Psychosocial interventions for mental illness in late‐life

Research into the efficacy of psychotherapy for mental illness in older adults has made several strides over the last 20 years. In the 1980s the work of Dolores Gallagher-Thompson and Larry Thompson shed new light on the potential for psychotherapy as a viable treatment alternative for depression in older people (Gallagher-Thompson et al., 1990). Since then, there have been several more well-designed studies that have found support for psychotherapies like cognitive behavioral therapy, brief dynamic therapy, life review and problem solving therapy. A recent review of the literature in late life depression has found that cognitive behavioral therapies in particular are efficacious in treating late life depression (Mackin and Areán, 2005). Despite these advancements, considerably more work is needed to understand the benefits of psychotherapy for mental illness in late life. A majority of the research to date has used relatively healthy, young-old samples, who suffer from major depression (Mackin and Areán, 2005). The benefits of psychotherapy for more complex presentations of late life depression, for instance, depression in medically ill samples, depression and co-morbid cognitive impairments, and depression with co-morbid anxiety and personality disorder, have not been well explored (Areán and Cook, 2002). Further, research on the utility of psychotherapy for anxiety disorder, late life psychosis, and substance abuse is in its earliest stages (Wetherell et al., 2003). The role that poverty, culture and faith play in determining treatment outcome is a question that is of significant relevance to any treatment outcome (Coon et al., 2004). Finally, a consensus as to the best methods for studying psychotherapy in older adults needs to be determined to better advance the psychotherapy field (Areán et al., 2003b). This special issue of the International Journal of Geriatric Psychiatry was developed to address some of these issues. In our search for high quality psychotherapy research, we were able to identify several excellent, albeit preliminary, studies that begin to address the benefits that psychotherapy can have on more complex presentations of late life depression. The paper by Lynch et al. and Gum et al. addresses the utility of cognitive behavioral therapy for older adults with depression and personality disorder. These papers find that, for this population, psychotherapy effectively addresses depressive symptoms and can result in decreased clinical manifestations of character pathology. The paper by Miller and Reynolds lends preliminary data on the efficacy of interpersonal therapies for treating depression in older adults with mild cognitive impairments. As many as 30% of older adults with depression also exhibit cognitive complaints, yet few studies have investigated the utility of psychotherapy for this subgroup of patients. Raue and Shulberg demonstrate that integrating psychotherapy into settings where older people are most likely to access services is feasible and reduces depressive symptoms and signs and improves function. Finally, Chen et al. show that among the most important processes that drive the effectiveness of mental health treatment in late life is the role of regular participation in spiritual activities. These papers indicate that psychotherapy has a valuable role for late-life mental illness. Given their preliminary nature, however, further study is needed to truly enhance what we know about these treatments, the processes by which they work, and their relative contribution to the management of late life mental illness. Additionally, these papers suggest that psychotherapy can be effective even in the face of significant psychiatric and cognitive comorbidity. More research to understand how these comorbidities moderate treatment outcome, and how the process of psychotherapy can in turn mediate treatment outcomes is important in improving these interventions and in determining when they may be the better choice among the available array of interventions. As an example, we have found that older adults with comorbid depression and executive functions have a poor an unstable INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY