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Meaningful Lives: Elders in Treatmentfor Depression

Meredith Ragan and Catherine F. Kane

rom the Tucrsing and Psyarlottesville, VorrespondingP, PMHNP-BC.-mail addres2010 Elsevi

883-9417/18oi:10.1016/j.

Depression among elderly persons is common. Major depression is dis-abling, highly prevalent, and adversely affects daily function and quality oflife. Although studies have demonstrated that interpersonal psychotherapy(IPT) and medication can relieve the symptoms of depression, many eldersdo not seek treatment. Of those elders who do participate in treatment ex-perience, 20% to 50% do not experience partial or full relief from depressivesymptoms. Improvements in treatment strategies are needed to better servethis population. In this study, 20 elders in treatment for depression with IPTand medication were interviewed to better understand their day-to-day lives.These interviews provided insights and perspectives to inform clinical prac-tice and improve treatment strategies. The major themes identified were in-dependence, spirituality, family, depression, medical comorbidities, andmotivation. Potential treatment strategies were derived from these themes.© 2010 Elsevier Inc. All rights reserved.

M ental disorders contribute to a major publichealth burden (United States Department of

Health and Human Services, 1999). In the UnitedStates and in other western countries, elderlypersons are the fastest growing population, andmany experience depression, which is one of themost common mental disorders of advanced age.Research indicates that older adults who areisolated or ill are more likely to be depressed butmay be less likely to seek care (Russo, Hambrick, &Owens, 2007). Clinically significant depressionaffects 15% to 20% of elders in the United States(Ciechanowski et al., 2004). Depressive conditionscan contribute to medical illness, disability in late

ker Psychiatric Clinic, Richmond, VA;chiatric Medicine, University of Virginia,A.Author: Meredith Ragan, DNP, MSN,

, Tucker Psychiatric Clinic, Richmond,

s: jamesrivert@comcast.neter Inc. All rights reserved.01-0005$34.00/0apnu.2010.04.002

Archives of Psychiatric

life, and suicide (Conwell, 2001; Pinquart, Duber-stein, & Lyness, 2006).

Depressive disorder is not a normal part of aging.Depression is treatable in 65% to 75% of elderlypatients (Alexopoulos, Katz, & Reynolds, 2001).Untreated depression delays recovery from thisdisability itself and may worsen the outcome ofother illnesses as well. Although some individualsrespond to treatment with psychotherapy or anti-depressant medication, the most effective outcomeshave been found when psychotherapy and anti-depressants are used to treat the condition (Pinquartet al., 2006). Despite the availability of effectivetreatments for depression, 20% to 50% of elderswith depression fail to respond to the existingtreatments (Simpson, Corney, Fitzgerald, & Beec-ham, 2003). Improved treatments are needed toimprove the care to this population.

INTERPERSONAL PSYCHOTHERAPY ANDPSYCHOPHARMACOTHERAPY

Interpersonal psychotherapy (IPT) is recommendedin many depression treatment guidelines (Alexo-poulos et al., 2001; Van Schaik, et al., 2006).

Nursing, Vol. 24, No. 6 (December), 2010: pp 408–417

409ELDER DEPRESSION

Therefore, it is important to understand theintervention from a real-life perspective. Reviewsof research on IPT indicate this is a practical,effective intervention for the elderly client withdepression (Van Schaik et al., 2006). The efficacyof IPT in the treatment of acute depression has beendemonstrated in several randomized trials accord-ing to Sadock and Sadock (2003).

THE PERSONAL PERSPECTIVES OF ELDERSWITH DEPRESSION

Regardless of the many randomized controlledtrials of IPT, there remains a portion of thepopulation for which treatment is not successful.Only a few studies report a qualitative analysis ofdepression in elders. Hedelin and Jonsson (2003)gathered elderly women's personal perspectives ofmental health and depression. The intervieweesparticipated in an intervention program to preventdepression in elderly women. Interviews wereconducted with 21 women who were not beingtreated for depression, and the interviews wereanalyzed descriptively. A review of their lifeexperiences revealed issues of self-esteem, exis-tence, and personal value. The women viewedthemselves as persons worthy of attention andrespect, with a special mission in life. Feelings ofshame and guilt made these women sensitive tohow others perceived them.

Black and Rubenstein (2004) conducted threeseparate interviews of 40 elderly men and women,focusing on the personal suffering of theseindividuals. Open-ended questions were used toexplore depression, sadness, and suffering. Thethemes of suffering in this study were related to lackof control, personal loss, and the personal value ofsuffering. Each elder in the study uniquely definedtheir feelings and “rooted his or her definitions inthe context of the joys and sorrows, triumphs andstruggles of a lifetime” (Black & Rubenstein,2004). In a later study, Black, White, and Hannum(2007) interviewed 20 depressed elderly AfricanAmerican women revealing three general themes:depression linked with diminishment of personalstrength, sadness and suffering, and depressionpreventable or resolvable through personal respon-sibility. These women “created a language” fordepression that was rooted in their personal andcultural history. Regarding personal strength, thesewomen spoke of depression as a lived experiencethat is characterized by (a) a perception that

emotional, mental, or physical strength is waningdue to the difficulties that occur throughout a longlife and (b) a sense of responsibility to combatdepression with the strength that remains. Thesewomen described depression as being related tosadness and suffering because all three weretriggered by the same event or state of being,such as lifelong poverty. Regarding responsibility,the primary means women used to prevent orresolve depression was religious belief. Religiousbelief provided a framework for explaining themeaning of life events and reassured them thatnegative situations would improve, or they wouldhave strength to bear them. Strength throughfaith emerged as empowerment formed throughan intimate union with God, the ultimate sourceof power.

Only one study (Miller, Wolfson, and Frank,1998) was found that collected case vignettes ofelderly persons with depression during treatmentwith IPT and psychopharmacotherapy. Onehundred eighty subjects at least 60 years of agewith recurrent unipolar major depression receiveddrug therapy with nortriptyline (NT) and IPTwith an experienced clinician. Acutely, 81% ofsubjects showed a full response to combinedtreatment. An analysis of concerns expressedduring therapy indicated that the most commonproblem areas were role transition, interpersonaldisputes, and grief. The combination of IPT andNT showed a powerful antidepressant effect. IPTwas found to be readily adaptable to the needs ofelders with depression.

No published research was found on the livedexperiences of elders with depression in treatmentwith IPT and psychopharmacotherapy. Qualitativeapproaches are appropriate to acquire an in-depthunderstanding of human behavior and the reasonsthat govern human behavior (Denzin & Lincoln,2005). Reports from elders about their day-to-daylives have the potential to reveal themes that caninform practice and improve treatment strategies.

METHODS

Design

The current study used a descriptive qualitativeapproach to understand the common experience ofelders with depression to inform practice andimprove treatment strategies. An open-ended inter-view protocol was implemented with elders with

410 RAGAN AND KANE

depression receiving the combination treatment ofIPT and psychopharmacotherapy. The interviewswere designed to elicit specific descriptions of theelder's daily life. The research method followedthat developed by Giorgi (1970) as described byFain (1999) and was intended to gather data abouthow elderly adults in treatment for depressionexperience their daily lives.

Setting

The setting for this study was a private psychiatricoffice in a southeastern metropolitan area where thefocus is assessment, evaluation, and treatment ofpersons who are seeking psychiatric care or thosewho were referred by physicians in the area.

Sample

Twenty persons who were in treatment with IPTand psychopharmacotherapy for a primary diagno-sis of depression, 60 years or older, Englishspeaking, without substance abuse disorder, wererecruited and interviewed until themes becamerecurrent in the narrative. Twenty elders participat-ed in the study, with 65% being female, 85%Caucasian, and 15% Black. The average age of theelders was 70 years (range = 60–88). The averagelength of time in therapy at the time of the interviewwas 17 months (range = 2–41). The procedureswere approved by The University of VirginiaHuman Investigation Committee.

PROCEDURE

Recruitment

Each elder person, meeting the above criteria, wasinvited by the researcher to participate in the studywhen they came to the psychiatric office for theirregular appointment. The researcher explained theresearch process to the person and ensured that heor she understood that the person had the right torefuse participation without consequences to theirtreatment and that interview was separate from thetherapy session. A consent form was providedwith an explanation and an opportunity forquestions. The interview was scheduled to beconducted immediately prior to the next regularlyscheduled clinic appointment. The interviews wereaudiorecorded and lasted from 40 minutes to1 hour.

Interview Protocol

The interview was conducted by the researcher andbegan with the open-ended question: “Pleasedescribe to me a typical day in your life? Describeyour day like you were telling me a story about allyou do and experience from one morning to thenext.” If the participant's narrative was too short foridentification of themes (less than 2 minutes), thenthe interviewer asked the participant additionalquestions designed to elicit specific descriptions ofthe participant's daily life, including “Tell me moreabout (a statement made by the participant); Whatare your usual activities (in the morning, afternoon,evening, at night)?”

Data Analysis

Each interview was tape recorded, transcribed, andanalyzed for content, thoughts, observations, andthemes in the lives of the participants. Phenome-nological qualitative analysis was conducted on thetranscribed interviews according to the followingmultistep procedure.

Step one: Data transformation. Relevant infor-mation was gathered from the transcriptions ofinterviews, observation notes, and clinical notes.These were reviewed following the researcher'sdecision, determining what data were relevantand what was not. This process is similar toediting (Cohen et al., 2000; Steeves, 1998).Step two: Analytical process or data analysis.The results from the first step were reviewed forcontent and meaning that addressed the experi-ences of the informants in their daily livesfollowing the guidelines for qualitative dataanalysis recommended by Steeves (1988).

Data analysis involves sorting portions of theinterviews into categories, which are classificationsof concepts that seem most logically related to thetopic area. Categories are built in the process ofbreaking down, examining, comparing, conceptu-alizing, and grouping the data (Cohen et al., 2000).

FINDINGS

As elders related their experience of a “typical day,”they portrayed a tapestry of feelings, observations,behaviors and responses to life's challenges, joys,and sorrows. Six significant themes emerged fromthe interviews: independence, spirituality, family

411ELDER DEPRESSION

relationships, depression, medical comorbidities,and finally, motivation.

Independence

Independence emerged as a theme in this study.Various elders stated they were independent andenjoyed doing things for themselves. They enjoyedhelping others. They desired to remain activethemselves and interactive with others. The follow-ing excerpts from the interviews present evidence ofthis theme.

A married woman said:

I am not one to stay at home all day, and just hang aroundthe home. I am not one to watch television that much. Iwould rather be out doing something else.

A recent divorcee stated:

I keep up with my responsibilities. Right now I amobligated to one of my best friends to take her to physicaltherapy.

One married female respondent stated:

I enjoy people. I am very independent.…I will take someladies to their doctors' appointments.…but I can't let themdo something for me. I am just like that. I want to be able totake care of myself.

Engagement of elders in daily activities promotescognitive functioning as well as the individual'swell-being and satisfaction. Singh-Manoux,Richards, and Marmot (2003) report that olderindividuals who self-report greater engagement in avariety of leisure, cognitive, and physical activitiesshow improvement on cognitive batteries relative toindividuals who self-report less engagement.

A symptom of major depression is isolatingoneself from others. Isolation does not seem to bethe goal of the independence evidenced by theseelders receiving medication and psychotherapy fordepression. They, for the most part, see themselvesas socially involved and apparently work to engagewith others.

Spirituality

Spirituality added meaning to the lives of theseelders. Although some respondents were veryreligious, per se, others had a personal philosophythat included spirituality and altruism. The follow-ing excerpts from the interviews present evidenceof this theme.

One married woman said:

I enjoy my church a whole lot. I do my church newsletterand hand-make Easter, Christmas, and birthday cards forthe church members. We have Wednesday soup supper atthe church and on Tuesday, we have Bible study.

One widower, 85 years of age, who drovehimself to church almost every morning offered:

I like to talk to the Lord because He takes good care of me.I ask Him to watch over me during the day, and I try to dothe best.

Of all the psychiatric disorders, the depressivedisorders have been most closely associated withthe core spiritual task of finding meaning (Blazer,2006). The spirituality of these elders is a themewhether they are a church member espousing aparticular faith or not. Their spirituality is subjec-tive, individualistic, personal, and dynamic (Lar-son, 2003) and is expressed in a sense of hope thatsustains them in managing the difficulties of theireveryday lives.

Spirituality was linked to altruistic behavior bymany of the respondents in this study. Numerousstudies suggest that positive behaviors may havehealth benefits for individuals who exhibit them(Fujiwara, 2007). Schwartz, Meisenhelder, Ma, andReed, (2003) found a positive and significantassociation between altruistic behaviors and im-proved mental health. Blazer (2006) states that late-life depression is viewed by some as emotionalsuffering that is especially open to spiritualintervention, given that it derives in part (theore-tically) from a failed search for meaning. Thealtruism of these elder interviewees seemed toreflect an innate healing and coping strategy as theyfound satisfaction in helping others as well asvalidation of their own lives having meaning.

Family Relationships

The elders talked at length about their familyrelationships. Some of these relationships wereclose and supportive; others were estranged andfailed. Regardless of the situation, these elders,again, found meaning in these relationships.Some spent a great deal of time interacting withtheir family members. Others spent time remi-niscing about earlier times. Those who wereestranged dwelled on what the relationships hadmeant to them and the absence in their presentlives of those involvements. The followingexcerpts from the interviews present evidence ofthis theme.

412 RAGAN AND KANE

One woman who was married reported:

I have two grandsons in….They mean the world to me. Nowthat I am retired, we can go down and visit. I have threegrandchildren….The highlight of my life is being able tohave grandchildren. And my husband, I do love that manvery much.

Another female respondent notes:

My family, ah, we are a close-knit family.…I don't knowwhat I'd do without my family, I really don't. They give meso much support.

An elderly widower who lived alone reported:

…I make ginger snaps. I make them year-round. Mygrandchildren and children love them and I enjoy them.…The family loves me and they tell me, Dad you're thegreatest. They all call at different times.

A divorced woman said:

I am very, very, very much in love with my grandchildren.They are wonderful little people. I talk to two of themevery day.

A married woman described the morning that shehad a heart attack:

I had just stayed with my mother all night. And ah, sheupset me about the things she was saying about mysiblings….My mother is very domineering. I just want[ed]to get away.

Whitbeck, Hoyt, and Tyler (2001) discussed thelife course in terms of the developmental perspec-tive and stated that the blueprint for mutual familysupportiveness is created through early andpersistent family interaction patterns. Early familyrelationships may have long-term consequencesfor family supportiveness and hence the well-being of elders. These relationships seem to set thestage for later-life relationships and issues relatedto depression.

Depression

The elders also spoke at length of grief, loss, andloneliness. These elders had experienced manylosses in their lives. Some of the grief associatedwith these losses remained unresolved over manyyears. Many of the losses were of importantrelationships, and many were of personal relation-ships. Because these elders were in treatment fordepression, the theme of depression would beexpected. However, the elder's descriptions of

these losses provide insights into their experiencesof pain and grief. Thus, “depression” emerged as amajor theme. The following excerpts from theinterviews present evidence of this theme.

One gentleman whose female friend left himreported:

And the thing I'm dealing with on a daily basis is thisloneliness. I had brief moments when I wish the hell Iwasn't here and say ‘God, you can take me any damn time.’That's part of the depression I'm going through.

One divorced woman said:

I really did have a hard life. My ex-husband really turnedout to be like my father which they say is always the way,but I don't think so. I am very sad about the divorce, I reallyam.…I would just love a man to love me because I am me.After 38 years or so (marriage), I think there is alwaysgoing to be pain about that emotionally.

A married female respondent offered:

I do live with my depression. January and February arealways very difficult for me. I believe that's because of thesun. Also, I get bothered by just crying for no reason.…Iwill start thinking of my family. My sister had surgery…Thethought that my sister had surgery and did not tell me,makes me cry.…The weeping is more of a sadness andsomehow it (relationship) is a failure, and I don't deal wellwith failure.

A married woman said this:

My depression comes from back in my life. I force myself,absolutely force myself to get up and enjoy a life that mostpeople will die to have. It takes a lot when you're really,really feeling bad. It scares me sometimes…

Medical Comorbidities

Another theme that was identified during thisanalysis revolved around the serious medicalconditions that these elders coped with each day.The elders described the impact of these conditionson their lives, how they coped with thesedisabilities, and how they continued to try to livetheir lives as fully as possible. Thus, “medicalcomorbidities” emerged as a major theme. Thefollowing excerpts from the interviews presentevidence of this theme.

One married woman stated:

I start my day by reading my e-mails and do my nebulizing'cause I have COPD. I have pump oxygen at all times now.I use a C-PAP machine. I have lost 90 pounds this pastyear and I need to lose another 90. Also, I need to have

413ELDER DEPRESSION

knee surgery. I sleep, but I think it's because I takemedicine to sleep.

One elderly woman said:

I have a lot of pain. I have headaches, bad headaches. I havemigraines. I get upset, I get bad headaches. In the pastmonth, I've had them every day. I finally went to my GP.He…said it was a heart attack. Now I'm seeing a heartdoctor and finished with the tests yesterday. I would hurt allover. I was sick. I would sweat, and just hurt in my head.

An elderly widower who joined the Coast Guardas a very young man after hearing of the bombingof Pearl Harbor said:

I have a lot of aches and pains that has been terrible with me.They say it is arthritis. I don't know, but it goes from thebottom of my feet to my head.…I was even using a cane.…Ihave prostate trouble, not cancer or anything but normal stufffor an old gent like me at 85.

A married gentleman with cardiac diseaseoffered:

I am back to about five doctors a month and am glad in onesense and sad in one sense. But I know I have to see thatmany doctors in order to live. But it keeps me fromcommitting suicide or whatever.

The elders in this study presented with variousmedical problems, and many of them were beingactively treated by medical specialists and/or theirfamily physicians. Medical problems can includegeneral health problems, illness and disability,chronic or severe pain, and/or damage to bodyimage due to surgery or disease. According to theAmerican Psychiatric Association’s Institute onPsychiatric Services, patients who are 65 yearsand older and are admitted to emergency roomshave more than two medical comorbidities (Evans,2002). These medical conditions may complicatetheir treatment. Many medical conditions that areprevalent in later life are associated with increasedrates of depression (Yohannes & Baldwin, 2008).

Motivation

In contrast to these expressions of depression andpainful comorbidities, respondents displayed moti-vation, hope, affirmation, and determination. Mo-tivation was a pivotal behavioral issue in the livesof the elders interviewed. These elders weremotivated toward helping themselves and others.They valued their independence in seeking andfinding help within their own spirituality, family

relationships, social organizations, and from med-ical professionals. Belief in one's efficacy toexercise control is a common pathway throughwhich psychosocial influences affect health func-tioning (Bandura, 2004). The elders acceptedpersonal responsibility for their lives, demonstrat-ing independence. Motivation is linked to perceivedself-efficacy. The individual feels he or she hascontrol over behavior in a way that will produce apersonal benefit. The stronger the sense ofmotivation, the stronger the individual feels intaking on challenges (Bandura, 2004).

DISCUSSION

These 20 interviews of elderly women and men intreatment for depression revealed remarkablysimilar themes. Six nonoverlapping themes wereidentified during the multistep analysis: indepen-dence, spirituality, family relationships, depression,medical comorbidities, and motivation.

There is an important perspective to considerwhen reflecting on these interviews and theirimplications. All of these elders at the time oftheir interviews were engaged in treatment fordepression, taking prescribed medicine regularly,and participating regularly in psychotherapy. Theseelders are therefore quite different from thoseindependent living elders who have major depres-sion but are not in treatment. In numerous cases,these interviewees had experienced exacerbationsand remissions over many years, yet they perse-vered in engaging in treatment so that they couldremain active and independent, finding meaning intheir sense of commitment to family, spirituality,and altruism and motivating them to remainindependent in the midst of their depressive illnessand medical comorbidities.

An unexpected finding in this study was theability of this cohort to actively seek, accept, andexpect positive outcomes for their medical pro-blems. Certainly, many of them were limitedphysically by pain, respiratory deficits, lack ofmobility, and cardiac disease. These elders wereaffected by physical limitations but were notmotivated “to give up” because of these deficits.They exerted some level of control over theirmedical problems. Seeking psychiatric care, bothpsychotherapy and psychopharmacotherapy, maybe an indication of their desire to solve mentalhealth issues as well as their medical problems.

414 RAGAN AND KANE

In the lives of the elders interviewed, thechallenge to find meaning transcended the pain ofsuffering with depression and/or their medicalproblems, family issues, losses, and so on. Onlyas they became aware, gaining insight into theissues in their lives that were preventing them fromexperiencing well-being, were they able to act togain control. They sought to gain control bymobilizing motivation with the perseverance need-ed to succeed. The feelings of depression and thelack of well-being became critical events in thelives of the elders interviewed. Depressive illnessmay have actually become the stimulus to motivatetheir individual resources to value living enough tosurvive with the illness and to continue to findmeaning in their lives.

Erikson and Kivnick (1986) described the laststage of adult development as integration versusdespair. Development in older adults focuses onpositive outcomes that relate to the final stages oflife, such as feeling positive about one's contribu-tion to society, having close and loving relationswith family and others, and maintaining a purposein life with a sense of autonomy (Evans, Elder, &Nizette, 2004). As the elder evolves through thecourse of his or her life, a sense of integration of lifeexperience can develop, bringing meaning intofocus. As the elder in treatment for depressionrelates “a typical day in his or her life,” feelings,observations, behaviors, and responses to lifechallenges are shared. Because he or she is ableto relate these experiences and feelings in atherapeutic trust relationship, psychological inte-gration or a sense of “wholeness” may ensue. Thiscan be a time of reflection and acceptance on theunique meaning of his or her life.

IMPLICATIONS FOR NURSING PRACTICE

The findings in this study provided insights forconsideration in improving treatment strategiesfor elders in treatment for depression. The sixthemes that emerged in the interviews with theseelders were independence, spirituality, familyrelationships, depression, medical comorbidities,and motivation.

First, the findings of this study indicated thatelders diagnosed with depression desired to beindependent. Clinicians need to be aware of thedesire for independence by elders, regardless ofdepression. A participant in this study said that hedid not want to “just sit around.” Clinicians must

intervene to promote participation in activities ofinterest to elders through referral sources. They cangive elders and their families certain lists of socialprograms available in the community where eldersare invited to participate. The clinician assists anengaged family member to support independenceand the desire to be active as an integral componentof the treatment strategy for the elder.

Secondly, spirituality was an important theme inthe lives of the elders interviewed. Many felt thechurch or religious experience brought meaninginto their lives. They reached out to God for helpand voiced a sense of community in their places ofworship. Clinicians must appreciate how spiritual-ity can impact elders. Each elder requires individualassistance when appropriate to come to terms withtheir belief system. The clinician must support theclient while educating themselves on the meaningand value the client places on his or her own senseof spirituality. During this developmental stage,successful resolution of grief, loss, and regret mayinvolve assisting the elder to reflect on spiritualityto recognize the unique meaning of his or life. Atreatment strategy for this group of elders was toencourage the personal feelings of spirituality intherapy and by offering referral for specialcounseling and guidance within the client's religionto assist with resolution of a particular spiritualissue. In addition, referral to spiritual supportgroups in the community must be part of thestrategic treatment plan to benefit elders.

Thirdly, present and past family relationships forthe elders were directly related to many of theirunresolved issues associated with depression.Feelings about family members and events relatedto family could be joyful or fraught with sorrow.The clinician must recognize there is one individualin the session, but the elder is part of a largersystem unknown to the therapist. These interviewsreveal that no matter the age, early family life isintegrally involved in one's sense of self and themeaning of life.

Careful, deliberate, and perhaps extended ses-sions may be needed to secure an accurate andcomplete history from the elder on familydynamics. A beneficial treatment strategy withthe client's approval is to include a member of thefamily to come to one or more sessions of therapy.Details of current or past relationships may beneeded in order for the elder to develop insight intoareas where perspective may have been lost. Two

415ELDER DEPRESSION

of the women in this study were struggling withunresolved issues related to divorce at a time andage in their lives when upheaval of home andfamily was particularly painful. A treatmentstrategy in both cases was to have childrenparticipate in the healing process by including theelders in family events involving grandchildrenand holiday planning. By connecting the past withthe present, elders learned to substitute losses intheir lives by surrounding themselves with closefamily members and to be a part of the family unitas it currently exists.

Depression emerged as a theme in terms ofloneliness, loss, isolation, and grief. This suggeststhat clinicians need to focus on the immediateexperience of suffering the elder may be having toalleviate the pain and to provide safety for theindividual. Engaging the support of a loved one isoften both practical and appropriate when emer-gency care is required. The clinician can be areferral source for health care providers in thecommunity. Networking with other medical profes-sionals allows the clinician to demonstrate avail-ability for consult and treatment of depressed elderclients to prevent possible self-harm.

These elders with depression coped with a varietyof chronic medical problems. This fact suggests thatclinicians must provide an in-depth physicalassessment of the elder client and be prepared tocontact the client's medical care provider for consultwhen appropriate. Collaboration with other healthprofessionals must be a routine treatment strategyfor treatment in the clinician's practice. The 85-year-old gentleman in the study with severe arthritispain, suddenly requiring a cane to walk, wasreferred to a rheumatologist for assessment andpossible treatment.

Finally, motivation was a theme found in thelives of these elder clients. Self-efficacy beliefsoperate with goals, outcome expectations, andperceived environmental barriers and facilitatorsin the regulation of human motivation, behavior,and well-being (Bandura, 2004). Clinicians mustuse strategies to promote self-efficacy.

Motivational Interviewing

A counseling strategy that has been incorporatedinto substance abuse treatment and has been usedfor other mental health conditions is motivationalinterviewing (MI), which was designed to apply theconcepts of the Transtheoretical Model (TTM) of

Change (Proschaska & DiClemente, 2005). Thisapproach can be used therapeutically in the courseof psychotherapy and medical intervention and isintended to assist the individual in engaging inbehavior change. Given the motivational ability bythe elders interviewed for this study, MI may be astrategy of choice when working with elders whohave demonstrated the initial motivation to engagein treatment for depression.

MI, as described by Treasure (2004), is adirective, patient-centered counseling strategy thatis intended to help clients make behavioral changes.MI is not that different from IPT because itcombines elements of style (warmth and empathy)with technique (focused reflective listening andidentification of discrepancies), and a perspectivethat conflict is unhelpful. A collaborative relation-ship between therapist and patient is essential. Acore tenet of MI, however, is that the patient'smotivation to change is enhanced if there is a gentleprocess of negotiation in which the patient, not thepractitioner, articulates the benefits and costsassociated with change. Thus, the client makesactive choices about the changes he or she is willingto make consonant with the TTM.

RECOMMENDATIONS FOR FUTURE RESEARCH

This study revealed that personal motivationbrought elders with depression into treatmentfor depression. The respondents sought andengaged in psychiatric therapy on their own.Future studies should more explicitly examinemotivation as it relates to the illness trajectory ofelders with depression. Such studies furtherinform the development of more effective treat-ment for this population.

Furthering the development of evidence-basedpractice on the findings of this study would involveconducting similar interviews and analyzing theiremergent themes with other samples of elders withdepression, such as those who are homebound,those who refuse treatment, and those being treatedwith only IPT or antidepressants. Comparisons ofmajor themes in the interviews could be made todetermine whether similar themes emerge in thesesamples. Such study would provide insights as tohow to improve treatments for these populations.

The prospect of using MI with elders withdepression could be evaluated in clinical trials. Therole of the clinician as health care coordinatorshould also be examined with clinical trials. Lastly,

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educational programs for clinicians should bedeveloped and evaluated for their impact inreducing the stigma of advancing age that preventshealth care providers from truly promoting thehealth and well-being of elders.

SUMMARY

This study used a qualitative approach and wasconducted to gain insights into the lives of elderswith depression that could eventually lead toimprovements in treatment strategies for thispopulation. Twenty elders described a typical dayin their lives. Using a multistep analysis of theinterviews, six themes emerged: independence,spirituality, family relationships, depression, med-ical comorbidities, and motivation. A perspective ofthe process of elders finding meaning in their liveswas explicated such that characteristics of indepen-dence, motivation, and spirituality enabled theseelders to identify their need for treatment and tocope with their comorbidities. During treatment,these elders began to appreciate their experiences ofsocial and family relationships and began to be ableto appreciate the meaning inherent in their livedexperience. Developing the role of the clinician ascoordinator of health care and the appropriatenessof MI as a treatment strategy were presented aspossible avenues to improving treatment for elderswith depression.

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