•  

Intervention Summary

Back to Results Start New Search

Cognitive Behavioral Therapy for Late-Life Depression

Cognitive Behavioral Therapy (CBT) for Late-Life Depression is an active, directive, time-limited, and structured problem-solving approach program that follows the conceptual model and treatment program developed by Aaron Beck and his colleagues. CBT for Late-Life Depression includes specific modifications for elderly depressed individuals who are being treated as outpatients. The intervention includes strategies to facilitate learning with this population, such as repeated presentation of information using different modalities, slower rates of presentation, and greater use of practice along with greater use of structure and modeling behavior. Patients are taught to identify, monitor, and ultimately challenge negative thoughts about themselves or their situations and develop more adaptive and flexible thoughts. Where appropriate, emphasis is also placed on teaching patients to monitor and increase pleasant events in their daily lives using behavioral treatment procedures. The intervention consists of up to 20 50- to 60-minute sessions following a structured manual.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: December 2006
1: Symptoms of depression
2: Diagnosis of depression
3: Life satisfaction
4: Coping strategies and involvement in pleasurable activities
5: Severity of other psychiatric symptoms
Outcome Categories Mental health
Quality of life
Social functioning
Ages 55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Settings Outpatient
School
Geographic Locations Urban
Suburban
Implementation History The CBT for Late-Life Depression basic protocol (or variations of this protocol) has been in use for about 25 years in the United States. CBT has been used in Scotland in a randomized clinical trial using a modification of the protocol. Since 1980, the developer has trained more than 50 psychologists, psychiatrists, social workers, and nurse specialists in using the protocol, most of whom have assumed clinical positions in their settings. Many clinical centers have used the protocol or parts of it, and five have been evaluated for outcomes (three under the developer's supervision). About 700 patients and more than 1,000 caregivers have participated in the program through Stanford University's Older Adult and Family Center over the past two decades. Modifications of the protocol are being used to treat special populations, such as family caregivers in a group format.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations The developers have treated individuals from numerous ethnic-minority groups in their training and research programs using the original protocols with successful outcomes. Adaptations have been developed for use with special populations such as family caregivers, Hispanic Americans, Asian Americans, African Americans, and Persians. A male-specific adaptation has also been developed. Translations and back-translations of the manuals and instruments for evaluation have been made available in Spanish and Chinese. Randomized trials have shown the effectiveness of this intervention among Latinos, Chinese, and African Americans.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: December 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Gallagher, D. E., & Thompson, L. W. (1982). Treatment of major depressive disorder in older adult outpatients with brief psychotherapies. Psychotherapy: Theory, Research and Practice, 19(4), 482-490.

Gallagher, D. E., & Thompson, L. W. (1983). Effectiveness of psychotherapy for both endogenous and nonendogenous depression in older adult outpatients. Journal of Gerontology, 38(6), 707-712.  Pub Med icon

Study 2

Gallagher-Thompson, D., Hanley-Peterson, P., & Thompson, L. (1990). Maintenance of gains versus relapse following brief psychotherapy for depression. Journal of Consulting and Clinical Psychology, 58(3), 371-374.  Pub Med icon

Thompson, L. W., Gallagher, D., & Breckenridge, J. S. (1987). Comparative effectiveness of psychotherapies for depressed elders. Journal of Consulting and Clinical Psychology, 55(3), 385-390.

Thompson, L. W., Gallagher, D., & Czirr, R. (1988). Personality disorder and outcome in the treatment of late-life depression. Journal of Geriatric Psychiatry, 21(2), 133-146.

Study 3

Thompson, L. W., Coon, D. W., Gallagher-Thompson, D., Sommer, B. R., & Koin, D. (2001). Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression. American Journal of Geriatric Psychiatry, 9(3), 225-240.  Pub Med icon

Study 4

Laidlaw, K., Davidson, K., Toner, H., Jackson, G., Clark, S., Cross, S., et al. (2006). A randomized controlled trial of cognitive behavior therapy versus treatment as usual in the treatment of mild to moderate late life depression. Manuscript submitted for publication.

Supplementary Materials

Crits-Christoph, P., Baronackie, K., Kurcias, J. S., Beck, A. T., Carroll, K., Perry, K., et al. (1991). Meta-analysis of therapist effects in psychotherapy outcome studies. Psychotherapy Research, 1(2), 81-91.

Laidlaw, K., Thompson, L. W., & Gallagher-Thompson, D. (2004). Comprehensive conceptualization of cognitive behaviour therapy for late-life depression. Behavioural and Cognitive Psychotherapy, 32, 389-399.

Letter of support for intervention from Dr. Forrest Scogin, Professor, University of Alabama. Dated September 25, 2006.

Report on reliability and validity of measures used. (n.d.). Unpublished report.

Outcomes

Outcome 1: Symptoms of depression
Description of Measures Symptoms of depression were assessed using (1) the Hamilton Rating Scale, which is used to rate the level of depression and improvement of depressive symptoms over time; (2) the Beck Depression Inventory, a 21-item self-report scale assessing the intensity of depressive symptoms; (3) the Zung Self-Rating Depression Scale, a self-report scale indicating frequency of depressive symptoms; (4) the Geriatric Depression Scale, used to assess presence or absence of depressive symptoms for geriatric patients; and (5) the Depression Scale of the Brief Symptom Inventory, a self-report depression scale that assesses several categories of depression.
Key Findings Patients reduced their depression symptoms after receiving any of the following: behavioral therapy, cognitive therapy, brief relational/insight psychotherapy, brief psychodynamic psychotherapy, desipramine therapy, CBT, CBT plus desipramine, and generic treatment as usual. However, improvement at 1-year follow-up was maintained more effectively by behavioral or cognitive therapy than by relational/insight therapy. Desipramine plus CBT therapy was more effective than CBT alone or desipramine alone in patients who were more severely depressed. In addition, larger treatment effect sizes were found with CBT compared with treatment as usual.
Studies Measuring Outcome Study 1, Study 2, Study 3, Study 4
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 2: Diagnosis of depression
Description of Measures This outcome was measured using structured clinical interviews that applied Research Diagnostic Criteria (RDC) to the Schedule for Affective Disorders and Schizophrenia--Lifetime version (SADS-L). The SADS-L was also used to establish RDC diagnostic criteria at the pretreatment, posttreatment, and follow-up stages. The Longitudinal Interval Follow-up Evaluation was used to ascertain retrospectively whether depressive episodes had occurred in the interval between follow-up evaluations.
Key Findings Among 91 older adults initially diagnosed with an episode of major depressive disorder, between 52% and 70% did not meet criteria for RDC depressive disorder after treatment with cognitive therapy, behavioral therapy, or brief psychodynamic psychotherapy. Over time, patients not depressed at posttreatment remained depression-free longer than patients who had minor or major depressive disorders. At 6-month follow-up, clients who completed CBT were less likely to meet criteria for diagnoses of depression than clients who completed treatment as usual.
Studies Measuring Outcome Study 2, Study 4
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)
Outcome 3: Life satisfaction
Description of Measures Life satisfaction was assessed using (1) the Hopelessness Scale, a 20-item self-report measure of the extent of negative attitudes towards the future that is linked to risk of suicide in depression; (2) the Automatic Thoughts Questionnaire, a self-report measure that indicates the level of negative dysfunctional thoughts; (3) the Young Loneliness Inventory, a self-report measure that assesses extent of loneliness; (4) the Beck Hopelessness Scale, a 20-item self-report measure of the extent of negative attitudes towards the future (linked to risk of suicide in depression); and (5) the Penn State Worry Questionnaire, a 16-item self-report measure of an individual's tendency to worry.
Key Findings Among older adults, measures of life satisfaction improved following treatment with cognitive therapy, behavioral therapy, or brief psychodynamic psychotherapy. At 6-month follow-up, CBT resulted in larger effect sizes for life satisfaction compared with treatment as usual.
Studies Measuring Outcome Study 2, Study 4
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)
Outcome 4: Coping strategies and involvement in pleasurable activities
Description of Measures Coping strategies and involvement in pleasurable activities were measured by (1) the World Health Organization Quality of Life Scale, a 20-item scale assessing satisfaction with various quality of life domains; (2) the Social Adjustment Scale, an interview and self-report scale used to assess level of social functioning; (3) the Behavioral Cognitive and Avoidance Coping Scales in the Health and Daily Living Questionnaire, a self-report scale where subjects indicate how they would deal with specific stressful situations; and (4) the Older Persons Pleasant Events Schedule, with which subjects review a list of pleasant activities and indicate how often they are doing them and whether or not they are pleasurable.
Key Findings Patients improved in overall adjustment and coping after treatment with cognitive therapy, behavioral therapy, or brief psychodynamic psychotherapy. CBT produced improved environmental quality of life when applied to older adults with moderate depression (p < .03).
Studies Measuring Outcome Study 2, Study 4
Study Designs Experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 5: Severity of other psychiatric symptoms
Description of Measures Severity of other psychiatric symptoms was measured using (1) the Global Severity and Anxiety subscales of the Brief Symptom Inventory, which assesses the client's level of anxiety; (2) the Brief Psychiatric Rating Scale, an interviewer measure that rates presence of severe psychiatric symptoms; and (3) the Schedule for Affective Disorder and Schizophrenia, a semistructured interview used to assess mental disorders as defined by the Research Diagnostic Criteria.
Key Findings Patients reduced their psychiatric symptoms other than depression after treatment with cognitive therapy, behavioral therapy, or brief psychodynamic psychotherapy.
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 2.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 55+ (Older adult) 76.7% Female
23.3% Male
93.3% White
3.3% Black or African American
3.3% Hispanic or Latino
Study 2 55+ (Older adult) 67.4% Female
32.6% Male
Data not reported/available
Study 3 55+ (Older adult) 67% Female
33% Male
Data not reported/available
Study 4 55+ (Older adult) 72.5% Female
27.5% Male
Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Symptoms of depression 4.0 4.0 3.3 2.3 2.1 2.8 3.1
2: Diagnosis of depression 3.5 3.5 3.0 2.5 2.0 2.5 2.8
3: Life satisfaction 3.7 3.7 3.0 2.0 2.0 2.3 2.8
4: Coping strategies and involvement in pleasurable activities 2.3 2.3 2.5 2.3 2.3 2.5 2.3
5: Severity of other psychiatric symptoms 3.0 3.0 3.0 2.5 2.0 2.0 2.6

Study Strengths

The studies made good use of reliable and valid measures. Given the nature of the target population, the developers did a good job of looking at attrition and missing data. Data evaluation was good. CBT clearly is effective with older adults, despite the treatment challenges that can be inherent with this population. The use of standardized manuals and appropriate training supports efficacy.

Study Weaknesses

Concerns with severity, age, socioeconomic status, high function levels, and high exclusions all limit generalizability. Testing fatigue was a possibility for the elderly participants, who were tested very frequently in some studies. The use of interns as opposed to experienced therapists adds variables as well. One study lacked a tested fidelity instrument. The use of a wait-list control group in one study could be problematic as this could have led to other help-seeking behavior.

Readiness for Dissemination
Review Date: December 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Cognitive Behavioral Therapy for Late-Life Depression [PowerPoint presentation]

Dick, L., Gallagher-Thompson, D., Coon, D., Powers, D., & Thompson, L. (2005). Cognitive-behavioral therapy for late life depression: A client manual. Palo Alto, CA: Older Adult and Family Center, VA Palo Alto Health Care System.

Laidlaw, K., Thompson, L., Dick-Siskin, L., & Gallagher-Thompson, D. (2003). Cognitive behaviour therapy with older people. United Kingdom: John Wiley & Sons Ltd.

Thompson, L., Gallagher-Thompson, D., & Dick, L. (2005). Cognitive-behavioral therapy for late life depression: A therapist manual. Palo Alto, CA: Older Adult and Family Center, VA Palo Alto Health Care System.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 1.5 0.5 1.8

Dissemination Strengths

The implementation materials include clearly explicated and detailed adaptations of cognitive behavioral therapy for older adults. Materials include a section for working with special issues, such as physical disabilities and comorbid anxiety, and provide "what if" scenarios with suggestions for handling challenging questions from clients. The manual provides sequencing for continual client feedback, which can be used to monitor the intervention's effectiveness. Training is available in the form of the traditional clinical model through postdoctorate or practicum training.

Dissemination Weaknesses

Detailed information for administrators on the organizational requisites for effective implementation is not provided. No materials, resources, or technical assistance are available to support training or coaching in a more portable manner. No information is provided on developing a therapeutic relationship. Programmatic quality assurance measures to support intervention fidelity are not addressed.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Treatment guide and client workbook About $60 Yes
Cognitive Behavior Therapy with Older People (book) $60 each No
Software program for scoring and interpreting the California Older Person's Pleasant Events Schedule Free No
2- to 3-day workshop $500 per day per trainer plus travel expenses Yes
10 tape reviews for each trainee $1,000 per trainee No
12-16 weekly phone consultations with trainees $150 per trainee per consultation No
Quality assurance scales Varies Yes
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

* Gallagher, D. E., & Thompson, L. W. (1982). Treatment of major depressive disorder in older adult outpatients with brief psychotherapies. Psychotherapy: Theory, Research, and Practice, 19(4), 482-490.

* Gallagher-Thompson, D., Hanley-Peterson, P., & Thompson, L. (1990). Maintenance of gains versus relapse following brief psychotherapy for depression. Journal of Consulting and Clinical Psychology, 58(3), 371-374.  Pub Med icon

* Thompson, L. W., Coon, D. W., Gallagher-Thompson, D., Sommer, B. R., & Koin, D. (2001). Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression. American Journal of Geriatric Psychiatry, 9(3), 225-240.  Pub Med icon

* Thompson, L. W., Gallagher, D., & Breckenridge, J. S. (1987). Comparative effectiveness of psychotherapies for depressed elders. Journal of Consulting and Clinical Psychology, 55(3), 385-390.

Contact Information

To learn more about implementation or research, contact:
Larry W. Thompson, Ph.D.
(650) 400-8171
larrywt@stanford.edu

Dolores Gallagher-Thompson, Ph.D., ABPP
(650) 400-8172
dolorest@stanford.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):