4

Evidence-Based Psychological
Treatments for Geriatric
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Depression
Avani Shah, Forrest Scogin, and Mark Floyd

Depression is one of the most common and debilitating psychological

disorders experienced in late life, with prevalence rates of significant
depressive symptoms in community-dwelling older adults as high as 25%
(Koenig & Blazer, 1992), resulting in mortality, disability, and health
decline. Unfortunately, older adults face a number of challenges in obtain-
ing adequate depression treatment. Geriatric depression is often compli-
cated by the presence of medical conditions (Katon & Ciechanowski,
2002) and polypharmacy (Pollock, 1999), requiring more specialized care.
Other barriers to adequate depression treatment for older adults include
underrecognition of depression (Cole & Yaffe, 1996; Mulsant & Ganguli,
1999), lack of transportation and mobility limitations (Bruce, Citters,
& Bartels, 2005), and stigma (Sirey et al., 2001). Older adults also wait
longer before they seek treatment, with an average delay of 6 to 8 years
(P. S. Wang et al., 2005). Moreover, the lack of professionals who special-
ize in mental health and aging (LaMascus, Bernard, Barry, Salerno, &
Weiss, 2005) creates a gap in treatment availability for older adults and
signals a significant problem, especially with the expected growth of this
population from 2010 to 2030.

87

http://dx.doi.org/10.1037/13753-004
Making Evidence-Based Psychological Treatments Work With Older Adults, edited by
F. Scogin and A. Shah
Copyright © 2012 American Psychological Association. All rights reserved.
 With these factors as a backdrop, in this chapter, we first provide an
overview of evidence-based psychological treatments (EBTs) for depression.
Psychological treatments are an important aspect of health care for older
adults, especially with respect to depression. Because our overarching goal in
this chapter is to help bridge the research-to-practice translation, coauthor
Mark Floyd then shares his perspective on implementing such treatments
in nonacademically based practice settings. This we hope will illuminate
some of the strengths and weaknesses of providing services informed by an
evidence-based perspective. There are undoubtedly many challenges to the
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use of protocol-driven psychological interventions, yet our belief is that prac-

tice guided by evidence is optimal. We conclude the chapter by providing
information on resources that can aid the implementation of evidence-based
practice with depressed older adults.

The Evidence
Avani Shah and Forrest Scogin

In this section, we overview the evidence base for psychological treat-

ments for depression experienced by older adults. This section builds on
the work of our team (Scogin, Welsh, Hanson, Stump, & Coates, 2005)
undertaken as part of the Society of Clinical Geropsychology’s effort to
identify EBTs for older adults. At that time, we conducted an exhaustive
review of the literature on psychological treatments for geriatric depres-
sion. A more thorough description of the methods used to identify EBTs
is provided in the introductory chapter of this book. In simplified terms, it
was necessary to have two controlled trials of the same treatment in which
significant reductions in depressive symptoms were found. It is impressive
that six approaches were identified as EBTs for geriatric depression: behav-
ior therapy, cognitive behavioral therapy (CBT), cognitive bibliotherapy,
problem-solving therapy (PST), brief psychodynamic therapy, and remi-
niscence therapy (RT). In that approximately 5 years has passed since the
publication of this review, our first task for this chapter was to review the
literature to determine whether work published between 2005 and 2008
had altered the list of EBTs. Whereas several noteworthy publications on
psychological treatment of depression appeared during this interval, and
are noted in this review of the evidence, there were no changes to the list
of EBTs for late-life depression. A brief overview of the six approaches and
the research support follows.

88    shah, scogin, and floyd

 Behavior Therapy

Behavior therapy for depression has great promise for application in a vari-
ety of settings and aging populations. The major premise of the treatment is eas-
ily understood by most older adult clients, and the application of the protocol is
arguably less technically demanding for clinicians. Much of the work in the area
stems from the contributions of Lewinsohn and colleagues (Lewinsohn, 1974;
Lewinsohn, Biglan, & Zeiss, 1976). They observed that depressed individuals
tended to participate in fewer and at times less satisfying pleasant activities and
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experienced a higher number of negative events. From these findings, behav-

ioral therapy for depression emerged in which the connection between mood
and behaviors was central. One of the goals of behavior therapy is to teach cli-
ents to observe the mood–behavior relation by recording their mood and activ-
ity patterns. Subsequently, clients learn to identify pleasant activities through
activity checklists and eventually to increase the frequency and quality of their
pleasant activities. According to the behavioral theory, depression will improve
when clients engage more often in satisfying pleasant activities.
Behavior therapy with depressed older adults has been reasonably well-
researched. Six out of seven studies support behavior therapy as an EBT for
depression in older adults (Gallagher & Thompson, 1982; Haringsma, Engels,
Cuijpers, & Spinhoven, 2006; Lichtenberg, Kimbarow, Morris, & ­Vangel,
1996; Rokke, Tomhave, & Jocic, 1999; Teri, Logsdon, Uomoto, & McCurry,
1997; Thompson, Gallagher, & Breckenridge, 1987). Behavior therapy was
superior to a control condition in five of the studies (Gallagher & ­Thompson,
1982; Lichtenberg et al., 1996; Rokke et al., 1999; Teri et al., 1997;
­Thompson et al., 1987). In one of the studies, behavior therapy was found
to be nonsignificantly different in efficacy from other EBTs, psychodynamic
therapy, and CBT (Gallagher & Thompson, 1982). The results of one pilot
study also suggest that behavior therapy could possibly be beneficial for older
adults in nursing home settings, but not enough information was provided to
determine whether this study contributes to the evidence-based status of this
treatment (Meeks, Looney, Haitsma, & Teri, 2008).
The versatility of behavior therapy can be ascertained by examining
the varying contexts in which it has been successful. For example, behavior
therapy has been effective with lower levels of depressive symptomatology
as well as for those meeting criteria for major depressive disorder. Across the
five studies, behavior therapy has also improved depressive symptoms with
differing session number and length, with as few as six 30-minute sessions
(Lichtenberg et al., 1996). Moreover, behavior therapy has the potential to
be administered by professionals other than mental health clinicians, as indi-
cated by the Lichtenberg et al. (1996) study in which occupational therapists
delivered the treatment.

geriatric depression    89
 Behavioral activation (Jacobson et al., 1996) is a promising variant of
this approach that presents a simplified approach that can be appealing for
use with older adults who are evidencing cognitive impairment. It has not
currently received EBT status with older adults, although our group has con-
ducted several pilot investigations (e.g., Snarski et al., 2011).
Resources are provided in Appendix 4.1 to assist those who may be
interested in using behavior therapy techniques with depressed older adults.
Refer to Table 4.1 for a list of studies contributing to the EBT status of behav-
ior therapy for older adults.
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Cognitive Behavioral Therapy

CBT, as exemplified by Beck et al. (1979), blends behavioral tech-

niques such as behavioral activation, relaxation training, and assertiveness
skills with cognitive techniques that identify, challenge, and change mal-
adaptive thoughts. The primary goal of the treatment is to target and change
both the depressogenic thinking and the behavioral patterns that lead to and
maintain depression.
We located eight studies that provide support for CBT as a beneficial
treatment for late-life depression (Campbell, 1992; Floyd, Scogin, McKendree-
Smith, Floyd, & Rokke, 2004; Fry, 1984; Gallagher & Thompson, 1982;
Gallagher-Thompson & Steffen, 1994; Laidlaw et al., 2008; Rokke et al.,
1999; Thompson et al., 1987). In these studies, CBT was found to be either
superior to a control condition or nonsignificantly different from another
EBT (behavioral therapy or brief psychodynamic therapy). On the basis of
the coding criteria, only one of the located CBT studies did not show evi-
dence for significantly reduced depressive symptomatology (De Berry, Davis,
& Reinhard, 1989). Thus, the majority of studies reviewed supported CBT.
In these studies, the average session length was 60 minutes, and the
number of treatment sessions varied between 10 and 18. A lengthier ver-
sion of CBT (Steuer et al., 1984) had 46 sessions and was efficacious when
compared with psychodynamic therapy; however, it was coded as a differ-
ent treatment because it was much longer than the other CBT protocols.
Another study was coded as a variant of CBT (Hyer et al., 2008) because the
intervention was delivered in blended group (13 sessions), individual (two
sessions), and staff-aided (two sessions) formats. In this randomized study,
CBT was shown to be more effective than treatment as usual.
Clinicians may be concerned that older adults will find CBT too
challenging. CBT does make demands on working memory capacity, but
with usually minor adaptations this form of treatment can be beneficial
for most older adults. CBT has been adapted by Thompson and colleagues

90    shah, scogin, and floyd

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Table 4.1
Research Contributing to the Evidence-Based Psychological Treatment Status of Behavioral Therapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

Gallagher & N = 30; 55 years and 1. Behavioral therapy 16 sess., BDI, HRSD, Significant and compa-
Thompson, older; BDI > 17, (n = 10) 90-min sess. SADS-C, rable initial improve-
1982 HRSD > 14 2. CBT (n = 10) SRS, SDS ment for all groups;
3. Brief–relational cognitive and behav-
insight therapy ioral groups main-
(n = 10) tained gains longer
than those in brief–
relational group
Haringsma, N = 119; 55 years 1. Coping with 11 group CES-D Significant improvement
Engels, and older; depression sess., 2-hr in the intervention
Cuijpers, & Presence of prior (n = 61) sess. condition
Spinhoven, depressive 2. Wait-list control
2006 symptoms (n = 58)
Lichtenberg, N = 37; 60 years and 1. Behavioral therapy 6 sess., GDS Significantly greater
Kimbarow, older; GDS > 10 by psycho-logists 30-min sess. improvement in
Morris, & (n = 13) behavioral groups
Vangel, 1996 2. Behavioral therapy than in no-treatment
by occupational control group
therapists (n = 13)
3. No treatment
control (n = 11)
Meeks, Looney, N = 20; 55 years and 1. Behavioral 10 sess., GDS, HRSD
Haitsma, & older; GDS > 11 therapy (n = 13) 40-min sess.
Teri, 2008 2. Control group
(n = 7)

geriatric depression   
(continues)

91
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Table 4.1

92   
Research Contributing to the Evidence-Based Psychological Treatment Status of Behavioral Therapy (Continued)
Length of Outcome
Authors Sample Conditions treatment measures Findings

Rokke, Tomhave, N = 40; 60 years 1. Behavioral 10 sess., BDI, GDS Comparable improve-
& Jocic, 1999 of age or older; therapy (n = 8) 60-min sess. ment for CBT and BT;
HRSD > 9, BDI 2. CBT (n = 9) significantly greater
> 9, GDS > 10 3. Wait-list control improvement in CBT
(n = 23) & BT compared with
wait-list control group
Teri, Logsdon, N = 72; patient–care- 1. Behavioral 9 sess., BDI, CSDD Significantly greater

shah, scogin, and floyd

Uomoto, & giver dyads, GDS therapy (n = 42) 60-min sess. improvement in
McCurry, 1997 > 9, met RDC and 2. Typical care control behavioral group
DSM–III–R criteria (n = 10) than in typical care
for major or minor 3. Wait-list condition and wait-list control
depressive dis- (n = 20) conditions
order
Thompson, N = 95; 60 years of 1. Behavioral 18 sess., BDI, BSI-D, Comparable improve-
Gallagher, & age or older; met therapy (n = 25) 60-min sess. GDS, HRSD ment for BT, CT, and
Breckinridge, RDC criteria for 2. Cognitive therapy BPT; control group did
1987 MDD, BDI > 16, (n = 27) not improve
HRSD > 13 3. Brief psycho-dynamic
therapy (n = 24)
4. Wait-list control
(n = 19)
Note. sess. = session; CBT = cognitive behavioral therapy; BDI = Beck Depression Inventory; BSI-D = Brief Symptom Inventory–Depression subscale; CES-D = Center for
Epidemiologic Studies Depression; CSDD = Cornell Scale for Depression in Dementia; DSM–III–R = Diagnostic and Statistical Manual of Mental Disorders—Third Edition–
Revised; GDS = Geriatric Depression Scale; HRSD = Hamilton Rating Scale for Depression; MDD = major depressive disorder; RDC = Research Diagnostic Criteria;
SADS-C = Schedule for Affective Disorders and Schizophrenia–Change Interview; SDS = Zung Self-Rating Depression Scale; SRS = Self-Rating Scale; BT = behavioral
therapy; CT = cognitive therapy; BPT = brief psychodynamic therapy.
 (­ Gallagher-­Thompson & Thompson, 2010; Laidlaw, ­Thompson, Dick-Siskin,
& Gallagher-Thompson, 2003) to meet the needs of older adults. The
modifications needed for CBT have been identified in several articles (e.g.,
Rybarczyk, Gallagher-Thompson, Rodman, Zeiss, Gantz, & Yesavage,
1992). For example, age-related physical and cognitive declines for some
older consumers may impede compliance with written homework assign-
ments or other aspects of the treatment program. Specifically, modifications
such as providing in-session memory aids (e.g., cue cards, written material
on an easel), slowing down the pace of the therapy process, providing a
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recording of the session, and simplifying homework assignments can maxi-

mize fit between the treatment and the older adult. At this time, CBT is
the most extensively researched psychological treatment for depressed older
adults. Refer to Appendices 4.1 to 4.6 for additional resources in conducting
CBT and to Table 4.2 for studies contributing to the EBT status of CBT.

Cognitive Bibliotherapy

Cognitive bibliotherapy, that is, cognitive therapy (CT) delivered

through a book, is one of the most thoroughly researched self-help approaches.
CT includes a number of psychoeducational components, such as reading
and homework assignments. Thus, it is not surprising that CT has been
developed for self-administration in book format. Because of the availability
and low cost of cognitive bibliotherapy, it has the potential to be provided to
older adults, who may otherwise encounter barriers to traditionally delivered
psychotherapy because of mobility limitations, transportation difficulties, or
financial concerns.
Four studies support cognitive bibliotherapy as an EBT for depression
in older adults (Floyd et al., 2004; Landreville & Bissonnette, 1997; Scogin,
Hamblin, & Beutler, 1987; Scogin, Jamison, & Gochneaur, 1989). All of
the studies used the Feeling Good book (Burns, 1980), allowing participants
to work through the book at their own pace over approximately a 4-week
period. During this time, participants received only minimal brief weekly
contacts. Refer to Table 4.3 for a list of studies that contribute to the EBT
status of cognitive bibliotherapy.

Problem-Solving Therapy

PST (Nezu, Nezu, & Perri, 1989) has become a highly valued approach
for treating depression in older adults. According to PST for depression
(Arean et al., 1993), deficiencies in problem-solving skills prevent older

geriatric depression    93
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94   
Table 4.2
Research Contributing to the Evidence-Based Psychological Treatment Status of Cognitive Behavioral Therapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

Campbell, 1992 N = 103; aged 1. CBT (n = ?) 16 sess., SDS Significantly greater improve-
64–82; met 2. Attention placebo 60-min ment in CBT group as
DSM–III–R criteria (n = ?) sess. compared with the attention
for depression 3. No treatment control placebo and no treatment
(n = ?) control groups
De Berry, Davis, N = 32; aged 65–75 1. Relaxation– 20 sess., BDI RM group showed greater

shah, scogin, and floyd

& Reinhard, Meditation (n = 13) 45-min improvement than CBT and
1989 2. CBT (n = 10) sess. attention placebo, but not
3. Attention placebo significantly so
(n = 9)
Floyd, Scogin, N = 35, 60 years 1. CBT (n = 8) 16 sess., GDS, Significantly greater improve-
McKendree- of age or older, 2. Cognitive bibliother- 50-min HRSD ment in CBT and CB than in
Smith, Floyd, & HRSD > 9 apy (n = 13) sess. the wait-list control group;
Rokke, 2004 3. Wait-list control CBT superior to CB on GDS
(n = 14)
Fry, 1984 N = 28; aged 67–80 1. CBT (n = 17) 12 sess., DEQ, Significantly greater improve-
2. Wait-list control 60-min MMPI-2 ment in CBT group as
(n = 11) sess. compared with the wait-list
control group
Gallagher & N = 30; 55 years and 1. BT (n = 10) 16 sess., BDI, HRSD, Significant and comparable
Thompson, older; BDI > 17, 2. CBT (n = 10) 90-min SADS-C, initial improvement for all
1982 HRSD > 14 3. Brief–relational sess. SDS groups; CBT and behavioral
insight therapy groups maintained gains
(n = 10) longer than those in brief–
relational group
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Gallagher- N = 52; met RDC 1. CBT (n = 31) 18 sess., BDI, HRSD, Comparable improvement for
Thompson & criteria for major, 2. Brief psychodynamic 60-min GDS, both groups
Steffen, 1994 minor, or intermit- therapy (n = 21) sess. SADS-C
tent depressive
disorder, BDI > 9
Laidlaw et al., N = 40; HRSD > 7, 1. CBT (n = 21) 8 sess., HRSD Significantly greater improve-
2008 BDI-II > 13 2. Treatment as usual 60-min ment in CBT group as com-
(n = 23) sess.? pared with treatment as usual
group
Rokke, Tomhave, N = 40; 60 years 1. BT (n = 8) 10 sess., BDI, GDS, Comparable improvement for
& Jocic, 1999 of age or older; 2. CBT (n = 9) 60-min HRSD CBT and BT; significantly
HRSD > 9, BDI > 3. Wait-list control sess. greater improvement in CBT
9, GDS > 10 (n = 23) and BT groups as compared
with the wait-list control group
Steuer et al., N = 35; 55 years of 1. Psychodynamic 46 sess. HAMD, Both groups improved sig-
1984 age or older; met therapy (n = 10) SDS, BDI nificantly; significantly greater
DSM–III criteria for 2. CBT (n = 10) improvement in CBT group
major depressive than PT
disorder
Thompson, Galla- N = 95; 60 years of 1. BT (n = 25) 18 sess., BDI, BSI- Comparable improvement for
gher, & Breck- age or older; met 2. Cognitive therapy 60-min D, GDS, all treatment groups; control
inridge, 1987 RDC criteria for (n = 27) sess. HRSD group did not improve
MDD, BDI > 16, 3. Brief psychodynamic
HRSD > 13 therapy (n = 24)
4. Wait-list control
(n = 19)
Note. sess. = session; ? = indicates sample size is unknown; BDI = Beck Depression Inventory; BSI-D = Brief Symptom Inventory–Depression subscale; BT = behavioral
therapy; CB = cognitive bibliotherapy; CBT = cognitive behavioral therapy; DEQ = Depressive Experiences Questionnaire; DSM–III–R = Diagnostic and Statistical Manual of
Mental Disorders—Third Edition—Revised; GDS = Geriatric Depression Scale; HAMD = Hamilton Depression Scale; HRSD = Hamilton Rating Scale for Depression; MMPI-2 =
Minnesota Multiphasic Personality Inventory–2; PT = psychodynamic therapy; RDC = Research Diagnostic Criteria; SADS-C = Schedule for Affective Disorders and
Schizophrenia–Change Interview; SDS = Zung Self-Rating Depression Scale.

geriatric depression   
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96   
Table 4.3
Research Contributing to the Evidence-Based Psychological Treatment Status of Cognitive Bibliotherapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

Floyd, Scogin, N = 35; 60 years 1. CBT (n = 8) 4 weeks GDS, Significantly greater improvement
McKendree- of age or older; 2. CB (n = 13) HRSD in CBT and CB as compared
Smith, Floyd, & HRSD > 9 3. Wait-list control with the wait-list control group;
Rokke, 2004 (n = 14) CBT superior to CB on GDS
Landreville & N = 23; 55 years of 1. CB (n = 12) 4 weeks GDS, Significantly greater improvement
Bissonnette, age or older; diag- 2. Wait-list control HRSD in CB as compared with the

shah, scogin, and floyd

1997 nosed depressive (n = 11) wait-list control group
disorder
Scogin, Hamblin, N = 20; 60 years 1. CB (n = 8) 4 weeks BDI, Significantly greater improvement
& Beutler, 1987 of age or older; 2. Attention placebo GDS, with CB as compared with the
HRSD > 9 (n = 6) HRSD attention placebo and wait-list
3. Wait-list control control group
(n = 6)
Scogin, Jamison, N = 44; 60 years 1. CB (n = 15) 4 weeks GDS, Significantly greater improvement
& Gochneaur, of age or older; 2. BB (n = 14) HRSD with CB and BB as compared
1989 HRSD > 9 3. Wait-list control with the wait-list control group;
(n = 15) comparable efficacies between
CB and BB
Note. CBT = cognitive behavioral therapy; BB = behavioral bibliotherapy; BDI = Beck Depression Inventory; CB = cognitive bibliotherapy; GDS = Geriatric Depression Scale;
HRSD = Hamilton Rating Scale for Depression.
 adults from successfully coping with routine problems as well as the chal-
lenges in late life (e.g., health, financial, loss, retirement), resulting in depres-
sion. The premise of PST is to teach clients the skills to address their own
problems in an organized step-by-step fashion. This approach encourages
clients to first identify their problems and then to formulate a number of
potential solutions. Next, each solution is examined for feasibility, and the
most suitable course of action is selected for implementation. Finally, the cli-
ent is asked to evaluate the outcome after each solution is applied. In PST,
the therapist serves as a coach in the problem-solving process, allowing each
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stage of the process to be primarily guided by the client to allow for the devel-
opment of problem-solving skills that can be applied independently even
after psychotherapy has ended.
Five studies have shown for support PST as an EBT for depression in
older adults (Alexopoulos, Raue, & Arean, 2003; Arean et al., 1993; Gellis
et al., 2008; Gellis, McGinty, Horowitz, Bruce, & Misener, 2007; Hussian
& Lawrence, 1981). These studies speak to the flexibility of PST in being
applied to different populations of older adults, including nursing home resi-
dents, home care recipients, and the community dwelling. Session number
and length ranged from as few as five 30-minute sessions for nursing home
patients to as many as 12 sessions, 90 minutes in length, for community-
dwelling older adults. Fewer and shorter sessions were common in the nursing
home and home-care settings. Refer to Appendix 4.1 for resources to assist in
conducting PST. See Table 4.4 for a list of studies contributing to the EBT
status of PST.

Brief Psychodynamic Therapy

The goal of brief psychodynamic therapy is to increase insight through

the patterns observed in the therapeutic relationship, to examine areas of
conflict, and to explore unconscious processes in a time-limited manner
(Horowitz & Kaltreider, 1979). Two studies (Gallagher-Thompson & Steffen,
1994; Thompson et al., 1987) have examined the efficacy of brief psycho-
dynamic therapy for older adults with depression, supporting the treatment
as an EBT. Both studies involved 18 one-hour sessions. Refer to Table 4.5 to
obtain additional information about these studies. A study with 46 ses-
sions of short-term psychodynamic psychotherapy (Steuer et al., 1984) was
coded as a distinct treatment because of its length. This study showed that
a lengthier form of psychotherapy effectively treated depressive symptoms
in older adults. Brief psychodynamic therapy is not to be confused with
classic psychoanalysis, in which much longer treatment duration is typi-
cal and the goals of treatment tend to be more far-reaching. We did not

geriatric depression    97
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Table 4.4

98   
Research Contributing to the Evidence-Based Psychological Treatment Status of Problem-Solving Therapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

Alexopoulos, N = 25; 65 years of 1. PST (n = 12) 12 sess., HRSD Significantly greater improvement in
Raue, & age and older; 2. Supportive therapy 60-min PST group as compared with the
Areán, 2003 HRSD > 17 (n = 13) sess. supportive therapy group
Areán, Perri, N = 67; aged 55–80; 1. PST (n = 19) 12 sess., BDI, GDS, Significantly greater improvement in
Nezu, Schein, met RDC criteria 2. RT (n = 28) 90-min HRSD PST & RT groups as compared
Christopher, for MDD; BDI > 3. Wait-list control sess. with the wait-list control group;
& Joseph, 20, HRSD > 18, (n = 20) improvement significantly greater
1993 GDS > 10 for PST than for RT

shah, scogin, and floyd

Gellis, McGinty, N = 40; 65 years 1. PST (home care; 6 weeks, BDI, CES-D, Significantly greater improvement in
Horowitz, of age or older; n = 20) 6 sess. GDS, PST group as compared with the
Bruce, & CES-D > 22 2. Usual care (n = 20) QOLI usual care
Misener, 2007
Gellis, McGinty, N = 62; 65 years 1. PST (home care; 6 weeks, GDS-15, Significantly greater improvement in
Tierney, of age or older; n = 30) 6 sess., HRSD sf, PST group as compared with the
Jordan, CES-D sf > 15, 2. Usual care (n = 32) 60-min QOLI usual care except on QOLI
Burton, & HRSD sf >11 sess.
Misener, 2008
Hussian & N = 36, nursing 1. PST (n = 12) 5 sess., BDI, SRS Significantly greater improvement
Lawrence, home residents 2. SR (n = 12) 30-min in PST & SR as compared with
1981 3. Wait-list control sess. the wait-list control group; PST
(n = 12) showed greater improvement than
SR on BDI
Note. sess. = session; BDI = Beck Depression Inventory; CES-D = Center for Epidemiologic Studies Depression Scale; GDS = Geriatric Depression Scale; HRSD = Hamilton
Rating Scale for Depression; MDD = major depressive disorder; PST = problem-solving therapy; RDC = research diagnostic criteria; RT = reminiscence therapy; SR = social
reinforcement; QOLI = Quality of Life Inventory; SRS = Self-Rating Scale.
 Copyright American Psychological Association. Not for further distribution.

Table 4.5
Research Contributing to the Evidence-Based Psychological Treatment Status of Brief Psychodynamic Therapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

Gallagher- N = 52; met RDC criteria 1. CBT (n = 31) 18 sess., BDI, GDS, Comparable
Thompson & for major, minor, or 2. Brief psychodynamic 60-min HRSD, improvement for
Steffen, 1994 intermittent depressive therapy (n = 21) sess. SADS-C both groups
disorder; BDI > 9
Thompson, N = 95; 60 years of age 1. Behavioral therapy (n = 25) 18 sess., BDI, BSI-D, Comparable
Gallagher, & or older; met RDC 2. Cognitive therapy (n = 27) 60-min GDS, improvement for all
Breckinridge, criteria for MDD, 3. Brief psychodynamic sess. HRSD three experimental
1987 BDI > 16, HRSD > 13 therapy (n = 24) groups; control
4. Wait-list control (n = 19) group did not
improve
Note. sess. = session; BDI = Beck Depression Inventory, BSI-D = Brief Symptom Inventory: Depression Subscale, CBT = cognitive behavioral therapy; GDS = Geriatric
Depression Scale, HRSD = Hamilton Rating Scale for Depression, MDD = Major Depressive Disorder, RDC = Research Diagnostic Criteria, SADS-C = Schedule for Affective
Disorders and Schizophrenia–Change Interview.

geriatric depression   
99
 find any controlled studies of psychoanalysis for depression experienced by
older adults. Consult Appendix 4.1 for additional resources on implementing
­psychodynamic psychotherapy.

Reminiscence Therapy

RT is one of the only psychological therapies developed specifically for

older adults. On the basis of Erickson’s (1963) stages of psychosocial develop-
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ment, the primary developmental task in late life is reflecting on meaningful

life events to achieve ego integrity and avoid despair. The rationale for RT is
straightforward: focusing on the narration of significant positive and negative
life events to achieve ego integrity and self-actualization (Birren & Deutchman,
1991). The opportunity to reflect on and integrate successes and failures at this
stage in one’s life can help resolve conflicts, develop a renewed sense of mean-
ing, and even reshape identity. Many older adults find RT appealing because
it tends to capitalize on well-preserved memories rather than on emphasizing
working memory. Working memory tends to show age-related declines, and
therapies that emphasize working memory, such as CBT, are sometimes chal-
lenging for older adults with mild and moderate cognitive impairment.
According to Webster, Bohlmeijer, and Westerhof (2010), three major
types of reminiscence interventions are available: simple and unstructured;
life review or structured reminiscence; and life review therapy, which is highly
structured and frequently combined with other treatment modalities (e.g., CT,
PST, narrative therapy). Six out of eight studies support RT as an EBT for
late-life depression (Arean et al., 1993; Goldwasser, Auerbach, & Harkins,
1987; Serrano, Latorre, Gatz, & Montanes, 2004; J. J. Wang, 2005, 2007; Watt
& Cappeliez, 2000). Most of these studies used life review therapy, which is
highly structured. As few as four to as many as 12 session protocols were rep-
resented in the studies. Session lengths also varied, with some studies having
sessions as short as 30 minutes and others using 90-minute sessions. An advan-
tage of RT is its logical delivery in a group setting, which is cost-effective and a
format favored in the EBT studies (e.g., Arean et al., 1993; Goldwasser et al.,
1987; J. J. Wang, 2007). Three of the studies provided RT in long-term-care
settings, suggesting the potential for application to a vulnerable subpopula-
tion (Goldwasser et al., 1987; J. J. Wang, 2005, 2007). This approach could
also be useful for those with memory impairments as two of these studies
provided RT to depressed older adults with dementia (Goldwasser et al.,
1987; J. J. Wang, 2007). Many long-term-care settings for older adults already
incorporate elements of reminiscence into recreational activities (e.g., music
from prior eras, discussion groups), which may make RT more acceptable
to staff and therefore more likely to be implemented. Though RT has the

100    shah, scogin, and floyd

 potential to be delivered by social workers, nurses, occupational therapists,
and recreational therapists, particularly in long-term settings, none of the
EBT studies evaluated this. Stinson and Kirke (2006) examined the impact
of nurse-delivered RT in an assisted living facility, but depressive symptoms
did not significantly decrease following treatment compared with the control
group. Refer to Appendix 4.1 for additional resources in implementing RT
and to Table 4.6 for a list of studies contributing to the EBT status of RT.
Copyright American Psychological Association. Not for further distribution.

Interventions Needing Further Study

Several other treatments for late-life depression did not meet EBT sta-
tus because only one controlled study assessed was available. A list of the
interventions is included in Table 4.7.
In these next sections, we hope to take this presentation on EBTs
for depressed older adults to a more practical level. In the abstract, most
psychologists would agree that the use of treatments with a solid record of
effectiveness is the proper course of action. However, we do not practice in
the abstract, and when it comes time to implement a treatment plan, issues
arise. As clinical researchers, we encounter the same issues in clinical trials;
rarely can a protocol be delivered with complete fidelity to depressed older
adults even in the context of a carefully monitored efficacy investigation.
Nonetheless, we believe that EBTs adapted to the context in which they are
provided should be given first consideration by clinicians and consumers. In
the paragraphs that follow, Mark Floyd discusses his conceptualization and
implementation of evidence-based practice.

Adapting EBT for the Real World

Mark Floyd

I am currently a full-time clinician in the Veterans Affairs system, split-

ting my time between a 120-bed skilled nursing facility and home-based pri-
mary care. The patients in both locations are predominantly older adults
and have a mixture of mental disorders (e.g., depression, anxiety disorders,
psychotic disorders) and health problems (e.g., chronic pain, chronic ill-
ness, disability). I have participated in a randomized clinical trial using
CBT, and I am a firm believer in using the science of psychotherapy to guide
my work as a clinician. However, I find it difficult to follow treatment

geriatric depression    101

 Copyright American Psychological Association. Not for further distribution.

102   
Table 4.6
Research Contributing to the Evidence-Based Psychological Treatment Status of Reminiscence Therapy
Length of Outcome
Authors Sample Conditions treatment measures Findings

shah, scogin, and floyd

Areán et al., N = 67; aged 55–80; 1. PST (n = 19) 12 sess., BDI, GDS, Significantly greater
1993 met RDC criteria 2. RT (n = 28) 90-min HRSD improvement in PST
for MDD; BDI > 3. Wait-list control (n = 20) sess. and RT groups as
20, HRSD > 18, compared with the
GDS > 10 wait-list control group;
significantly greater
improvement for PST
than RT
Goldwasser, N = 30; demented 1. RT (n = 9) 10 sess., BDI Significantly greater
Auerbach, nursing home 2. Reality orientation (n = 9) 30-min improvement in RT as
& Harkins, residents 3. No treatment control sess. compared with other
1987 (n = 9) conditions
Klausner N = 13; ages 55 and 1. RT (n = 4) 11 sess., BDI, HRSD, Improvement in both
et al., above; met criteria 2. Goal-focused psycho- 60-min Montgomery- groups, but GFP
1998 for MDD therapy (n = 4) sess. Asberg improved more
Scale for
Depression
 Copyright American Psychological Association. Not for further distribution.

Serrano, N = 43; ages 60 1. Life review (n = 20) 4 sess., CES-D Significantly greater
Latorre, years and above 2. Social services as usual 1/week improvement in LR
Gatz, & (n = 23)
Montanes,
2004
J. J. Wang, N = 48; 65 years of 1. RT (n = 25) 4 months, GDS-15, AER Significantly greater
2005 age or older; long- 2. Control group (n = 20) 1/week, improvement in RT
term-care facility 30–45-min group as compared
sess. with control group
J. J. Wang, N = 102; 65 years of 1. Experimental (n = 51) 8 sess., GDS-15, Significantly greater
2007 age or older 2. Control (n = 51) 1/week CSDD improvement in experi-
mental group on CSDD
than control group
Watt & N = 40; ages 60 1. Integrative reminiscence 6 sess., GDS, HRSD Significantly greater
Cappeliez, years and above; therapy (n = 16) 90-min improvement in RT
2000 GDS > 13 2. Instrumental reminiscence sess.
therapy (n = 12)
3. Attention placebo (n = 12)
Note. sess. = session; AER = Apparent Emotion Rating Scale; BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies Depression Scale; CSDD = Cornell
Scale for Depression in Dementia; GDS = Geriatric Depression Scale; GFP = goal-focused psychotherapy; HRSD = Hamilton Rating Scale for Depression; MDD = major
depressive disorder; LR = life review; PST = problem-solving therapy; RDC = research diagnostic criteria; RT = reminiscence therapy.

geriatric depression   
103
 Table 4.7
Interventions Needing Further Study
Study Modality Outcome

Viney, Benjamin, & Personal construct Superior to no treatment

Preston, 1989 therapy ­control
Dhooper, Green, Huff, Coping together group Superior to no treatment
& Austin-Murphy, therapy ­control
1993
Mossey, Knott, Higgins, Short-term inter- Superior to attention-placebo
Copyright American Psychological Association. Not for further distribution.

& Talerico, 1996 personal psycho- control

therapy
Scogin et al., 1989 Behavioral bibliotherapy Comparable to cognitive
bibliotherapy and superior
to delayed treatment control
Gallagher & Thompson, Relational–insight Comparable to behavioral
1982 therapy and CBT
Klausner et al., 1988 Goal-focused therapy Superior to reminiscence
therapy
Steuer et al., 1984 Psychodynamic therapy Comparable to CBT
Hyer et al., 2008 Group, individual, and Superior to treatment as usual
staff CBT
Spek et al., 2008a Internet-based CBT Superior to a delayed
treatment control
Van Schaik et al., 2005 Interpersonal psycho- Superior to care as usual
therapy
Note. CBT = cognitive behavioral therapy.
aMean age of participants was 55.

manuals verbatim and frequently feel compelled to deviate from protocol.

The guiding principles I follow are: (a) deliver as closely as is practicable,
the treatments as outlined in the treatment manuals used in EBT research;
(b) remain flexible and deviate from the treatment manual when it makes
good clinical sense; and (c) approach each case from a scientist–practitioner
viewpoint, using a hypothesis generation and testing methodology for each
specific intervention. My orientation is primarily cognitive behavioral, but
I also frequently use RT and motivational interviewing because these tech-
niques work well with the home-based primary care population. Motivational
interviewing is not an EBT for late-life depression, but it does have a strong
track record with adult populations.
I start each case in hopes of following the CBT protocol verbatim. I
begin the first therapy session with the treatment rationale. Most patients
are active participants in this session and respond favorably to the rationale.
The first problem I encounter in the home-based primary care population is a
resistance to homework. This resistance is not specific to psychotherapy, but
rather it is more of a general characteristic of the patient’s problems. Many

104    shah, scogin, and floyd

 of the patients in home-based primary care have chronic health problems
resulting from a lifetime of poor decision making, unhealthy lifestyle, and
a refusal to follow the suggestions of health care providers. The patients are
noncompliant with psychotherapy homework in the same way they are non-
compliant with diet, exercise, and medication schedules. The compliance
problems begin when I introduce activity recording and the patient balks
at having to write something down. We discuss the reluctance and typically
end the session with the patient making a commitment to attempt the home-
work. At the start of the next session, the patient confesses to not doing the
Copyright American Psychological Association. Not for further distribution.

homework assignment. At this point, I must choose between sticking to the

protocol and refusing to continue therapy if the patient is unwilling to do
homework or accepting that the patient is not likely to ever do homework
and proceeding as best we can. In most cases, I accept they will not do home-
work on their own and never assign it again. We do all exercises together
during the session. It is much less time efficient and possibly fosters more of
a dependence on me in the beginning, but with repetition the patient learns
the techniques and begins using them outside the session.
Elements of CBT that I almost always use include the three- and five-
column techniques and collaborative empiricism. Whenever I hear a cogni-
tive distortion, I ask whether the statement is indeed true or whether it is an
exaggeration due to the influence of emotions. I summarize the treatment
rationale again if necessary to reinforce how thoughts and emotions are con-
nected. We examine the evidence and accordingly revise the thought. With
repetition, the patient learns to recognize a cognitive distortion and how to
use these cognitive behavioral techniques to reduce distress. We review the
importance of identifying the specific words in their self-talk and stress the
need to avoid exaggerations of distress.
Another CT technique I frequently use is described as “the downward
arrow technique” in Feeling Good (Burns, 1980). This technique is well suited
for dealing with situations that are a realistic problem (as opposed to a cogni-
tive distortion) on the surface. For example, the downward arrow technique
is useful in helping patients to accept the realities of such late-life situations
as loss of independence, increased disability, and loss of loved ones. The
technique teaches them how to drill down into their thought processes and
identify cognitive distortions. It often exposes distorted thoughts, such as
“I cannot be happy if I am disabled” or “my life is meaningless without my
spouse,” that coexist with what appears to be normal grief for the loss of
mobility or the loss of a spouse. Loss is an inevitable consequence of aging,
but loss does not mean everyone is doomed to unhappiness.
As mentioned previously, loss is a difficult part of aging and a recurrent
issue in work with the older population. I find that everyone “knows” they
will die, and in most cases they have no distress associated with the thought

geriatric depression    105

 of death. However, they rarely consider how the aging process is a gradual
progression toward disability, loss of independence, and the loss of loved
ones, and when faced with these circumstances they often become depressed.
Rather than focusing on what they have and making adjustments to enjoy
life as much as possible, they focus on their losses and remain stuck in a rut of
trying to continue their life as it was before the loss. Acceptance, or passive
coping, is necessary when active coping fails, and I help them understand and
apply both. I encourage the use of the serenity prayer as a general problem-
solving model—to accept what they cannot change but to do as much as
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possible to make changes to match their wants and needs.

RT provides another path toward acceptance of events in life. Older
adults frequently stray off topic into a review of the past, and when they do,
I encourage them to elaborate on the events and the downstream effects.
This gives me an opportunity to rid the patient of cognitive distortions
associated with their past. When there are no distortions, I try to stress how
mistakes can have positive effects later in life and that the nature of life is
we are forced into making decisions between mutually exclusive options.
Another difficult scenario in home-based primary care is the patient with
a chronic health condition and depression secondary to their medical condi-
tion. Chronic diabetes is a common problem, and patients become depressed
because of the disability and prognosis. It is unfortunate that these patients
are often unwilling to make the necessary lifestyle changes to improve their
health and alleviate their depression. I have trouble using typical cognitive
behavioral techniques because it seems that no matter how I try to stick with
a collaborative approach, they perceive me as preaching to them about what
they should do, just like every other health care professional. To avoid this
trap, I empathize with their challenges and use motivational interviewing to
increase health-promoting behaviors. It is a slow process to shift them into
action, and I have to remind myself that changing lifelong habits takes time.
I also keep in mind that maintaining the status quo is a victory when dealing
with a progressively debilitating condition.
In summary, although it is difficult to follow an EBT protocol verbatim,
there are many specific interventions within each EBT that can be used as
designed. I think it is best to have the freedom to select bits and pieces from
several EBTs and apply them as needed in each individual case.

Case Example

The patient is a 77-year-old, married Caucasian male veteran with

chronic diabetes and associated neuropathy, including visual limitations.
“Sam” is a retired truck driver and electrician with a high school education

106    shah, scogin, and floyd

 who was referred for the treatment of depression and anxiety. There were a
total of 10 sessions, the last of which was primarily a check-in to monitor
status and confirm treatment gains were being maintained. The following
is a synopsis of the progress notes with elaborations on the techniques used.

Session 1

The first session is a psychological evaluation. Sam admits to being

depressed, endorsing sadness, anhedonia, lack of energy, sleep disturbance
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(hypersomnia), and worthlessness. He scores a 6 on the Geriatric Depres-

sion Scale–15 (GDS-15; Yesavage et al., 1982–1983; see Appendix 4.5). Sam
denies suicidal or homicidal thoughts, psychoticism, and substance problems.
He feels somewhat helpless due to his visual limitations and hopeless because
there is no cure for diabetes. He fears becoming injured secondary to the visual
limitations and therefore must constantly remind himself to be cautious. He
complains that he sleeps too much, with about 7 hours of sleep at night plus a
2-hour or longer nap each afternoon and sometimes also a 2-hour nap in the
morning, and he states he would like to do all of his sleeping at night. Sam
denies relationship problems and states that he and his wife get along well
with each other. Brief evaluation of cognition indicates attention is intact;
there are some deficits in working memory and recall, but recognition is intact.
Overall, his pattern of cognitive deficits is consistent with the effects of depres-
sion, yet it is possible he is experiencing some mild cognitive impairment.
Further testing would be necessary to discern this, but it is clear his memory is
intact enough for psychotherapy, especially if I give him reminders and repeat
important information. His visual limitations also prevent the use of written
reminders, diagrams, and homework, which otherwise would have enhanced
retention of treatment information. We agree to meet again in 2 weeks after
he returns from vacation.

Session 2

Sam reports his mood has been “pretty good” and that they had a good
vacation. He denies sadness and anhedonia, but he reports having night-
mares and getting really angry several times while on vacation. He says the
nightmares were not identical, but the content followed the general form
of someone or something trying to kill him, and he awoke with a feeling of
dread. I ask about his thoughts about death, and he says he gets claustropho-
bic whenever he envisions himself buried in a coffin, and he admits that is
stupid because he knows he would be dead and it wouldn’t matter. He also
states he has very strong religious beliefs and has been a lifelong member of
his church. Sam says he believes God has forgiven him, but although he has

geriatric depression    107

 not done anything terribly wrong, he is not certain he will go to heaven when
he dies. We discuss how this uncertainty would make the thought of death
very uncomfortable, stressing the connection between thoughts and emo-
tions. Sam then describes some of the incidents that triggered his anger while
on vacation. In each instance, he got mad when someone disagreed with him
or said something that he interpreted as being critical of him. Sam says this
has been a long-standing problem for him, and it is his biggest problem. We
did not have time remaining in this session for an intervention, so we agree
to focus on this during our next session.
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This session changed my conceptualization of Sam. In the first session,

my impression was depression because he had not accepted his chronic illness
and disability. However, by the end of the second session, a pattern of perfec-
tionism, sensitivity to criticism, and general lack of self-acceptance emerged
and appeared to be at the root of his problems, and this became my working
hypothesis. I also noted I would need to tread lightly given his sensitivity to
criticism and be cautious when challenging his viewpoints.

Session 3

Sam starts this session by engaging in life review, with a focus on his
employment history, and admits he has always been very self-conscious, fear-
ful of evaluation by others, and easily hurt by negative comments made by
others. He says he knows it is wrong, but he has had trouble forgiving some
who have hurt his feelings. He knows this is part of his anger problem.
To illustrate, Sam recalls an incident that occurred more than 30 years
ago in his church. Sam describes his church as being a “small, close-knit con-
gregation,” and everyone is expected to take an active part in the worship
service. This expectation of involvement is especially true for the men, who
are expected to say prayers aloud each week as a regular part of the service.
Sam says he heard one of the church elders at the end of the service say to
someone, “You know, Sam can’t even hardly speak right.” Sam says it was
wrong for anyone to say that sort of thing about another church member, and
it was especially wrong for an elder, so he has still not forgiven him and is still
angry. I explain the CT rationale of how emotions are connected to thoughts,
and I ask Sam what else he is thinking and feeling. He admits he felt embar-
rassed and sad and that this incident made him even more fearful of public
speaking. Sam’s thoughts include “I cannot even pray well,” “I’m not a good
church member,” and “If I speak in public again, I’ll just embarrass myself.”
We discuss the connection between his thoughts and his emotions, and I cau-
tiously emphasize that it was his thoughts rather than the elder’s words that
made him feel so bad. I then use the downward arrow technique as described
in Feeling Good (Burns, 1980) and find that Sam thought he was worthless. I

108    shah, scogin, and floyd

 ask him what his expectation for himself was in regard to public prayer, and
he says he should not be as good as the preacher but still pretty good. I ask
if it were reasonable for all lay members of a congregation to be good public
speakers and if public speaking was the only talent valued by a church. Sam
agrees. He then explains how at that time he decided to contribute to the
church through volunteer work on their electrical system instead of saying
public prayers. Sam says he got really mad when after having worked all day
Saturday on the church wiring, one of the church members chastised him for
refusing to say a prayer during Sunday service:
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He told me I needed to start pulling my weight, and I told him I was

doing other things than praying but I resented what he said and still feel
bad about it even though it happened 30 years ago.

We review his thoughts, which were similar to the previous ones, except
it is clear Sam expects himself to fulfill others’ expectations and believed
that if he did not, he was a failure. I agree with him that these other people
were wrong to have said what they did, but it was his own beliefs and
self-expectations causing the problem. We discuss how his need to satisfy
others’ expectations puts his emotional well-being in the hands of others.
I encourage him, as homework, to monitor his feelings and note exactly
what he feels and thinks such that we can review this information in the
next session.
In this session, we used the CT rationale and verbally went through the
three-column technique, and then we used the downward arrow technique
to help identify the core negative beliefs. I did not do a thorough review of
the evidence to dispute his negative thoughts because he responded quickly
to rational disputation.

Session 4

Session 4 is essentially a repeat of Session 3, with no new content. Sam

admits that his fear of evaluation and criticism has been a huge influence on
his life and puts him at risk for overreacting with anger. We go back over the
events he described in the previous session and review CT principles. I stress
how we cannot control what other people say and think.
I am a little disappointed with the lack of new content but also realize
there would likely be some repetition necessary for consolidation of the learn-
ing in the prior session. As I did at the end of the prior session, I encourage
Sam to continue monitoring his emotions and to note exactly what he feels
and thinks,. I also encourage Sam to not shy away from activities that sub-
ject him to evaluation and to use these activities as opportunities to practice
monitoring his thoughts and emotions.

geriatric depression    109

 Session 5

Sam reports getting mad at a contractor who failed to live up to his

promises. We explore his thoughts and identify “He is doing this to inten-
tionally take advantage of me” and “I used to be able to do all this for myself,
but now I have to rely on others.” We focus on the former because his anger
was far greater than his hopelessness and sadness. We review anger manage-
ment principles with a focus on the mind-reading fallacy and how we can
only see what people do, not why they are doing it. I ask Sam for alternative
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explanations for the contractor’s behavior, and he offers the following: he

could have encountered an unexpected delay, he could have had something
critical come up, or he might be less responsible than I supposed he is, and
this may be his normal work ethic. Sam reviews all of the possibilities and
agrees he has no reason to suspect the contractor was deliberately taking
advantage of him; his anger decreases accordingly. Sam says he still does not
like being at the mercy of others, which leads us into an introduction of how
to use acceptance.

Session 6

Sam reports that his mood has been angry since last session, and he is par-
ticularly upset by politics and all of the argument over changing the health care
system. I review the general problem-solving model of doing whatever he can
to solve a problem and then accepting the status quo if he is unable to make the
change he wants. We discuss things he could do to influence politics. Sam says
he called his congressman once and will not do it again, because it didn’t help.
Likewise, he is unwilling to get involved in a political organization at either
the local or national level, and after discussion admits that national politics is
beyond his control and influence. I suggest that he has the choice of continuing
to be angry or using acceptance to cope with it. We review in more detail the
principles of acceptance and how to apply them in anger management.

Session 7

Sam reports that he continues to be easily angered and cites an incident

in which he lost his temper and said some harsh words to his wife. Sam says
he was listening to TV and said something to his wife about being angry that
they were devoting far more attention to a particular issue than was war-
ranted and it was the same thing on all the channels. His wife said, “Well,
nobody is making you watch the TV,” and he said he got angry because he
felt like she was demeaning him. I remind him that we cannot read anyone’s
mind and truly know their motives, and I ask him to consider what other

110    shah, scogin, and floyd

 reasons she might have had for making the comment. Sam admits she could
have just been making a suggestion to him but also says she did not say what
he wanted her to say. I ask what he was expecting, and he says he wanted her
to simply agree with him that the coverage was excessive. We also discuss
how it was possible she was tired of hearing him complain, and he says he
can understand that. After reviewing the alternatives and considering how
his wife was not one to say demeaning things to him, Sam agrees she prob-
ably meant her comment to be supportive or at worst was making an attempt
to stop his complaining, and he felt much less angry. We also discuss how
Copyright American Psychological Association. Not for further distribution.

he sometimes allows himself to get angry over small issues and stress that his
first step in coping with any upset is to ask himself whether it’s a big enough
issue to justify it.

Session 8

Sam reports that his mood has improved significantly and that he has
had a good week. He says he talked with his wife, and they have improved
their relationship. He says he got frustrated this week with a painter they
hired but was able to use the principles we discussed to reduce his anger and
deal effectively with him. In particular, he says he is getting better at not
mind reading, not making mountains out of molehills, and acceptance. Sam
says he is still having trouble with accepting things he does not like, but he
admits it is necessary and useful.

Session 9

Sam says he had another good week. He says he was better able to con-
trol his anger and feels much better about himself. Sam says he no longer feels
depressed, anxious, or angry. I suggest that our work together is finished and
that we meet one more time in a month to monitor his status. Sam says he
enjoys talking with me and is in no hurry to stop meeting, but we agree that we
have accomplished the purpose and think a follow-up meeting is a good idea.

Session 10 (1 Month After Session 9)

Sam says he continues to do well and is having good control over his
emotions. We review the techniques discussed in therapy. We discuss some
possible challenges he might be facing in the future. He reports noticing
his wife’s worsening memory problems, and in light of her family history of
Alzheimer’s disease, he suspects she will eventually need care that he cannot
provide because of his visual limitations. I ask how he is coping with this, and
he explains how he has already talked with their children and feels confident

geriatric depression    111

 they will both have the support they need in their final years. He denies
significant anxiety and feels like they will cross that bridge when they get to
it. I tell him that I am available if and when he needs to meet again, and he
thanks me for all my help.

Final Comments

I feel like we fully addressed his anger problems and to a lesser extent
his anxiety problems. I regret not more fully addressing his death anxiety, but
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on the occasions I brought up the topic it was not important to him. I think
his need for approval from others is an issue that will continue to give him
trouble occasionally if he does not continue to practice what he has learned.
After all, we met for only 10 sessions, and he has held onto this belief for more
than 70 years. I am optimistic, however, because his problem solving and his
attitude about his future (which is uncertain but does not look very good)
show excellent emotional coping.

112    shah, scogin, and floyd

 APPENDIX 4.1: Resources and Suggestions
for Further Reading

Behavioral Therapy

Gallagher, D. E., & Thompson, L. W. (1981). Depression in the elderly: A behavioral

treatment manual. Los Angeles: University of Southern California Press.
Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activa-
tion treatment for depression treatment manual. Behavioral Modification, 25,
Copyright American Psychological Association. Not for further distribution.

255–286.
Lewinsohn, P., Biglan, A., & Zeiss, A. (1976). Behavioral treatment of depression.
In P. Davidson (Ed.), Behavioral management of anxiety, depression, and pain.
New York, NY: Brunner/Mazel.
Rider, K. L., Gallagher-Thompson, D., & Thompson, L. W. (2004). California older
person’s pleasant events schedule: Manual. Stanford University, Stanford, CA.
Retrieved from http://oafc.stanford.edu/coppes.html
Teri, L. (1991). Behavioral assessment and treatment of depression in older adults.
In P. A. Wisocki (Ed.), Handbook of clinical behavior therapy with the elderly client
(pp. 225–243). New York, NY: Plenum Press.
Teri, L. (1994). Behavioral treatment of depression in patients with dementia.
Alzheimer Disease and Related Disorders, 8, 66–73.

Cognitive Behavioral Therapy

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York, NY: Guilford Press.
Ellis, A. (1979). Theoretical and empirical foundations of rational emotive therapy.
Monterey, CA: Brooks/Cole.
Emery, G. (1981). Cognitive therapy with the elderly. In G. Emery, S. Hollon, &
R. Bedrosian (Eds.), New directions in cognitive therapy (pp. 84–98). New York,
NY: Guilford Press.
Gallagher-Thompson, D., & Thompson, L. W. (2010). Therapist guide: Treating late
life depression: A cognitive-behavioral therapy approach. New York, NY: Oxford
University Press.
Thompson, L. W., Dick-Siskin, L., Coon, D. W., Powers, D. V., & Gallagher-
Thompson, D. (2010). Patient workbook: Treating late life depression: A cognitive-
behavioral therapy approach. New York, NY: Oxford University Press.
Yost, E. B., Beutler, L. E., Corbishley, M. A., & Allender, J. R. (1986). Group cognitive
therapy: A treatment approach for depressed older adults. New York, NY: Pergamon
Press.

geriatric depression    113

 Cognitive Bibliotherapy

Burns, D. D. (1980). Feeling good. New York, NY: Avon Books.

Problem-Solving Therapy

Nezu, A. M., & D’Zurilla, T. J. (2001). Problem-solving therapies. New York, NY:
Guilford Press.
Copyright American Psychological Association. Not for further distribution.

Reminscence Therapy

Birren, J. E., & Deutchman, D. E. (1991). Guiding autobiography groups for older adults.
Baltimore, MD: Johns Hopkins University Press.
Kunz, J. A. & Soltys, F. G. (2007). Transformational reminiscence: Life story work. New
York, NY: Springer.

Psychodynamic Psychotherapy

Evans, S., & Garner, J. (2004). Talking over the years: A handbook of dynamic therapy
with older adults. New York, NY: Brunner/Routledge.
Morgan, A. C., & Goldstein, M. Z. (2003). Psychodynamic psychotherapy with older
adults. Psychiatric Services, 54, 1592–1594.

114    shah, scogin, and floyd

 APPENDIX 4.2: Sample Cognitive Behavioral Therapy
Session Outlines

Session no. Session outline

1–2 • Establish rapport

• Elicit expectations about therapy
• Explain therapy structure
• Explain roles of therapist and client
• Set goals for therapy
Copyright American Psychological Association. Not for further distribution.

• Explain rationale for cognitive therapy

• Demonstrate cognitive therapy technique applied to a problem
• Elicit reaction to session
3 • Effects of first session
• Activity scheduling
• Mastery and pleasure ratings
• Problems since last session
• Schedule of activities until next session
• Agenda setting
• Elicit reaction to session
4 • Prepare agenda
• Effects of prior sessions
• Review homework assignments
• Explanation of unhelpful thoughts
• Assign homework
• Elicit reaction to session
5 • Prepare agenda
• Effects of prior sessions
• Review homework assignments
• Further explanation of unhelpful thoughts
• Assign homework
• Elicit reaction to session
6 • Prepare agenda
• Effects of prior sessions
• Demonstrate identification and correction of unhelpful thoughts
• Daily record of unhelpful thoughts
• Assign homework
• Elicit reaction to session
7–8 • Prepare agenda
• Effects of prior sessions
• Review homework assignments
• Explain how to dealt with anger and anxiety
• Explain relaxation
• Assign homework
• Elicit reaction to session
(continues)

geriatric depression    115

 Session no. Session outline

9–12 • Increase responsibility for client for all activities in session

• Prepare agenda
• Effects of prior sessions
• Review homework assignments
• Explain assertiveness skills, overthinking, and problem solving
• Assign homework
• Elicit reaction to session
13–16 • Continue increased responsibility for client; move towards
termination
Copyright American Psychological Association. Not for further distribution.

• Prepare agenda
• Effects of prior sessions
• Review homework assignments
• Identification and testing of underlying assumptions
• Assign homework
• Anticipate problems and how to address them
• Application of techniques as a life-long process—consolidate
gains

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 APPENDIX 4.3: Unhelpful Thoughts Worksheet

Responses

Step 1: Event
Step 2: Unhelpful Thoughts Rate how true you believe it is from 1 to 10:__
Rate how true you believe it is after Step 5 & 6:__
Step 3: Unhelpful Thought 1) Name-Calling
(Circle type of unhelpful 2) Should, Could, Would
thought) 3) Tune Into Negative/Tune Out Positive
Copyright American Psychological Association. Not for further distribution.

4) Black & White Thinking

5) Exaggerations
6) What’s the Use
7) If Only
8) Doomsday Thinking/Fortune telling
Step 4: Circle Emotions Angry Sad Bothered Worried Scared Other_______
Rate how strong your emotions are from 1 to 10:___
Rate how you feel after finishing Step 5 & 6:___
Step 5: Way to Change 1) Action
Unhelpful Thoughts 2) Language
(Pick as many as needed) 3) As If (You Were A Friend)
4) Consider Alternatives/In-Betweens
5) Scale Technique
6) Examine Consequences
7) Credit Positives
8) Helpful Thoughts
9) Thought Stopping
Step 6: Helpful Thought Rate how strongly you believe it from 1 to 10:__

From Making the Golden Years Golden Again Workbook (p. 30), by A. Shah, 2007, Tuscaloosa: University
of Alabama. Copyright 2007 by A. Shah. Reprinted with permission.

geriatric depression    117

 APPENDIX 4.4: Daily Mood Rating Form
Copyright American Psychological Association. Not for further distribution.

From Treating Late-Life Depression: A Cognitive-Behavioral Therapy Approach, Workbook (p. 184), by L. W.
Thompson, L. Dick-Siskin, D. W. Coon, D. V. Powers, and D. Gallagher-Thompson, 2010, Oxford, England:
Oxford University Press. Copyright 2010 by Oxford University Press. Reprinted with permission.

118    shah, scogin, and floyd

 APPENDIX 4.5: Mood Screen

Geriatric Depression Scale

Instructions: Answer yes or no for how you have felt over the past week
on these questions.
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
Copyright American Psychological Association. Not for further distribution.

3. Do you feel that your life is empty?

4. Do you often get bored?
5. Are you hopeful about the future?
6. Are you bothered by thoughts you can t get out of your head?
7. Are you in good spirits most of the time?
8. Are you afraid that something bad is going to happen to you?
9. Do you feel happy most of the time?
10. Do you often feel helpless?
11. Do you often get restless and fidgety?
12. Do you prefer to stay at home, rather than going out and doing
new things?
13. Do you frequently worry about the future?
14. Do you feel you have more problems with memory than most?
15. Do you think it is wonderful to be alive now?
16. Do you often feel downhearted and blue?
17. Do you feel pretty worthless the way you are now?
18. Do you worry a lot about the past?
19. Do you find life very exciting?
20. Is it hard for you to get started on new projects?
21. Do you feel full of energy?
22. Do you feel that your situation is hopeless?
23. Do you think that most people are better off than you are?
24. Do you frequently get upset over little things?
25. Do you frequently feel like crying?
26. Do you have trouble concentrating?
27. Do you enjoy getting up in the morning?
28. Do you prefer to avoid social gatherings?
29. Is it easy for you to make decisions?
30. Is your mind as clear as it used to be?

Reprinted from “Development and Validation of a Geriatric Depression Screening Scale: Preliminary
Report,” by J. A. Yesavage, T. L. Brink, O. Lum, V. Huang, M. Adey, & V. O. Leirer, 1983, Journal of
Psychiatric Research, 17, (p. 41). Scale in public domain.

geriatric depression    119

 APPENDIX 4.6: California Older Person’s Pleasant
Events Schedule
Copyright American Psychological Association. Not for further distribution.

From Treating Late-Life Depression: A Cognitive-Behavioral Therapy Approach, Workbook (pp. 169–172),
by L. W. Thompson, L. Dick-Siskin, D. W. Coon, D. V. Powers, and D. Gallagher-Thompson, 2010,
Oxford, England: Oxford University Press. Copyright 2010 by Oxford University Press. Reprinted with
permission.

120    shah, scogin, and floyd

 Copyright American Psychological Association. Not for further distribution.

geriatric depression   
121
 Copyright American Psychological Association. Not for further distribution.

122   
shah, scogin, and floyd
 Copyright American Psychological Association. Not for further distribution.

geriatric depression   
123
 Copyright American Psychological Association. Not for further distribution.

124   
shah, scogin, and floyd
 Copyright American Psychological Association. Not for further distribution.

geriatric depression   
125
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