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This chapter reviews both seminal and recent work on late-life depression (LLD), with an emphasis on the vascular depression subtype of LLD. We first describe the clinical features and symptom presentation of LLD, highlighting executive functioning deficits that are a core feature of the “depression with executive dysfunction” syndrome. We discuss both vascular and nonvascular etiological pathways to depression with executive dysfunction in older adults. We highlight recent findings on the association between vascular disease, altered structural and functional brain network connectivity, and clinical symptoms in LLD. Vascular depression is associated with nonresponse to standard pharmacologic treatment. As such, behavioral interventions offer promising avenues for treatment. Novel behavioral approaches encompass psychotherapy, noninvasive brain stimulation, and cognitive remediation that are targeted toward the specific neural circuitry dysfunctions that underlie both affective and cognitive symptoms in older adults. We review these approaches, as well as psychosocial, exercise, and lifestyle interventions.
In the past decades, the effects of problem-solving therapy (PST) for depression have been examined in several randomized controlled studies. However, until now no meta-analysis has tried to integrate the results of these studies.
We conducted a systematic literature search and identified 13 randomized studies examining the effects of PST, with a total of 1133 subjects. The quality of studies varied.
The mean standardized effect size was 0.34 in the fixed effects model and 0.83 in the random effects model, with very high heterogeneity. Subgroup analyses indicated significantly lower effects for individual interventions in studies with subjects who met criteria for major depression, studies in which intention-to-treat analyses were conducted instead of completers-only analyses, and studies with pill placebo and care-as-usual control groups. Heterogeneity was high, and the subgroup analyses did not result in clear indications of what caused this high heterogeneity. This indicates that PST has varying effects on depression, and that it is not known to date what determines whether PST has larger of smaller effects.
Although there is no doubt that PST can be an effective treatment for depression, more research is needed to ascertain the conditions and subjects in which these positive effects are realized.
Medical advances have expanded life, resulting in an extended dying process that allows for time to contemplate mortality and the broader existential themes of life. This period of time is rich with opportunities for the dying person to have one last opportunity to understand and resolve issues previously left unaddressed. This chapter aims to assist clinicians in addressing the psychosocial concerns of patients approaching the end of life.
Problem-solving therapy (PST) is an evidence-based psychotherapy for depression, with particularly robust evidence for use among older adults. It is based on the premise that depression is maintained by ineffective problem-solving and resultant poor coping, low self-efficacy, and negative emotions. Problem-solving therapy aims to reduce symptomatology and maximize quality of life by developing problem-solving skills and emphasizing goal setting and action planning to achieve those goals. This chapter presents the theoretical framework of PST and reviews a typical course of treatment, illustrated by a case of an older depressed patient with cognitive impairment and complex biopsychosocial needs. Problem-solving therapy is a brief and effective intervention for older adults with depression, including those with concurrent medical problems. Recent empirical findings and considerations for special populations are presented, along with resources for further PST training.
This chapter reviews the most researched psychotherapeutic interventions for individuals with cognitive impairment (CI) and common symptoms targeted by these interventions. Elements of assessment and psychotherapy modifications to consider when working with individuals with dementia are also discussed. Assessment components might include clarification of medical symptom overlap, collateral information, assessment instruments developed for individuals with cognitive difficulties, and incorporating consultation with other specialties. In general, clinicians should consider using simplified skills, increasing the number and frequency of sessions, shortening sessions, reducing group size, and providing more guidance during skill instruction and practice when working with individuals with cognitive impairments. Despite their promise and recommendations for their use, nonpharmacological therapies for individuals with dementia have a small research base and warrant continued development and evaluation.
Problem-solving therapy (PST) is one of the best examined types of psychotherapy for adult depression. No recent meta-analysis has examined the effects of PST compared to control groups or to other treatments. We wanted to verify whether PST is effective, whether effects are comparable to those of other treatments, and whether we could identify the possible sources of high heterogeneity that was found in earlier meta-analyses.
We conducted systematic searches in bibliographical databases, including PubMed, PsycInfo, Embase and the Cochrane database of randomized trials.
We included 30 randomized controlled trials on PST (with 3530 patients), in which PST was compared to control conditions, with other therapies, and with pharmacotherapy. We could compare these 30 trials on PST also with 259 trials on other psychotherapies for adult depression. The effect size of PST versus control groups was g = 0.79 (0.57–1.01) with very high heterogeneity (I2 = 84; 95% CI: 77–88). The effect size from the 9 studies with low risk of bias was g = 0.34 (95% CI: 0.22–0.46) with low heterogeneity (I2 = 32; 95% CI: 0–68), which is comparable to the effects of other psychotherapies. PST was a little more effective than other therapies in direct comparisons, but that may be explained by the considerable number of studies with researcher allegiance towards PST. In meta-regression analyses of all controlled studies, no significant difference between PST and other therapies was found.
PST is probably an effective treatment for depression, with effect sizes that are small, but comparable to those found for other psychological treatments of depression.
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