Mohammed T. Abou-Saleh

PSYCHOTHERAPY OF DEPRESSION AND DYSTHYMIA 447Research does suggest that the amount of structure inreminiscence therapy may influence outcome 39 . Fry 39 comparedindividual structured reminiscence therapy, non-structuredreminiscence and non-reminiscence visits in a sample ofmoderately depressed elderly. Subjects in the non-reminiscencecontrol group had significantly higher post-treatment depressionscores than those in either reminiscence group; the subjects inthe structured reminiscence groups had lower depression scoresthan those in the unstructured reminiscence groups. Reminiscencegroup therapy has also been tested in nursing homeresidents with dementia and has been found to reduce selfreportedsymptoms of depression to a greater degree thansubjects in supportive therapy or control groups 40 . However,the therapy did not improve cognitive or behavioral outcomes,and the reduction in depression was short-lived 40 . Rattenburyand Stones 41 found that both reminiscence and current eventdiscussion groups showed positive changes on measures ofpsychological well-being when compared to non-treatmentcontrols. However, because subjects were not selected for highdepression scores, this was not an empirical test of treatmentfor clinical depression. Yet the results do suggest that there issomething beneficial about client-focused interaction, a fundamentalcomponent of any form of psychotherapy.INTERPERSONAL PSYCHOTHERAPYInterpersonal psychotherapy (IPT) is a manualized, time-limitedoutpatient treatment for depression, focusing on currentinterpersonal issues in four problem areas: interpersonaldisputes, role transitions, interpersonal deficits and abnormalgrief 42 . The therapist and client collaborate to identify whichproblem area to focus on in treatment; commonly, more thanone problem area is chosen. Klerman et al. 42 pointed out that,regardless of the origin of depression (genetic, biochemical,developmental vulnerability, personality), the condition isexpressed within an interpersonal context. The initial goal oftherapy is to reduce symptoms of depression, but the overarchinggoal is to improve the patient’s social functioning andinterpersonal relationships 43 . With its emphasis on addressinginterpersonally relevant problems, IPT appears particularly wellsuited to the life changes that many older people experience.Techniques utilized in treatment include: role playing, communicationanalysis, clarification of the patient’s wants and needs,and links between affect and environmental events 44 . Frank andcolleagues 45 have developed separate treatment manuals for IPTin late life (IPT-LL) and interpersonal maintenance therapy forolder patients (IPT-LLM) (cited in ref 44). These manualsinclude adaptations specific for use in elderly patients, including,but not limited to, flexibility in length of sessions, longstandingrole disputes, and the need to help the patient withpractical problems.Controlled trials in adult depressed populations have demonstratedthe efficacy of IPT for the treatment of acute depression(reviewed in refs 43, 44). IPT has also been found as effective inthe acute treatment of major depressive disorder in elderlypatients as nortriptyline 46 . Of additional importance were findingsthat elderly patients in IPT treatment were less likely to drop outof treatment than those taking nortriptyline, because of themedication’s side effects.Research from the Reynolds group at the University ofPittsburgh has shown IPT in combination with nortriptyline tobe an effective treatment for elderly depression in geriatricsamples 47,48 . In an attempt to understand more regarding thetreatment of elderly patients with recurrent depression, Reynoldset al. 47 selected patients only if they reported at least oneprior episode of depression. The authors reported that 78.4%(116/148) remitted during the acute phase of treatment (8–14weeks). During the continuation phase, 15.5% (18/116) experiencedrelapse of major depression; thus, a total of 66.2%patients recovered fully 47,48 . Consequently, the authors concludedthat older patients with recurrent major depression cansuccessfully be treated with a combination of antidepressantmedication and interpersonal psychotherapy, and that olderpatients respond as well, albeit more slowly, than middle-agedpatients 49 .COGNITIVE-BEHAVIORAL THERAPYThe cognitive model of depression 50 is based on the notion that, asa consequence of early learning, depressed individuals developstable cognitive schemas or core beliefs which predispose them tonegative interpretations of life events (i.e. cognitive distortions).This distorted style of thinking is hypothesized to result indepressive behavior and experience.Cognitive-behavioral interventions for depression typicallyinvolve three active components. First is a behavioral activationcomponent, in which the patient is exhorted to increaseactivities that are reinforcing, and thus increase the amountof pleasurable experience in life. Second, automatic dysfunctionalthoughts are identified, explored, challenged and replacedwith more accurate cognition, based on a thorough assessmentof the patient’s contextual environment. Third, underlyingcognitive schemas or structures, which are hypothesized todrive automatic cognitive distortions and limit access toexperiences that may alter these schemas, are identified andaltered to more accurately reflect the patient’s actual environmental,social and personal experience. Recent componentanalysis research suggests that behavioral activation andautomatic thought modification are equally effective, and bothcomponents together are no more effective in preventing relapsethan when used alone 51,52 .More purely behavioral interventions are derived from classiclearning theory, in which problem behaviors are viewed as theresult of specific antecedent stimuli and consequential events thatreinforce, punish or maintain behavioral responses 53 . Thistherapeutic approach views depression as a state in which thereis a relative shift toward an increase in certain aversive affectivereactions (respondent processes) and a concomitant reduction inthe frequency of overt activities (operant extinction or punishment).In addition, histories of pervasive inescapable punishment,reinforcement of distressed behavior, classically conditioneddysphoric responses, and the evocative salience of certain stimulidepending on mood, may be examined as part of a functionalanalysis of depressed behavior 53,54 . For example, a previouslyactive person suffering from a serious illness may experience areduction in the frequency of self-esteem-generating activities andpositive social contacts, as well as increased dependency on othersfor the provision of positive reinforcers, and may feel bored,helpless and pessimistic. Restoration of the predictability andavailability of positive reinforcers, and reduction in negativereinforcers (i.e. avoidance behaviors), is seen as linked to thecurative process, with goals of symptom reduction and increasedskill at identifying and obtaining appropriate reinforcement.Techniques used might include monitoring behavior and affectpatterns, assigning pleasant events, stimulus control, limitingworry and depressive ruminations with time limits, behavioralexposure, and skills training (relaxation, problem-solving, interpersonalskills).A related therapy for elderly depression, which utilizes elementsassociated with both cognitive and behavioral interventionsdescribed above, examines problems associated with socialproblem solving. Social problem-solving therapy (PST) is based