Integrating CBT and CFT within a case formulation approach to reduce depression and anxiety in an older adult with a complex mental and physical health history: a single case study

Abstract

Depression and anxiety are major contributors to growing healthcare costs in the UK, particularly with an increasingly ageing population. However, identification of mental health needs in older adults has been overshadowed by a tendency to focus on physical health issues, despite the established co-morbidity of depression, anxiety and physical health conditions. When older adults seek psychological support, treatment options may vary and may be time limited, either because of protocol guidance or due to the resource constraints of psychology services. Time-limited treatment, common in many adult services, may not best meet the needs of older adults, whose physical, cognitive and emotional needs alter with age. It is, therefore, important to identify treatments that best meet the needs of older adults who seek psychological support, but who may arrive with complex mental and physical health histories. This paper aims to explore how a case formulation-driven approach that draws on the theoretical underpinnings of cognitive behavioural therapy (CBT) and compassion-focused therapy (CFT) can be used to reduce anxiety and depression in an older adult with a complex multi-morbid mental and physical health history. This study employs a single-case (A–B) experimental design [assessment (A), CBT and CFT intervention (B)] over 28 sessions. Results suggest the greatest reductions in depression and anxiety (as measured using PHQ-9 and GAD-7) occurred during the CFT phase of the intervention, although scores failed to drop below subclinical levels in any phase of the intervention. This case highlights the value of incorporating CFT with CBT in case formulation-driven interventions. Key learning aims (1) To consider the value of using case formulation approaches in older adult populations. (2) To demonstrate flexibility in balancing evidence-based interventions with service user needs by incorporating CBT and CFT to treat anxiety and depression in an older adult. (3) To present a clinical case to identify how assessment, formulation and treatment of anxiety and depression are adapted to best meet the needs of older adults with complex co-morbid mental and physical health conditions. (4) To appreciate the impact of contextual factors, such as austerity measures, on therapeutic work with individuals with long-standing mental and physical health difficulties.

Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees.

“…There are other reasons that the findings here may differ to those of recent reviews, for example, the reviews included clinical trials with a variety of treatment settings, whereas here the sample comes from a wholly primary care and community based mental health setting, from eight services that all follow similar protocols. In addition, the treatments may have differed; unlike the protocol-guided approaches in the RCTs (particularly as few were pragmatic RCTs; Rothwell, 2005 ) treatments in IAPT are perhaps more flexible and formulation-based, an approach which may be more desirable to older adults ( Birdsey, 2020 ). This may be supported by the finding that older adults were more likely to be receiving high-intensity interventions, relative to working-age adults, after adjusting for differences in clinical presentations.…”

Embedding the silver thread in all-age psychological services: training and supervising younger therapists to deliver CBT for anxiety or depression to older people with multi-morbidity

“…Depression and/or anxiety symptoms reduced from moderate to mild or asymptomatic on psychometric scales for all cases except for 'Ray' who scored above clinical cut-off for the duration of therapy (Birdsey, 2020). There were self-rated reductions in helplessness, memoryrelated worry and embarrassment (Richardson and Marshall, 2012), increased confidence and/ or activity (Harris and Hiskey, 2015;Richardson and Marshall, 2012), increased social contact (Walshe and Allen, 2020) and reduction in emergency bed days (Slaughter and Allen, 2020).…”

“…Three of the studies were with octogenarians (Harris and Hiskey, 2015;Richardson and Marshall, 2012;Walshe and Allen, 2020), one with a septuagenarian (Slaughter and Allen 2020) plus one person in their late 60s (Birdsey, 2020). Three of the clients were male, and two female.…”

“…The number of sessions of CBT delivered ranged from 7×30 minutes (Richardson and Marshall, 2020) through to 28×1 hour (Birdsey, 2020). Most were delivered in the client's own home with 1 Although the highest Altmetric score for articles in the special issue is currently held by Charlesworth and Reichelt (2004), 'Keeping conceptualizations simple' .…”

“…Worry management, sleep hygiene, motivational self-statements and relapse prevention were also used in more than one case. Two of the case studies labelled their approach 'transdiagnostic CBT' (Slaughter and Allen, 2020;Walshe and Allen, 2020) and two combined CBT with compassion-focused therapy (Birdsey, 2020;Harris and Hiskey, 2015). All included between-session tasks.…”