REVIEW OF: Werson AD et al, J Affect Disord 2022;319:189–201
STUDY TYPE: Meta-analysis

Older adults receive less psychological treatment than any other age group. Some of that gap reflects practical barriers, but some of it reflects a clinical assumption that talk therapy is less effective in late life. Werson and colleagues examined that assumption in their meta-analysis.

They pooled data from 37 RCTs comparing cognitive behavioral therapy (CBT) to medication, other psychotherapies, waitlist, treatment as usual, delayed treatment, and placebo for depression. Twenty-five studies enrolled adults aged 18–65 (n = 2,948), and 12 studies enrolled older adults aged 60 and up (n = 551). The primary outcome was post-treatment depression severity, measured with self-report instruments like the Beck Depression Inventory or clinician-rated scales like the Hamilton Depression Rating Scale.

Older adults responded to CBT just as well as younger adults. The effect sizes were virtually identical (0.49 for adults and 0.45 for older adults), a difference that was not statistically significant. This held whether CBT was compared to active treatments (other psychotherapies, medication) or to passive controls (waitlist, treatment as usual). Against active comparators, CBT showed a small advantage with no age difference. Against passive controls, CBT’s advantage was predictably larger, but still equivalent across age.

The study had two caveats. The older adult studies were generally smaller, which limits precision. Also, the mean age in the older adult studies was 67.5, which is relatively young for a geriatric sample; we need more trials recruiting the oldest old (85+), who face greater medical comorbidity and functional limitations.

CARLAT TAKE
You can prescribe CBT for older adults with depression using the same approach as for younger patients. The evidence supports equivalent efficacy across age groups, with no need to lower expectations or dilute the protocol.