Mrs. E, age 74, has been distraught for 6 months since the death of her husband of 45 years. She is brought for evaluation by her daughter, who is exasperated and worried about her mother’s sad mood, frequent tearfulness, weight loss (11 pounds), and social isolation.
Mrs. E says she feels lost and paralyzed, that she “sticks out like a sore thumb” when among couples “that still have each other.” She refuses to go to church, though she attended regularly in the past.
Unresolved grief appears to be linked to the onset and persistence of Mrs. E’s depressive symptoms. After a thorough evaluation confirms major depression, the psychiatrist explains the diagnosis to Mrs. E. She agrees to begin an antidepressant and interpersonal psychotherapy (IPT).
IPT is easy to use and well-suited to address abnormal grieving, role transitions, and role disputes in depressed older patients. In controlled trials, IPT has been shown effective as acute1 and maintenance treatment2,3 of depression. This article describes how IPT can work effectively for depressed older adults and their clinicians.
IPT and elder depression
New-onset or recurrent depression is common in older patients experiencing retirement, relocation, disabilities, or loss of important persons in their lives (Box 1) 4 IPT recognizes that depression, regardless of psychosocial stress or biologic vulnerability, is expressed in an interpersonal environment (Box 2).5,6 The environment may have contributed to the depression, but it also can be a platform for intervention.
Depressed older adults who are verbal, nondemented, and engageable are candidates for IPT, with or without adjunctive antidepressant therapy. Psychotherapy is not indicated for patients with severe dementia, but this article will describe how IPT is being adapted for those with early dementia or mild cognitive impairment.
Depression causes specific to later life
Box 2Biologic insults. Any brain injury that is more common in late life or that accumulates with age (such as cerebrovascular, Alzheimer’s, or Parkinson’s disease) increases the risk of damage to the neural circuitry that maintains mood.4 Common metabolic abnormalities such as hypothyroidism and vitamin B12 deficiency also can contribute to late-life depression, which is why routine blood screening is recommended.
Older patients often take multiple medications, increasing the risk for interactions and adverse events. Drugs with depression as a potential side effect include antipsychotics, antihypertensives, and corticosteroids.
Losses in later life can include bereavement for departed family and friends; changes in ego support and financial security with retirement; lack of transportation to sustain hobbies and interests; and declining vision, hearing, and physical function such as urinary continence or ambulation.
Role disputes and interpersonal conflicts. Marriages may be strained by role changes related to retirement or to caring for a physically frail or cognitively impaired partner. Problems of adult children or grandchildren—illnesses, substance abuse, unemployment—can burden elders, especially if families expect financial support, child-care help, or cohabitation. Elder abuse or neglect may also add to late-life stress.
Death and dying issues. Older persons may worry about dying, experiencing pain, being a burden to their families, and whether their lives have been meaningful. Moving to a long-term care facility can demoralize those who view this transition as “the last abode before the grave.”
IPT targets depression’s themes, such as losses and role changes
Klerman et al5 developed interpersonal psychotherapy (IPT) in the 1970s while working with depressed adults. These authors adopted an empiric approach, reviewing the literature for evidence-based outcomes from various schools of thought to pull together elements that proved to be effective in treating depression.
Social workers on the team reported that interpersonal themes—such as family disputes, life changes, and grief reactions—seemed to trigger or perpetuate many patients’ depressions. Using these observations and the literature review, the group developed IPT as a practica psychotherapy to address depression in an interpersonal environment. IPT’s case discussions and guidelines are designed to help health professionals learn the approach quickly, use it with broad populations, and complete therapy within weeks rather than years.5,6
Case continued: ‘he made all the decisions’
At Mrs. E’s first IPT session, the therapist assigns her the “sick role.” They contract to meet 12 to 16 weeks, and Mrs. E’s daughter agrees to drive her to sessions.
In the next few weeks, the therapist explains depression’s biopsychosocial model and explores dual strategies with Mrs. E: to ease her mourning and explore new interests or relationships. The therapist encourages her to express her feelings and seeks to understand the dynamics of her marriage.
Mrs. E said she was raised by nurturing parents and married soon after high school. She depended on her husband for almost every decision, including their social calendar. She describes their relationship as mutually loving. As part of an interpersonal inventory, her therapist encourages her to describe in detail all the ways she misses him.