Helen, a 77-year-old woman with depression, mild osteoarthritis, and hypertension, is here for a medication check-in. Since her husband died two years ago, she says she has “nothing to look forward to.” She sleeps all day and skips family visits and day trips. She isn’t interested in more medication, saying, “I hate seeing that pile of pills.” Her score on the 15-item Geriatric Depression Scale (GDS) is 9, indicating moderate depression.

Keeping it brief
Older adults respond well to psychotherapy, but most can’t access it. Barriers include getting to an office on a weekly basis for months, cognitive fog, sensory impairments that make fine print and paperwork difficult, and the scarcity of therapists trained to work with older adults.

Brief behavioral interventions (BBIs) are a middle ground between supportive listening and formal psychotherapy. They are structured, but short enough that you can fit them into a standard 30-minute medication-management appointment. When the therapeutic work is timed and documented separately from the medication review, the encounter can be billed as an E/M service plus a psychotherapy add-on on the same day. Even a single session helps with depression and anxiety, though the strongest evidence supports a course of 8–12 weekly sessions (Bannon SM et al, Front Public Health 2025;13:1515440). There are three approaches with the best evidence and adaptability for older adults:

• Motivational interviewing (MI)
• Behavioral activation (BA)
• Problem-solving therapy (PST)

For more on each one, see the table “Three Brief Manualized Evidence-Based Therapies to Use With Older Adults” on page 3.

From the Clinical Update
“Brief Behavioral Interventions for Older Adults”
by Kathryn Kieran, MSN, PMHNP-BC
The Carlat Geriatric Psychiatry Report, Volume 5, Number 7 & 8
October/November/December 2026
www.thecarlatreport.com

Motivational interviewing
MI is a collaborative, goal-oriented communication style that elicits a patient’s own motivations for change. Anticipate resistance and regulate your own reaction so a stuck patient doesn’t get a lecture.

The four processes:

1. Engaging: Building trust and rapport
2. Focusing: Setting a specific behavioral goal
3. Evoking: Drawing out the patient’s rationale for change
4. Planning: Translating motivation into small, concrete steps

MI centers on autonomy. Patients set the agenda, and you collaborate and offer expertise. For older adults who may have spent decades feeling talked at by clinicians, that shift can be powerful.

When and how to use it
MI fits naturally into a medication check. When a patient expresses reluctance about doing anything differently, ask, “What would need to change for you to feel better?” or “What matters most to you right now?” These open-ended questions often raise value conflicts that a medication-focused visit would miss.

A brief action plan (BAP) takes under five minutes. Ask the patient to commit to one small, concrete step before the next visit, like walking to the mailbox and back after breakfast on Monday, Wednesday, and Friday. Then ask how confident they are they can do it, from 0 to 10. A low number is a signal to scale back the plan until the patient’s confidence rises, and to troubleshoot whatever obstacle they name.

You use MI to help Helen work through her mixed feelings about re-engaging. She identifies cooking for others and her old book club as things she misses. You focus on one activity before the next visit: inviting a book club friend for dinner. She’d like to make a three-course meal, but you agree the main goal is company and conversation, and she accepts a plan to get takeout. You give her a simplified mood-activity log, plan to recheck her GDS, and schedule follow-up in three weeks.

Behavioral activation
BA targets the cycle that sustains depression: less activity → lower mood → less activity. Breaking that cycle by scheduling meaningful activity is the whole intervention, and it holds up as a stand-alone treatment. A meta-analysis of 18 randomized trials found that BA meaningfully reduces depressive symptoms in older adults living independently (Orgeta V et al, Br J Psychiatry 2017;211(5):274–279).

BA doesn’t take long or require highly specialized skills. One modified program delivered by bachelor’s-level interventionists over six weekly sessions improved loneliness, depressive symptoms, and social connectedness in homebound older adults receiving home-delivered meals (Pepin R et al, Am J Geriatr Psychiatry 2021;29(8):761–770).

When and how to use it
A structured BA course moves through phases:

• Psychoeducation about the mood-activity connection
• Activity monitoring to establish a baseline
• Identifying values and goals
• Scheduling specific activities
• Graded task assignment to build from small wins
• Problem-solving obstacles
• Ongoing review

You don’t need every element every time. Help your patient connect mood to activity and identify one small thing to try (similar to the BAP technique in MI). That alone can help some people improve.

To adapt BA for older adults, scale activities to physical capacity (eg, going for a short walk instead of a run; cooking one dish for a potluck rather than hosting a sit-down dinner). Simplify worksheets and build in repetition for patients with cognitive slowing. Explicitly schedule relationship-based activities, since social isolation is common after losing a spouse, retiring, or losing mobility.

Problem-solving therapy
Late-life depression often has a practical root, as functional decline, financial strain, caregiver burden, and medical complexity may accumulate faster than the patient can manage. PST tackles those problems directly, rather than targeting cognitive distortions or avoidance.

The six steps are:

1. Identifying a problem
2. Goal setting
3. Brainstorming
4. Weighing options
5. Implementation
6. Evaluation

Working through them helps overwhelmed patients regain a sense of agency.

PST has strong evidence in older adults. It reduces depression and is particularly useful for patients with executive dysfunction, who often respond poorly to standard antidepressants (Wu X et al, Front Psychol 2023;13:1030104). In this group, PST has been shown to reduce suicidal ideation more than supportive therapy (Gustavson KA et al, Am J Geriatr Psychiatry 2016;24(1):11–17). It also works well with caregivers, where the problem may be caregiver distress or a management challenge like care refusal or patient aggression.

When and how to use it
When a patient is buried under mounting challenges, have them select the one that bothers them most. Define it together and set a concrete goal (eg, “I want to go to my grandchild’s recital next month”). Brainstorm solutions without judgment, weigh pros and cons, choose the most realistic option, and make a specific action plan. At follow-up, ask how it went. Setbacks are expected, and working through the steps again helps the patient regroup.

Fitting BBIs into your practice
These approaches don’t require a dedicated psychotherapy appointment. You can use MI in any clinical encounter. A brief BA exercise reviewing the week’s activities and adding one takes about 10 minutes. The first PST session covering problem identification and goal setting fits a standard 30-minute follow-up. Written worksheets extend the work between visits and reinforce learning for patients with mild cognitive changes.

Trained and supervised social workers, nurses, and behavioral health consultants embedded in geriatric psychiatry or primary care can deliver structured BBI sessions, and BA can be delivered over the phone by bachelor’s-level staff when resources are tight. Documenting the technique used in a medication visit makes for a clearer record and better continuity.

At follow-up, Helen’s GDS is 7 (a modest improvement). Dinner was delightful, she says, but she hasn’t seen anyone since. You propose a potential weekly excursion. Her face brightens: “To a bookshop? There’s one around the corner.” You respond, “That sounds perfect for the next few weeks. Now, who would you like to invite this week?” No new medication required.

CARLAT VERDICT
Try MI, BA, or PST before adding another prescription, especially when a patient is already reluctant to take more medication. Use BBIs in the visits you’re already having and share delivery with your team when you can.