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J Ment Health, 2015; 24(3): 168–171

! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.971143

REVIEW ARTICLE

Cognitive behavioural therapy for older adults with depression:

a review
Rasika Jayasekara1, Nicholas Procter1, Julie Harrison2, Kerim Skelton2, Sally Hampel3, Russell Draper2, and
Kate Deuter1
1
School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, Australia, 2Adelaide Metro Mental Health Directorate,
Older Persons Mental Health Service, Central and Northern Adelaide Local Health Network, Adelaide, Australia, and 3Eastern Mental Health Service,
Adelaide Metropolitan Mental Health Directorate, Adelaide, Australia
J Ment Health Downloaded from informahealthcare.com by University of Otago on 07/11/15

Abstract Keywords
Background: Depression is a major public health concern of global significance. The illness CBT, cognitive behavioural therapy, cognitive
diminishes overall quality of life and has been associated with significant distress and disability therapy, depression, older adults
in physical, interpersonal, and social role functioning. Over the past few decades, a consensus
has evolved that cognitive behavioural therapy (CBT) can be an effective treatment for History
depression in older adults; however, little attention has been given to its effect on them.
Aims: The purpose of this review was to examine the current use of CBT and its effect on older Received 4 September 2013
adults with depression. Revised 28 August 2014
Method: A web-based literature search was performed to identify original research articles Accepted 18 September 2014
published from 2000 to 2013 using a three-step search strategy. Published online 29 October 2014
For personal use only.

Results: Evidence indicates that cognitive behavioural therapies are likely to be efficacious in
older people when compared with treatment as usual. This is consistent with the findings of
several systematic reviews and meta-analyses undertaken across a wider age range.
Conclusions: Given that many older adults with depression are reluctant to accept antidepres-
sant medication or unable to tolerate their side effects, CBT can be used as an option in treating
depression in older adults.

Introduction behavioural therapy, psychodynamic psychotherapy, rational

emotive behaviour therapy, behavioural activation, reminis-
Depression is a substantive cause of disability worldwide
cence therapy, and exercise (Frazer et al., 2005; Szentagotai
(World Health Organization, 2012). Major depression (MD)
et al., 2008). Pharmacotherapy is an accepted and often front-
or major depressive disorder (MDD) is a leading cause of
line treatment for depression (Lockwood et al., 2004).
morbidity and mortality in the elderly, with an estimated
Epidemiological data have found that the widespread use of
prevalence of 7% of the general elderly population and it
antidepressants is associated with a significant decline in
accounts for 1.6% of total disability among over 60 year olds
suicide rates in most countries with traditionally high baseline
(Institute for Health Metrics and Evaluation, 2010). If left
suicide rates (Rihmer & Akiskal, 2006). Approximately 50–
untreated, there is evidence of an increased risk of physical
60% of patients are supposed to improve clinically as a
and psychological morbidity and mortality, with an associated
consequence of antidepressant treatment (Schneider & Olin,
economic and societal burden (Gould et al., 2012; Lockwood
1995). These findings are supported by a systematic review of
et al., 2004; Smits et al., 2008). At its worst, depression can
antidepressant versus placebo in the treatment of depression
lead to suicide, highlighted by the loss of 1 million people
in older adults (Mottram et al., 2006). However, it is evident
every year worldwide (World Health Organization, 2012).
that older, frail depressed patients are particularly prone to
Predictions of an ageing population suggest that there will be
side effects of antidepressants (Arroll et al., 2009; Kennedy,
increased demand for treatments and therapies that address
2013; Schatzberg, 2007; Seitz et al., 2011) and older patients
the specific needs of older people.
are more prone to the cardiovascular side effects of
The treatments for depression among older adults
antidepressants (Pacher & Kecskemeti, 2004). The World
include antidepressants, electroconvulsive therapy, cognitive
Health Organization (2011) has recommended that if anti-
depressant treatment is required for older people, tricyclic
Correspondence: Dr. Rasika Jayasekara, Senior Lecturer, School of
antidepressants (TCA) should be avoided if possible.
Nursing and Midwifery, University of South Australia, North Terrace,
Adelaide, SA 5001, Australia. Tel: +61 8 8302 2750. Fax: +61 8 8302 Therefore, older people, despite taking medication, continue
2168. E-mail: rasika.jayasekara@unisa.edu.au to experience symptoms and/or disabling adverse effects
 DOI: 10.3109/09638237.2014.971143
(Bogner et al., 2009; Candy et al., 2008; Mottram et al.,
2006). There is thus a growing need to consider alternative
forms of treatment for depression. Since the early 1980s,
several well-controlled clinical trials have demonstrated that
depression in older adults can be treated with psychotherapy,
either alone or in combination with antidepressant medica-
tion. Several psychological therapies have been studied, but
the cognitive-behavioural therapy (CBT) has been most
widely investigated in this population (Bogner et al., 2009;
Candy et al., 2008; Mottram et al., 2006). CBT, a form of
psychotherapy, is regarded as a non-pharmacological inter-
vention that can provide depressed individuals with the skills
with which to manage their own illness (Bogner et al., 2009;
Lockwood et al., 2004; Ridgway & Williams, 2011). CBT has
no known adverse side effects, unlike antidepressant medica-
tions and, has the potential to go on assisting the individual
long after the symptoms subside and the therapy ceases.
However, the usefulness of CBT as an intervention for older
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adults with depression has not been adequately evaluated.
The purpose of this review paper is to examine current
evidence on the effectiveness of CBT for older adults with
depression.
Background
CBT for depression
In the 1970s, psychology underwent a cognitive revolution
For personal use only.
that led to a greater interest in the significance and relevance
of cognitive processes to therapy (Grant, 2010). The
increasing interest in cognition resulted in the development
of various cognitive behavioural therapies (Eifert & Plaud,
1993; Grant, 2010). The theoretical structure and a basic
method for CBT were outlined by Aaron Beck in a series of
seminal papers published in the 1960s and then elaborated in
a treatment manual for depression (Eifert et al., 1993; Eifert &
Plaud, 1993). CBT is an action-oriented treatment approach
that has become a widely used psychotherapy for major
mental disorders. CBT methods were initially developed for
depression and anxiety disorders and, later they were
modified for many other conditions (Linehan et al., 1991,
1993). CBT has also been adapted for use as an adjunct to
medication in the management of mental disorders
(Andersson et al., 2013; Binks et al., 2006; Henschke et al.,
2010; Martinez-Devesa et al., 2010; Montgomery & Jane,
2003).
Although the label cognitive behavioural therapy has
been applied to a variety of interventions, accordingly, it is
difficult to provide a single, unambiguous definition. In a
Cochrane review, CBT was classified as ‘‘well-defined’’ if it
clearly demonstrated that (i) the intervention involved
recipients establishing links between their thoughts, feelings,
and actions with respect to the target symptom; and (ii)
correction of recipients’ misconceptions, irrational beliefs,
and reasoning biases was related to the target symptom.
A further component of the intervention should have
involved one or both the followings: (i) the recipient
monitoring his or her own thoughts, feelings and behaviours
with respect to the target symptom; and (ii) the promotion of
alternative ways of coping with the target symptom (Jones
et al., 2004, 2012).
Cognitive behavioural therapy 169
Search strategy
The search strategy was limited to English language papers
published from 2000 to 2013. A three-step search strategy
was developed using MeSH terminology and keywords to
ensure that all materials relevant to the review were captured.
An initial limited search of MEDLINE and CINAHL was
undertaken followed by an analysis of the text words
contained in the title and abstract, and of the index terms
used to describe the article. A second search using all
identified keywords and index terms was then conducted.
Third, the reference lists of all identified articles were
searched for additional studies. All systematic reviews and
randomised controlled trials (RCT) assessing the effectiveness
of CBT as a treatment for older adults (aged 55 or above)
with major depression when compared with standard care,
specific medication, other therapies, and no intervention were
considered.
Results
The effectiveness of cognitive behavioural therapy
for older people
Reviews and meta-analyses of the voluminous literature on
CBT outcome studies have concluded that CBT is a highly
effective approach for the treatment of depression (Gaffan
et al., 1995; Oei & Dingle, 2008; Samad et al., 2011). Most
Clinical Practice Guidelines advocate the additional benefit of
supporting antidepressant medication with CBT (National
Institute for Clinical Excellence, 2009). Despite the wealth of
evidence evaluating CBT for depression, little attention has
been given to its effect on older adults. The following studies
were identified as meeting the inclusion criteria and are
summarized below.
A Cochrane systematic review was conducted to investi-
gate the effectiveness of psychotherapeutic treatments for
depression in older people (aged 55 or over) (Wilson et al.,
2008). This review was limited to RCTs and cluster
randomised trials. All types of psychotherapeutic treatments
were considered such as cognitive behavioural therapies,
psychodynamic therapy, interpersonal therapy, and supportive
therapies (Wilson et al., 2008). The review included seven
small trials, involving 153 older adults that examined
psychotherapeutic treatments for depression in older people.
Five RCTs compared cognitive behavioural therapy with
control conditions, and the results revealed that cognitive
behavioural therapy was more effective than waiting list
controls. Two RCTs with 57 older adults compared the
effectiveness of cognitive behavioural therapy versus psycho-
dynamic therapy. However, there is no statistically significant
difference between cognitive behavioural therapy and psy-
chodynamic therapy (Wilson et al., 2008). It is reasonable to
suggest that the findings of this review have limited clinical
implications due to the small number of trials and small
sample size. However, the review author concluded that
cognitive behavioural therapies are likely to be efficacious in
older people when compared with waiting list controls
(Wilson et al., 2008). The authors recommended conducting
a large-scale research on this area because of the paucity of
high-quality studies in this field.
 170 R. Jayasekara et al.
A systematic review was conducted to examine the
effectiveness of psychotherapy for treating depression in
older adults (aged 55 or over) (Peng et al., 2009). This
systematic review was also limited to RCTs and three types of
psychotherapy were included: CBT, reminiscence therapy,
and general psychotherapy (GPT). This review included 14
RCTs involving 705 older adults. The primary outcome
measure was the depression score, measured using a range of
scales, including the 20-item Symptom Checklist (SCL-20)
for depression, the Hamilton Rating Scales for Depression,
the Beck Depression Inventory, and the Geriatric Depression
Scale. Meta-analysis and subgroup analysis showed that
psychotherapy (CBT, reminiscence therapy, or GPT) was
significantly more effective than placebo/no intervention in
decreasing depression scores. The review further found that
psychotherapy as an adjunct to antidepressant medication did
not increase effectiveness. There was no statistically signifi-
cant difference between CBT and reminiscence therapy in
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improving depression. Although this review was published in
2009, all RCTs in cognitive behavioural therapy were
published before 2004.
The findings of these systematic reviews are largely
consistent with other research on the effectiveness of CBT
in all ages. A meta-analysis which was used to integrate the
results of 89 controlled studies of treatments involving 5328
older adults receiving pharmacotherapy or psychotherapy
found that psychotherapy and pharmacotherapy did not show
For personal use only.
strong differences in effect sizes (Pinquart & Sorensen, 2001).
A meta-analysis of 25 studies revealed that psychological
treatments have moderate to large effects on depression in
older adults (standardized mean effect size d ¼ 0.72) (Cuijpers
et al., 2006). In a recent systematic review, a meta-analysis
showed that, compared with waiting list, group cognitive
behavioural therapy is an effective intervention for reducing
depressive symptoms in older adults with sub-threshold
depression (Krishna et al., 2013). However, major limitations
of these studies were the inclusion of non-randomised studies
(Samad et al., 2011) and broadly defined interventions (e.g.
psychotherapy) (Cuijpers et al., 2006; Peng et al., 2009;
Wilson et al., 2008).
Furthermore, studies comparing CBT or other evaluated
psychotherapies against combined psychotherapy and medi-
cation for depression showed that psychotherapy delivered in
conjunction with pharmacotherapy is significantly more
efficacious in treating depression than is pharmacotherapy
alone (Cuijpers et al., 2013; de Maat et al., 2007; Hollon
et al., 2005). A systematic review of 16 trials with 932 adult
patients concluded that psychological treatment combined
with antidepressant therapy is associated with a higher
improvement rate than drug treatment alone (Pampallona
et al., 2004). The combination treatment of CBT and
antidepressants had a lower risk of discontinuation compared
with antidepressants alone (RR 0.81; 95% CI 0.65, 1.01)
(National Collaborating Centre for Mental Health, 2010).
The use of CBT as a treatment for older adults with
depression remains uncommon despite recognition of its
efficacy. Ageism, or the discrimination against people on the
grounds of age alone, has been slow to gain public awareness
in Western society, which has been a significant hindrance
to development of expertise, research, and services
J Ment Health, 2015; 24(3): 168–171
(Hepple, 2004). In addition, potential barriers to older
adults receiving CBT may include invalid beliefs that older
adults are unlikely to benefit from psychotherapy (Laidlaw
et al., 2008). This commonly held belief can be traced back to
Freud’s assertion that older people lack the mental flexibility
to change or to benefit from psychotherapy (Pinquart &
Sorensen, 2001). As older people respond very positively
towards CBT therapies as a treatment option for depression
(Hanson & Scogin, 2008; Landreville et al., 2001), much
should be done to make this more widely known in the
community. Noting that many older people are unable to
access CBT services, comprehensive educational campaigns
directed at both professionals and older people could be
considered. Some authors have suggested the core elements of
less than optimal usage of CBT by older people has been
created by the increasing cost of the required services (Beach
et al., 2010) and insufficient numbers of trained therapists
both in primary care and in specialist mental health services
(Hoifodt et al., 2011). A gradually increasing awareness of,
and skills in, psychotherapies among mental healthcare
professionals and the consumers will probably deliver the
most overall benefit.
Conclusion
The key finding of this review is that cognitive behavioural
therapies are likely to be efficacious in older people with
depression when compared with treatment as usual. However,
the small size of included studies, the varied participant
demographics, and the heterogeneity of the interventions have
considerable impact with regard to generalising these findings
to wider clinical populations of older adults. It is widely
viewed that psychological treatments derived from CBT can
be used as an option in treating depression in older adults
because many older people with depression are reluctant to
accept antidepressant medication or unable to tolerate its side
effects. Future research should be aimed at developing a
broader understanding of the usefulness of CBT as an
intervention for older adults with depression and encompass
treatment availability, costs, and preferences.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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