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March 18, 2020

The Age of Depression and Its Treatments

Author Affiliations
  • 1Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
JAMA Psychiatry. 2020;77(7):667-668. doi:10.1001/jamapsychiatry.2020.0158

Depression is a serious and common mental health problem. Although a number of psychological and pharmacological treatments are available for this serious psychiatric condition, there is still a lot of room for improvement. As is true for virtually all mental disorders, the most common and comparatively most effective form of psychological treatment for depression is cognitive behavioral therapy (CBT).1

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2 Comments for this article
Th age of depression
Carolyn Quadrio, MD | School of Psychiatry, University of New South Wales, Australia
Your commentary on depression in children did not address the issue of family and social context. Treating children as individuals is rarely helpful to the child. They are not yet functioning as individuals but as part of a family or other group system. Often they are presenting as identified patients, meaning their difficulties are symptomatic of systemic issues, something like referred pain, they are the symptom not the source. Some 15-30% of them are suffering abuse, which they are unlikely to disclose; to continue treating their anxiety or their depression in such contexts is futile. Other contexts like parental mental health problems, parental substance abuse, and family violence may not be disclosed, and then there is the wider context of poverty and disadvantage in which so many children live. Finally, many older children are suffering an existential angst as they witness the helplessness or the unwillingness of the adult world to come together and deal with the many threats to survival that the world faces.

A/Prof Carolyn Quadrio
The older ages of depression
Susan-Mary Benbow, FRCPsych | Centre for Ageing Studies, University of Chester, UK
The age of depression and its treatments (1) highlights differences in depression associated with younger age/ children. What about older adults? We note that only 10 of the 366 trials included in Cuijpers et al’s meta-analysis of psychotherapies in depression examined “older old” adults (fewer than the number focused on children) and that “older adults” (deemed to be aged 55-74) accounted for only 58 trials (2). In accounting for age differences, Hoffman posits the hypothesis that “it is quite possible that we are dealing with different disorders.” It is well recognized that depression in older people has different biopsychosocial determinants and treatment responses, not the least including a risk benefit ratio and rate of physical comorbidities that favour the use of psychotherapies over pharmacotherapy for all but severe depression.

Yet, depression in older people is underdiagnosed, undertreated and attracts therapeutic nihilism, particularly with regard to psychological treatments, which are underexplored and under- accessed in older age groups. 3 This is despite the efficacy of psychotherapies in older people (3) A particular type of psychotherapy that is underutilised in older groups is family and systems therapy. Just as the family and social context is important for children, it is equally important for older people who may be subject to a range of social inequalities and relational challenges. Carr (4) has reviewed the evidence base for the effectiveness of systemic interventions, either alone or as part of multimodal programmes, in adults, and concludes that the evidence supports systemic interventions for a range of relational and mental health problems including mood disorders. As evidenced by Cuijpers et al, older adults are still likely to be excluded from psychotherapy research, so it is not surprising that we need to advocate for access to and empirical investigation of psychotherapies for older people.

1. Hofmann SG. The Age of Depression and Its Treatments. JAMA Psychiatry 2020;77:667-68. doi: 10.1001/jamapsychiatry.2020.0158
2. Cuijpers P, Karyotaki E, Eckshtain D, et al. Psychotherapy for Depression Across Different Age Groups: A Systematic Review and Meta-analysis. JAMA Psychiatry 2020;77:694-702. doi: 10.1001/jamapsychiatry.2020.0164
3. housing21. Westminster Dementia Adviser Service. Interim Review Report: Executive Summary 2011 [Available from: http://www.housing21.co.uk/files/5213/0072/0785/Westminster%20Dementia%20Adviser%20Service%20Review%20Report.pdf accessed 4 June 2013.
4. Carr A. Couple therapy, family therapy and systemic interventions for adult-focused problems: the current evidence base. Journal of Family Therapy 2018;41(4):492–536. doi: 10.1111/1467-6427.12225

Susan Mary Benbow, Centre for Ageing Studies, University of Chester, UK, and Older Mind Matters Ltd, UK

Carmelle Peisah, University of New South Wales, Australia, University of Sydney, Australia
CONFLICT OF INTEREST: SMB is a UKCP-registered family and systemic psychotherapist