Web audio at CurrentPsychiatry.com Dr. Chand: Key points on providing CBT to older patients How to adapt cognitive-behavioral therapy for older adults To improve efficacy, focus on losses, transitions, and changes in cognition ome older patients with depression, anxiety, or insom- nia may be reluctant to turn to pharmacotherapy and Smay prefer psychotherapeutic treatments.1 Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients (Table 1).2 Research evaluating the efficacy of CBT for depression in older adults was first published in the early 1980s. Since then, research and application of CBT with older adults has expanded to include other psychiatric disorders and re- searchers have suggested changes to increase the efficacy of CBT for these patients. This article provides: © JOHN LUND/MARC ROMANELLI/BLEND IMAGES/CORBIS • an overview of CBT’s efficacy for older adults with de- Suma P. Chand, PhD pression, anxiety, and insomnia Associate Professor • modifications to employ when providing CBT to older George T. Grossberg, MD patients. Samuel W. Fordyce Professor Director, Geriatric Psychiatry • • • • The cognitive model of CBT Department of Neurology and Psychiatry In the 1970s, Aaron T. Beck, MD, developed CBT while Saint Louis University School of Medicine working with depressed patients. Beck’s patients reported St. Louis, MO thoughts characterized by inaccuracies and distortions in association with their depressed mood. He found these thoughts could be brought to the patient’s conscious atten- tion and modified to improve the patient’s depression. This finding led to the development of CBT. CBT is based on a cognitive model of the relationship among cognition, emotion, and behavior. Mood and be- havior are viewed as determined by a person’s perception Current Psychiatry 10 March 2013 and interpretation of events, which manifest as a stream of automatically generated thoughts (Figure, Table 1 page 12).3 These automatic thoughts have their origins in an underlying network of Indications for CBT beliefs or schema. Patients with psychiatric Mild to moderate depression. In the case of disorders such as anxiety and depression severe depression, CBT can be combined with typically have frequent automatic thoughts pharmacotherapy that characteristically lack validity because Anxiety disorders, mixed anxiety states they arise from dysfunctional beliefs. The Insomnia—both primary and comorbid with other medical and/or psychiatric conditions therapeutic process consists of helping the patient become aware of his or her internal CBT: cognitive-behavioral therapy stream of thoughts when distressed, and to identify and modify the dysfunctional thoughts. Behavioral techniques are used to As patients get older, cognitive impair- bring about functional changes in behavior, ment with comorbid depression can make regulate emotion, and help the cognitive re- treatment challenging. Limited research structuring process. Modifying the patient’s suggests CBT applied in a modified format underlying dysfunctional beliefs leads to that involves caregivers and uses problem Clinical Point lasting improvements. In this structured solving and behavioral strategies can sig- For depressed older therapy, the therapist and patient work col- nificantly reduce depression in patients laboratively to use an approach that features with dementia.15 adults, RCTs have reality testing and experimentation.4 found CBT is superior Anxiety. Researchers have examined the to treatment as efficacy of variants of CBT in treating older usual, wait-list Indications for CBT in older adults adults with anxiety disorders—commonly, control, and talking Depression. Among psychotherapies generalized anxiety disorder (GAD), panic used in older adults, CBT has received disorder, agoraphobia, subjective anxi- as control the most research for late-life depression.5 ety, or a combination of these illnesses.16,17 Randomized controlled trials (RCTs) have Randomized trials have supported CBT’s found CBT is superior to treatment as efficacy for older patients with GAD and usual in depressed adults age ≥60.6 It also mixed anxiety states; gains made in CBT has been found to be superior to wait-list were maintained over a 1-year follow- control7 and talking as control.6,8 Meta- up.18,19 In a meta-analysis of 15 studies us- analyses have shown above-average effect ing cognitive and behavioral methods of sizes for CBT in treating late-life depres- treating anxiety in older patients, Nordhus sion.9,10 A follow-up study found improve- and Pallesen16 reported a significant effect ment was maintained up to 2 years after size of 0.55. In a 2008 meta-analysis that CBT, which suggests CBT’s impact is likely included only RCTs, CBT was superior to to be long lasting.11 wait-list conditions as well as active con- Thompson et al12 compared 102 de- trol conditions in treating anxious older pressed patients age >60 who were treat- patients.20 ed with CBT alone, desipramine alone, However, some research suggests that or a combination of the 2. A combination CBT for GAD may not be as effective for of medication and CBT worked best for older adults as it is for younger adults. In severely depressed patients; CBT alone a study of CBT for GAD in older adults, or a combination of CBT and medication Stanley et al19 reported smaller effect sizes worked best for moderately depressed compared with CBT for younger adults. Discuss this article at patients. Researchers have found relatively few www.facebook.com/ CurrentPsychiatry CBT is an option when treating de- differences between CBT and comparison pressed medically ill older adults. Research conditions—supportive psychotherapy indicates that CBT could reduce depres- or active control conditions—in treating sion in older patients with Parkinson’s dis- GAD in older adults.21 Modified, more ef- ease13 and chronic obstructive pulmonary fective formats of CBT for GAD in older Current Psychiatry disease.14 adults need to be established.22 Mohlman Vol. 12, No. 3 11 Figure The cognitive model of CBT Core belief: I am unlovable CBT for older adults Intermediate belief: If someone is critical of me it means I am not a likeable person Situation: Automatic thoughts: Reactions: Social gathering No one will want to Physiological— Clinical Point talk to me Tension in shoulders Adding memory Behavioral—Quiet, avoid eye contact and learning aids Emotional—Anxious, to CBT for anxious sad older patients may improve the CBT: cognitive-behavioral therapy Source: Adapted from reference 3 response rate et al23 supplemented standard CBT for treatment for late-life insomnia.25 late-life GAD with memory and learn- RCTs have reported significant im- ing aids—weekly reading assignments, provements in late-life insomnia with graphing exercises to chart mood ratings, CBT-I.26,27 Reviews and meta-analyses have reminder phone calls from therapists, and also concluded that cognitive-behavioral homework compliance requirement. This treatments are effective for treating insom- approach improved the response rate from nia in older adults.25,28 Most insomnia cases 40% to 75%.23 in geriatric patients are reported to occur secondary to other medical or psychiatric Insomnia. Studies have found CBT to be an conditions that are judged as causing the effective means of treating insomnia in geri- insomnia.25 In these cases, direct treatment atric patients. Although sleep problems oc- of the insomnia usually is delayed or omit- cur more frequently among older patients, ted.28 Studies evaluating the efficacy of only 15% of chronic insomnia patients re- CBT packages for treating insomnia occur- ceive treatment; psychotherapy rarely is ring in conjunction with other medical or used.24 CBT for insomnia (CBT-I) should be psychiatric illnesses have reported signifi- considered for older adults because man- cant improvement of insomnia.28,29 Because aging insomnia with medications may be insomnia frequently occurs in older pa- problematic and these patients may prefer tients with medical illnesses and psychiat- nonpharmacologic treatment.2 CBT-I typi- ric disorders, CBT-I could be beneficial for cally incorporates cognitive strategies with such patients. established behavioral techniques, including sleep hygiene education, cognitive restruc- turing, relaxation training, stimulus control, Good candidates for CBT and/or sleep restriction. The CBT-I mul- Clinical experience indicates that older ticomponent treatment package meets all adults in relatively good health with no Current Psychiatry 12 March 2013 criteria to be considered an evidence-based significant cognitive decline are good can- didates for CBT. These patients tend to Table 2 comply with their assignments, are inter- ested in applying the learned strategies, Contraindications for CBT and are motivated to read self-help books. High levels of cognitive impairment CBT’s structured, goal-oriented approach Severe depression with psychotic features makes it a short-term treatment, which Severe anxiety with high levels of agitation makes it cost effective. Insomnia patients Severe medical illness may improve after 6 to 8 CBT-I sessions Sensory losses and patients with anxiety or depression CBT: cognitive-behavioral therapy may need to undergo 15 to 20 CBT ses- sions. Patients age ≥65 have basic Medicare coverage that includes mental health care and psychotherapy. transitions. For example, depressed pa- There are no absolute contraindica-