PSYC 636 Week 7 Treatment Paper: Final Submission Example

Treatment Paper Final Submission: A Stepped, Collaborative Treatment Plan for Depression in a Seventy-Six-Year-Old Widow

Abstract

Depression in later life is common, disabling and frequently missed, because it often appears as fatigue, poor sleep and physical complaints rather than sadness. This paper develops a treatment plan for Dorothy, a composite seventy-six-year-old widow living alone with moderate depression, arthritis and limited transportation. It reviews evidence on assessment with brief screening tools, on collaborative care in primary care settings, on psychotherapies adapted for older adults, especially problem-solving therapy, on maintenance treatment to prevent recurrence and on home-based programs delivered through aging services. It also considers religiously integrated cognitive behavioral therapy for clients whose faith is central to their lives. The resulting plan proceeds in three phases: assessment and engagement, active treatment coordinated by a care manager with problem-solving therapy and medication as indicated and maintenance with community and church supports. Each phase includes measurable goals, with symptoms tracked on a standard depression scale. The paper addresses barriers of stigma, cost and transportation and closes with a biblical perspective on suffering, relationship and hope in old age.

Introduction

Dorothy is seventy-six. Two years after her husband's death, she still lives by herself in the brick house in Lynchburg, Virginia, that she and her husband bought in 1974. Arthritis in both knees has made stairs difficult, and she stopped driving last winter after a near miss at an intersection. Her daughter, who lives in Ohio, noticed during their weekly calls that Dorothy no longer mentioned her garden or her Bible study group. Dorothy's physician, seeing her for knee pain, recorded that she was sleeping poorly and had lost eight pounds.

Whitbourne and Whitbourne (2017) describe depression as one of the most common mental health problems of later life and note that it is often underdiagnosed because its symptoms are mistaken for normal aging or for physical illness. Untreated, it worsens physical health, increases disability and raises the risk of suicide. Yet older adults respond to treatment, often as well as younger adults. This paper reviews the evidence on treating depression in later life and applies it to a phased plan for Dorothy.

Presentation and Assessment

Older adults with depression often say little about sadness and much about their bodies: fatigue, broken sleep, poor appetite and pain, together with a retreat from activities they once valued (Whitbourne & Whitbourne, 2017). Cognitive complaints are common and can make depression difficult to distinguish from early dementia. Losses typical of later life, including bereavement, declining health and reduced mobility, are risk factors, and Dorothy has experienced all three.

Bereavement complicates assessment. Grief after a spouse's death brings sadness, yearning and disrupted sleep that are normal and usually ease with time, and clinicians should not rush to treat ordinary mourning as illness. Dorothy's symptoms, however, have lasted for many months, have spread beyond her grief to a loss of interest in nearly everything she once enjoyed and are accompanied by weight loss and withdrawal from her church, a pattern that points to depression rather than grief alone. Asking whether her sadness centers on her husband or has become a general sense of worthlessness helps make the distinction.

Assessment begins with screening. The Geriatric Depression Scale, created for older adults by Yesavage et al. (1982), uses a simple yes or no format and leaves out somatic items that might reflect physical illness rather than mood. The scale and its short form remain widely used in primary care and community settings. A positive screen should be followed by a clinical interview to confirm the diagnosis, rule out medical causes such as thyroid disease or medication side effects and assess suicide risk directly. Because executive dysfunction affects treatment response, a brief cognitive screen is also useful. Kok and Reynolds (2017) recommend measurement-based care, in which symptoms are tracked with a standard scale throughout treatment so that a plan that is not working can be changed promptly.

Evidence for Treatment

Collaborative Care in Primary Care

Because a family physician, not a psychiatrist, is usually the only clinician a depressed older adult sees, the strongest evidence concerns care delivered in that office. In the IMPACT trial, 1,801 older primary care patients with depression were divided at random between their clinics' usual care and a collaborative model (Unützer et al., 2002). A depression care manager worked with each patient's physician and a consulting psychiatrist, offering education, support for antidepressant treatment or a brief course of problem-solving therapy and stepping up treatment when symptoms did not improve. A year later, the collaborative care group was more than twice as likely to have improved substantially, 45% against 19% with symptoms cut at least in half, and its members also reported better daily functioning and quality of life. Collaborative care is therefore the organizing framework of this plan. Its logic is stepped care: begin with the least intensive treatment the patient accepts, measure progress regularly and intensify treatment, adding therapy, changing medication or referring to specialty care, when symptoms do not respond. This approach suits older adults, many of whom prefer to start with counseling or are wary of medication.

Psychotherapy Adapted for Older Adults

Psychological treatments work for older adults. In a review of psychological interventions for depression in older age, Cuijpers et al. (2014) found that cognitive behavioral therapy, problem-solving therapy and life review therapy all reduced depressive symptoms, with effects comparable to those seen in younger adults. Problem-solving therapy deserves particular attention for clients with cognitive changes. A trial by Areán et al. (2010) tested this with 221 older adults whose depression came with measurable planning deficits, comparing twelve weekly sessions of problem-solving therapy against supportive therapy. The problem-solving sessions lowered symptoms further and produced more responders and more remissions. Because it teaches a concrete sequence, defining a problem, generating options, choosing one and evaluating the result, it can compensate for difficulties with planning that make other treatments harder to use.

Medication and Maintenance

Antidepressant medication is effective for many older adults, though side effects, drug interactions and slower response require careful prescribing (Kok & Reynolds, 2017). Preventing recurrence is equally important, since late-life depression tends to return. Reynolds et al. (2006) studied adults aged 70 and older who had responded to combined paroxetine and interpersonal psychotherapy and then randomly assigned them to continue the medication or switch to placebo, with or without monthly psychotherapy, for two years. Continued medication substantially reduced recurrence compared with placebo, while monthly psychotherapy alone did not significantly prevent it. For a client who responds to medication, continuing it after recovery is a reasonable recommendation.

Home-Based Care Through Aging Services

Some older adults cannot or will not attend clinic appointments. Ciechanowski et al. (2004) tested PEARLS, a program in which counselors from senior service agencies visited older adults with minor depression or dysthymia at home, using problem solving, planned pleasant activities and psychiatric consultation. At 12 months, 43% of participants had at least a 50% reduction in symptoms, compared with 15% of those receiving usual care. The program shows that agencies older adults already trust can deliver effective treatment.

Integrating Faith

Dorothy has attended the same Baptist church for forty years, and her faith shapes how she understands her losses. Koenig et al. (2015) compared religiously integrated cognitive behavioral therapy, which used patients' own religious beliefs, scriptures and practices to challenge unhelpful thoughts, with conventional cognitive behavioral therapy for 132 adults with major depression and chronic medical illness. Both treatments reduced depression to a similar degree, and the religious version appeared somewhat more effective for participants who were more religious. For Dorothy, a therapist might help her examine the thought "God has left me alone" in light of Scripture she already trusts, while also restoring the church relationships that depression has eroded. The therapist would not supply theology but would invite Dorothy to bring her own beliefs into the work, respecting her tradition and her pastor's role. If her pastor agrees, a brief conversation about how the church can support her, without disclosing clinical details she has not chosen to share, could strengthen the plan.

The Treatment Plan

Phase 1: Assessment and engagement, weeks 1 to 2. Dorothy's physician will administer the Geriatric Depression Scale and confirm the diagnosis through a clinical interview, review her medications, order basic laboratory tests and assess suicide risk directly. A brief cognitive screen will guide the choice of therapy. With Dorothy's permission, her daughter will be included by telephone. Goal: a confirmed diagnosis, a baseline symptom score and Dorothy's agreement to a plan she has helped choose.

Phase 2: Active treatment, weeks 3 to 16. Following the collaborative care model, a care manager in the primary care practice will contact Dorothy every one to two weeks, track her symptoms on a standard scale and consult with the physician and a psychiatrist. Dorothy will begin problem-solving therapy, in eight to twelve sessions, with a counselor from Horizon Behavioral Health, beginning by telephone and moving to in-person visits once transportation is arranged. Her first problems are likely to include getting to church and to appointments, reconnecting with her Bible study group and managing evenings alone. Should her scores stay in the moderate or severe range, or fail to fall within six to eight weeks, the physician will consider an antidepressant. If she prefers, religiously integrated techniques will be woven into therapy. Alongside problem solving, the counselor will schedule small, pleasant activities each week, such as calling a friend from her Bible study, sitting in her garden or attending a midweek church supper, since withdrawal from rewarding activity both reflects and deepens depression. The care manager will review her symptom score at every contact, and the physician, care manager and counselor will confer monthly about whether the plan needs to change. Goal: at least a 50% reduction in her symptom score by week 16, with improved sleep and return to at least one valued weekly activity.

Phase 3: Continuation and maintenance, months 4 to 12 and beyond. After response, the care manager will continue monthly contact for at least six months and then taper. If Dorothy takes medication and responds, she will be encouraged to continue it for at least a year, given evidence that maintenance prevents recurrence. Community supports from the resource map will sustain recovery: home-delivered meals and transportation through the Central Virginia Alliance for Community Living, the Friendship Line for evenings and her church's visitation ministry. Goal: remission sustained at 12 months, with a written relapse prevention plan listing early warning signs and whom to call, including the 988 Suicide and Crisis Lifeline.

Barriers and Considerations

Three barriers are likely. First, stigma: Dorothy may see depression as weakness or spiritual failure, so the plan frames treatment as care for grief and health, uses her language and offers faith-integrated approaches. Second, cost: Medicare covers depression screening and outpatient mental health services, and a free insurance counselor can help with prescription coverage. Third, transportation: telephone sessions, home visits and volunteer drivers address her inability to drive. Her arthritis and possible cognitive changes also call for shorter sessions, written summaries and coordination with her physician about pain, which can worsen mood. Generational values matter as well. Many adults of Dorothy's age were raised to keep private troubles within the family and to avoid burdening others, so the counselor should respect her pace, emphasize her strengths and present help-seeking as good stewardship of the years she still has.

A Biblical Perspective

Scripture does not treat sorrow in old age as unspiritual. The psalmist asks God not to forsake him when he is old and gray, until he has proclaimed God's power to the next generation (English Standard Version Bible, 2001/2016, Psalm 71:18). That prayer joins honest need with continued purpose, two themes central to Dorothy's recovery. Her plan seeks relief from symptoms, but also restored relationships and a renewed sense that her life still has work to do, whether teaching a grandchild or praying with a homebound friend. Christian care for the depressed older adult therefore holds together competent treatment and faithful presence. Medication and therapy are not substitutes for the church's love, and the church's love is not a substitute for treatment.

Conclusion

Depression in later life is treatable, and the evidence points to a coordinated approach. Collaborative care in primary care, problem-solving therapy adapted for executive dysfunction, maintenance treatment after recovery and home-based programs through aging services each address part of the problem. For Dorothy, a phased plan with measurable goals, built on these findings and on the community and church resources around her, offers a realistic path from isolation and despair toward recovery and continued purpose. The plan's success will be measured not only by a lower score on a depression scale but by whether Dorothy is back in her pew, back in her garden and back on the telephone with the friends who have missed her.

References

Areán, P. A., Raue, P., Mackin, R. S., Kanellopoulos, D., McCulloch, C., & Alexopoulos, G. S. (2010). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. American Journal of Psychiatry, 167(11), 1391-1398. https://doi.org/10.1176/appi.ajp.2010.09091327

Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., Kulzer, J., Gray, S., Collier, C., & LoGerfo, J. (2004). Community-integrated home-based depression treatment in older adults: A randomized controlled trial. JAMA, 291(13), 1569-1577. https://doi.org/10.1001/jama.291.13.1569

Cuijpers, P., Karyotaki, E., Pot, A. M., Park, M., & Reynolds, C. F. (2014). Managing depression in older age: Psychological interventions. Maturitas, 79(2), 160-169. https://doi.org/10.1016/j.maturitas.2014.05.027

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Koenig, H. G., Pearce, M. J., Nelson, B., Shaw, S. F., Robins, C. J., Daher, N. S., Cohen, H. J., Berk, L. S., Bellinger, D. L., Pargament, K. I., Rosmarin, D. H., Vasegh, S., Kristeller, J., Juthani, N., Nies, D., & King, M. B. (2015). Religious vs. conventional cognitive behavioral therapy for major depression in persons with chronic medical illness: A pilot randomized trial. Journal of Nervous and Mental Disease, 203(4), 243-251. https://doi.org/10.1097/NMD.0000000000000273

Kok, R. M., & Reynolds, C. F. (2017). Management of depression in older adults: A review. JAMA, 317(20), 2114-2122. https://doi.org/10.1001/jama.2017.5706

Reynolds, C. F., Dew, M. A., Pollock, B. G., Mulsant, B. H., Frank, E., Miller, M. D., Houck, P. R., Mazumdar, S., Butters, M. A., Stack, J. A., Schlernitzauer, M. A., Whyte, E. M., Gildengers, A., Karp, J., Lenze, E., Szanto, K., Bensasi, S., & Kupfer, D. J. (2006). Maintenance treatment of major depression in old age. New England Journal of Medicine, 354(11), 1130-1138. https://doi.org/10.1056/NEJMoa052619

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836

Whitbourne, S. K., & Whitbourne, S. B. (2017). Adult development and aging: Biopsychosocial perspectives (6th ed.). Wiley.

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. https://doi.org/10.1016/0022-3956(82)90033-4