Life review therapy is an effective intervention for adults aged 55 and older with depressive symptoms, a Dutch pragmatic randomised controlled trial has found.

Participants aged 55 and above were recruited through media advertisements and information booklets available in healthcare settings. Those with a CES-D score

≥ 10 were eligible for randomisation to life review therapy (n=100) or care as usual (n=102). Applicants were excluded if they had severe depression, had recently commenced antidepressants or were receiving other psychological treatment.

Life review therapy was provided to small groups of participants and consisted of eight 2-hour sessions.

At three-month follow-up, the mean CES-D score had fallen by 5.2 in the treatment group and by 0.2 in the control group (difference = -5.0, p < 0.001). There was a moderate effect size (d = 0.5). The odds of a clinically significant improvement (reduction in CES-D score of at least 5 while crossing the CES-D cut-off of 16) were significantly higher in the treatment group, OR 3.76 (95% CI: 1.45-9.72, p< 0.001).

It is natural for older people to reflect on, and construct narratives, about their lives. If they describe themselves as being in control, overcoming challenges, finding a positive dimension to traumatic experiences in life and achieving a sense of purpose and identity, they are likely to be content.

Conversely, if they see themselves as passive victims who have been prevented from achieving their life goals by a series of negative experiences, they are at risk of depression. Moreover, depressed patients are more likely to evaluate their lives in a negative way, which in turn will make them more depressed, creating a negative feedback cycle.

Life review therapy aims to break this cycle by encouraging patients to consider alternative narratives which increase their sense of self-mastery, integrate difficult life events in a more constructive way and focus on positive experiences.1

The study protocol was designed to identify participants with subthreshold depressive symptoms rather than major depression. Subthreshold depressive symptoms are common in the elderly and are associated with reduced quality of life, impaired functioning and increased mortality.2

Furthermore, recognition and treatment is advocated in order to prevent future progression to major depression. However, as only 8% of patients develop major depression within two years,3 the number needed to treat to prevent one case of major depression will be high.

NICE recommends a low-intensity psychosocial intervention for patients with persistent subthreshold symptoms (>2-3 months). Life review therapy would seem to be an attractive option for older patients, but the positive findings of the present study should be treated with caution.

First, the participants in this study were recruited by advertisement and may therefore have been more highly motivated and more likely to respond to therapy than patients presenting in a primary care setting.

Second, comparison with usual care does not control for non-specific benefits of group participation, so we do not know what proportion, if any, of the response to treatment was due to the specific intervention.

Finally, there is a problem of publication bias among trials of psychotherapy for adult depression.4

GPs are primarily diagnosticians, not therapists. The diagnosis of depression is complex and should incorporate an assessment of cognition as well as the number and severity of symptoms and the degree of functional impairment.

Depressed patients have negative, unhelpful thoughts about themselves, their current experiences and the future: Beck’s cognitive triad.⁵

I suggest that for older patients we should add a fourth category i.e. negative evaluation of their past life.

I find that the use of genograms is an effective way of placing the presenting problem within a historical and family context, and encouraging patients to tell stories about their lives.