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The Life Course, Independence & Late-Life Depression

Professor of Psychiatry, School of Medicine, University of Pittsburgh; Director, University Center for Social and Urban Research

First published in Psychiatry Weekly, Volume 7, Issue 4, February 20, 2012

This interview was conducted on January 31, 2012 by Lonnie Stoltzfoos

Introduction

Treatment of depression in late life can be particularly vexing because of the other inevitable life changes that occur during those years—bereavement, changing health or illness, and functional disability. Dr. Richard Schulz has conducted extensive research on how late-life disease and depression affect patients and their loved ones, and how people adapt to the changes that can occur in later years.

“One of the key factors driving depression symptomatology in late life is, I think, the issue of functional disability,” says Dr. Schulz. “Losing autonomy because of illness, and having a limited ability to engage in activities that once brought fulfillment and pleasure, can curtail one’s world in such a way that often generates depressive symptoms. Functional disability may also result in having to rely on others in order to avoid placement in a long-term care facility. The issue of becoming a burden to others, especially family members, is a particular source of stress in older people.”

Adaptive Development

Dr. Schulz approaches geriatric depression from a perspective that considers the entire life course, especially in terms of adaptive capacity and self-regulation of motivation.

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“We have articulated in a number of studies that, throughout life, people develop strategies for enhancing their ability to control important outcomes in their world,” explains Dr. Schulz. “The underlying assumption of our life-span theory of control is that people seek to control the environment around them throughout their life span. People seek education to develop skills and abilities, for example, in order to enhance personal and economic opportunity, and to enhance social networks; it’s about making the world predictable and controllable. After a lifetime of extending and maintaining control over important life domains, late-life poses major challenges as people begin to encounter restrictions in the ability to control certain outcomes. Successful adaptive development at that point is tied to the ability to appropriately disengage from goals and control strategies that are no longer possible to carry out, and, in some cases, to adopt new ones. We find that people have differential abilities to do this, and the extent to which they can very often determines whether they become depressed.”

Disengagement & Remission

Meredith Wallace and colleagues weighed this theory in a treatment context. In their randomized clinical trial,¹ published in early 2012, subjects with late-life depression were helped to identify health-related stressors, such as health goals that were obsolete or unattainable, and to “disengage” from them with the intent of reducing or eliminating the stress associated with failure to meet those goals. Disengagement strategies were intended to help guide the intervention subjects of the 2-year trial away from unhelpful health goals; engagement strategies guided them toward newly relevant, helpful health goals. In this trial successful implementation of a disengagement strategy predicted earlier remission of depression, especially in cases of more severe depression. Engagement strategies, however, did not predict earlier remission.

It is unclear what specific personality traits are more or less associated with adaptability. In general, though, neuroticism tends to work against aging successfully, whereas higher levels of openness are beneficial to adaptive aging, according to Dr. Schulz.

Conclusion

Is it difficult to persuade patients to disengage from a long-held health goal or to engage with an altogether new type of goal?

“It can be difficult, because you’re going against a lifetime of strategies—that are unique and highly contextual—that people develop for dealing with problems and you’re trying to shift them in a new direction,” says Dr. Schulz. “Cognitive behavioral therapy is one strategy that can enable the patient to figure out what kinds of goals are worth giving up. Getting that process right is critical for remaining active and healthy in late life.”

Disclosure: Dr. Schulz has received research support from the National Institutes of Health, and the National Science Foundation.

Reference:

1. Wallace ML, Dombrovski AY, Morse JQ, et al. Coping with health stresses and remission from late-life depression in primary care: a two-year prospective study. Int J Geriatr Psychiatry. 2012;27:178-186.

Additional Resources

1. Heckhausen J, Wrosch C, Schulz R. A motivational theory of life-span development. Psychol Rev. 2010;117:32-60.

2. Schulz R, Heckhausen J. A life span model of successful aging. Am Psychol. 1996;51:702-714.

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