REVIEW ARTICLE

The effectiveness of behavioural therapy for the treatment of depression in older adults: a meta-analysis
Zara Samad 1, Stephen Brealey 2 and Simon Gilbody 2
1 2

Humber Mental Health Trust, Trust Headquarters, Willerby Hill, Willerby, East Yorkshire, UK Department of Health Sciences, University of York, York, UK Correspondence to: S. Brealey, E-mail: stephen.brealey@york.ac.uk

To systematically review the effectiveness of behavioural therapy in depressed older adults. Methods: Electronic databases were searched to July 2009. Reference lists of systematic reviews and identied studies from the search strategy were also screened. Randomised controlled trials (RCTs) of behavioural therapy compared with waiting list controls or other psychotherapies in older adults (aged !55 years) with clinical depression were included. One author independently identied studies for inclusion. Two authors extracted data and assessed the included studies for risk of bias. Estimates of depression were combined using a random effects model and the I2 statistic to examine heterogeneity. Results: Four RCTs were included in the meta-analysis. For post-treatment self-rated depression symptoms, behavioural therapy was not signicantly more effective than a waiting list control [standardised mean difference (SMD) of 0.52, 95% condence interval (CI) 1.35 to 0.30, p 0.21, n 117], cognitive therapy (SMD of 0.23, 95% CI 0.24 to 0.70, p 0.33, n 134) or brief psychodynamic therapy (SMD of 0.37, 95% CI 0.84 to 0.11, p 0.13, n 69). For post-treatment clinician-rated depression, behavioural therapy was not signicantly more effective than cognitive therapy or brief psychodynamic therapy but was signicantly more effective than a waiting list control (weighted mean difference (WMD) of 5.68, 95% CI 7.71 to 3.66, p < 0.001, n 117). Conclusions: Behavioural therapy in depressed older adults appears to have comparable effectiveness with alternative psychotherapies. Further research is recommended with the need for larger sample sizes, more clarity on trial design and the intervention, longer term follow-up and concomitant economic evaluations. Copyright # 2011 John Wiley & Sons, Ltd.
Objective: Key words: behavioural therapy; cognitive therapy; psychotherapy; depression; meta-analysis History: Received 13 July 2010; Accepted 29 November 2010; Published online 23 February 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/gps.2680

Introduction Depression is an important global public health problem as it is estimated to effect 121 million people worldwide and is the fourth leading cause of burden amongst all diseases with rising trends expected over the next 20 years (World Health Organisation, 2001). In England alone the economic burden from depression exceeds 9 billion per annum (Thomas and Morris, 2003). Older adults are particularly vulnerable to depression, typically categorised by United Kingdom (UK)
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health services as !65 years of age. This is not necessarily because of age per se, but rather there are a variety of major medical illnesses such as heart disease and diabetes that are associated with depression being higher in older adults (Carney and Freedland, 2003; Djernes, 2006; Li et al., 2008). It is these illnesses which increase in prevalence with age, which can lead to depression and in turn signicantly inuence the outcome of the medical illness (Penninx et al., 2001; Katon, 2003; Von Korff et al., 2005; Department of Health, 2009). With the UK population aged over 60 set to rise from 21% to 29% by 2050 (Mental Health
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and Older People Forum, 2008), it is likely that the problem of depression in older adults will increase. In terms of prevalence, it is estimated that 25% of people aged over 65 have symptoms of clinical depression (Department of Health, 2009). If left untreated, depression in older adults is associated with increased mortality and a range of negative outcomes including poor quality of life, difculty with social functioning and an increased risk of suicide (Blazer, 2003; Unutzer, 2007). Depressed individuals engage in fewer pleasurable and more aversive activities resulting in less positive reinforcement from interactions with the environment (MacPhillamy and Lewinsohn, 1974). This can lead to self-critical cognitions (Beck et al., 1979), which can lower activity engagement further and therefore negatively reinforce the cognitions. In depressed older adults, the reduced activity and self-critical cognitions can arise for reasons including: threats to competency, health or independence and role changes due to spousal bereavement (Fiske et al., 2009). Behavioural therapy addresses the negative cognitions and emotions associated with depression in an indirect way (Hopko et al., 2003). It has been described as being different from traditional cognitive approaches in that it seeks to help patients modify their environment, not their thinking. It is negative life circumstances and patients difculty in changing these circumstances that may lead to passivity in depressed patients (Jacobson et al., 2001). Treatment originally involved scheduling an increase in pleasant activities and positive interactions with the environment (Lewinsohn and Graf, 1973). Recent developments include positive activation which places an increased emphasis on reducing negative reinforcement characterised by avoidance behaviour (Jacobson et al., 2001). Other developments include the positive model which involves: baseline assessment of activity; identifying behavioural goals within a number of life areas (e.g. hobbies, relationships, employment etc.); listing these goals in a hierarchy of easiest to most difcult and then planning implementation of these goals via weekly diary sheets (Hopko et al., 2003). Behavioural therapy may be delivered via a range of formats (e.g. face to face sessions, telephone support, workbooks) and can be supported by a range of professionals (e.g. psychology graduates, mental health nurses) who provide various levels of support. For use in older adults, behavioural therapy potentially has several advantages. In comparison to pharmacological interventions, it can be considered a safer option as anti-depressants are likely to result in negative reactions with other medications (De Leo and
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Dieksta, 1990), with older patients on average 3.6 times more prescriptions than younger adults (those aged 1559 years) (Wong et al., 2004). Fears about the side effects of antidepressant medication in older adults often result in the prescription of medication at sub-therapeutic levels (Laidlaw et al., 2008). Furthermore, prescribing medication does not address the changes in behaviour that are needed to overcome depression which is important given the complex beliefs and attitudes that have been found in older adults towards mental illness (Quinn et al., 2009). As behavioural therapy is a relatively simple and brief intervention which requires less intensive professional training and support compared to other psychological interventions it could be more cost-effective (Centre for Economic Performances Mental Health Policy Group, 2006; Ekers et al., 2007). In addition, as it is a briefer, simpler intervention it might benet older adults with cognitive impairment or a low educational level (Porter et al., 2004) who nd cognitive restructuring, as used in cognitive behavioural therapy (CBT), more challenging than younger adults (Hertzog and Hultsch, 2000). The aim of this systematic review of randomised controlled trials (RCTs) was to determine the effectiveness of behavioural therapy compared to other psychological approaches for the treatment of depression in older adults. Methods
Identification of suitable studies

We searched electronic databases mostly from 1980 until July 2009 to coincide with the introduction of behavioural therapy into clinical practice: Cochrane Library (from 1980), Web of Science (from 1980), Medline (from 1950), EMBASE (from 1980), CINAHL (from 1982), AMED (from 1985), PsychINFO (from 1987), British Nursing Index (from 1995) and NHS evidence for mental health. MESH headings and free text along with truncation and wild cards were used and randomised controlled trial lters. Searches were structured as four concepts: diagnosis (e.g. depression, depressive disorder), intervention (e.g. activity scheduling), age (e.g. frail older, aging population) and design (e.g. randomised controlled trials). Reference lists were also screened of existing systematic reviews on psychotherapeutic interventions and of identied studies from the search strategy. To minimise publication bias grey literature was identied by searching for unpublished doctoral theses (via
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http://opensigle.inist.fr/), conference proceedings (via the Web of Science Conference Proceedings Citation Index database) and government publications (via the British Ofcial Publications Current Awareness Service and the Health Management Information Consortium). The World Health Organisation (WHO) International Clinical Trials registry was also searched to identify relevant ongoing clinical trials. One author (ZS) screened abstracts and the full text of selected studies for eligibility and consulted with a second author (SB) when necessary.
Inclusion criteria

(e.g. examining evidence for or against dysfunctional cognitions) and behavioural methods (e.g. behavioural experiments to test out predictions based on dysfunctional cognitions).
Interpersonal therapy (IPT). Approaches that looked

at links between depressed mood and difculties in the following areas of conict: transition, bereavement, interpersonal relationships with signicant others and long term difculties in forming and maintaining relationships (Klerman et al., 1984).
Psychodynamic therapy. This concerns approaches

All available RCTs in any language were included to reduce the potential for publication bias (Khan and Kleijnen, 2002). Studies included participants: who were aged !55 years (although studies that included a younger population were eligible if it was possible to extract data for patients aged !55 years); with or without physical co-morbidities; and with a diagnosis of clinical depression using structured diagnostic interviews such as DSM-IV-TR (American Psychiatric Association, 2000), clinician-rated scales (e.g. Hamilton Depression Rating Scale (HDRS); Hamilton, 1967) or self-report scales (e.g. Beck Depression Inventory (BDI); Beck et al., 1961). Studies were excluded which included participants with co-morbid dementia or severe cognitive impairment or met a diagnosis of psychosis, bi-polar disorder, substance-misuse or a primary diagnosis for any other mental health disorder. We included RCTs in the behavioural therapy group which involved an intervention based on either the basic behavioural principles (e.g. increasing access to positive reinforcement) or the more recent developed forms of behavioural therapy (e.g. learning about the maintenance of depression symptoms and restarting avoided pleasant/routine/necessary activities). Studies were excluded where behavioural therapy was used in combination with cognitive techniques which directly addressed the negative cognitions associated with depression. The comparators which could be included are described below.
Treatment as usual. This could include a number of

used to bring repressed thoughts and feelings into consciousness and to develop new ways of tolerating and coping with the emotional pain (Leiper, 2006).
Supportive counselling. This approach focuses on an

individual exploring any problems they may have and to develop ways to resolve them (Rogers, 1961).

Outcome measures

The primary outcome measure was a change in depression symptoms using self-rated (e.g. BDI) or clinician-rated measures (e.g. HDRS) presented as continuous data (e.g. means and standard deviations). As psychotherapy trials often present multiple depression measures we gave validated self-report measures precedence over clinician-rated measures. As a proxy for acceptability, dropout rates from treatment were recorded as dichotomous data.

Assessment of risk of bias in included studies

options such as usual General Practitioner treatment (e.g. prescribed anti-depressants) or being on a waiting list for psychological therapy.
CBT. This included interventions that directly modied cognitions using both cognitive techniques
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Each eligible study was assessed for risk of bias (yes, no or unclear) by two independent authors (ZS and SB) using the Cochrane Collaboration risk of bias tool (Higgins and Green, 2008). Disagreements were resolved through discussion. This assessment addresses methodological issues such as adequate sequence generation in treatment allocation, adequate concealment of treatment allocation, blinding of treatment allocation, addressing incomplete outcome data, nonselective outcome reporting and other potential threats to study validity. The extent of agreement between the authors was expressed as a percentage and Kappa statistic. The implications of risk of bias to the results of included studies are discussed narratively.
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Data extraction

Data were extracted for each eligible study independently by one author (ZS) and checked by another author (SB). Characteristics of included studies were extracted regarding: participants (e.g. age, baseline depression), the intervention and control groups (e.g. mode of delivery, therapist level) and outcome measures. If data were missing from individual studies the authors were contacted via email.
Data synthesis

to be low, 50% moderate and 75% high (Higgins et al., 2003). Four sources of clinical heterogeneity were identied a priori: diagnosis of depression at baseline; type of professional who delivered the behavioural therapy intervention; mode via which the treatment was delivered and presence of physical co-morbidity. The impact of the potential sources of clinical heterogeneity on the overall treatment effects were explored, when possible, using sensitivity analyses (Higgins and Thompson, 2002). Results Searching electronic database identied 633 studies of which 579 were excluded from screening titles and abstracts as shown in Figure 1. Full copies of 54 publications were then retrieved and assessed for eligibility. From these publications another 4 potentially eligible studies were identied from reference lists. Of these 58 studies there were four RCTs which met the inclusion criteria (Gallagher and Thompson, 1982; Thompson et al., 1987; Scogin et al., 1989; Rokke et al., 1999). Table 1 summarises the main characteristics of the included studies and shows that whilst they were all undertaken in the community, include patients of a similar age and used similar outcome measures, there is some variability in the assessment of baseline depression, the interventions being compared, and particularly the delivery of the intervention such as whether this was face-to-face or in the form of bibliotherapy.
Risk of bias in included studies

Analyses were conducted for self-report measures and clinician-rated measures separately. When individual studies reported more than one self-rated depression measure, precedence was given to the Geriatric Depression Scale (GDS) as this measure is validated specically for the older adult population. In the absence of the GDS, scores from the BDI were used as it is one of the most frequently used instruments in depression research and has widespread acceptability (Rokke et al., 1999). For clinician-rated depression, scores from the HDRS were used in the data analysis. For self-rated depression symptoms the standardised mean differences (SMD) were calculated across trials to facilitate analysis of the same outcome using different scales. We assigned effect sizes according to the standard convention where the SMD is small (00.32), medium (0.330.55) and large (0.56 or more) (Lipsey and Wilson, 1993). For clinician-rated depression symptoms using the HDRS, the weighted mean difference (WMD) was calculated and interpreted with reference to its effect size. Data for drop out from treatment were presented as odds ratios (OR) to indicate the likelihood of these events occurring in the intervention group compared to the comparison groups. In anticipation of variation in the delivery of therapies (e.g. number of sessions, therapy approaches, setting) data were pooled with 95% condence intervals (CI) using a random effects model taking into account both within- and between-study variance (Sutton et al., 1998).
Exploration of heterogeneity

We measured statistical heterogeneity using the I2 statistic which describes the percentage of variability in effect size that can be attributed to study heterogeneity rather than due to chance (Higgins and Thompson, 2002). Values of the I2 statistic of 25% are considered
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For the assessment of risk of bias the percentage agreement between the two independent authors was 83% with a Kappa of 0.72 (95% CI 0.470.96). All included studies stated the use of random assignment in treatment allocation. Figure 2 shows, however, that it was unclear as to whether there was adequate allocation sequence or concealment. In addition, none of the included studies reported sufcient details about whether treatment allocation was blinded to the outcome assessors who completed the clinician-rated measures. Incomplete outcome data did not appear to be a source of bias in one study with missing outcome data balanced in numbers across intervention groups (Gallagher and Thompson, 1982). Details were insufcient in explaining or dealing with incomplete outcome data in the other three studies. For selective reporting, three of the studies presented the results of all outcome
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Figure 1 Flow of studies through the systematic review.

measures which they stated to have used (Gallagher and Thompson, 1982; Scogin et al., 1989; Rokke et al., 1999), although there was a lack of clarity as to what was the primary outcome in two of these studies (Gallagher and Thompson, 1982; Scogin et al., 1989). For other potential threats to study validity, three of the studies were potentially at risk of another source of bias. This concerned how patients were approached to take part in the trial (Scogin et al., 1989), how participants in the no-choice condition were yoked to participants in the choice condition (Rokke et al., 1999), and how patients who dropped out of treatment were replaced (Gallagher and Thompson, 1982).
Effectiveness of behavioural therapy compared with waiting list control

Three RCTs were included in this comparison (Thompson et al., 1987; Scogin et al., 1989; Rokke et al., 1999). Data were used from the behavioural therapy group at treatment completion and from the delayed treatment group at the end of the waiting period. For posttreatment self-rated depression symptoms the analysis used the GDS (Scogin et al., 1989; Rokke et al., 1999) and the BDI (Thompson et al., 1987). Figure 3 presents a pooled SMD of 0.52 (95% CI 1.35 to 0.30) suggesting a medium effect in symptom level scores of depression
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favouring the behavioural therapy group but which was not statistically signicant ( p 0.21). There was signicant heterogeneity (x2 8.94, df 2, p 0.01) with the I2 statistic suggesting that 78% of variation in the effect size was due to between study heterogeneity. For post-treatment clinician rated depression, HDRS scores were used in all studies. The pooled WMD was estimated to be 5.68 (95% CI 7.71 to 3.66) demonstrating a highly signicant difference in symptom-level scores of depression favouring the behavioural therapy group ( p < 0.001). For this analysis statistical heterogeneity was not signicant (x2 0.11, df 2, p 0.94, I2 0%). There were insufcient studies to explore the impact of our a priori sources of clinical heterogeneity. In terms of acceptability of behavioural therapy, Thompson et al. (1987) found that 16% (4 of 25) of patients in the behavioural therapy group dropped-out of treatment; Scogin et al. (1989) found 17.3% (4 out of 23) of patients dropped out; and Rokke et al. (1999) found 53% (9 of 17) of patients dropped out.
Effectiveness of behavioural therapy compared with cognitive therapy

All four RCTs contributed to this comparison (Gallagher and Thompson, 1982; Thompson et al.,
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1216 Table 1 Main characteristics of included studies First named author (year) Setting Mean age (SD) Sex (% female) Community 67.8 (6.1) 77% Baseline depression diagnosis Research Diagnostic Criteria for Major Depressive Disorder Thompson (1987) Community 67.1 (5.8) 67% Research Diagnostic Criteria for Major Depressive Disorder Interventions (number of patients) Mode of delivery Therapist level Session number (duration) Face-to-Face Doctoral level psychologists 16 (90 min) over 12 weeks Face-to-Face Doctoral level psychologists 1620 (twice a week rst 4 weeks and once a week thereafter)

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Outcome measures

Gallagher (1982)

Behavioural therapy (10) Cognitive therapy (10) Brief psychotherapy (10) Behavioural therapy (25) Cognitive therapy (27) Brief psycho-dynamic therapy (24) 6 week delayed treatment control (19)

Self rated: BDI and Zung depression scale Clinician rated: HDRS

Self rated: BDI, GDS and BSI (depression) Clinician rated: HDRS

Scogin (1989)

Community 68.3 (6.8) 85%

HDRS ! 10

Behavioural bibliotherapy (23) Cognitive bibliotherapy (22) 4 week delayed treatment control to bibliotherapy (22)

Work book and weekly telephone support Researchers

Self rated: GDS Clinician rated: HDRS

Rokke (1999)

Community 66.3 (5.3) 38%

HDRS ! 10, BDI ! 10 and GDS ! 11

Choice of behavioural therapy or cognitive therapy (15) No choice of behavioural therapy or cognitive therapy (20) 10 week delayed treatment control (29)

Face-to-Face Doctoral/masters level psychologist or graduate students in clinical psychology/counselling 10 (1 h) weekly

Self-rated: BDI and GDS Clinician rated: HDRS

HDRS, Hamilton Depression Rating Scale; BDI, Beck Depression Inventory; GDS, Geriatric Depression Scale; BSI (Depression), Depression subscale of the Brief Symptom Inventory.

1987; Scogin et al., 1989; Rokke et al., 1999). The analysis used data from the immediate treatment completion stage which compares to a follow-up from 1 to 3 months. For post-treatment self-rated depres-

sion symptoms, three studies used the GDS (Thompson et al., 1987; Scogin et al., 1989; Rokke et al., 1999) and the other study used the BDI (Gallagher and Thompson, 1982). Figure 4 presents a pooled SMD of

Figure 2 Summary of risk of bias assessment in included studies.

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Figure 3 Self-rated effectiveness of behavioural therapy compared with waiting list control at treatment completion.

Figure 4 Self-rated effectiveness of behavioural therapy compared with cognitive therapy at post-treatment (or 13 month follow-up).

0.23 (95% CI 0.24 to 0.70) suggesting a small effect in the difference in symptom level scores of depression favouring the cognitive therapy group but which was not statistically signicant ( p 0.33). There was no signicant heterogeneity between studies (x2 5.24, df 3, p 0.15, I2 43%). As specied a priori, to explore the inuence of a formal depression of diagnosis at baseline (e.g. Major depressive disorder diagnosis) the two studies which did not require a formal depression diagnosis (Scogin et al., 1989; Rokke et al., 1999) were removed from the meta-analysis. The pooled SMD was then 0.02 (95% CI 0.44 to 0.48), which was not statistically signicant ( p 0.93). To explore the inuence of the type of professional used to deliver the intervention (e.g. mental health vs. non mental health professional), data from one study was removed from the analysis as researchers delivered the intervention (Scogin et al., 1989). The pooled SMD was then 0.00 (95% CI 0.40 to 0.41), which was not statistically signicant ( p 1.00). To explore the inuence of the mode of delivery of an intervention meant that the same study should be removed from the analysis as bibliotherapy was used to deliver the intervention whereas the other studies used face-to-face sessions. This analysis produced the same results as for removing the nonmental health professional. There was insufcient data to allow us to explore the effect of physical comorbidities on self-rated depression symptoms. For post-treatment clinician-rated depression, HDRS scores were calculated for all four RCTs. The pooled WMD was estimated to be 0.05 (95% CI
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2.10 to 2.00) in favour of the behavioural therapy group which was not statistically signicant ( p 0.96). There was no signicant heterogeneity between studies (x2 3.45, df 3, p 0.33, I2 21%). The inuence of sources of clinical heterogeneity on treatment effect as described above was again repeated. When formal depression was diagnosed at baseline the pooled WMD was 1.25 (95% CI 4.30 to 1.79) in favour of behavioural therapy which was not statistically signicant ( p 0.42). The overall effect remained in favour of behavioural therapy when the intervention was delivered by a mental health professional or faceto-face with a pooled WMD of 1.40 (95% CI 3.84 to 1.03), which remained non-signicant ( p 0.26). It was not possible to explore the effect of physical comorbidities on clinician-rated depression symptoms. The number of participants dropping out from treatment between baseline and treatment completion was reported in all four included RCTs. The pooled dropout was greater for cognitive therapy with an odds ratio of 2.04 (95% CI 0.87 to 4.78), which was not statistically signicant ( p 0.10).
Effectiveness of behavioural therapy compared with brief psycho-dynamic therapy

Two studies were included in this comparison using data at the end of treatment which is comparable with a 3-month follow-up (Gallagher and Thompson, 1982; Thompson et al., 1987). For post-treatment self-rated depression symptoms, the analysis used the GDS
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Figure 5 Self-rated effectiveness of behavioural therapy compared with brief psycho-dynamic therapy at post-treatment (or 3 month follow-up).

(Thompson et al., 1987) and BDI (Gallagher and Thompson, 1982). Figure 5 presents a pooled SMD of 0.37 (95% CI 0.84 to 0.11) suggesting a moderate effect in favour of behavioural therapy which was not statistically signicant ( p 0.13). The evidence for statistical heterogeneity was non-signicant (x2 0.00, df 1, p 0.96, I2 0%). For post-treatment clinician rated depression, HDRS scores were used for both studies. The pooled WMD was estimated to be 1.56 (95% CI 4.64 to 1.52) in favour of behavioural therapy which was not statistically signicant ( p 0.32). For this analysis statistical heterogeneity was non-signicant (x2 0.24, df 1, p 0.62, I2 0). There were insufcient studies to explore the impact of our a priori sources of clinical heterogeneity. For dropout rates, the pooled odds ratio was 1.50 (95% CI 0.326.96) with patients more likely to dropout of the behavioural therapy intervention which was not statistically signicant ( p 0.61). Discussion The main ndings from this review show that behavioural therapy for older people is signicantly more effective than waiting list control when measured by clinician-rated depression using the HRDS, but not signicantly different when measured by patient self-report. It is unclear as to whether clinicians who administered the HRDS were blind to treatment allocation (Schulz et al., 1995), which could have inuenced its completion and thus the estimated effectiveness of behavioural therapy. We also found that behavioural therapy is not signicantly different in effectiveness compared with cognitive therapy or brief psycho-dynamic therapy whether using self-reported measures or clinician-rated assessment. To examine sources of heterogeneity and to improve our understanding of what factors might inuence the effectiveness of behavioural therapy in older adults it was possible to explore this for the four RCTs included in the meta-analyses comparing behavioural therapy with cognitive therapy. We found that when two studies were excluded (Scogin et al., 1989; Rokke et al.,
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1999), which did not include a formal depression of diagnosis at baseline this reduced the effectiveness of cognitive therapy compared to behavioural therapy in self-reported depression. Furthermore, when a study was excluded (Scogin et al., 1989) because a researcher delivered the intervention, which was not face-to-face but in the form of work books and telephone support (i.e. bibliotherapy), then there was no clinical or statistically signicant difference in self-reported depression at all. Therefore, it appears that who delivers the intervention and how it is delivered such as whether bibliotherapy is used or not is important for determining the effectiveness of behavioural therapy. We could not explore whether the presence of physical co-morbidities inuenced the effectiveness of interventions as three studies did not provide sufcient detail to judge whether they included participants with physical co-morbidities (Gallagher and Thompson, 1982; Thompson et al., 1987; Scogin et al., 1989) and one study excluded those patients with physical comorbidities (Rokke et al., 1999). Because we had relatively few studies we were unable to more formally explore sources of heterogeneity using techniques such as meta-regression. For this review a systematic approach was used to identify the literature and there was independent data extraction and assessment of study quality by two authors and used meta-analytical techniques to combine the results of studies to increase power and to obtain a combined estimate of effect. It was not meaningful to explore publication bias statistically with only four included RCTs and expect its presence is unlikely with the thorough searches undertaken of grey literature. There are, however, limitations to the evidence presented. First, for the included RCTs it was unclear as to how randomisation was implemented and whether there was blinded assessment of outcome in clinician-rated measures which are important sources of bias (Schulz et al., 1995). None of the studies were designed to have sufcient power to detect statistically signicant differences and only had small sample sizes. It was also only possible to combine studies with short-term follow-up of around 13 months. Second, with regards the intervention itself, it
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is not clear as to whether it was adapted to the delivery of behavioural therapy for older adults. Nor were any details provided about the efforts to remove treatment barriers typically faced by older adults. This became apparent as reasons for patients dropping out included transportation problems (Gallagher and Thompson, 1982; Thompson et al., 1987), physical illness (Thompson et al., 1987; Rokke et al., 1999) and difculty reading bibliotherapy due to visual impairment (Scogin et al., 1989). In contrast, other studies have adapted an existing behavioural treatment manual for use in older adults by adding written examples of activities more relevant to the older and using large print (Martell et al., 2001; Yon and Scogin, 2009) and for older adults in assisted living and medical settings emphasising the need for changes in the environment (Lichtenberg et al., 1998; Cernin and Lichtenberg, 2009). In an attempt to remove treatment barriers such as access, other studies have used community based non-mental health professionals (e.g. nurse, social worker, occupational therapist) to deliver the behavioural intervention within participants homes (Unutzer et al., 2002; Ciechanowski et al., 2004; Quijano et al., 2007; Cernin and Lichtenberg, 2009). Third, there are problems with generalising results from the meta-analysis as the RCTs included older adults with mild to moderate depression, who were predominantly in their 60s and living independently in the community. Caution should be taken when generalising results to older adults with more severe depression and those in residential care settings. Additionally, three of the included studies recruited participants through non-traditional means such as media announcements and community yers (Thompson et al., 1987; Scogin et al., 1989; Rokke et al., 1999) and two of the studies did not require a formal diagnosis of major depressive disorder for inclusion of patients into the study (Scogin et al., 1989; Rokke et al., 1999). This is problematic as these study participants are not necessarily representative of those who normally access mental health services. Fourth, also with respect to the age of participants included in the RCTs and generalisability, our inclusion criteria species that older adults aged !55 years were eligible for inclusion when usually people !65 years of age are recognised as being older adults. This was done because if a threshold of !65 years of age was used as an inclusion criterion then none of the RCTs would have been eligible. The mean age of patients included in the eligible RCTs was between 66 and 68 and therefore most patients included in the meta-analysis were !65 years of age. In conclusion, this review has shown that behavioural therapy is potentially as effective as alternative
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Key Points
 Older adults are particularly vulnerable to

depression. Behavioural therapy for the treatment of depression is a relatively safe, simple and brief intervention which requires less intensive professional training and support compared to other psychological interventions.  Behavioural therapy in depressed older adults has comparable effectiveness with alternative psychotherapies in terms of patient self-reported depression symptoms.  Further research is recommended, however, in particular larger sample sizes are required, with more clarity on trial design and adaptation of the intervention for older adults, longer term followup, and concomitant economic evaluation.

psychotherapies. This concurs with evidence from other systematic reviews of the effectiveness of behavioural therapy mainly in adult populations which found that as a treatment for depression it has outcomes comparable to that of the current recommended psychological interventions (Cuijpers et al., 2007; Ekers et al., 2007). These ndings are of interest given that behavioural therapy is a relatively safe, simple and brief intervention which can be delivered by non-mental health professionals and thus potentially be more cost-effective. However, these ndings should be interpreted with caution as there is insufcient data from the eligible RCTs to answer with adequate certainty about whether behavioural therapy is more or less effective than alternative psychological approaches. Further research is recommended for which larger sample sizes are required, with more clarity on trial design and the adaptation of the intervention for older adults, longer term follow-up and economic evaluations alongside clinical trials.

Conflict of interest None declared.

References
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). American Psychiatric Association: Washington DC. Beck AT, Rush AJ, Shaw BF, Emery G. 1979. Cognitive Therapy of Depression. Guilford Press: New York. Beck AT, Ward C, Mendelson M, Mock J, Erbaugh J. 1961. An inventory for measuring depression. Arch Gen Psychiatr 4: 561571. Blazer DG. 2003. Depression in late life: review and commentary. J Gerontol 58: 249 265.

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