Metaanalysis Of The Efficacy Of Psychological Treatments For Depression In Older Adults

Scogin & McElreath (1994) produced the first meta-analysis of the efficacy of psychosocial treatments for late-life depression mainly in response to the National Institutes of Health (NIH) consensus statement (NIH, 1991) that suggested limited supporting evidence for psychotherapy for late-life depression. In 1997, the consensus statement was updated to take account of important new information in a range of areas pertinent to psychotherapy for depression in older adults. Lebowitz et al. (1997) concluded that cognitive-behavioural and interpersonal approaches had established evidence for treatment efficacy, and that psychological treatments deserved greater emphasis as a treatment alternative to antidepressant medications and ECT. Scogin & McElreath (1994) produced effect sizes for treatment versus no treatment or placebo that were substantial and very similar to the effect sizes calculated by Robinson et al. (1990) in their review of psychotherapy for depression across all age ranges. Despite the clear superiority of psychological treatments to no treatment or waiting list control, there was no evidence to support the superiority of any single treatment modality. Cross-comparisons investigating differences in efficacy between brief forms of psychotherapy suggested that many treatments were equally successful in treating late-life depression (Scogin & McElreath, 1994).

Scogin and McElreath (1994) included personal construct therapy, self-administered bib-liotherapy, and behaviour therapy within their broad definition of psychosocial treatments. In consequence, their overall meta-analyses were too broad and over-inclusive. There would appear to be questions over the merits of combining apparently markedly different treatments (psychodynamic psychotherapy and behaviour therapy) to derive a single composite measure of effect. More information would appear to be lost than is gained by such an approach. Overall, the review by Scogin and McElreath (1994) was a timely and thorough evaluation of the effectiveness of psychological treatments for depression, but the analyses by Scogin and McElreath ought to be supplemented by more focused meta-analytic reviews.

A useful supplementary meta-analytic review to that performed by Scogin and McElreath (1994) was published by Koder et al. (1996), who evaluated cognitive therapy for the treatment of depression in older adults. Koder et al. (1996) identified seven treatment comparison studies between 1981 and 1994. Three of these seven studies favoured CBT over other treatment modalities, three failed to find significant treatment differences between modalities, and one study was positive for some aspects of cognitive treatment.

A minor point to note is that this meta-analysis contains an unfortunate error in that Koder et al. (1996) counted the studies by Jarvik et al. (1982) and Steuer et al. (1984) as separate studies, whereas Jarvik et al. (1982) reported interim results and Steuer et al. (1984) reported the final analysis (Jarvik et al., 1997). Koder et al. (1996) concluded that while there were too few studies of sufficient scientific and methodological merit upon which a definitive conclusion could be reached over the relative efficacy of cognitive therapy and other treatment modalities, cognitive therapy is undoubtedly an effective treatment procedure for late-life depression.

Engels and Verney (1997) reviewed 17 psychological outcome studies for late-life depression published between 1974 and 1992. The mean effect size calculated in this metaanalysis was moderate at 0.63, although lower than other reported effect sizes; on average, older adults receiving treatment for depression are better off than 74% of older people not receiving treatment. Cognitive therapy and behavioural therapy were the most effective treatments. A surprising result showing that CBT was less effective than either cognitive treatment or behavioural therapy alone may be explained in part by narrow inclusion criteria for CBT. Engels and Verney (1997) characterised studies as purely cognitive that are probably more accurately described as cognitive-behavioural. For example, studies published by Gallagher-Thompson, Thompson and colleagues are much more accurately characterised as CBT, as these researchers generally stress the behavioural components of treatment within a framework of cognitive strategies.

An important finding from the analysis by Engels and Verney (1997) is that individual therapy is more efficacious than group therapy in older adults. This would appear to be particularly so for cognitive and behavioural treatments. Overall, in this meta-analysis, psychotherapy with older adults appears to be most efficacious when the diagnosis is major depression or depression rather than multiple complaints. A possible difficulty in this conclusion is that information about achievement of diagnoses was often unclear in a number of studies.

In a departure from meta-analyses that looked at only pharmacological or only psychosocial treatments for late-life depression, Gerson et al. (1999) investigated the effectiveness of pharmacological and psychological treatments for depression in older people. Gerson et al. (1999) reviewed 45 studies carried out between 1974 and 1998. Four of the 45 studies used non-drug (psychological) methods of treatment for depression in later life. All patients were diagnosed with major depressive disorder. Gerson et al. (1999) also utilised stricter inclusion criteria for their analyses, such as a minimum of 15 patients in each treatment group, description of dose regimen in both treatment and control groups, documentation of side effects by self-report or questionnaire, specification of attrition rates and, lastly, statistical evaluation. The stricter criteria reduced the number of studies entered into the meta-analysis to 28, two of which used psychological methods of treatment.

The results of Gerson et al.'s meta-analyses were identical with either criteria (inclusive versus strict) in that pharmacological and psychological treatments for major depressive disorder in late life were equally efficacious. There were no significant differences in the relative reduction of quantitative measures of mood between treatments. Analyses also revealed no significant difference in attrition rates between pharmacological and psychological treatments. Gerson et al. (1999: 20) conclude: 'Effective psychological interventions constitute a much-needed addition to antidepressant medication for depressed older patients.'

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