Aspects of Mental Health and Aging
Pages 45–52
By Amanda Leggett and Steven H. Zarit
Prevention of Mental Disorders in
Older Adults: Recent Innovations
and Future Directions
As the world’s population of older adults rapidly
increases, more and more in this cohort will seek
mental health care. Prevention is a promising approach
to lower overall disease burden.
I
n the field of mental health, prevention efforts
have the ability to decrease healthcare costs,
reduce mental illness incidence, and enhance
individuals’ well-being and functioning. The
National Institute of Mental Health (NIMH)
lists in its Strategic Objective 2.3 the goal “to
develop and test novel interventions that are
targeted at pre-symptomatic or prodromal stages
of illness, [and] are designed to preempt syndrome development . . .” (NIMH, 2014). In some
disciplines such as public health, prevention
programs have been widely discussed and
implemented, but innovations for preventing
mental disorders lag behind, particularly for
older adults, where the focus has been on
sickness, disability, and disease treatment.
Traditionally, preventive efforts have focused
on children and adolescents to promote positive health trajectories early in life (National Research Council and Institute of Medicine, 2009).
However, mental health problems are common
in older adults and associated with risk and protective factors that differ from those active in
early life. Some factors, such as education and
early-life socioeconomic advantage, cannot be
modified in late life; however, more salient
late-life factors, such as social support, sleep
disturbance, and activity levels, are malleable
in the later years.
As the global population of older adults
expands, an increasingly large number will seek
mental health care. We also know that current
treatments are only partly successful. For example, approximately 20 percent to 30 percent
of a person’s years lived with disability due to
depression can be avoided by using existing
treatments, and treatments do not prevent the
full burden of anxiety disorders (Andrews et al.,
2004). Prevention efforts to stop mental health
problems before they start is a promising approach to lower overall disease burden.
This article presents encouraging findings
from existing preventive interventions in
pharmacotherapy, psychotherapy, and psychosocial efforts. Much of this work addresses
depressive and anxiety disorders, and interrelated areas of health, such as sleeping patterns.
We conclude by providing suggestions for
future directions of research and practice in
geriatric mental health prevention.
Copyright © 2014 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Fall 2014 • Vol. 38 . No. 3 | 45
GE NER ATIO NS – Journal of the American Society on Aging
Pages 45–52
First, we will review prevention terminology.
As opposed to treatment, prevention targets
individuals before the development of a disorder.
Gordon (1983) labeled preventive interventions
as universal, selected, and indicated, depending upon risk level of the targeted population.
Indicated interventions focus on individuals
who already show preliminary signs or subsyndromal symptoms of a disorder, but not severe
enough for diagnosis; selected interventions
target those at high risk; and, universal programs
are aimed at an entire population. The Institute
of Medicine adopted Gordon’s terminology and
added a category of more general mental health
promotion (National Research Council and Institute of Medicine, 2009). We highlight some
recent preventive interventions that fall into
each of these categories, starting in the domain
of pharmacological prevention.
management sessions for two years, or until
a new major depressive disorder episode.
Individuals who received two years of paroxetine were less likely to develop a new episode
of major depressive disorder. Adjusting for the
psychotherapy effect, individuals receiving the
placebo had a 2.4 times greater relative risk of
recurrence than individuals on paroxetine.
Robinson and colleagues (2008) assigned
three randomized groups of adults, ages 50 to
90, who had suffered a stroke in the past three
months, to escitalopram (brand name: Lexapro),
problem-solving therapy, or placebo in a twelvemonth trial. In that time period, 22.4 percent of
individuals on a placebo developed depression,
compared to only 8.5 percent of individuals
taking escitalopram and 11.9 percent of individuals receiving problem-solving therapy. At six
months following escitalopram discontinuation,
participants who had received escitalopram
Pharmacological Prevention
exhibited significantly worse levels of depressive
Positive effects of antidepressants for the
symptoms than the problem-solving therapy or
treatment of depression are well-documented,
placebo group (Mikami et al., 2011). In other
even among the oldest old (Trappler and Cohen, work, Fournier and colleagues (2010) found the
1998). While the majority of older adults recover benefit of an antidepressant over a placebo rose
from depression, many will relapse, but current
with increasing severity of depression. The
or prior antidepressant use has been associated
antidepressant had only a small effect for individwith a better prognosis (Denihan et al., 2000).
uals with none to moderate symptoms, suggestProphylactic antidepressant use has been trialled ing greater use for treatment than prevention.
primarily for treatment maintenance and relapse
These results show that antidepressants may
prevention in older adults recently recovered
have some preventive benefit for relapse of defrom a major depressive disorder episode.
pression in older adults, but results are mixed.
There are also ethical concerns
regarding prescription of
Mental health problems are common in older
antidepressants or other
adults, and associated with risk and protective
medications to individuals
factors that differ from those found earlier in life. without a diagnosed disorder.
Medications such as antideReynolds et al. (2006) examined adults ages
pressants and benzodiazepines (brand names:
70 and older with major depressive disorder
Valium, Zanax, Halcion, etc.) tend to be less
who responded to combined psychotherapy
effective for mild symptoms, are associated with
and paroxetine (brand name: Paxil) treatment.
a number of side effects (e.g., fall risk, cognitive
Patients were randomized into four groups reimpairment), add to a potential medication
ceiving paroxetine or a placebo, combined with
cascade effect in elders, and many older adults
either interpersonal psychotherapy or clinicalprefer non-pharmacological treatment (Fournier
46 | Fall 2014 • Vol. 38 . No. 3
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
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Aspects of Mental Health and Aging
Pages 45–52
et al., 2010; Gum et al., 2006; Landi et al., 2005;
Verdoux, Lagnaoui, and Begaud, 2005). While
pharmacotherapy may be called for in some
high-risk cases, or where it is helpful for individuals who had past depressive episodes, it
should not be the initial choice for primary
prevention efforts.
Psychological Intervention
Baby boomers are high users of psychotherapy
and thus demand may grow for non-pharmacological prevention. Few researchers have considered psychotherapy as a preventive intervention
compared to treatment, however, several studies
show promising results (see Lee et al., 2012, for a
review). Below, we discuss a few recent efforts
predominantly focusing on cognitive behavioral
therapy and problem-solving therapy.
questionnaire in which participants are asked to
answer yes or no questions in reference to how
they felt over the past week) (Yesavage et al.,
1982) declined significantly over time (baseline to
six months post-treatment) and were significantly better in comparison with the control group.
Over the six months of treatment and
follow-up, no participants in the Coping with
Stress course developed major depressive disorder (out of n=20), while two participants in
the control group did (out of n=23). However,
the intervention group did not differ significantly
from the control group on two other depression symptom scales (The Center for Epidemiologic Studies Depression Scale and Dysfunctional
Attitudes Scale for Medically Ill Elders) (Koenig
et al., 1994; Radloff, 1977).
Problem-solving therapy
Problem-solving therapy is a behavioral approach
Cognitive behavioral therapy
that aims to reduce depression by targeting inMost psychotherapy studies use a cognitive
accurate problem appraisals and teaching skills
behavioral framework, which targets dysfuncto solve these problems adaptively. Rovner and
tional thoughts and levels of activity, aiming to
restructure one’s thoughts and ultimately change colleagues (Rovner et al., 2007; Rovner and
Casten, 2008) employed a problem-solving therabehavior. The most commonly used form is
py selective intervention (six hour-long sessions
Lewinsohn’s “Coping with Depression” course,
which is a psycho-educational form of cognitive across eight weeks) that targeted individuals
with macular degeneration. Given that macular
behavior therapy (Lewinsohn et al., 1984). A
degeneration would modify an individual’s
therapist serves as instructor for a group of
capability to perform some activities, problemparticipants, teaching useful skills to manage
solving therapy presents a creative behavioral
depressive feelings such as scheduling and
completing pleasant activities, developing social solution to address these visual challenges and
potentially prevent depression.
skills, relaxation, and techniques for restrucAt two months, the experimental group had
turing one’s maladaptive thought processing.
half the incidence rate of depression compared
Konnert, Dobson, and Stelmach (2009)
trialled an adapted version of this course, geared to the control group (11.6 percent versus 23.2
percent). The researchers did not find differspecifically for prevention and called “Coping
with Stress,” in nursing home residents (thirteen ences in incidence at six months; however,
activities were better maintained in the experisessions over seven weeks). The course was
mental group. This intervention may be effecmodified to provide relevant examples and
tive in older adults with other chronic diseases
pleasant events that would be appropriate for
older adults in nursing homes. Participants were where both depression and disability are
common. Taken together, with findings from
assisted, where needed, to write in their treatRobinson and colleagues (2008) problem-solving
ment manuals and to get to the sessions. Scores
therapy and escitalopram comparison, results
on the Geriatric Depression Scale (a thirty-item
Copyright © 2014 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
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Fall 2014 • Vol. 38 . No. 3 | 47
GE NER ATIO NS – Journal of the American Society on Aging
Pages 45–52
als’ symptoms spontaneously remit without
treatment. If significant symptoms lasted after an
initial three months, participants were randomized to either a usual care control group or
cognitive-behavioral therapy bibliotherapy (a
self-help book version of the Coping with
Innovative and multi-component
Depression course) intervention. A nurse first
psychotherapy approaches
Internet-based Interventions. In a three-group visited to provide information about anxiety and
depression and basic advice on coping skills. In
randomized control trial, Spek et al. (2008)
a second visit, the Coping with Depression (and
compared group participants in the ten-week
Anxiety) course was provided and the nurse
Coping with Depression course and an eightmade several follow-up visits or calls to monitor
session Internet-based, cognitive-behavioral
therapy self-help intervention with individuals in progress. If participants were still symptomatic
three months later, they would progress to a
a wait-list control. Participants were adults ages
seven-session problem-solving therapy.
50 and older, with sub-threshold symptoms of
Finally, symptomatic participants at three
depression. While both interventions had a large
improvement effect size, the differences between months later would be referred to their primary
the Coping with Depression course group and the care physician for antidepressant treatment. At
wait-list control were negligible. While 62 percent the end of any period, if participants’ symptom
of individuals in the Internet cognitive-behavioral scores were below threshold, they would enter or
remain in a watchful waiting period. The twelveintervention were below the threshold indicator
for depression on the Beck Depression Inventory month incidence of anxiety and depressive disorders was 0.12 in the stepped-care group and
(a self-report scale that measures symptoms of
0.24 in the control group. Participants in this
depression) (Beck, Steer, and Brown, 1996), only
45 percent of the Coping with Depression course study were ages 75 and older, suggesting that
a stepped-care intervention was tolerable for
and 38 percent of the wait-list participants were
individuals in late-life and primary care was an
below threshold one year following initiation of
effective setting for recruitment and intervention.
treatment. This reflects the natural course of
Sleep Problems Prevention. Sleep disturimprovement over time as well as the potential
bance and mood are strongly associated, and as
efficacy and desirability of Internet-based
circadian rhythms and sleep patterns change
interventions.
with age, these associations are pivotal in older
Stepped Care. Van’t Veer-Tazelaar and
adults (Buysse, 2004). Targeting the treatment
colleagues (2009) provide an example of a
stepped-care program for older adults in primary of late-life insomnia, Germain and colleagues
(2006) conducted a Brief Behavioral Treatment
care that reduced the odds of developing an
of Insomnia intervention, including one fortyanxiety or depressive disorder by more than
five minute session and a short booster session
half and showed long-term effects. Steppedcare interventions start with no intervention but two weeks later.
The Brief Behavioral Treatment includes
progress to more involved interventions if an
education about sleep regulation, what influindividual is not improving. This method aims
ences sleep, and behaviors that can inhibit or
to make the best use of clinical and economical
promote sleep. In particular, participants were
resources by only giving intervention as needed.
Van’t Veer-Tazelaar and colleagues’ stepped-care asked to follow four instructions for the fourweek intervention: spend only the amount of
program consists of four three-month periods,
starting with watchful waiting as many individu- time in bed one expects to sleep; wake up at the
suggest that problem-solving therapy provided
over only a few weeks may have long-term
effects in preventing depression, particularly
in individuals with a medical comorbidity.
48 | Fall 2014 • Vol. 38 . No. 3
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distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Pages 45–52
Aspects of Mental Health and Aging
same time each day; only go to bed when sleepy; video on aging successfully, or an intervention
and get out of bed if not sleeping. Individuals
called “Looking for Meaning,” which consisted
with “unstable” or untreated psychiatric diagno- of twelve, two-hour sessions in which particises were excluded from the study, and so the
pants performed various life-review activities
mean Hamilton Rating Scale for Depression and (discussing life experiences, sensory recall, or
Anxiety (Hamilton, 1959, 1960) scores at baseline other creative activities) on various topics such
were well below accepted cut scores. Compared as former dwellings or smells from the past.
to a control group, participants receiving the
Pot et al. reported a significant improvement in
Brief Behavioral Treatment of Insomnia
intervention improved in their number
While pharmacotherapy may be called for in
of nighttime awakenings after falling
some high-risk cases, it should not be the
asleep; sleep latency, quality, and
efficiency; and, in symptoms of anxiety
initial choice for primary prevention efforts.
and depression. More research is needed
to see whether sleep interventions can reduce
depression scores in the intervention compared
incidence of mental health disorders or be
to the control group, which translated into a
useful in multi-component interventions.
large-effect size for the between group difference in pre- and post-assessment (Δd=0.58).
Other Prevention Programs
Both the intervention and control groups
Other prevention programs, such as psychosodeclined in anxiety, so there was not a significant
cial or exercise interventions, are less standardbetween-group change-effect. A meta-analysis
ized than pharmacotherapy and psychotherapy
found similar effects of reminiscence and
interventions, yet have an opportunity to address life-review programs in reducing depressive
specific risk factors in a way that may be more
symptoms in individuals with mild to moderate
tolerable and less stigmatizing to older adults.
symptomatology (d=0.37) (Bohlmeijer, Smit, and
Most psychosocial studies are targeting mental
Cuijpers, 2003).
health promotion in samples of communitydwelling older adults, as opposed to indicated
Exercise
or selective prevention for a specific disorder.
While physical exercise long has been associated
These programs provide some promising efforts with improvements in mood, few interventions
that may be replicated, modified, or incorpohave focused on prevention and promotion, as
rated in a multifaceted way in indicated or
opposed to treatment of clinical disorders. Baker
selected randomized control trials. We consiet al. (2007) randomly assigned retirement
der some recent and promising examples (see
community residents having none to mild
Forsman, Schierenbeck, and Wahlbeck, 2011, for depressive symptoms to a ten-week exercise
further review).
program (approximately one-hour sessions,
three days a week) of high-intensity resistance
Reminiscence
training, moderate-intensity aerobic training,
Pot and colleagues (2010) trialled an indicated
and balance training, or, alternately, to a wait-list
preventive intervention of “life review.” Particicontrol group. Since depressive symptoms were
pants ranged from ages 50 to 90 and had subalready low, there were no significant differences
syndromal symptoms (symptoms that are not
between treatment and control groups, but parsevere enough for an actual depression diagnoticipants who had more depressive symptoms
sis) of depression. Participants were randomized at baseline improved most. Rosenberg et al.
to a control group that watched an educational
(2010) examined a twelve-week Nintendo Wii
Copyright © 2014 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
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Fall 2014 • Vol. 38 . No. 3 | 49
GE NER ATIO NS – Journal of the American Society on Aging
Pages 45–52
Sports “exergame” intervention in older adults
with sub-syndromal depression (three thirtyfive-minute sessions a week; no control group).
Participants’ depressive symptoms significantly
declined with the reduction maintained at a
twenty-four-week follow-up and 37 percent
of participants’ symptom scores declined by
50 percent or more. Anxiety scores declined
across the intervention, but not significantly.
or no symptoms at the initial time point, it is
difficult to detect effects over the short term,
and given the uncertain risk of increased depression or anxiety in samples, it would be
necessary to have a very large sample to detect
differences in new cases of clinical disorders
or even increases in sub-syndromal symptoms.
Thus, indicated trials targeting specific risk and
protective factors in older adults with beginning signs of disorders may be
most effective. Besides the
The biological underpinnings of mental disorders need for more selective and
are only beginning to be understood.
indicated prevention trials in
geriatric mental health, other
These studies highlight the opportunity, yet
new directions for innovation in research and
also the paucity and lack of development, in
practice may be proposed.
prevention studies. Many of the described
It is important to take into account the
prevention studies only discussed improvement disabilities, mobility, and cognitive capabilities,
in symptoms or a comparison between an inter- in addition to the resiliencies, wisdom, and
vention and control group over time. When symp- strengths of the older population in preventive
toms are low or absent, however, the goal cannot designs. In line with the growth of patientbe to reduce depression or anxiety, but rather to centered outcomes research, new initiatives
demonstrate reduced risk or lower incidence of
that consider specific preferences and needs of
new disorder over time.
older adults relating to mental health care may
be particularly beneficial to prevention work.
Conclusion and Future Directions
To further increase participation, it might be
The above studies provide an overview of the
helpful to work through primary care physipotential for prevention and also challenges and cians, or through social services used by older
limitations of this work. Pharmacotherapy has
adults with depressive or anxiety symptoms,
shown efficacy in preventing the recurrence of
and consider how programs can reach rural
depression, yet antidepressants and benzodiazelders or those who cannot pay for mental
epines are associated with a number of negative health services.
side effects for older adults. Psychotherapy has
Innovations in technology may help to reach
been shown to reduce the incidence of depresolder adults with mobility, transportation, or
sive and anxiety disorders; but therapy sessions
economic difficulties. Internet-based prevention
are lengthy and may require older adults to
programs have a number of benefits in that there
travel to a therapist. Finally, psychosocial
is no need for appointment scheduling and
prevention has shown success in promoting
travel, they allow individuals to work at their
mental health, however, more indicated and
own pace, they may be shared globally, are
selective studies are needed to show whether
inexpensive, and are reusable (in contrast to
psychosocial prevention can reduce incidence
a therapist’s time—or a pill). Interventions
of disorder in at-risk individuals.
powered through mobile phones, tablet computThe greatest challenge with selected and
ers, or applications such as Skype may be a parindicative prevention trials is the need for an
ticularly fertile area for growth (Muñoz et al.,
adequate follow-up period. If everyone has low 2010). However, as Internet programs do not
50 | Fall 2014 • Vol. 38 . No. 3
Copyright © 2014 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: [email protected]. For information about ASA’s publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Aspects of Mental Health and Aging
Pages 45–52
offer crisis assistance, the ethics of these interventions must be considered (Reynolds, 2009).
A best-case scenario for prevention research
would be the ability to target the etiology of
mental disorder. The biological underpinnings
of disorders are beginning to be understood. For
example, the stress hormone cortisol has been
associated with depression and melatonin levels
are related to insomnia (Burke et al., 2005; Wade
et al., 2007). With increasing knowledge, biomarkers may help better target individuals for
prevention so resources are not used on individuals who, while at risk, are not likely to
develop a disorder. Ultimately, biomarkers may
help individualize programs and make them
more efficient, and might be measured when
assessing response to an intervention.
In conclusion, the prevention of geriatric
mental disorders is a field laden with challenges,
yet ripe for growth, holding potential for great
health and economic payoffs. This brief overview of the domains of geriatric prevention can
provide clinicians with strategies for helping
older adults at risk for disorders, and with examples of successful interventions from which
researchers can build new ideas and trials. Disorders can be stopped before they begin and,
as our population ages, prevention work promises to have increasing salience.
Amanda Leggett, Ph.D., is a National Institute of
Mental Health Geriatric Mental Health Services
postdoctoral research fellow in the Department of
Psychiatry, at the University of Michigan Medical
School in Ann Arbor, Michigan. Steven H. Zarit, Ph.D., is
distinguished professor, and head of the Department of
Human Development and Family Studies, at Pennsylvania State University, in University Park, Pennsylvania.
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