1. The programme at a glance
Indication. A major depressive episode, or a long-lasting depression, in an older person who lives at home or in residential care: in practice, from about sixty onwards, the inclusion age of most trials. The programme is also suitable when the depression comes with executive difficulties, that is, difficulties in planning, organising and starting an action, or with a mild neurocognitive disorder. Severe depression calls first for a medical opinion, and established dementia for other manuals (sections 2 and 9).
Reference model. Four psychotherapies evaluated in older people, with probably comparable effects (Cuijpers et al., 2026), brought together in a single protocol: behavioural activation (Orgeta et al., 2017), problem solving adapted to executive difficulties (Areán et al., 2010), a cognitive behavioural therapy that takes age into account (Laidlaw et al., 2004), and life review (Bohlmeijer et al., 2003). The whole is coordinated with the registered family doctor (médecin traitant, a provision of French law; elsewhere, the local equivalent), on the principle of the collaborative care of the IMPACT trial (Unützer et al., 2002): follow-up that is measured, shared, and adjusted when the depression does not give way (section 18). Each of these approaches has data at this age; bringing them together in twelve sessions is a choice made by this programme, and that combination has not been evaluated as such (section 15).
Format. Twelve individual sessions of 45 to 50 minutes, once a week, at the practice, at home, or by telephone or video when the person cannot travel. Twelve weekly sessions is the format of the two reference trials in depressed older people with executive or cognitive difficulties (Areán et al., 2010; Kiosses et al., 2015). When fatigue makes it necessary, sessions can be shortened to thirty minutes, up to sixteen sessions at most: this adjustment has not been evaluated (section 18). Someone close to the person can join the end of sessions. Three booster sessions follow, at one, three and six months.
Mechanism targeted. Four changes. Putting back into the week activities that bring pleasure or a sense of being useful, taking into account the real limits of the body. Replacing helplessness in the face of practical problems with a method that takes them one at a time. Loosening the beliefs that close the door, such as "at my age, there's no point any more" or "I'm a burden". And distinguishing, in what life has taken away, what is really lost from what the depression has led the person to give up, so as to take back what can be taken back.
| Session |
Focus |
Session output |
| 1 |
Assess, make safe, measure |
Risk assessed, baseline measures, letter to the doctor |
| 2 |
Understand and agree |
Circle drawn, two or three goals written down |
| 3 |
Observing one's days |
One week recorded, list of what has disappeared |
| 4 |
Getting going again |
Three dated activities, adjusted to the body |
| 5 |
One problem at a time: defining |
One problem defined, solutions listed |
| 6 |
One problem at a time: acting |
A plan tried out, interim measures |
| 7 |
What I tell myself |
A belief put to the test |
| 8 |
What is lost, what remains |
An activity adapted rather than given up |
| 9 |
Connection |
Two contacts scheduled |
| 10 |
The thread of my life |
Two periods reviewed, specific memories written down |
| 11 |
What still matters |
What matters, linked to dated plans |
| 12 |
Review and plan for what comes next |
Measures repeated, written plan, dated boosters |
What the person takes away. Nine printable worksheets, including a safety plan, a worksheet for those close to the person and a plan for what comes next (section 41).
What distinguishes this programme from the other manuals on this site. Treating depression in adults: a therapist's manual remains the reference at any age, and this manual refers to its way of conducting activation and to its section on suicide risk. It deals with what changes with age: what belongs to the doctor and the distinction from a neurocognitive disorder, two interventions that have data specific to this age — adapted problem solving and life review —, and a format that goes towards the person, because those who need it most are often those who do not come.
2. Before you begin
The four preliminary decisions
What is the suicide risk, today? It is asked about at the first session, without exception, and all the more so in an older man, because it is at this age and in men that suicide rates are highest (section 13). Acute risk is dealt with before everything else; risk that is present but contained requires a written safety plan, without suspending the programme.
Has a medical assessment been carried out for this reason? In an older person, an illness or a medicine can explain or worsen the picture. If the doctor has not seen the person for this low mood, the first session prepares a letter, and the programme begins in parallel (section 12).
Does cognition allow the programme? A memory complaint, common in depression, settles nothing on its own. Executive difficulties or a mild neurocognitive disorder do not prevent the programme: they change how it is conducted (section 33). A major neurocognitive disorder that has already been diagnosed, that is, a cognitive decline that compromises independence, belongs to the manuals devoted to dementia (section 9).
Is it in fact bereavement? Intense sadness in the months following the death of a spouse is not, on its own, a depressive episode, and prolonged grief belongs to Treating prolonged grief in adults: a therapist's manual (section 11).
What this programme does not treat
It does not treat on its own a severe depression with delusional ideas, refusal to eat or extreme slowing. These situations call for a rapid psychiatric opinion, sometimes for hospital admission; the programme resumes afterwards (section 16). Nor does it replace the doctor: the decision about medication, the review of treatments and the search for a physical cause belong to the doctor (section 12).
How to use it
Read the whole thing before the first session, in particular sections 9, 12, 13 and 33: the distinction from a neurocognitive disorder, what belongs to the doctor, suicide risk, and adapted problem solving.
One warning concerns you: some therapists expect less of an older person without realising it, especially when that person is ill or has suffered losses, and put down whatever does not shift to age; Laidlaw et al. (2004) describe this bias.
3. Four presentations not to be confused
When an older person "is not doing well", four situations are possible, and they do not call for the same approach.
1. The sadness to be expected after a loss
What you observe. After the death of someone close, an illness, a house move or the move into residential care: sadness, tears, disturbed sleep, a withdrawal lasting a few weeks.
What points the way. The sadness is linked to the loss and comes in waves. Between two waves, the person can still feel pleasure, and their self-esteem holds.
What this implies. Listening, support, keeping up activities and relationships, and a reassessment a few weeks later. No treatment for depression. The guide for the general public Grief: understanding it, getting through it, and knowing when to ask for help can be given to the person.
2. The depressive episode
What you observe. For at least two weeks, nearly every day, a sad mood or a loss of interest and pleasure, with other manifestations: fatigue, disturbed sleep and appetite, slowing, guilt, thoughts of death. At this age, the sadness may be missing (section 4).
What points the way. Its pervasiveness: everything has gone out, not only what touches on the loss, and the person runs themselves down.
What this implies. The programme described here, with a medical assessment.
3. The neurocognitive disorder that is beginning
What you observe. A gradual decline in memory or other functions, often noticed by those around the person more than by the person, with apathy, that is, a loss of initiative without sadness: the person no longer gets started, but does not say they are suffering.
What this implies. A medical and neuropsychological assessment, and section 9, which says what points the way. The two pictures often coexist.
4. Confusion and a medical cause
What you observe. A rapid change, over a few hours or a few days: disorientation, inattention, drowsiness or agitation that vary over the course of the day. Or else a depressive picture that appeared at the same time as an illness or a new treatment.
What points the way. The speed, the fluctuations, and the link in time with a medical event.
What this implies. Confusion is a medical emergency: a doctor the same day. A physical or medication-related cause calls for a rapid medical opinion (section 12).
The three sorting questions
"Since when, and what changed at that time?" It places the onset, and it brings to light a loss, an illness or a new treatment.
"What still gives you pleasure, even a little?" It distinguishes a sadness centred on a loss from a loss of pleasure that extends to everything.
"And those close to you, what have they noticed?" It opens up the cognitive question, which the person alone cannot always settle.
4. What is specific to this age: presentations that are often atypical
The criteria are the same
Depression shows itself in older people through the same symptoms as in younger adults. What differs is the context: several illnesses at once, cognitive difficulties more often, and a depression that is frequently neither identified nor properly treated (Kok and Reynolds, 2017). The presentations that follow help to understand why it goes unnoticed.
Depression without sadness
Many depressed older people do not say they are sad. They describe fatigue, a loss of interest, slowing, an absence of desire. This picture is not benign. In a cohort followed for thirteen years, people aged fifty and over who had depressive symptoms without sadness had an increased risk of death, of loss of independence and of cognitive decline, compared with those who had no symptoms (Gallo et al., 1997).
What this changes. You do not settle for asking "are you sad?". You also ask what still interests the person, what gives pleasure, what has been given up, and how the days go.
Bodily complaints
Fatigue, pain, digestive problems, sleep, appetite and weight loss are often to the fore. The French recommendations on psychological suffering in older people estimate that two thirds of the complaints linked to depression are expressed through the body (Agence nationale de l'évaluation et de la qualité des établissements et services sociaux et médico-sociaux [French national agency for the evaluation and quality of social and medico-social establishments and services], 2014).
What this changes. Two symmetrical errors are to be avoided: attributing everything to the illnesses, and attributing everything to the depression. The doctor explores the physical side; you explore what has changed in the person's life, and when.
Anxiety
Worries about health, fear of falling, the fear of being a burden, fear of going out or of being alone, agitation, repeated calls to those close: anxiety often accompanies depression at this age, and it sometimes masks it. Generalised anxiety that persists after the depression is treated in its own right, with Treating generalised anxiety disorder in adults: a therapist's manual.
The memory complaint and slowing
Depression slows thinking, interferes with concentration and makes memory less reliable, and the person sometimes complains a great deal about it. Section 9 says how to distinguish it from a neurocognitive disorder.
Withdrawal, irritability and refusal
Withdrawal from activities and relationships, a new irritability towards those close, refusal of help or of care, self-neglect — meals, hygiene, medicines — can be the way a depression shows itself. Refusal to eat, staying in bed, or a rapid withdrawal after a medical event call for a medical opinion the same day. And the conviction of being ruined, guilty of a grave fault or suffering from an incurable illness signals a delusional form, which is serious and calls for a rapid psychiatric opinion (section 2).
"It's just age"
Most older people are not depressed. A major depressive episode affects about 2% of adults aged 55 and over, with a frequency that increases with age, and 10 to 15% of older people have clinically significant depressive symptoms without meeting the criteria for an episode (Kok and Reynolds, 2017). In residential care settings, the frequency is higher: in a systematic review, the median prevalence was 10% for major depressive episode and 29% for depressive symptoms (Seitz et al., 2010).
What this changes. Depression is not a normal stage of ageing. The phrase "it's normal at their age", said by the person, by those close and sometimes by professionals, is one of the attitudes that keep older people away from the care they would need (Conwell et al., 2011).
5. What maintains depression at this age
Losses, and what they take away
With age, losses add up: people close who die, health that deteriorates, independence that shrinks, roles that disappear — work, the place of parent, sometimes that of carer —, the driving licence, the home. Each one takes away sources of pleasure, of a sense of usefulness and of contact. This is the behavioural model of depression, described in section 4 of Treating depression in adults: a therapist's manual: fewer activities that bring something, so less desire, so even fewer activities.
Withdrawal that goes beyond the loss
This is the most useful mechanism to identify. A real loss imposes part of it; the depression adds the rest. "I can't walk for long any more, so I don't go out any more." "I can't hear well in noise any more, so I don't go to family meals any more." The limit is real; the conclusion is all or nothing. The withdrawal extends well beyond what the limit imposes, and each week without activity adds fatigue and physical deconditioning.
Isolation and loneliness
Isolation is a fact: few contacts. Loneliness is a feeling: the gap between the relationships one has and those one would like. The two do not overlap, and loneliness is maintained by expectations: "I don't want to be a bother", "they have their own lives", "nobody is interested in old people any more". Among the interventions against loneliness evaluated in randomised trials, the most effective are those that work on these ways of thinking about others, more than those that merely multiply the opportunities for contact (Masi et al., 2011).
Practical problems that pile up
Paperwork that is overdue, a home that is no longer suitable, medical appointments to organise, a question of money, a family conflict. In a depressed person, and even more in someone whose executive functions have declined, these problems do not get solved: they pile up, and their accumulation produces a sense of helplessness that feeds the depression. This is the target of problem solving (sessions 5 and 6).
Beliefs about age and about oneself
"I'm a burden to my children." "At my age, you don't change any more." "I'm no use to anyone any more." "It's not worth starting anything any more." These phrases mix generational beliefs, stereotypes about old age that the person has made their own, and the distorted reading that belongs to depression. The feeling of being a burden matters particularly: the interpersonal theory of suicide makes it one of the two proximal sources of the desire to die, and it is a theme clinicians often hear in older people at risk, even though it has been less studied than the other factors (Conwell et al., 2011).
The body
Pain, insomnia, sensory deficits, certain medicines and alcohol lower activity and mood. They belong to the doctor and to other manuals (sections 10 and 12), but they are part of the circle.
The complete circle
A loss reduces activities, and so pleasure, usefulness and contact; mood drops, fatigue increases, and the withdrawal extends beyond what the loss imposed. Problems pile up, beliefs are confirmed — "you can see I'm no use to anyone any more" —, and mood drops further. This is the diagram you draw with the person at session 2.
Frequently asked questions
The person says it's normal, at their age. What should I reply?
That most older people are not depressed, that depression is not a stage of ageing, and that psychological treatments work at their age as they do in younger people (sections 4 and 15). Then suggest a very small first step, so that they can see it for themselves.
She has memory problems. Is it dementia, and is the programme still possible?
Often you do not know straight away: you treat the depression and reassess cognition once mood has improved (section 9). With executive difficulties or a mild neurocognitive disorder, the programme remains possible, with a written summary, someone close acting as a relay and the problem-solving variant (section 33).
He says he has lived long enough. Is that a suicidal thought?
Not necessarily, but the question must be asked: "Do you sometimes think about ending your life?" What should alert you is intent, a plan, preparations, and access to means (section 13).
Should I use the PHQ-9 or the Geriatric Depression Scale?
The PHQ-9 by default, because its sensitivity to change has been established in older people and response and remission have published benchmarks on it. The GDS when illnesses make the PHQ-9's questions about sleep, appetite and fatigue impossible to interpret, or when the care home already uses it. In all cases, the same scale from beginning to end (section 14).
She cannot travel. Is the telephone enough?
The data on home-based and video work are favourable (section 15). By telephone, send the worksheets beforehand, dictate the summary at the end, and always know where the person is and who can be reached.
The family wants to attend every session. Should I agree?
No. Always see the person alone for at least part of the session: some things are not said in front of a child. The relative joins the end of sessions, with the person's agreement (section 18).
She is already taking an antidepressant. Is the programme worthwhile?
Yes. Psychotherapy is added to the medication, in particular for activities, practical problems and connection, which the medication does not treat. The management of the medication remains the doctor's (section 16).
Is life review likely to stir up painful memories?
It can bring some back. It forces nothing, the person chooses what they tell, and a traumatic memory that comes back with intrusive images calls for an assessment of its own (section 34).