Psychological treatments in the management of severe late-life depression: At least as important as ECT
Depressive illness in late life is a complex disorder that warrants complex interventions. It needs to be viewed as a long-term illness which in some sufferers will include severe episodes. At present, there is very little randomized trial evidence to support the use of either ECT or psychological treatments in the management of severe depression episodes although clinical experience and evidence from trials with younger adults support the use of ECT to bring about rapid and short-term relief from symptoms. Regrettably, potentially helpful psychological interventions are frequently overlooked at this stage. We know that older people are more likely than younger people to be offered ECT (Dombrovski and Mulsant, see above) and it is likely that the opposite is true for psychological treatments. The creation of a "cognitive milieu" in inpatient settings is advocated, in which staff members are trained in cognitive techniques to help patients with early symptom relief and later relapse prevention. Straightforward techniques can lead to small changes which can foster hope and also increase compliance with treatment. Findings from research trials conducted mainly with younger adults may be difficult to apply to the most severely depressed older adults but there is reason for optimism that psychotherapy in combination with medication in the continuation phase may reduce the likelihood of further episodes. Psychiatrists and other mental health workers have a responsibility to take patients' treatment preferences into account and to keep abreast of developments in both biological and psychological treatments to promote good practice and further research in the management of late-life depression. © International Psychogeriatric Association 2006.