Promoting Geropsychology: A Memorandum for Research, Policies, Education Programs, and Practices for Healthy Aging

BACKGROUND

This viewpoint paper reports the state of the art at a global level on research, practice and assessment, policies, and training in the clinical psychology of aging and, more specifically, in geropsychology. The main sources of information were as follows: (1) the most recent reviews of the literature available in the scientific literature; (2) the resources on the internet referable to professional and academic associations dealing with the topic; and (3) the laws, policy initiatives, and funded programs that are aimed at the diffusion and applications of mental health in aging.

METHODS

The present study aims to provide an updated and comprehensive memorandum highlighting the importance of prioritizing mental health in older adults. It seeks to promote health in general and disease prevention strategies, ensuring equitable access to mental health services integrated into primary care and designed for aging. This paper also aims to shed light on the slow development process and lack of consolidation in the adaptation of academic training at master's and doctoral levels in most developed countries, despite the long-declared importance of enhancing resources for the promotion of geropsychology.

RESULTS

The results of the present study are patchy. Although the importance of enhancing resources for the promotion of geropsychology has long been declared, the development process seems very slow, and the adaptation of academic training at master's and doctoral levels in most developed countries-those that, for demographic reasons and attitudes, should be more sensitive to the issue, does not yet seem to have consolidated.

CONCLUSIONS

Collaboration among diverse professionals is crucial for providing integrated and comprehensive care to older adults that addresses their physical, psychological, and social needs.

Effects of Home-Delivered Cognitive Behavioral Therapy (CBT) for Depression on Anxiety Symptoms among Rural, Ethnically Diverse Older Adults

BACKGROUND

We examined the effects of home-delivered cognitive-behavioral therapy (CBT) for depression on anxiety symptoms in an ethnically diverse, low resource, and medically frail sample of rural, older adults.

METHOD

This was a secondary analysis of a randomized clincial trial with 134 rural-dwelling adults 65 years and older with decreased quality of life and elevated psychological symptomatology. Anxiety symptoms were assessed with the anxiety and phobic anxiety subscales of the Symptom Checklist-90-Revised (SCL-90-R).

RESULTS

Compared to a minimal support control condition, CBT for depression resulted in significantly greater improvements in symptoms of anxiety and phobic anxiety from pre-treatment to post-treatment.

CONCLUSION

Home-delivered CBT for depression can be an effective treatment for anxiety in a hard-to-reach older populations.

CLINICAL IMPLICATIONS

Additional research should explore integrated anxiety and depression protocols and other treatment modalities, including bibliotherapy or telehealth models of CBT, to reduce costs associated with its in home delivery. Flexibility in administration and adaptations to the CBT protocol may be necessary for use with vulnerable, rural older adults.

National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans

OBJECTIVES

Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.

METHOD

Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.

CONCLUSIONS

Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings.

Comparison of the effectiveness of cognitive behavioral therapy for depression among older versus younger veterans: results of a national evaluation

OBJECTIVES

The effectiveness of cognitive behavioral therapy for depression (CBT-D) among older adults in routine clinical settings has received limited attention. The current article examines and compares outcomes of older versus younger veterans receiving CBT-D nationally.

METHOD

Patient outcomes were assessed using the Beck Depression Inventory-II and World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

A total of 764 veterans aged 18-64 and 100 veterans aged 65+ received CBT-D; 68.0% of older and 68.3% of younger patients completed all sessions or finished early due to symptom relief, and mean depression scores declined from 27.0 (standard deviation [SD] = 10.7) to 16.2 (SD = 12.4) in the older group and from 29.1 (SD = 11.2) to 17.8 (SD = 13.5) in the younger group. Within-group effect sizes were d = 1.01 for both groups. Significant increases in quality of life and therapeutic alliance were observed for both groups.

DISCUSSION

CBT-D resulted in significant improvements in depression and quality of life among older patients. Outcomes and rate of attrition were equivalent to younger patients. Findings indicate that CBT-D is an effective and acceptable treatment for older veterans in real-world settings with often high levels of depression.

Effectiveness of acceptance and commitment therapy for depression: comparison among older and younger veterans

OBJECTIVES

Limited data exist on outcomes of older adults receiving psychotherapy for depression in real-world settings. Acceptance and Commitment Therapy for depression (ACT-D) offers potential utility for older individuals who may experience issues of loss, reduced control, and other life changes. The present article examines and compares outcomes of older and younger Veterans receiving ACT-D nationally in the U.S. Department of Veterans Affairs health care system.

METHOD

Patient outcomes were assessed using the Beck Depression Inventory-Second Edition and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.

RESULTS

Six hundred fifty-five Veterans aged 18-64 and 76 Veterans aged 65+ received ACT-D. Seventy-eight percent of older and 67% of younger patients completed all sessions or finished early. Mean depression scores declined from 28.4 (SD = 11.4) to 17.5 (SD = 12.0) in the older group and 30.3 (SD = 10.6) to 19.1 (SD = 14.3) in the younger group. Within-group effect sizes were d = .95 and d = 1.06 for the two age groups, respectively. Quality of life and therapeutic alliance also increased during treatment.

CONCLUSION

The findings suggest that ACT-D is an effective and acceptable treatment for older Veterans treated in routine clinical settings, including those with high levels of depression.

Correlates of perceived need for and use of mental health services by older adults in the collaborative psychiatric epidemiology surveys

OBJECTIVES

Older adults are especially unlikely to seek mental health services, but little is known about whether their perceptions of need for help contribute to this problem. The objectives of this study were to compare perceived need across the lifespan and to examine sociodemographic and mental health correlates of whether older adults sought professional help, perceived the need for help without seeking it, and sought help from specialty mental health professionals.

METHODS

The authors examined help-seeking and perceived need with the Collaborative Psychiatric Epidemiology Surveys, focusing on 3,017 adults aged 55 years and older. Logistic regressions predicted help-seeking and perceived need from sociodemographic factors, past-year psychiatric disorders, and past-year suicidal behaviors. Individuals who perceived the need for help without receiving it also reported barriers to help-seeking.

RESULTS

Levels of perceived need were highest among 25-44 year olds and lowest among adults aged 65 years and older. Among older adults with psychiatric disorders, 47.1% did not perceive a need for professional help. Diagnoses and suicidal behaviors were strong predictors of whether individuals perceived need, whereas among those who perceived the need for help, only older age was positively associated with help-seeking. Few factors clearly distinguished those who did and did not seek help from specialty mental health professionals with the exception of having three or more psychiatric diagnoses. Finally, the most common barrier to help-seeking was a desire to handle problems on one's own.

CONCLUSIONS

A lack of perceived need for mental health services and self-sufficiency beliefs are significant barriers to older adults' use of mental health services.

Veterans Affairs Intensive Case Management for older veterans

BACKGROUND

There is a growing need for information on evidence-based practices that may potentially address needs of elderly people with severe mental illness (SMI), and more specifically on community-based services such as assertive community treatment (ACT).

METHODS

This study examines national evaluation data from fiscal year 2001-2005 from Veterans Affairs Mental Health Intensive Case Management (MHICM) program (N = 5,222), an ACT-based service model, to characterize the age distribution of participants and the distinctive needs, patterns of service delivery, and treatment outcomes for elderly veterans.

RESULTS

Altogether, 24.8% of participants were 55-64 years; 7.4% 65-74 years; and 2.8% were older than 75. Veterans over 75 formed a distinct subgroup that had a later age of onset of primarily nonpsychotic illnesses without comorbid substance abuse and had experienced more limited lifetime hospital treatment than younger participants. Older veterans were less symptomatic and more satisfied with their social relationships than younger clients. They mostly live independently or in minimally restrictive housing, but they received less recovery-focused services and more crisis intervention and medical services. They thus do not appear to be young patients with SMI who have aged but rather constitute a distinct group with serious late-onset problems. It is possible that MHICM services keep them in the community and avoid costly nursing home placement while providing a respite service that reduces family burden.

CONCLUSION

These data highlight the unique characteristics of older veterans receiving ACT-like services and the need to focus greater attention on recovery-oriented services as well as community support for this subgroup.

Public mental health care utilization by older adults

The present study examined the extent to which older adults began public mental health treatment throughout Texas in 1999, the types of services they used, and how they compared on demographic and clinical variables to younger consumers. Notwithstanding recent policy and related developments, older adults were found to use public mental health services at substantially low rates, as in past decades. Significantly, older consumers tended to be relatively healthy and independent. Among younger and, even more so, older consumers, there were relatively high proportions of rural residents and minorities, groups previously found to be unlikely to utilize private mental health services. Overall, the findings urge that greater attention be devoted to public mental health outreach and service delivery with the elderly, and raise the question of what role the public mental health system should have in nursing homes and other long-term care settings.