bibliotherapy as an adjunct to psychotherapy for depression in older adults

Bibliotherapy as an Adjunct to Psychotherapyfor Depression in Older Adults

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Mark Floyd

University of Nevada, Las Vegas

Bibliotherapy, reading a self-help book for the treatment of psychologicalproblems, has been shown to be effective as a “stand-alone” treatment fordepression. Many practitioners recommend self-help books as an adjunctto treatment. This article offers some guidelines for the use of bibliother-apy as an adjunct to individual psychotherapy with depressed older adults.Two clinical cases demonstrate how bibliotherapy can be used effectivelyin conjunction with individual psychotherapy. © 2003 Wiley Periodicals,Inc. J Clin Psychol/In Session 59: 187–195, 2003.

Keywords: psychotherapy; bibliotherapy; adjunctive treatments; depression

Although the prevalence of mood disorders is lower in older adults than in other agegroups, depression is still a significant problem, especially when considering the numberof older adults in significant distress who do not meet full diagnostic criteria (Blazer,2002). Individual psychotherapy has been effective for older adults (Scogin & Mc-Elreath, 1994). Bibliotherapy also has been effective for the treatment of depression inolder adults (Floyd, Scogin, McKendree-Smith, Floyd, & Rokke, in press; Scogin,Hamblin, & Beutler, 1987; Scogin, Jamison, & Gochneaur, 1989). However, little hasbeen written about combining treatments or specifically the use of bibliotherapy as anadjunct to individual psychotherapy. In this article, I will describe how bibliotherapy canbe an important supplement to psychotherapy and provide two illustrative case studies.

Indications and Advantages of Bibliotherapy

Bibliotherapy for depression is effective. Gould and Clum (1993), in a meta-analysis ofself-administered treatments, reported an effect size of 0.74 for three depression biblio-

Correspondence concerning this article should be addressed to: Mark Floyd, Box 455030, Las Vegas, NV89154–5030; e-mail: [email protected].

JCLP/In Session: Psychotherapy in Practice, Vol. 59(2), 187–195 (2003) © 2003 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10141

therapy studies. Cuijpers (1997) reported an effect size of 0.83 in his meta-analysis ofseven depression bibliotherapy studies (including the three studies in the Gould and Clummeta-analysis). These meta-analyses were not specific to older adults; however, biblio-therapy has been successfully used in treating geriatric depression.

In the first study of bibliotherapy for depression in older adults, Scogin et al. (1987)found that participants who read Feeling Good (Burns, 1980) showed significantly moreimprovement than participants who read Man’s Search For Meaning (Frankl, 1959) andparticipants in a waiting-list control. Scogin et al. (1989) followed up this initial studywith a comparison of cognitive bibliotherapy using Feeling Good, behavioral bibliother-apy using Control Your Depression (Lewinsohn, Munoz, Youngren, & Zeiss, 1986), anda waiting-list control. Results indicated that participants in both active bibliotherapyconditions improved significantly compared with control, and there were no outcomedifferences between the active treatments. Floyd, Scogin, McKendree-Smith, Floyd, andRokke (in press) compared bibliotherapy (Feeling Good ), 16 sessions of individual cog-nitive psychotherapy, and a waiting-list control for depressed older adults. Results at post-treatment indicated that both active treatments were superior to control. Although individualpsychotherapy was superior to bibliotherapy at posttreatment, the bibliotherapy partici-pants continued to improve after treatment, and there were no differences between thetreatments at the three-month follow-up evaluation. Thus, research has consistently dem-onstrated that bibliotherapy is an effective treatment for depression in older adults.

Cognitive-behavioral therapy (CBT) has been generally described as a process inwhich the client and therapist collaborate to identify maladaptive beliefs, gather pertinentdata on the beliefs, and then modify those beliefs through an objective review of the data(Beck, Rush, Shaw, & Emery, 1979). CBT tends to be didactic, especially in the earlysessions when it is necessary to teach the client the connection between thoughts, behav-iors, and emotions and to introduce the CBT techniques (e.g., daily record of dysfunc-tional thoughts). Clients in CBT are assigned homework to solidify the in-session learningand to promote application in the client’s life outside of therapy. Reading a self-help bookcan be integrated into this process, much in the same way that textbooks are used toaugment lectures in academic classes.

There are several reasons for using bibliotherapy as an adjunct to CBT. First, itseems to accelerate the learning process. Once clients have learned how to use the tech-niques, treatment progresses rapidly. (Indeed, I have had some clients dramatically improveand terminate after only a few sessions when they learned that their emotions were causedby their thoughts and that they could change the way they thought.) Other clients needmultiple exposures to the material, and these are the cases in which adjunctive biblio-therapy is most obviously important. Second, if a client can learn the basics of CBT bybibliotherapy, then the in-session time usually dedicated to didactics can be used for otherpurposes, such as focusing on the interpersonal process. Third, bibliotherapy can be usedto shore up deficiencies or address problems that may not be the primary focus of therapy.Fourth, if the length of therapy is going to be limited (e.g., as in managed care), biblio-therapy can help compensate for the lack of therapy time. Finally, bibliotherapy is self-administered and, as such, increases the client’s feelings of responsibility for psychotherapyand treatment-related self-efficacy.

Although there are good reasons for the use of bibliotherapy within psychotherapy,there also are some reasons to be cautious. One reason is the potential to offend clients.For example, clients could either perceive that their therapist does not want to work withthem or that the therapist thinks their problems are simple enough that a book could help.A second reason to be cautious is that many clients have a history of lackluster perfor-mance in school and are afraid of being evaluated on tasks that resemble academic work.

188 JCLP/In Session, February 2003

A third reason is a more general case of the second one in that some clients resist home-work (and therapist suggestions). Reading a self-help book is a relatively lengthy “home-work assignment” and therefore gives more potential for this type of conflict. In accordancewith these recommendations, I first determine if the client is sufficiently self-motivatedand interested in bibliotherapy. Often the client initiates by asking me if there is anythinghe/she could do outside of therapy that would help. In such cases, I feel comfortable andconfident with recommending bibliotherapy.

We have discovered several depression-specific caveats based upon our researchusing bibliotherapy as a primary (and only) intervention. First, clients who complain ofcognitive limitations (e.g., memory problems, poor attention) tend to not respond well tobibliotherapy (Floyd, Scogin, & McKendree-Smith, 2002). They complained of havingto re-read the same paragraph several times and still not retaining the information. Theytended to become very frustrated with themselves and drop out of treatment. Second,bibliotherapy seems to be particularly difficult for clients who are having problems withmotivation and behavioral initiation. Clients with such problems do better with a psycho-therapist because the therapist can help specifically with these deficits whereas biblio-therapy alone puts the entire burden on the client. The third observation is that if a clientis not responding well to individual psychotherapy, the chances are slim that addingbibliotherapy will improve outcome. Nonresponders to bibliotherapy also failed to respondto 16 sessions of individual cognitive psychotherapy. Therefore, the overall suggestion isthat for depressed older adults, bibliotherapy is probably not going to be an effectiveadjunctive treatment if the client has subjective cognitive limitations, trouble with moti-vation and/or initiation, or has not responded to individual psychotherapy.

The next topic to address is what books are suitable for use as an adjunctive treat-ment. Research on bibliotherapy indicates that practitioners have utilized a variety ofbooks (Starker, 1988a, 1988b). In a recent review of self-administered treatments fordepression (McKendree-Smith, Floyd, & Scogin, in press), the two most frequently usedbooks in bibliotherapy research were Feeling Good (Burns, 1980), which was used in sixstudies, and Control Your Depression (Lewinsohn et al., 1986), which was used in twostudies. Furthermore, the depression-specific Feeling Good was more effective than theinspirational (nonspecific) Man’s Search for Meaning for the treatment of depression inolder adults. Thus, based upon the extant literature, it would seem that the depression-specific books are better suited for the bibliotherapy of depression.

The Case of Jack

Client Description

Jack, a 62-year-old White male, presented with complaints of sadness, loneliness, andguilt that had not resolved since his wife’s death approximately three years earlier. Hiswife had died of breast cancer after several painful years. She lived her last six months intheir home under hospice care. Jack was attentive and supportive, spending all his “free”time with her and denying himself recreation or social activities. However, he continuedto work. (It is notable to mention that his wife had strongly encouraged him to continueworking instead of retiring early.) He felt terribly guilty that he had not retired from hisjob earlier and spent more time with her (“I placed more priority on income than on beingwith her”). Jack was an avid golfer and appeared to be in excellent physical condition.However, he had a myocardial infarction at age 45 and had been treated for hypertensionsince that time. His father had died at age 70 after a series of progressively debilitatingstrokes beginning at age 60. Jack expected a similar fate, given his family and personal

Bibliotherapy as an Adjunct 189

history. Jack had an undergraduate degree in accounting and had recently retired after 40years of service with the same accounting company. He did not have any children andlived 750 miles from his only close relative, a younger brother. Jack reported beingsocially active and having several good friends he saw on a regular basis at church andwhile golfing. Jack’s symptoms met criteria for Major Depressive Disorder, ChronicEpisode. Jack did not meet the full criteria for Dependent Personality Disorder, but haddependent features that were obvious in therapy and in his relationships with women.

Case Formulation

Jack’s current depressive episode was the product of an interaction among the loss of hiswife, his dependent tendencies, and his fear of having a disabling heart attack or stroke.His wife had been his primary connection his entire adult life. They did virtually every-thing together, and the loss created a substantial void in his life. His primary core beliefsin this area were “I cannot be happy unless I have a loving, caring wife” and “Lifewithout love (being happily married) is meaningless.” Furthermore, Jack reported that herelied upon his wife for all decisions and was reluctant to initiate much without hersupport. Although he had several good friends, he also admitted that he did not discusshis feelings with them and had received all his emotional support from his wife. Hisprimary core belief in this regard was “I cannot make it on my own.” This belief wasparticularly salient for him because he felt threatened by his health condition and increas-ing age. He was convinced that within a few years his vascular system would begin aprogressive deterioration that would render him incapable of self-care. His dependenttendencies had a particular urgency because he perceived the lack of a significant other asbeing not only a threat to his emotional well-being but also a threat to his survival. Hiseagerness to find a spouse led him to become involved with women who took advantageof him. These negative relationships compounded his sadness, and he became hopelessthat he would ever find a suitable spouse. This hopelessness further increased his exis-tential fears, which in turn increased his perceived needs for a suitable spouse.

Course of Treatment

In accordance with cognitive-behavioral therapy, the first session involved building rap-port, identifying goals, and explaining the treatment rationale. Rapport-building was easy.He seemed eager for therapy and enjoyed talking about his problems. His therapy goalswere to alleviate his sadness and guilt. He understood the treatment rationale, and itappeared we were well on our way to a good therapeutic relationship. In the secondsession, he reported that he had looked up cognitive therapy in the library and that AlbertEllis and Aaron Beck were the “founders” of CBT. He was indeed motivated for therapyand had the initiative to work independently. Furthermore, he enjoyed reading and research-ing topics at the library. When he asked if there were any good books to read on CBT, Isuggested Feeling Good (Burns, 1980), an excellent book on cognitive therapy for depres-sion. Jack was diligent in his reading and quickly developed a good working knowledgeof cognitive techniques. In each session, he would bring in examples of how he hadsuccessfully used what he had read, and we would work together to solve the problems hehad trouble with. After several such sessions, we had eliminated his guilt. He was takingthe lead during therapy and was making excellent progress on reducing his sadness. I wasbeginning to anticipate termination.

A recurrent difficulty for him at this point in therapy was that he persisted in arelationship with a woman who was taking advantage of him. However, instead of focus-


ing on problem solving, he began telling me about what had happened to him in the lastweek. I found that I was not as engaged during the sessions, and I was sometimes havingtrouble staying alert. I realized our therapy had changed. It occurred to me that he knewhow to solve his problems and that something must be preventing him from taking thesteps towards termination, in both his romantic relationship and in psychotherapy withme. In the next session, when he began in story-telling mode, I asked him about this. Hesaid he did not think he was capable of functioning alone. In terms of therapy, he attrib-uted his improvement to me, and in terms of his romantic relationship, he said a badrelationship was better than no relationship. His core beliefs regarding his inability tomake it on his own or to be happy on his own were still intact.

I challenged his attribution for his improvement, pointing out how much he knewabout cognitive therapy and how well he had used it on his own. We conducted a briefreview of the evidence, and he concluded that in most cases, he had been able to success-fully use cognitive therapy during the week on his own. In the few cases that he not beenable to solve the problem independently, he had not required much assistance from me.We likewise examined the evidence regarding his current romantic relationship, and heconcluded that it was a greater source of anguish than joy. He said that the only reason hehad continued was that he was afraid he would not be able to find a better relationship.We agreed that he needed to challenge that fear and to also challenge the belief that hehad to have a relationship at all.

He soon ended the romantic relationship, and we worked on the grief and othernegative emotions associated with the breakup. For a few weeks, he resisted the urge toinitiate another relationship. He became involved with another woman; however, thistime he was aware of his motivations and was continually checking his negative thoughts.He was having a good time with her, and he also began to experience a joy associatedwith his individual activities (e.g., golf, reading, walking) and became comfortable withbeing alone. His mood had returned to normal. At our termination, he was still concernedabout the possibility of his physical deterioration, but for different reasons: He did notwant his lover to experience the sadness associated with care giving. He expressed hisconcerns to her, and they resolved it together.

Outcome and Prognosis

Jack’s outcome was excellent. His depression had been successfully treated, and he wasmaking continual progress on changing some dysfunctional personality characteristics.He had learned how to use cognitive techniques and had practiced them in numeroussituations. He had identified and addressed his primary dysfunction beliefs. Thus, he waswell prepared to deal with future negative events. Two obvious scenarios that would bedifficult for him would be the loss of his relationship or a major health problem. How-ever, he had been dealing with these concerns, and I think he was prepared for both. Wewere both confident that he would seek treatment before he became depressed, and thathis approach to therapy would make future treatment a success.

Clinical Issues

Bibliotherapy was an appropriate recommendation in this case because the client was anavid reader, had taken the initiative to research CBT on his own, and asked the therapistfor recommended readings. Furthermore, the client showed no signs of resistance ormotivation problems. The advantage of bibliotherapy in this case was that it facilitated


self-efficacy in a client with significant dependent characteristics. The client was able toquickly gain an expertise in CBT and use it on his own. He took responsibility for hisown treatment, thus lessening his dependency on the therapist. If bibliotherapy had notbeen used, treatment with this client probably would still have been successful, but itwould have been lengthier.

The Case of Sarah

Client Description

Sarah, a married 65-year-old White female, presented with sadness, lack of motivation,anhedonia, guilt, thoughts of death, fatigue, hopelessness, memory complaints, and insom-nia. Sarah was in otherwise excellent physical health. Sarah had three children (all girls),eight grandchildren, and two great-grandchildren. All the family members lived within ahalf-hour drive and frequently visited Sarah and her husband. Sarah had been a house-wife all her life, and her family had always been her top priority.

Her husband suffered a myocardial infarction at age 39 and, although he fully recov-ered, Sarah was constantly aware of her husband’s condition. In particular, she feared thather children would grow up without a father. To compensate for this potentially fore-shortened time together, Sarah chose to do everything she could to maximize the freetime her husband had with the children. For example, Sarah would do all the work aroundthe house and yard rather than allow others to help her. Thus, while Sarah worked, thechildren and husband enjoyed their time together.

The consequences of her decision were that everyone took her work for granted.Sarah’s husband retired five years ago and did not assist around the home. Her childrenexpected her help for everything from ironing and babysitting to shopping and errands.Sarah typically did not have the time to participate in the family fun activities, and onthose rare occasions when she did, she felt like she did not fit in. She said: “It’s like myhusband and the kids have a special club, and I don’t have a membership card.” Althoughnot on her initial list of presenting problems, Sarah resented the way her family treatedher.

Unfortunately, Sarah’s family was not the only group of people that Sarah served.She also was a devout Methodist and seemed to be doing the lion’s share of the work forher church’s activities. When the pastor asked for volunteers, he would always look inSarah’s direction, and she would oblige.

Sarah said her mood problems began a few months after her husband’s retirementand had been getting progressively worse. Her mental status had deteriorated to the pointthat it was a struggle to get out of bed and move to the living room to spend the day in theeasy chair. She said she was afraid to wait any longer to seek treatment, considering theway it had progressed from mild to severe. Sarah’s symptoms met the criteria for MajorDepressive Disorder, Chronic Episode.

Case Formulation

Sarah was a very religious woman. She believed that the ideal Christian mother wouldconduct herself in a self-sacrificing manner, placing others’ wants and needs before herown. Pleasure seeking would not be consistent with self-sacrifice; the ideal Christianmother would derive joyful satisfaction from her service. Thus, her core belief was that ifshe were a good person, she should entirely give herself to others and feel good about hersacrifice. Although she was able (for many years) to work in a self-sacrificing manner,


she did not enjoy it. She no longer could motivate herself to serve others, and she wascraving some of the recreation time that others had. She interpreted this as being selfishand sinful. In addition, she was angry with the people she served, and anger was sounacceptable to her that she condemned herself for it. Thus, Sarah’s depression stemmedprimarily from her perfectionistic attitudes.

A second contributor to Sarah’s depression was that she lacked the assertiveness torefuse a request. Thus, not only was refusing to serve a sin in her eyes, on those rareinstances when she wanted to refuse, she still could not say “no.” To recover from depres-sion, Sarah would have to relax her standards and set appropriate boundaries to allowherself time for rest and recreation. This was not going to be easy because Sarah, likemany women in the current cohort of older adults, had been taught to be unassertive.

Course of Treatment

Sarah was timid in the early sessions, but she readily provided sufficient information toidentify her problems. Her therapy goals were to improve her depression and increase herassertiveness. Her activity recording sheet revealed that she was not doing much morethan watching television. Behavioral activation was essential; however, increased activa-tion would not help if she were only to return to being overwhelmed by her family’srequests. Thus, it appeared from the beginning that we would be led into a direct con-frontation with her perfectionistic standards and lack of assertiveness.

Rather that confront directly, I encouraged her to adopt the sick role. I explained thatone of the key characteristics of depression is a lack of motivation and that to overcomethis, it is best to start with activities that are fun. She resisted initially, saying that it wasbeing selfish, but she said it made good sense and accepted the strategy. We declared theeasy chair in front of the television as being her worst enemy, and developed a list of funactivities for her to do each day. Fortunately, her family had been so worried about herlethargy that they were glad to see her being active again and did not ask her to doanything. This “vacation” lasted about two weeks before she began to perceive her familyresuming their prior expectations for her.

At this point, psychotherapy with Sarah was a precarious balance. Her increase inactivity level had made her family comfortable enough to ask for her help. In one sense,this was progress because it would give Sarah practice in assertiveness and in the iden-tification of dysfunctional thoughts. In another sense, too many requests would probablyforce her to retreat to the easy chair. There was not enough time in a session to provideadequate instruction in both assertiveness and cognitive techniques. I was afraid that wewould not progress quickly enough to meet the demands in her life. She needed morefrequent sessions, but unfortunately her schedule would not permit more than one sessioneach week. Sarah had completed all the homework tasks to date, and I knew reading hadbeen one of her fun tasks in the prior weeks, so I asked if she were willing to read a bookon assertiveness. She agreed, and I recommended When I Say No, I Feel Guilty (Smith,1975). She really liked the sound of the book title and promised to stop at a bookstore onthe way home after the session. The book defines assertiveness, gives a list of reasonswhy it is appropriate to be assertive, and provides examples of assertive behaviors in avariety of situations.

Her willingness to use bibliotherapy allowed me to concentrate on modifying herperfectionistic beliefs. In more of a rational disputation method, we discussed what itmeant to fall short of her standards. She acknowledged that no one is truly perfect andthat God is very forgiving. She agreed that God would not want her to go through life


denying herself the basic joys of having some free time to pursue hobbies or recreation.She gradually came to accept that even a life dedicated to serving others also couldinclude some time off. The question that remained for her was one of balance—howmuch service and how much recreation would be the proper mix.

Since she did not know what the “balance” should be, it was initially difficult torefuse requests without experiencing negative affect. She had been reading the book andpracticing assertiveness, so we had the opportunity to capture her thoughts. At this point,we became aware that she not only had perfectionism but also a significant need forapproval from others. Thus, whenever she was assertive and refused a request, she wasfighting such thoughts as “They’ll think I’m not a good Christian,” “They’ll think I’mlazy,” and “They won’t like me.” The assertiveness book seemed essential at this pointbecause the reasons for being assertive listed in the book reinforced our discussions ofwhy she should stand up for herself despite her negative thoughts. We tested these thoughtswith her family and her church members. Progress was slow, but she continued to workhard practicing her assertiveness and modifying her attitudes.

Outcome and Prognosis

At the time of termination, Sarah was choosing which activities to do and working towardsa good balance between fun and service. She reported occasionally being manipulatedinto doing things for others, but she accepted that she would continue to make mistakesand that the important thing was to learn. In such instances, she reported being able to dothe work without becoming resentful. She no longer had problems with anger or depres-sion. I expected her to continue to improve and, ultimately, to find a balance that wasacceptable to her.

Clinical Issues

In this case, bibliotherapy was an excellent supplement to therapy. She was able to learnhow to be assertive from reading the book and could begin practicing on her own. Equallyimportant, the book has a compelling logic for why assertiveness is good. This wasimportant in Sarah’s case because her dysfunctional attitudes were so deeply ingrainedand she benefited from multiple sources of “evidence.” The most salient argument forbibliotherapy in this case was that she needed more therapy sessions than was possible.The supplemental instruction in assertiveness seemed to be the deciding factor in theoutcome of this case.

Conclusions

The two cases illustrate that bibliotherapy can be a useful adjunct to psychotherapy fordepressed older adults. In both cases, the clients were able to learn quickly on their ownand apply their knowledge to not only alleviate their depression but also to modify long-standing beliefs and interpersonal patterns. I would reemphasize that it is probably unrea-sonable to expect all clients to benefit from adjunctive bibliotherapy. Both clients describedin this article were avid readers and open to the therapist’s suggestions, and as such, theywere unlikely to have a negative reaction to bibliotherapy. When used appropriately,adjunctive bibliotherapy should facilitate more rapid improvement and compensate forany limitations in the number of psychotherapy sessions. This could be a critical consid-eration given the current domination of the managed-care industry.


Select References/Recommended Readings

Beck, A.T., Rush, J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York:Guilford Press.

Blazer, D. (2002). Depression in late life (3rd ed.). New York: Springer.

Burns, D.D. (1980). Feeling good. New York: Avon.

Cuijpers, P. (1997). Bibliotherapy in unipolar depression: A meta-analysis. Journal of BehaviorTherapy and Experimental Psychiatry, 28, 139–147.

Floyd, M., Scogin, F., & McKendree-Smith, N. (2002). Subjective cognitive problems: A contra-indication for the use of bibliotherapy for geriatric depression? Manuscript in preparation.

Floyd, M., Scogin, F., McKendree-Smith, N., Floyd, D., & Rokke, P.D. (in press). Cognitive ther-apy for depression: A comparison of individual psychotherapy and bibliotherapy for depressedolder adults. Behavior Modification.

Frankl, V. (1959). Man’s search for meaning. New York: Pocket Books.

Gould, R., & Clum, G. (1993). A meta-analysis of self-help treatment approaches. Clinical Psy-chology Review, 13, 169–186.

Lewinsohn, P., Munoz, R., Youngren, M., & Zeiss, A. (1986). Control your depression. EnglewoodCliffs, NJ: Prentice Hall.

McKendree-Smith, N.L., Floyd, M., & Scogin, F. (in press). Self-administered treatments for depres-sion: A review. Journal of Clinical Psychology.

Scogin, F., Hamblin, D., & Beutler, L. (1987). Bibliotherapy for depressed older adults: A self-helpalternative. The Gerontologist, 27, 383–387.

Scogin, F., Jamison, C., & Gochneaur, K. (1989). Comparative efficacy of cognitive and behavioralbibliotherapy for mildly and moderately depressed older adults. Journal of Consulting andClinical Psychology, 57, 403– 407.

Scogin, F., & McElreath, L. (1994). Efficacy of psychosocial treatments for geriatric depression: Aquantitative review. Journal of Consulting and Clinical Psychology, 62, 69–74.

Smith, M.J. (1975). When I say no, I feel guilty: How to cope—using the skills of systematicassertive therapy. New York: Bantam.

Starker, S. (1988a). Do-it-yourself therapy: The prescription of self-help books by psychologists.Psychotherapy, 25, 142–146.

Starker, S. (1988b). Psychologists and self-help books: Attitudes and prescriptive practices of cli-nicians. American Journal of Psychotherapy, 42, 448– 455.


bibliotherapy as an adjunct to psychotherapy for depression in older adults

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