bt28.1

Treatment of Late Life Depression: A Response to the NIH Consensus Conference

Antonette M. Zeiss, and Julia Steinmetz Breckenridge, VA Palo Alto Health Care System

Conclusions of the NIH Consensus Conference on treatment of late life depression, particularly with regard to their recommendations regarding cognitive behavioral therapies as those compare to a review of empirical findings, are examined. In contrast to the NIH recommendations, research demonstrates that psychotherapy is at least of equal effectiveness as compared to antidepressant medication for older depressed patients. Cognitive and behavioral approaches have not been shown to be more effective than other brief therapies, particularly interpersonal therapy and brief psychodynamic therapy. There are more studies, however, demonstrating the effectiveness of cognitive and behavioral therapies than any other approach. Older adults hold generally positive attitudes towards such treatments and may prefer them to medication treatment. Offering cognitive or behavioral therapy as a first line intervention for mild to moderately depressed older adults could be the most cost-effective approach in most settings. Promotion of cognitive and behavioral therapies for older depressed patients would be supported by involvement in the development of treatment guidelines at the national level, expansion of the work of the APA task force on empirically validated treatments to include therapies for older adults, and by the efforts of individuals to present information to older adults in the community on the potential benefits of cognitive and behavioral treatments for depression.

Suicide In Later Life

Dolores Gallagher-Thompson, VA Palo Alto Health Care System & Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Nancy J. Osgood, Virginia Commonwealth University, Richmond, VA

This paper addresses a number of issues related to suicide among persons over the age of 60 in the United States. We begin with a presentation of the epidemiology of late life suicide in the United States, followed by discussion of related demographic information, including known risk factors for both suicide attempts and completed suicides. We then proceed to discuss issues related to the assessment of suicidality among older men and women. The next issue is the topic of "rational" suicide, which is a highly controversial, yet increasingly common phenomenon, to which psychotherapists and health care providers will be exposed in working with older adults. Finally, the paper concludes with suggestions for intervention in order to reduce suicide ideation and improve the individual's quality of life.

Functional Impairments in Elderly Patients With Schizophrenia and Major Affective Illness in the Community: Social Skills, Living Skills, and Behavior Problems

Stephen J. Bartels, Kim T. Mueser, and Keith M. Miles, New Hampshire-Dartmouth Psychiatric Research Center

Despite recent advances in the psychosocial treatment of schizophrenia and other severe mental illnesses, little is known about the specific needs of elderly persons with these disorders. To address this gap in understanding, we examined the functional impairments of a sample of elderly patients with diagnoses of schizophrenia or schizoaffective disorder (N=55), bipolar disorder (N=39), or major depression (N=90) who were living in the community and receiving mental health services. Functioning in four different areas was assessed: social skills, behavior problems, self-care skills, and community living skills. Diagnostic group comparisons indicated that the schizophrenia-schizoaffective disorder group had worse functioning than the other groups across all of the different domains. The clinical and research implications of the findings for the development of psychosocial interventions for elderly persons with schizophrenia are discussed.

Behavioral Interventions for Sexual Dysfunction in the Elderly

Jane E. Fisher, Diane E. Swingen, and William O'Donohue, University of Nevada-Reno

In this paper we review and evaluate the status of information regarding sexual dysfunction in advanced age. We argue that the behavioral approach has considerable promise for the conceptualization of the sexual problems of older adults, because in rejecting the medical model of nomothetically defining psychological disorders, it allows for considerable variability for individuals to define their problems in living. The great heterogeneity in health and psychological functioning that is found among the elderly can be mirrored in the heterogeneity of problem definitions. Further, the behavioral approach views problem definition as a behavior that may be a product of problematic societal contingencies that may need to be addressed themselves. The utility of this feature for guiding behavior therapists in helping their elderly clients understand their sexual functioning is addressed. Finally, we propose a research agenda that addresses the limitations in the extant literature regarding the assessment and treatment of sexual dysfunction in old age.

Anxiety Disorders in the Elderly: The Emerging Role of Behavior Therapy

J. Gayle Beck, State University of New York at Buffalo, and Melinda A. Stanley, University of Texas Health Sciences Center

In recent years, behavior therapists have made a deliberate effort to expand their horizons to include underserved populations. The application of behavioral and cognitive behavioral procedures to anxiety disorders in the elderly represents one such beginning effort. In this review, we will present an overview of available literature concerning the psychopathology, assessment, and behavioral treatment of the anxiety disorders in later life. As will be noted, research is beginning to elucidate specific features and treatment of anxiety in the elderly, although the majority of this attention has been directed at Generalized Anxiety Disorder, specific phobias, and nonclinical anxiety complaints. Areas for future research are highlighted throughout this review in the hopes of stimulating increased attention in these areas.

Future Directions for Clinical Research in Mental Health and Aging

George Niederehe, National Institute of Mental Health

With the geropsychological papers assembled in the present issue, the miniseries on "Mental Health in the Elderly: Challenges for Behavior Therapy" lives up to its title and intent. Tackling an array of important topics in the mental health and aging field, the five papers highlight gaps in knowledge, define questions with respect to which behaviorally oriented research could make substantial contributions, and challenge readers to rise to these tasks. The papers are diverse both in focus and approach. While not comprehensively surveying all the major areas of concern in clinical geropsychology, they range from areas in which we know quite a good deal and can debate just how much solid information we already have (as in Zeiss & Breckenridge's [1997] discussion of the treatment of late-life depression) to others in which we appear to have little or no scientifically established data specific to the aged (see Fisher, Swingen, & O'Donohue's [1997] appraisal of sexuality research). In between these extremes, we have informative papers on several other issues of great importance in the elderly population. Beck and Stanley (1997) review the epidemiology, phenomenology, assessment, and cognitive behavioral treatment of anxiety disorders in elderly patients. Gallagher-Thompson and Osgood (1997) consider various perspectives on suicide in late life, encompassing both conceptual vantage points and empirical findings. Bartels, Mueser, and Miles (1997) report new data on chronic mental illness (schizophrenia and bipolar disorder) in the aged.

Self-Efficacy in the Thermal Biofeedback Treatment of Migraine Sufferers

Douglas J. French, Janel G. Gauthier, Claude Roberge, Stéphane Bouchard, and Arie Nouwen, Laval University, Sainte-Foy, Quebec, Canada

Despite the demonstrated efficacy of thermal biofeedback (TBF) for the treatment of migraine headaches, therapeutic mechanisms underlying this widely used therapy remain poorly understood. Previous investigations of electromyograph (EMG) biofeedback treatment of tension-type headache have suggested that reductions in headache activity may be mediated primarily by changes in perceived self-efficacy, rather than actual self-regulation ability. The present study examined perceived self-efficacy as a potential therapeutic mechanism in TBF using an experimental manipulation of perceived success. Twenty-seven females meeting International Headache Society (IHS) diagnostic criteria for migraine headache were randomly assigned to one of two TBF conditions. Subjects were shown bogus computer-generated graphs that ostensibly demonstrated that subjects displayed either superior (high success condition) or inferior (moderate success condition) hand-warming skills relative to a fictitious normative sample. Although the manipulation of perceived success produced significant group differences on measures of perceived self-efficacy, the groups did not experience significantly different reductions in headache activity or medication consumption. The present findings suggest that perceived self-efficacy, as measured in the present study, may not be a significant mediator of TBF treatment outcome.

Hypnotic Enhancement of a Cognitive Behavioral Treatment for Public Speaking Anxiety

Nancy E. Schoenberger, University of Medicine and Dentistry of New Jersey, Irving Kirsch, Paul Gearan, Guy Montgomery, and Steven L. Pastyrnak, University of Connecticut

The effectiveness of a multidimensional cognitive behavioral treatment for public speaking anxiety was compared with that of the same treatment supplemented by hypnosis. The hypnotic treatment included all components of the cognitive behavioral treatment. It differed from the nonhypnotic treatment only in that relaxation training was presented as a hypnotic induction, automatic thoughts were referred to as self-suggestions, and explicit hypnotic suggestions for improvement were added. Participants in both treatment conditions improved more than those in a wait-list control group. Moreover, labeling the treatment "hypnotic" appeared to enhance treatment effectiveness. The hypnotic treatment generated expectancies for greater change among participants than did the nonhypnotic treatment, and these expectancies were correlated with treatment outcome. Implications for the use of hypnosis in treatment are discussed.

Savings in Animal Learning: Implications for Relapse and Maintenance After Therapy

E. James Kehoe and Michaela Macrae, School of Psychology, University of South Wales, Australia

Savings are the proactive influences of prior learning on later learning even when the original behavior has been extinguished or forgotten. Therapists can capitalize on savings both to understand the sources of relapse and to maintain and extend therapeutic outcomes in the client's ordinary environment. This paper reviews recent findings from our laboratory that savings in animal learning are more extensive than previously thought. Not only can responding to an extinguished stimulus reappear spontaneously, but reacquisition of a conditioned response can also occur very rapidly. Moreover, once conditioning has taken place with one stimulus, subsequent acquisition of the same response to a completely novel stimulus will be accelerated. At the same time as this novel acquisition, the response to the original, extinguished stimulus also shows recovery that is distinct from generalization. We propose a neural network model that explains a wide range of savings and therefore illuminates a common mechanism that underpins both relapse and maintenance after therapy.

Private Events in Behavior Analysis: Conceptual Basis and Clinical Relevance

Cynthia M. Anderson, Robert P. Hawkins, and Joseph R. Scotti, West Virginia University

Behavior analysis has been criticized extensively since its inception. While most criticisms seem ill-informed, two foci that relate to behavior therapy seem to have significant validity: the behavior analytic conceptualization of private events and the dearth of demonstrated efficacy of this approach with adult outpatient populations. These two issues are related and seem to result from the fact that behavior analysts have largely ignored private events until recently. However, we believe that behavior analysis is developing a position on the role of private events that is consistent with the pragmatic, contextual, nonmentalistic perspective taken by behavior analysis. We attempt to present such a perspective here. Further, and in line with the natural science tenets underlying behavior analysis, this perspective is beginning to be supported by empirical research. Because the clinical relevance of any theoretical model is related to the degree to which it guides effective treatments, a recently developed therapeutic approach that uses a behavior analytic account of private events will be sketched.