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Older Adults' Acceptance of Psychological and Pharmacological Treatments for Depression

^a School of Psychology, Université Laval, Sainte-Foy, Québec, Canada
^b Family Medicine Department, Université Laval, Sainte-Foy, Québec, Canada
^c Research Center, Institut de Gériatrie de Montréal, Montréal, Québec, Canada
^d Department of Psychology, Centre Hospitalier Robert-Giffard, Beauport, Québec, Canada

Philippe Landreville, École de psychologie, Université Laval, Sainte-Foy, QC, G1K 7P4, Canada. E-Mail: philippe.landreville@psy.ulaval.ca

Decision Editor: Toni C. Antonucci, PhD

	Abstract

TOP Abstract Methods Results Discussion Appendix ENDIX References

 
Two hundred participants aged 65 and older recruited from 4 different family medicine clinics rated the acceptability of 3 different treatments for geriatric depression: (a) cognitive therapy (CT), (b) cognitive bibliotherapy (CB), and (c) antidepressant medication (AM). Results showed that the acceptability of the treatments is a function of the severity of the symptoms of the depressed patient to whom they would be applied. CT and CB were rated as more acceptable than AM when patient symptoms were mild to moderate. However, CT was more acceptable than both CB and AM when patient symptoms were described as severe. Acceptability ratings were not related to the raters' own depressive symptoms. The practical implications of these results are discussed.

THE general health care sector is the main source of treatment for older persons suffering from depression (Lebowitz et al. 1997). Referral by a family physician to a psychiatrist or other mental health professionals for depression is rare (Gallo, Ryan, and Ford 1999), and the proportion of individuals receiving outpatient treatment from mental health professionals is lower for persons aged 65 years or older than for any other adult age group (Olfson and Pincus 1996). Antidepressant medication (AM), especially selective serotonin reuptake inhibitors (SSRIs), appears to be the predominant approach to treating depressed elders in primary care (Gallo et al. 1999; Glasser and Gravdal 1997). Although older adults tolerate SSRIs better than tricyclic antidepressants (TCAs), adverse effects of SSRIs are significant and include nausea, diarrhea, insomnia, headache, agitation, and anxiety (Lebowitz et al. 1997). Psychotherapy is another approach to treating depression that does not present the adverse effects of antidepressants. The efficacy of psychotherapy for late life depression has been confirmed by various meta-analyses (Engels and Vermey 1997; Scogin and McElreath 1994) and clearly stated in the National Institute of Health (NIH) Consensus Statement update (Lebowitz et al. 1997).

One reason for the predominant use of pharmacotherapy despite its adverse effects may be that older persons prefer taking antidepressant medication to receiving psychotherapy. This view has been expressed by the head of the consensus panel of the NIH Consensus Conference on depression in late life (see Adler 1992, p. 17). A strong majority of older adults do report a preference for consulting a family physician rather than a mental health professional for psychological problems (Waxman, Carner, and Klein 1984). Older adults are more likely than middle-aged persons to talk about a mental health problem during a visit in the general medical sector (Gallo, Marino, Ford, and Anthony 1995). However, the available evidence suggests that elderly adults do not prefer pharmacological over psychological treatments for depression and that some of the latter are even perceived as more acceptable than drugs. In a first study of 20 older adults, whose age ranged between 62 and 83 years, Lundervold and Lewin 1990 obtained acceptability ratings for two interventions: behavior therapy and medication. Results indicated that older adults judge behavior therapy more favorably than pharmacotherapy to treat geriatric depression. A second study, by Rokke and Scogin 1995, examined depression treatment preferences in younger and older adults. Participants were 116 older adults whose age ranged from 60 to 97 years. Only 52 of them rated the acceptability of the treatments. Acceptability and credibility ratings were obtained for the following treatments for depression: activity change (a form of behavior therapy), cognitive therapy (CT), psychodynamic therapy, and drug therapy. Older adults rated activity change as more acceptable and credible than drug therapy. Cognitive and psychodynamic therapy were as acceptable and credible as drug therapy. No information is provided in either study regarding the proportion of nondepressed versus depressed participants and their respective ratings of the various treatments.

Although the above findings are thought provoking, they are also limited in several ways. First, the evidence is based on small samples, which seriously limits the generalization of the findings. It is noteworthy that acceptability ratings for both cognitive and psychodynamic treatments in the Rokke and Scogin 1995 study are higher than that of drug therapy, a trend similar to the difference involving activity change and drug therapy. It is possible that the absence of significant differences for these treatments is a consequence of low statistical power. Second, the relevance of the samples of the previous studies to elderly consumers of treatments for depression is unclear. It would seem important to assess acceptability in primary care patients in that the general health care sector is the main source of treatment for late life depression (Lebowitz et al. 1997). Third, the results obtained by Lundervold and Lewin may have been biased by the fact that almost half of the participants (40%) had already consulted a mental health professional in the past, which is not representative of older adults in general. These limitations are sufficiently serious to warrant further research in this area.

Two additional questions need to be addressed by new research on this topic. First, do acceptability ratings vary according to the severity of the clients' depression? Some treatments may be more acceptable for mild to moderate depression but less so if depression is severe. There is already some evidence that both psychological and pharmacological approaches for geriatric depression are less acceptable for severe than for mild to moderate symptoms, but these results were observed in young adults (Landreville and Guerette 1998). Second, are acceptability ratings related to the raters' own depressive symptoms? This is important because persons displaying depressive symptoms, who are consumers of treatments for this disorder, may rate the acceptability of treatments differently than do nondepressed persons. Rokke and Scogin 1995 found no significant correlation between their elderly participants' ratings of the credibility of the various treatments and their scores on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, and Erbaugh 1961). However, participants who had been previously depressed found CT more credible and tended to rate psychodynamic therapy and drug therapy as more credible. In addition, participants with previous treatment experience found CT more credible.

The purpose of this study was to compare the acceptability of three treatments of geriatric depression as rated by older patients of family medicine clinics. The treatments examined were CT, cognitive bibliotherapy (CB), and AM. Psychological treatments using a cognitive approach were examined because, as noted above, previous findings concerning the acceptability of this type of intervention are inconclusive and deserve further investigation. The cognitive approach to treating depression basically aims at helping clients identify their distorted and depressogenic thinking and learn more realistic ways to formulate their experiences (Beck, Rush, Shaw, and Emery 1979). We examined two formats of this psychological treatment, therapy and bibliotherapy, in this study. Traditional CT typically involves regular meetings with a therapist and exercises to do between sessions. In comparison, bibliotherapy is a self-treatment format involving readings and exercises to be done at home with minimal supervision from a therapist. The acceptability of CB from the point of view of older adults has not been investigated despite the demonstrated effectiveness of this format of treatment for mild to moderate depression in this population (Scogin, Hamblin, and Beutler 1987; Scogin, Jamison, and Davis 1990; Scogin, Jamison, and Gochneaur 1989). We examined the acceptability of the three treatments in this study as a function of the severity of symptoms of (a) the depressed client and (b) the person rating the treatments.

	Methods

TOP Abstract Methods Results Discussion Appendix ENDIX References

 
Participants
To be included in the study, participants had to be (a) 65 years of age or older or had to reach that age in the month following their participation in the study and (b) patients of family medicine clinics located in large urban hospitals. Two hundred ninety-five persons were asked to participate in the study. Among them, 55 persons refused to participate, 32 persons did not fulfill the age criteria, and 8 persons did not complete their questionnaire. This left a sample composed of 200 participants, all of whom were Caucasian and French speaking. The sample characteristics are summarized in Table 1 .

Background information.
We collected sociodemographic information such as age, gender, annual family income, marital status, and schooling level. We also asked about depressive episodes during the participants' lifetime and types of treatments received during these episodes.

Case descriptions.
Two descriptions of older adults presenting depressive symptoms of different severity (mild to moderate and severe) were prepared by a clinical psychologist and a general practitioner. These descriptions had between 90 and 106 words. To standardize the case descriptions, both patients were described as women of 75 years of age presenting the same symptoms but of different severity. The symptoms described were feelings of sadness, diminished life satisfaction, difficulty in making decisions, lack of sleep and appetite, fatigue, and thoughts of death. For example, the person presenting mild to moderate symptoms was described as sleeping less well, having less appetite, and thinking that she would be better off dead but would not commit suicide. In contrast, the severely depressed person was described as waking up several hours earlier than usual and being unable to go back to sleep, having no appetite, and contemplating suicide. The case descriptions are based on criteria of a major depressive episode of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (American Psychiatric Association 1994) and the levels of symptoms severity found in the Beck Depression Inventory (Beck et al. 1961). Case descriptions are presented in the Appendix.

Each case description was validated in a previous study (Landreville and Guerette 1998). Briefly, seven experienced PhD-level clinical psychologists were asked to rate the severity of symptoms for each case. The case with severe symptoms was identified as such by all judges. The case with mild to moderate symptoms was classified as mild by five judges and as moderately depressed by two. Among a sample of 88 participants, 95% reported that the case description they read was clear and 84% agreed that it contained sufficient information.

Treatment descriptions.
The treatment descriptions were also prepared by a clinical psychologist and a general practitioner and had between 90 and 124 words. CT and CB were described as treatments to help clients (a) identify situations that increase depressive feelings, (b) determine if their interpretation of these situations is overly negative and unrealistic, and (c) learn ways to interpret these situations less negatively and more realistically. We described CT as involving weekly meetings with a health care professional. CB was characterized by readings and exercises done at home under the supervision of a health care professional that the client met at the beginning and at the end of the treatment. Weekly phone calls by the health care professional served to supervise this treatment and support the patient. We described AM as being prescribed by a health care professional who regularly readjusts doses as a function of the patient's functioning. We further described AM as having a chemical stimulation effect on neurotransmitters that improves their functioning and therefore diminishes depressive symptoms. The class of antidepressant (such as SSRIs or TCAs) was not specified, as this information is not typically provided to depressed patients. For all treatments, we used the neutral term health care professional to designate the person who prescribes and administers the treatment. This was done to control for the possible effect that identifying more specific professionals, such as physicians, psychologists, or psychiatrists, may have on acceptability ratings. Similarly, we omitted deliberately comments on the efficacy and secondary effects of the different treatments to prevent a bias in acceptability ratings. The treatment descriptions are presented in the Appendix. Among a sample of 88 persons, 86% of the respondents indicated that the treatment descriptions they read were clear and 69% agreed that the descriptions contained sufficient information (Landreville and Guerette 1998).

Treatment acceptability.
We used a modified version of the Treatment Evaluation Inventory (TEI; Landreville and Guerette 1998) to rate the acceptability of each treatment. We deleted four of the original 15 items of the TEI (Kazdin 1980), which referred to ethical aspects of the treatment, because they were not relevant in the context of CB and CT. Also, we modified the wording of some items slightly to specify that the treatment was to be used to treat depression. The 11 items on the modified TEI measure positive or negative reactions to treatments. Examples of individual items include asking respondents to rate how effective the treatment is likely to be, how likely the treatment is to make permanent improvements in the person, and how much discomfort the person is likely to experience during the course of treatment. Each item is rated on a 7-point Likert-type scale ranging from 1 to 7 with a higher rating indicating greater acceptability. Total scores are obtained by adding together the ratings of the individual items and range between 11 and 77, with a score of 44 indicating moderate acceptability.

A factor analysis revealed two factors that accounted for 73% of the total variance and can be used as subscales of the modified TEI (Landreville and Guerette 1998). The first subscale, named General Acceptability (8 items), is composed of items reflecting positive qualities of treatment such as effectiveness. The second subscale is named Negative Aspects (3 items) and is made up of those items assessing undesirable consequences of treatment, such as side effects. Landreville and Guérette found adequate congruent validity, test–retest reliability, and internal consistency for the global scale as well as each of the subscales.

Depressive symptoms.
The Geriatric Depression Scale (GDS; Yesavage et al. 1983) is a 30-item self-report questionnaire. Respondents are asked to answer by "yes" or "no" whether an item describes how they have felt during the past week. Total scores range between 0 and 30. Scores ranging from 0 to 10 indicate the absence of depression, scores ranging from 11 to 20 indicate mild depression, and scores ranging from 21 to 30 suggest a moderate to severe depressive state. The validity and reliability of the GDS has been described by Yesavage and colleagues 1983.

Procedure
Participants were recruited in the waiting rooms of family medicine clinics of four large urban hospitals. Between 48 and 52 participants were recruited in each hospital. The researcher approached potential participants directly. After listening to a brief description of the study, the potential participant was asked to give his or her age and sign a consent form. We assigned each participant randomly to 1 of 12 conditions (2 Levels of Severity x 6 Counterbalanced Presentation Orders of Treatments). Each condition included between 15 and 20 participants. We gave participants a questionnaire and asked them to answer it at the clinic either before or after their appointment with their physician. The questionnaire included (a) questions regarding background information, (b) one of the two case descriptions, (c) the descriptions of the three treatments, (d) three copies of the modified TEI, and (d) the GDS. Each copy of the TEI followed each treatment description and was reserved for rating that treatment only. Instructions on the TEI specified that each treatment was to be rated by supposing that it would be used with the patient described previously. The participant was offered the choice to read and answer the questionnaire by him- or herself (n = 77) or have it read to him or her by the researcher (n = 123). No significant differences were found on the acceptability ratings of each treatment between these two groups. The questionnaire took between 20 and 45 min to complete, with a mean duration of 35 min.

	Results

TOP Abstract Methods Results Discussion Appendix ENDIX References

 
Fig. 1 illustrates the mean scores on the modified TEI for each treatment and case description. Note first of all that acceptability scores for all treatments are above 44, the score designating moderate acceptability. We performed a repeated measures analysis of variance (ANOVA) on these data and revealed a significant interaction between treatment acceptability and case description, F(2,396) = 3.23, p < .0405. We performed contrasts analyses to specify the nature of this interaction. For the case of mild to moderate depressive symptoms, CT was more acceptable than AM, F(1,104) = 27.85, p < .0001, and CB was more acceptable than AM, F(1,104) = 16.07, p < .0001. No significant difference was found between CT and CB. For the case presenting with severe symptoms, CT was more acceptable than both CB, F(1,94) = 12.60, p < .0006, and AM, F(1,94) = 14.60, p < .0002. There was no significant difference between CB and AM. We found no significant differences when comparing acceptability ratings for each treatment across case descriptions.

View larger version (16K): [in this window] [in a new window]   Figure 1. Modified Treatment Evaluation Inventory (TEI) scores as a function of severity of patients' depression. CT = cognitive therapy; CB = cognitive bibliotherapy; AM = antidepressant medication.

View larger version (17K): [in this window] [in a new window]   Figure 2. Modified Treatment Evaluation Inventory (TEI) scores as a function of raters' depressive symptoms. CT = cognitive therapy; CB = cognitive bibliotherapy; AM = antidepressant medication.

	Discussion

TOP Abstract Methods Results Discussion Appendix ENDIX References

 
Our results indicate that older adults consider all treatments examined in this study at least moderately acceptable for treating late-life depression. Moreover, the acceptability of treatments varies according to the severity of depressive symptoms of the patient. CT and CB are equally acceptable and more acceptable than AM for a patient presenting mild to moderate symptoms. However, CT is more acceptable than both CB and AM for a patient presenting severe symptoms. This interaction pattern is due to a consideration of negative aspects of treatments only. When positive aspects are considered, acceptability ratings still vary, however, with CT being the preferred treatment, followed by CB.

The findings of this study confirm the importance of verifying the acceptability of treatments in different populations. In our previous work (Landreville and Guerette 1998), we compared exactly the same treatments for geriatric depression, but participants were university students. In this population, all treatments were equally acceptable and more acceptable for mild to moderate than for severe depression. When the same treatments were evaluated by elderly adults, their acceptability is not equivalent and varies according to the severity of the patients' symptoms. It is interesting to note that CT was judged more acceptable than AM across depression severity levels. Detailed analyses of specific dimensions of acceptability further indicate that older adults find CT both more positive and less negative than AM. It is unclear why CT is rated more positively than medication. We speculate that our participants perceived that it provides patients with more control over depression because it supplies them with specific skills. With respect to CT being rated less negatively than AM, it is possible that older adults perceive that psychotherapy does not have the undesirable physical effects of medication. Although such effects were not stated in the treatment descriptions, elderly participants may be more familiar with side effects of medication than are young adults because of their greater experience with pharmacotherapy. This may lead them to prefer less invasive alternatives such as psychotherapy.

The results of the present study are in line with those of Lundervold and Lewin 1990 and Rokke and Scogin 1995 in showing that psychological treatments are considered by older adults as more acceptable than AM for the treatment of geriatric depression. However, our results differ from those of Rokke and Scogin, who did not find CT to be significantly more acceptable than AM. This difference can be explained by sample size. In the study by Rokke and Scogin, only 52 elderly participants provided acceptability ratings compared with 200 in the present study. Although close examination of the means on the TEI obtained in the Rokke and Scogin study suggests a trend similar to our results, we can suppose that their study did not have sufficient power to detect a significant difference between CT and drug therapy.

An important question for this line of research is whether treatment acceptability ratings are related to the raters' own depressive symptoms. Our results indicate that this is not the case. More specifically, those participants with significant depressive symptoms did not rate acceptability differently than those without such symptoms. These findings are consistent with those of Rokke and Scogin 1995. Unlike these researchers, however, we found that perception of treatment is not related to previous experience of depression and treatment for depression.

We found a modest but significant relation between education and acceptability of drug treatment. Older adults with more education may find AM less acceptable because they are more knowledgeable about side effects of such medication. Adults currently reaching the age of 65 are generally more educated than are their predecessors. As their number grows in the future, the population of older adults may be more critical of strictly medication-based approaches to treatment of depression. Marital status was also associated with acceptability of CT and AM. The reasons for this finding are unclear. Older adults living with a partner may be strongly oriented toward intimate relationships with others and this may lead them to favor psychotherapy. This orientation may be less marked in older adults without a partner and so this group favors AM, a form of treatment that involves much less revealing of oneself.

This study was conducted with consumers of primary general health care services. This sector of health care delivers the largest portion of psychiatric care to the elderly (Gottlieb 1994). Therefore, the results of this study raise important practical issues. In view of our findings, we concur with the NIH that psychosocial treatments deserve greater emphasis (Lebowitz et al. 1997). The fact that antidepressant medication remains the predominant approach to treating geriatric depression does not appear to reflect the preference of elderly adults themselves. Other factors, including primary care providers' beliefs about psychotherapy for elders, may explain this situation. Gallo and Colleagues 1999 found that family physicians consider medications for depression as effective for older patients as for younger patients but are less optimistic about the effectiveness of psychotherapy. Because of this, they may be reluctant to recommend psychotherapy to their depressed older patients. It may be useful to inform primary care providers about the efficacy of psychological treatments for late-life depression and older adults' acceptance of such treatments. The high financial cost of individual psychotherapy and geographical barriers may also prevent many older persons from receiving this type of treatment. In this context, the finding that CB is more acceptable than AM for patients presenting mild to moderate symptoms is particularly interesting. A considerable proportion of older adults present dysphoria (Blazer et al. 1987) or minor depression (Koenig and Blazer 1996). Using CB to treat mildly to moderately depressed older adults could be an economical, accessible, and acceptable way to help prevent the deterioration of depressive symptoms. Zeiss and Breckenridge 1997 have argued that offering cognitive or behavioral therapy as a first line intervention for mild to moderately depressed older adults would be the most cost-effective approach in most settings.

Some limits of the present study need to be considered. Results are limited to the population under study, that is, elderly patients of family medicine clinics. We cannot presume that our findings are representative of other populations, such as nursing home residents, in which depression is a significant problem. Moreover, we only examined the acceptability of treatments separately. As in a previous study with young adults (Landreville and Guerette 1998), some participants in the present study commented that a single therapeutic approach is not sufficient to effectively treat geriatric depression. Future studies should compare the acceptability of various treatment combinations with that of the same treatments used separately. We also need to better understand the reasons for the current findings and to examine how acceptability and other variables are related to treatment compliance.

	Acknowledgments

 
This study was conducted in partial fulfilment of the requirements for the degree of Master of Psychology of Julie Landry under the direction of Philippe Landreville. We thank Isabelle Potvin and Stéphanie Deslauriers for their collaboration with this project. We also thank two anonymous referees for their helpful comments about the manuscript.

Received for publication July 19, 1999. Accepted for publication August 10, 2000.

	Appendix ENDIX

TOP Abstract Methods Results Discussion Appendix ENDIX References

 
Case and Treatment Descriptions
CASE 1: MILD TO MODERATE DEPRESSIVE SYMPTOMS

This description refers to a 75-year-old woman. She has been feeling sad for the past few weeks. Although she is usually very active, she currently finds life less interesting than before and tires more easily. She sleeps less well and has less appetite. She finds it very difficult to make decisions. She sometimes thinks she would be better off dead but she would never commit suicide. All these symptoms make it more difficult for her to function in everyday life. In summary, this person presents mild to moderate depressive symptoms.

Case 2: Severe Depressive Symptoms

This description refers to a 75-year-old woman. She has been feeling extremely sad for several months. Although she used to be a very dynamic person, she now has no interest for her usual activities and derives no pleasure from them. She feels too tired to do anything. She wakes up several hours earlier than before and cannot go back to sleep. She is never hungry. She is unable to make decisions. She thinks she would be better off dead and contemplates suicide. All these symptoms make it very difficult for her to function in everyday life. In summary, this person presents severe depressive symptoms.

Cognitive Therapy

Cognitive therapy is a type of psychotherapy that aims to teach the patient skills to overcome depression. Treatment consists of weekly meetings with a health care professional. During meetings, the patient learns techniques to (a) identify situations that increase his or her depressive feelings, (b) determine if his or her interpretation of these situations is overly negative and unrealistic, and (c) interpret these situations less negatively and more realistically. Between meetings, the health care professional recommends readings or applying some techniques to integrate them.

Cognitive Bibliotherapy

Cognitive bibliotherapy is a type of course that aims to teach the patient skills to overcome depression. Treatment consists in readings and exercises that are done at home. The material given to the patient is designed to teach him or her techniques to (a) identify situations that increase his or her depressive feelings, (b) determine if his or her interpretation of these situations is overly negative and unrealistic, and (c) interpret these situations less negatively and more realistically. A health care professional meets the patient at the beginning and the end of treatment and contacts him or her every week during treatment by telephone. These calls serve to answer any question the patient may have and to encourage him or her to apply the treatment.

Antidepressant Medication

Antidepressant medication acts on chemical substances in the brain, called neurotransmitters, which are deficient in persons who are depressed. By their action, antidepressants improve the functioning of brain cells. These drugs are administered as pills that are prescribed by a health care professional. A particular antidepressant is selected on the basis of the type of depression and the characteristics of both the patient and the drug. The health care professional regularly monitors the clinical state of the patient and adjusts the dosage accordingly.

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