Research That Matters (January 17 - 20, 2008)

Purpose: Many older adults do not receive adequate treatment for depression. Obtaining qualitative information from older adults who do participate in treatment can provide useful information about how to specifically tailor services for this underserved population, with the goal of improving treatment efficacy, utilization, and accessibility. There is a particular need for patient perspectives among individuals with unique medical comorbidities, however few researchers have taken a qualitative approach to the study of patient perspectives of treatment among older adults with cognitive impairment. This study was conducted to evaluate patient perspectives about psychotherapy for older adults with depression and mild cognitive impairment, specifically around issues such as the decision to seek treatment, treatment expectations, and the most and least helpful aspects of treatment.

Method: Semi-structured individual qualitative interviews were conducted with 20 participants in a randomized clinical trial comparing Problem Solving Therapy (PST) to Supportive Therapy (ST) for depressed older adults with mild cognitive impairment. Individual qualitative interviews elicited participant perspectives various aspects of their treatment experiences (e.g., expectations regarding treatment, most and least helpful aspects of treatment). Interviews were digitally recorded and transcribed, and thematic analyses were conducted with the transcripts by two coders using the qualitative analysis software Transana.

Results: Prominent reasons for seeking psychotherapy involved depression stemming from health concerns, grief and loss, social isolation, feeling stuck and unable to tackle tasks and projects (a symptom of depression), and relationship difficulties. Relationship with the therapist emerged as a particularly critical aspect of treatment regardless of participant's treatment condition (PST or ST). Patients in the PST condition generally described treatment as being mutually efficacious for both mood and cognition. However, data suggest that the PST condition may not have been as impactful for patients who had commenced a dementia process over the course of the study. There was varied response to the ST condition, with mixed reactions to the opportunity to explore unresolved conflicts from earlier in the lifespan. Patients also indicated that the research component of the study strongly impacted their treatment experience in ways both positive and negative.

Conclusions and Implications: This study represents the first qualitative evaluation of patient perspectives of psychotherapy among older adults with mild cognitive impairment. The current study demonstrates the value of utilizing a qualitative approach within the context of a larger, randomized clinical trial of psychotherapy interventions. This study has implications for social workers involved in direct practice, administration, and research involving geriatric mental health interventions. It provides descriptive data from a patient perspective about the value of psychotherapy and the importance of the clinician-client relationship and rapport in addressing depression in late life. It also provides qualitative data supporting the use of PST as a valuable intervention for late-life depression with mild cognitive impairment, and its possible contraindication for individuals with early dementia, as well as the benefit of ST for many older adults. Finally, findings from this study urge the consideration of the possibly unintended clinical implications of the research study when planning geriatric mental health interventions research.