On Veterans Day, the Journal of Gerontology, Series B: Psychological and Social Sciences published “Comparison of the Effectiveness of Cognitive Behavioral Therapy for Depression among Older Versus Younger Veterans: Results of a National Evaluation” co-author Bradley E. Karlin joins us to discuss the evaluation’s promising results.
Why do older adults utilize mental health services at very low rates?
Research over the past several decades has consistently found older adults to utilize mental health services at rates substantially lower than those for their younger counterparts. In fact, a national study we completed several years ago found that older adults (those 65 and older) were three times less likely than younger adults to receive mental health care. Research has identified factors at individual, system, and policy levels that have contributed to enduring under-use of mental health services by older adults. One barrier has been stigma on the part of older adults and health care providers alike that symptoms of depression and other mental health conditions are natural byproducts of aging, which we know is not the case. As a result, many primary care physicians fail to detect mental health symptoms in older adults. For example, one study found that physicians assessed for depression in only 14% of older patient visits. Compounding the problem is recent research that suggests that older individuals often fail to identify mental health symptoms as symptoms of a mental health problem, and when they do they often do not know where to go for help. When older adults do seek help for these symptoms, they often present to their primary care physician who may mistakenly attribute these symptoms to a medical condition or to aging. So, it’s a vicious cycle.
Furthermore, older adults have often been viewed by some professionals as less treatable clients, which has further limited referral for mental health treatment. Older individuals, particularly those born around or before 1940, often hold negative views toward mental illness and mental health treatment, due to differences in how mental illness was conceptualized and treated in the first half of the 20th century when they grew up. Many older adults also grew up in a time when self-resilience and getting through difficult circumstances on one’s own was important and emphasized.
Restrictive Medicare reimbursement policies related to psychological services and lack of affordability have also contributed to limited access to mental health services among older adults, particularly for those without supplemental Medicare (“Medigap”) insurance. For decades, Medicare only reimbursed outpatient psychological services at the rate of 50 percent, whereas general outpatient medical services are reimbursed at the rate of 80 percent. Having to pay 50% of a $100-$150 psychotherapy session is certainly prohibitive for many older adults. We have also identified in our work a number of additional regulatory barriers that have further limited Medicare coverage of mental health services for older adults. Fortunately, there are some very positive regulatory and policy changes on the horizon that portend greater financial access to mental health services for older adults. Thus, it is imperative that effective mental health treatments be available for older individuals.
Depression among older adults is a major concern for both the individual suffering from it and society at-large. What are some of the consequences of untreated depression in older adults?
Untreated depression in older adults has profound consequences, including mental health and physical health consequences, as well as family, social and economic, and societal costs. Some specific examples include increased risk of heart disease, reduced motivation, increased disability, exacerbation of and/or delay in recovery from medical illness, greater use of medical services, increased mortality, reduced treatment compliance, and increased suicide and mortality, as well as lower quality of life. In light of these major consequences, untreated depression among older adults is a significant public health concern and is on track to become an even greater public health concern due to large increases in the older adult population projected in the years ahead.
What is cognitive behavioral therapy (CBT) for depression? What are its most significant
differences from other forms of therapy?
Cognitive behavioral therapy is a structured, short-term approach to psychotherapy that helps clients learn and apply specific strategies to modify rigid or extreme thoughts and behaviors that are associated with depression. CBT has been shown to be effective for mild, moderate, and severe depression symptoms, though most of the research examining CBT has been conducted on younger populations and conducted in research settings with approved research subjects, as opposed to routine clinical settings where “real-world” older and younger individuals present for care.
While several other forms of psychotherapy are effective, cognitive behavioral therapy is the most widely-researched and differs from other forms of psychotherapy in several ways. In CBT, the client takes an active role in treatment by learning new skills to change certain patterns (ways of thinking and interpreting situations, as well as behaviors) that contribute to and maintain depression. Specifically, CBT involves developing new ways of interpreting aspects about oneself, the world, and the future that allow for more flexible, realistic, and balanced appraisals that generally evoke different types of responses than do more extreme or inflexible ways of thinking. Individuals with depression (young and old) generally look through “distorted lenses” that color their perception of their lives and things around them. CBT provides skills for evaluating one’s self and day-to-day experiences that are more balanced and complete. The second main focus of CBT is on increasing pleasant and self-promoting behaviors. Decades of research has shown that individuals with depression engage in very few pleasurable and rewarding activities. In CBT, the therapist helps the client to identify and increase their involvement in such activities through a structured, therapeutic process. The process of changing unhelpful or extreme thoughts that contribute to depression and increasing self-promoting behaviors is tied to the specific understanding of the client and to specific behavioral goals that are developed between the therapist and client at the outset of therapy. Thus, CBT focuses more on active, change-oriented process and skills than some other forms of psychotherapy that are passive in nature. Other, more “supportive” psychotherapies, for example, may involve just talking about one’s life without the development of new skills and actions. CBT is also present-focused and does not involve extensive discussion about one’s past as some other forms of therapy may emphasize. CBT is also brief in nature, with a typical course of CBT lasting approximately 12-16 sessions. Other forms of psychotherapy can last significantly longer.
Your evaluation looks at 874 veterans treated for depression with cognitive behavioral therapy. What were the results? What is particularly noteworthy?
The results of the evaluation reveal that cognitive behavioral therapy resulted in significant reductions in depression and improvements in quality of life among both older and younger Veterans. Furthermore, the outcomes and rate of treatment completion were virtually identical for the two age groups. What is also particularly noteworthy is that these improvements were the experiences of real-world older and younger veterans, often with complicated presentations, treated in routine settings by clinicians completing training in CBT. This naturalistic evaluation design differs from research conducted in controlled settings. Moreover, the level of effectiveness observed in this evaluation is comparable to that reported in randomized controlled trials of CBT.
What implications do the results have for mental health policy?
The results suggest that cognitive behavioral therapy is an effective and acceptable treatment for older adults and that CBT can be disseminated to real-world settings with very favorable outcomes. These findings are timely given important changes in the Medicare Program that will significantly increase older adults’ financial access to psychological services. Beginning in January 2014, the rate of Medicare reimbursement for outpatient psychotherapy and other psychological services will increase to 80%. Consequently, the results of this evaluation suggest important opportunities for effectively treating older adults with depression who may present for care in greater numbers than in the past. The results also point to the need for qualified mental health professionals to treat older adults. We are closer than we have ever been to bridging wide and enduring gaps in mental health treatment for older adults.
Dr. Karlin is the co-author of “Comparison of the Effectiveness of Cognitive Behavioral Therapy for Depression among Older Versus Younger Veterans: Results of a National Evaluation,” published in The Journals of Gerontology, Series B: Psychological and Social Sciences. He is National Mental Health Director for Psychotherapy and Psychogeriatrics for the U.S. Department of Veterans Affairs (VA). He has national responsibility for developing, implementing, and evaluating mental health programs in evidence-based psychotherapy and psychogeriatrics in the VA health care system. Dr. Karlin is also Adjunct Associate Professor in the Department of Mental Health of the Bloomberg School of Public Health at Johns Hopkins University.
The Journals of Gerontology® were the first journals on aging published in the United States. The tradition of excellence in these peer-reviewed scientific journals, established in 1946, continues today. The Journals of Gerontology Series B® publishes within its covers the Journal of Gerontology: Psychological Sciences and the Journal of Gerontology: Social Sciences.
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Image credit: Dramatic close up portrait of a middle aged army veteran. © nstanev via iStockphoto.