychodynamic Psychotherapy (PP)

4. Empirical Review: CBT Cognitive Behaviour Therapy (CBT) is an active, directive time-limited and structured problem-solving treatment approach whose primary aim is symptom reduction (Laidlaw et al. 2003). Empirical evidence suggests that CBT is an efficacious treatment for late life depression. Recommended texts: Laidlaw et al, 2003 and Gallagher-Thompson, Steffen, & Thompson (2008) Handbook of Cognitive and Behavioural Therapies.

5. Empirical Review: IPT Interpersonal psychotherapy (IPT) is a short-term focussed treatment programme for depression (Hinrichsen & Emery, 2005). IPT focuses on 4 main problem areas in its treatment approach to depression, these are: (i) grief; (ii) interpersonal disputes (iii) role transitions and (iv) interpersonal deficits (Karel & Hinrichsen, 2000) Recommended text: Hinrichsen, G. & Clougherty, K. (2006) Interpersonal Psychotherapy for depressed older adults.

6. Empirical Review: PP There is no one single form of psychodynamic psychotherapy with older people. PP can be interpreted very broadly although many approaches focus on the therapeutic relationship as the means of change and focus on transference and counter-transference Recommended texts: Evans & Garner (2004) and Sadavoy & Leszcz (1987) Treating the Elderly with Psychotherapy: The Scope for Change in Later Life

7. How is Psychotherapy Different with Older People? • Chronicity and lifetime history of distress • Decisions have been made and lived with • Physical illnesses with Psychological Consequences • Loss experiences and experiences of aging • Different value systems • Older people don’t identify themselves as OP, so maybe sometimes its not different! Sadavoy talks about the 5 cs of psychogeriatrics: Chronicity, Complexity, Comorbidity, Continuity & Context

8. Empirical Review of CBT with Older People • Scogin & McElreath(1994) 17 studies. Meta-analysis • Koder, Brodaty & Anstey(1996) 7 studies, Meta-analysis • Engels & Verney(1997) 17 studies, Meta-analysis • Cuijpers (1998) Cuijpers et al., (2005) • Gatz et al., (1998) APA sponsored Evidence review • Gerson et al.,(1999) 45 studies, Meta-analysis • Laidlaw(2001) 9 studies, Meta-analysis • Pinquart & Sorensen(2001) 122 studies, Meta-analysis • Frazer et al., 2005 Evidence based review • Pinquart, Duberstein & Lyness(2006) 89 Studies, Meta-analysis • Scogin et al., (2005) 20 studies: Evidence based review • Wilson, Mottram, Vassilas (2008) Cochrane Review

9. CBT vs TAU for Late Life Depression RCT of CBT with Older People, Laidlaw et al, 2008 Results (Intention to Treat Analyses) • Both groups improved significantly by end of treatment phase. • At 6 month follow-up participants improved on all primary outcome measures. • Adjusting for baseline scores CBT group performed better on BHS at 6 months follow-up (F (1,37) = 6.12, p = .018) • Adjusting for gender differences at baseline, CBT participants performed better on BHS at six months follow-up (F (1. 37) = 5.00, p = .03). • Age was not a factor in determining outcome.

10. Empirical Review: CBT For Late Life Anxiety • A number of RCTs have been conducted with older people with anxiety. Many of these conducted in the US. Some criticisms re: age and health status of participants. • Increasing No. of substantive reviews of CBT for LLA • Recent paper in JAMA (301(14), 1460-67) by Stanley et al conducted in Primary Care settings comparing CBT to EUC. • Other recent developments in late life anxiety include highly specialised CBT for people with executive dysfunction (Mohlman & Gorman, 2005; Mohlman et al., 2008).

11. Emergent Evidence with Older People • There are 5 published studies looking at CBT for depression in Parkinsons’s disease. This is very promising as depression especially as “Pharmacological treatment of depression in PD remains something of a black hole” (Burn, 2002). • The picture for CBT for post-stroke depression is less clear. 2 RCTs with unclear results. The data suggests that an augmented format for CBT may be more successful. • Direct psychotherapy for people with dementia is less common and research needs to be conducted as a national priority – MHC Pilot

12. Strucutred Interventions with Dementia Caregivers Emerging consensus on Evidence Base: REACH • Active interventions better than passive interventions • CBT works best for reducing caregiver distress and burden • Psychoeducation improves SWB, distress only if it is active • Supportive approaches effects SWB only but may be ineffective for psychological distress • Individual interventions more effective than group • Structured Multi-component interventions may reduce and delay institutionalisation. • Sources: Burgio et al., 2008; Gallagher-Thompson & Coon, 2007; Longsden et al., 2007; Pinquart & Sorenson, 2002; Pinquart & Sorensen, 2006; Selwood et al. 2007.

13. Empirical Review of Psychotherapy with Older People • Evidence for CBT is stronger than for other forms of therapy (Frazer et al, 2005; Gatz et al, 1998; Laidlaw 2001; Pinquart et al, 2006; Scogin et al, 2005) • Individual therapy appears to be superior to group (Engels & Verney, 1997; Pinquart & Sorensen, 2001; Scogin et al 2005) • Psychotherapy seems comparable in efficacy to medication (Gerson et al, 1999; Pinquart et al, 2006) • Few studies have examined effect of combination treatments (Pinquart et al 2006; Scogin et al, 2005; Wilson et al, 2008). • The literature on psychotherapy outcome with oldest-old is insufficient (Engels & Verney, 1997; Laidlaw, 2001; Scogin et al, 2005) • The literature on CBT for depression comorbid with disorders more common in later life (Dementias, Post-stroke depression, etc,) is emerging but at very early stages

14. CBT and the Demographic Context The current evidence base for CBT with Older People is reasonably strong and mature BUT In psychological treatment models there are very few specific frameworks to characterize the experience of older people who develop depression/anxiety Maybe it is time to develop more age specific models of CBT for older people (Laidlaw & Pachana, 2009), and consider new targets for CBT such as attitudes to ageing and wisdom enhancement (Laidlaw, 2010) Wisdom is one of the few positive attributes associated with ageing and may enhance outcome for chronic dep.

15. Application of Psychological therapy with Older People Researchers are turning their attention to the issue of application of therapy with older people Knight et al., CALTAP (Contextual Adult Lifespan Theory for Adapting Psychotherapy) Laidlaw et al., CCF (Comprehensive Conceptualization framework – for CBT) Knight & Laidlaw, 2009, Laidlaw, 2010 – Wisdom Enhancement: Aim is to produce a developmentally appropriate theory for therapy with older people

16. A Radical Approach?Not just talking… • NHS Lothian OP Psychology has initiated the following • Introduction to CBT courses (x2 with a specialist CBT-OP course planned Oct. ’10) • “I found it challenging, inspiring and exciting. I got a buzz from learning new skills and gaining new perspectives.” • The Masterclass Experience: A Truly unique, innovative and valuing approach to training in psychological therapies • “Fantastic to hear from such experienced and knowledgeable clinicians - who aren’t too academic” • Univ. Edinburgh has given KT funds to develop proposal for a UK-wide training course in CBT with older people

17. Psychological Therapies With Older People: A Radical Approach? • The evidence is clear multiple forms of Psychotherapy work as well with older people as they work with adults of working age. • Older People want access to psychological therapies • Mental health in ageing can be complex and thus we need a properly equipped workforce. • We need to prioritise this where the need is greatest given the demographic transition in Scotland. • We need a radical approach to ensure that older people have access to quality psychological care delivered by those with the relevant expertise.