Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach

Background and Significance: The treatment of personality disorders in older adults, particularly those co-morbid with other Axis I disorders (e.g., Major Depressive Disorder), is an understudied clinical phenomenon. It has also been demonstrated that personality disorders in older adults complicate treatment of other psychopathology, as well as result in heightened interpersonal disturbance and emotional distress.Methods: Two studies utilizing standard Dialectical Behavior Therapy (DBT) to treat depression and personality disorders in older adults are reviewed. Study 1 examined 34 chronically depressed individuals aged 60 and older who were randomly assigned to receive 28 weeks of antidepressant medication plus clinical management, either alone (MED) or with the addition of DBT skills-training and scheduled telephone coaching sessions (MED?+?DBT). Study 2 had two phases of treatment: Phase I: 8-week open-trial of antidepressant medication (n?=?65); Phase II: 24-week randomized trial of DBT?+?MED versus MED alone for those who prospectively failed to respond to the Phase I medication trial (n?=?37).Results: Study 1 demonstrated that 71% of MED?+?DBT patients were in remission at post-treatment, in contrast to 47% of MED patients. This became a significant difference at the 6-month follow-up; where 75% of MED?+?DBT-D patients were in remission compared with only 31% of MED patients. Study 2 showed that after 8 weeks of treatment with antidepressant medication alone (Phase 1) only 14% of the sample had at least a 50% reduction in HAM-D scores. Phase II results showed on average, the DBT?+?MED group reached depression remission by the post-group assessment and maintained these gains while the MED group did not reach remission, until the follow-up assessment. Results demonstrated superiority of DBT?+?MED compared to MED alone on Interpersonal Sensitivity and Interpersonal Aggression at post-treatment and 6-month follow-up.Conclusion: Results from these two treatment development studies indicate that applying standard DBT for the treatment of co-morbid MDD or MDD?+?PD in older adults is feasible, acceptable, and has clinical promise. Modifications to standard DBT and an overview of a new treatment manual for this population are summarized.