(p. 3) How to Use This Treatment Approach
The cognitive-behavioral therapy (CBT) program presented in this clinician guide is intended to support your service delivery to clients in the second half of life who are experiencing clinical or subclinical depression, with or without accompanying anxiety. The program reflects continuing international scientific and clinical advances in applying CBT to specific age-related problems. Over the past four decades, the two senior authors of this approach (DGT, LT) have developed empirically supported clinical interventions for older adults that embody the spirit and change strategies of traditional CBT. Many of these efforts have focused on later-life depression, establishing research support for the use of this treatment approach (Coon & Thompson, 2003; Gallagher & Thompson, 1982; Gallagher-Thompson et al., 1990; Thompson, 1996; Thompson & Gallagher, 1984; Thompson et al., 1987, 2001). Our treatment approach is consistent with critical reviews (Braun et al., 2016), meta-analytic studies (Cuijpers et al., 2014, 2016, 2018; Wilkinson & Izmeth, 2016), and the depression treatment guidelines of the American Psychological Association (APA, 2019); all of these support and recommend the use of CBT with depressed older adults.
With the demographic shifts across the globe toward an increasingly aging population, we have packaged this intervention approach to be useful for clients aged 50 to 90+ years. This approach is a modular treatment program (rather than a “lock-step” therapy protocol) and is intended to be used flexibly by you, according to your clients’ needs. We expect this treatment to be compatible with individual and group psychotherapy conducted in a variety of settings, including community-based mental health clinics, inpatient services, and home-based programs, as well as being appropriate for briefer interventions within integrated primary care. As licensed psychologists working in the (p. 4) United States, we are less familiar with the structure of behavioral health service delivery in other parts of the world. We value our international connections to geropsychology colleagues and have attempted to refer to their research and clinical recommendations throughout this guide. It is our hope that the Treating Later-Life Depression workbook and this accompanying clinician guide can be useful for clinicians working beyond the United States.
Using a Stepped-Care Model of Behavioral Health Services
We designed this modular intervention program to be relevant across a range of client needs and care settings, employing a behavioral public health perspective that includes attention to stepped care. Within this feedback-informed approach, variability in symptom severity and daily functioning is used to match clients to an appropriate initial treatment that is of the lowest burden possible while also likely to result in clinically significant gains. Clients’ targeted outcomes are routinely monitored, with more intensive and costly “stepped-up” services provided only if and when the initial treatment does not lead to clinically significant improvements. This stepped-care approach to mental health treatment and preventive interventions is increasingly relevant for a number of community services and health care systems across the globe (van’t Veer-Tazelaar et al., 2009), including within the United States (Maragakis & O’Donohue, 2018). Stepped-care behavioral health supports contributions from a wide continuum of providers. Across these levels of training, the goal is for each professional to be working at the top of their own scope of practice. With adequate training and supervision, community peer-support specialists, behavioral technicians, and lower-level clinicians can serve as effective front-line staff to deliver some interventions for middle-aged and older adults (Stanley et al., 2016). Peer helpers and bachelor’s-level behavioral technicians can be used to implement specific interventions under the supervision of licensed master’s- and doctoral-trained therapists (Kraus-Schuman et al., 2015). Master’s- and doctoral-level clinicians then work directly with clients experiencing higher levels of symptom severity and functional impairment.
(p. 5) In keeping with this stepped-care approach to behavioral services, we believe that our treatment approach will be useful across a continuum of client severity, needs, providers, and service settings. As seen in Figure 1.1, we designed this second edition to be appropriate for clients across a range of severity, including levels 2 (mild to moderate symptoms), 3 (moderate to severe presentations), and 4 (severe presentations and disorders). This is an expanded population from the first edition, which was developed as a part of randomized clinical trials with older adults with moderate to severe major depressive disorder (MDD) who were predominantly on level 4 (sometimes 5) of that stepped-care model. Use of some portions of this treatment can be appropriate for case management and time-limited psychoeducational groups, which are on the lower end of the continuum of treatment. Some materials are relevant for inpatient and partial hospitalization, which are all more intensive than individual psychotherapy.
If your clinical work is with clients living in long-term care, we’d like to note that we have not evaluated or aimed for this treatment to be used in residential care settings. Because of the need for interventions that explicitly engage and involve staff, we encourage providers to instead utilize specific interventions developed for and within skilled nursing homes. An excellent example of a treatment for depressed older adults that has been created and evaluated specifically for long-term care settings is the BE-ACTIV program developed by Meeks and colleagues (Meeks et al., 2008, 2015, 2019).
Stepped-care approaches work when clients are evaluated both at the time that treatment is being considered and then also on an ongoing basis during treatment. Treatment is feedback-informed, because the treatment plan is collaboratively adjusted and modified by the provider and client together as symptoms improve, plateau, or become worse. We discuss how this feedback-informed treatment impacts assessment strategies in Chapter 3.
Outline of This Treatment Approach
The workbook that corresponds to this guide (Treating Later-Life Depression Workbook) is an integral part of treatment. You will need to have your copy of the workbook available and open while you are reading this clinician guide. When planning treatment for a specific client, you will look over both the didactic “Learn” materials and the between-session “Practice” resources for any modules that are under consideration. Do not, however, become overwhelmed by the volume of available materials! We do not expect that you will use all pages in any module with one individual or group; you will most certainly not use all of the modules with any one client. Later sections of this guide address what is needed to implement each specific workbook module, including our recommendations for using specific Learn pages and Practice forms. Thus, this initial chapter is meant to be a guide to general treatment planning; you will need to read specific corresponding chapters for detailed instructions for each module. As you begin the work of customizing treatment for a specific client, assessment is essential, and we provide recommendations in Chapter 3.
(p. 7) Behavioral health clinicians and case managers working in briefer and fewer sessions than is typical for psychotherapy are likely to pick and choose specific Learn pages and Practice forms to fit the needs of specific individuals. The following recommendations for psychotherapy treatment planning have been informed by the clinical research trials conducted at the Older Adult and Family Center of Stanford University School of Medicine and the VA Palo Alto Health Care System. These recommendations are also in keeping with the research literature that has accumulated since then, as well as being shaped by experiences with our clients and our training of professionals from a variety of disciplines. The modules in this treatment are organized into those that we have labeled “core” and others that we refer to as “personalized.”
Core Modules (for Most Psychotherapy Clients)
■ Skills for Getting Started (therapy orientation and goal setting)
■ Skills for Feeling (emotional literacy, positive and specific negative emotions)
■ Skills for Doing (behavioral activation and problem solving)
■ Skills for Thinking (self-compassion and cognitive reappraisal)
Personalized Modules (for Some Psychotherapy Clients)
■ Skills for Brain Health (preventing and managing cognitive concerns)
■ Skills for Managing Chronic Pain (psychoeducation and pain management)
■ Skills for Healthy Sleep (psychoeducation and sleep hygiene)
■ Skills for Caregiving (for family and informal caregivers)
■ Skills for Living with Loss (support for healthy grieving)
■ Skills for Relating (communication and interpersonal effectiveness skills)
(p. 8) Treatment Planning
Middle-Aged and Older Clients with MDD
We describe patterns of clinical symptoms and presentation of depression in Chapter 2 of this guide, including MDD. Clients who meet criteria for MDD and who will be seen in individual psychotherapy should receive the core modules in this order: Skills for Getting Started, Skills for Feeling, Skills for Doing, and Skills for Thinking. Continuous assessment of depression symptoms is indicated, along with periodic assessment of clients’ individualized therapy goals. Our experience is that many clients begin to see a lift in their mood at some point while working on Skills for Doing. We recommend moving ahead with Skills for Thinking, which we believe is useful in preventing relapse or later new episodes of MDD. If clients no longer meet criteria for MDD by the end of Skills for Thinking, depressive symptoms are lower, and the client appears to be functioning fairly well in daily life, you can move directly to working on termination in the Skills for Wrapping Up module. If the client is still experiencing dysphoria, anhedonia, or functional limitations in daily life, then it is appropriate to consider an additional module that is conceptualized as a contributing factor to maintaining the depression (e.g., brain health, pain, sleep, caregiving, loss, relationships).
The decision to implement a personalized module typically involves a commitment of at least three or four sessions (1 month of weekly psychotherapy). As a treatment for depression, progress occurs through active practice and skill development (i.e., between-session use of Practice forms), not from psychoeducation alone (i.e., an over-reliance on Learn pages without integration of skills in daily life). This means that we discourage frequent session-to-session shifts between materials from the various optional modules. A key danger in that strategy is that clinicians believe that they are “covering a lot of ground” while clients feel overwhelmed and confused about what they are supposed to do with that information.
Focus, repetition, and support for building new habits are all key to this approach (Bilbrey et al., 2020b). Regardless of which intervention (p. 9) modules you choose, your work with psychotherapy clients should conclude with the Skills for Wrapping Up module to support termination processes and relapse-prevention planning.
Clinicians trained in this treatment have primarily used an open group format (i.e., individuals enter and leave the group on an ongoing basis) to deliver the program to clients with MDD. This open format appears most compatible with clinical services for moderate to severely depressed individuals, including those in inpatient, partial hospitalization, and outpatient settings. Especially within psychiatric inpatient and partial hospitalization settings, time-limited, structured “closed” groups are not feasible. Instead, group treatment is offered for any patients within the unit who are deemed appropriate. Individuals need access to treatment as soon as possible, and it is not clinically appropriate to make them wait until a new group is ready to begin. The continual influx of new clients helps keep the group focused on skill development rather than devolving into general support. In these types of open-format groups, sections of Skills for Getting Started, Skills for Feeling, Skills for Doing, and Skills for Thinking are all appropriate.
There are a variety of ways to effectively integrate behavioral activation into acute inpatient services (Folke et al., 2016). Many inpatient and partial hospitalization programs treating patients with depression find that sleep concerns are so prevalent that there is value in some sleep education. Those settings may choose to use at least some portions of Skills for Healthy Sleep within their groups. We make specific recommendations for group treatment in Appendix B. Repetition and support for building new habits are key to this approach, and this is reflected in our recommendations for group content and process. For individuals with MDD who have some access to both group and individual psychotherapy, the termination planning within Skills for Wrapping Up is maximally helpful with the support of some individual sessions. Fixed-length closed groups appear less compatible with treating MDD than for clients experiencing milder, subsyndromal depressions.
(p. 10) Middle-Aged and Older Clients with Subsyndromal Depression
When middle-aged and older adults have mild to moderate symptoms of depression (e.g., Patient Health Questionnaire-9 [PHQ-9] < 15; Geriatric Depression Scale -Short Form [GDS-SF] < 10; Beck Depression Inventory-II [BDI-II) < 20] and do not meet diagnostic criteria of MDD, there is more choice involved in planning individual psychotherapy. For the majority of these clients, we suggest Skills for Getting Started (two or three sessions), Skills for Feeling (three or four sessions), and Skills for Doing (six to eight sessions), all using the recommendations provided in the chapters of this guide devoted to those modules. If depressive symptoms have abated (e.g., PHQ-9 < 4; GDS15 < 5; BDI-II < 14), then it is possible to move directly to termination planning in Skills for Wrapping Up (two to four sessions). Clients may get more benefit from behavioral activation and problem solving than you initially expect, so we advise you to resist the urge to shortchange that module in order to move on to topic-specific content. For all clients, repetition and support for building new habits are key to this approach, so sufficient time in behavioral activation and problem solving is important.
If your clients have had six to eight sessions of behavioral activation and problem solving (i.e., Skills for Doing) and are still experiencing clinically significant depressive symptoms, then the strategy for selecting additional module(s) becomes more customized. If your clients have no specialized concerns related to the personalized modules (e.g., pain, cognitive impairment, sleep, caregiving, loss, relating) and are engaged in daily activities but are not experiencing them as pleasurable, then moving on to Skills for Thinking is clinically indicated. Repeating some of the material on tracking positive emotions in Skills for Feeling may also be helpful in these cases.
There will also be times when your clients have specialized concerns (e.g., pain, cognitive impairment, sleep, caregiving, loss, relating to others) and it will be more effective to move into that personalized module directly after Skills for Doing. Difficulties in a personalized module that appear due to cognitive “stuck points” would suggest the advisability of (p. 11) your then using Skills for Thinking in a targeted way; focus work in that module on thoughts that are specific to the personalized life domain.
Following Skills for Doing, your clients who remain depressed and have specific concerns related to pain should next work within the Skills for Managing Chronic Pain module, even if they also have additional complaints and issues related to other modules. In other words, pain concerns take precedence over other areas covered in our program, due to the strong bidirectional relationships between chronic pain and depression. After four sessions using that module, you can re-evaluate and decide whether the client is now ready to move toward termination. If pain-related cognitions are proving to be a “stuck point” for implementing the suggested pain-management strategies, then move to Skills for Thinking, but with a targeted focus explicitly on their specific pain-related cognitions.
We suggest this general approach for your use of the other personalized modules as well. From Skills for Doing, you would transition to the module of most pressing concern to a specific client. With some individuals, this most pressing concern is immediately apparent within several sessions of beginning psychotherapy, if it was not already identified at the time of intake. This is especially the case for clients with chronic pain, distressed family caregivers, and individuals who are bereaved. Sometimes, the presenting concerns related to those areas feel so pressing that you and your client will collaboratively decide to move from Skills for Getting Started and Skills for Feeling directly to one of those areas (e.g., Skills for Managing Chronic Pain, Skills for Caregiving, Skills for Living with Loss). After four to six sessions in that personalized area, you are then more able to implement the strategies in Skills for Doing and Skills for Thinking using content and examples from that specific life domain. More suggestions for this approach are provided in the chapters of this clinician guide that are devoted to those modules.
For individual psychotherapy, however, we advise clinicians to first implement the behavioral activation and problem-solving module (Skills for Doing) before making a firm decision to include optional sections for a specific client. Although many of the modules sound interesting to older patients and appear relevant, that additional content may not be essential for alleviating the depression. There is a firm evidence (p. 12) base for the effectiveness of behavioral activation with depressed older adults (Solomonov et al., 2019). Our goal is for therapy to progress as efficiently as possible to improve the daily functioning and depressive symptomatology of clients. You want additional sessions focused on optional sections to be very strategically targeted at symptoms and concerns that have not sufficiently improved with behavioral activation. For the same reason, we would not expect any one psychotherapy client or group to actively work on skill development in more than two or three (at the very most!) optional modules. In many cases, your use of one personalized module with clients experiencing subclinical depression will be adequate.
When middle-aged and older adults have mild to moderate symptoms of depression (e.g., PHQ-9 < 15; GDS15 < 6; BDI-II < 20) and do not meet diagnostic criteria of MDD, there is more choice involved in designing group treatments. For these individuals who may not identify as having mental health concerns or be interested in something labeled as psychotherapy, it is useful to offer time-limited psychoeducational groups that include “Skills” or “Coping” in the titles. We find that 60 to 90 minutes is a good length for such groups that are focused on “Skills for Enjoying Your Life” or “Coping with Caregiving” or another related title. These programs require a full 90 minutes if the group is larger than six to eight members so that all have an opportunity to actively participate at each meeting.
Six weeks is a good length for a group focused primarily on behavioral activation and problem solving. Again, a shorter duration works well with smaller classes of four to six members, which often allows for slightly faster-paced group sessions. Clinicians who wish to include cognitive reappraisal skills, in addition to behavioral activation and problem solving, should consider a longer format and add three or four sessions specifically for that content. It is also possible to offer closed-format groups that are centered on one of the personalized modules, especially caregiving, pain, sleep, or living with loss. These psychoeducational programs can be delivered over a telehealth platform, which makes them accessible to a broad range of individuals, as long as they have access to (p. 13) the workbook. We provide some examples of week-by-week group content in Appendix B.
We understand that clinicians are able to do their best work when they are (1) prepared for the kinds of problems and reactions to expect, (2) provided with strategies to deal with them, and (3) encouraged to employ an individualized case formulation and treatment approach that fits with the needs, strengths, and limitations of individual clients (Pachana et al., in press). Across the chapters of this clinician guide, we aim to provide you with very concrete recommendations for how to use the workbook with your clients. Part I: Introductory Information for Clinicians, in this guide, provides background information about depression, assessment, and modifications to psychotherapy with aging individuals. Later parts of the guide then address what you need to know as you implement specific modules of the workbook.
The delivery of behavioral health interventions is overseen by state laws and regulating boards. To provide mental health services, an individual must be licensed within the state in which the services are delivered or under the supervision of a licensed clinician. (There are also state-specific laws and regulations for the delivery of telehealth services across state lines.) Once licensure issues are addressed, we find that this approach can be used by a range of clinicians who have completed professional training (or are in the advanced stages of completion) in one of the behavioral health–related specialties, for example social work, counseling, clinical psychology, psychiatry, advanced nursing specialist in psychiatry or another behavioral specialty, and advanced occupational therapy. The critical component here is that in addition to having the requisite interpersonal skills, one must be familiar with foundational attitudes, knowledge, and skills in CBT (Tolin, 2016). In our experience, professionals without training and supervised clinical experience in implementing CBT are typically less effective in using our approach. (p. 14) After agreeing to try the techniques and experiencing their effectiveness, many initially “CBT-reluctant” professionals become “converts” and proceed with further training with success.
Clinicians should also have knowledge about the problems and issues confronting adults in the second half of life and the general psychological, social, medical, and economic resources available to this population that enable them to accommodate to life stresses. Clinicians should also have some knowledge of how to work with aging individuals, for example regarding the strengths and weaknesses common to this group and how to use this information in maximizing their potential for change. We recognize that most clinicians do not have specialized training in gerontology, and this is not required for the effective use of this approach.
Client Access to Workbook
In terms of the timing for clients to purchase their own copy of the workbook, there are a range of options depending upon the clinical setting and your client population. We tend to print out copies of any Learn pages and Practice forms from Skills for Getting Started to share with our clients as they are beginning treatment. Once they have continued beyond the content in Skills for Getting Started, we then encourage clients to have their own copy of the workbook, which makes it easier for them to find and refer back to after therapy has ended. When treatment is provided via telehealth (e.g., either telephone or video), it becomes especially helpful for clients to have their own copy of the workbook available to use and refer back to. In some clinical settings, it is possible for the clinic to purchase copies of the workbook and prorate the cost over several sessions.
Numerous clients with depression from diverse racial, ethnic, and cultural backgrounds have been successfully treated in our training and research programs, using the original intervention approach described in the first edition. Adaptations of this approach for use with special populations (p. 15) have been developed for some groups, notably family caregivers who are Hispanic Americans, Asian Americans, African Americans, those of Persian background, and male caregivers. Appropriate translations and back translations of the manuals and instruments for evaluation have been made, and randomized trials have shown the effectiveness of this technique in Latinx, Chinese, Vietnamese, and African American individuals. We refer you to OptimalAgingCenter.com for examples and further information. This work is mentioned here because it suggests that if appropriate translations are made available and are being used by trained professionals who are bicultural/bilingual, there is little doubt that this treatment approach would be effective. It has been well received by numerous ethnic groups. Culture-specific adaptations for diverse older adults are described within the works edited by Iwamasa and Hays (2019) and by Lau and colleagues (2019). Several of the authors in those edited volumes were trained in our center at Stanford University School of Medicine.
Pharmacotherapy for Depression
Historically, pharmacotherapy has been viewed as the first line of treatment for severe depression in middle-aged and older adults, and psychological intervention has been considered an adjunctive treatment. More recent guidelines, however, emphasize combined treatment for severe and treatment-resistant major depression (Reynolds et al., 2019), with antidepressants less likely to be effective for minor or subsyndromal depression (APA, 2019). Clinicians are encouraged to build relationships with geriatric psychiatrists within their local community to serve as resources for referral and consultation.
Risks and Benefits of This Treatment Program
There have been no substantial adverse effects in clients while they were enrolled in treatment programs in our center. Over the years, less than 10% of those receiving CBT or a combination of CBT and pharmacotherapy have required outside consultation because of increasing symptoms (and due to deteriorating medical conditions). The benefits (p. 16) are most often very encouraging, as noted in earlier discussions focused on treatment evaluation. As an overall summary of the clients involved in our research and training programs, approximately 67% of the individuals we have treated with CBT alone have shown substantive improvement, and nearly 60% were classified as being in complete remission with no major clinical symptoms at the conclusion of treatment. The remaining clients either showed no change over the course of 12 to 20 sessions and a 1-year follow-up (12%), became worse during the initial therapy and required more aggressive treatment (roughly 7%), or experienced intermittent improvement and decline over the course of therapy and follow-up (14%).