Psychosocial aspects of the development of depression in later life and possibilities for using group psychotherapy

The psychosocial aspects of depression in later life and possibilities for using group psychotherapy Introduction

According to Litomerický [1], aging is a complex and variable process that is modifiable by environmental, chemical, and physical influences, but it is also influenced by genetic factors and diseases. It is a process conditioned by the effect of time on the functioning of organs and the entire organism and applies to the entire animal kingdom, with specific age-related changes in various organ systems. Aging is an inevitable and, in essence, continuous phenomenon that appears in the life of every human being [2].

This process is characterized by the fact that it is long-term encoded, irreversible, non-repeating, and leaves lasting traces. Aging ends in old age, while old age as a stage of human life occurs at the end of the individual's natural developmental process [3]. In this context, Hrozenská [2] argues that old age, as one of the later stages of an individual’s ontogeny, is a manifestation and consequence of involutional and morphological changes that show different variability among people. Old age is divided into age-bound stages: early old age (60 to 74 years), old age proper (75 to 89 years), and longevity (90 years and above) [4].

Because of the topic, it is important to define some terms related to aging and old age. These include: senium—a term covering the entire age stage after the age of 60; older age—from 60 to 74, where the individual is referred to as an older person and is classified in educational activities among younger seniors; old age—from 75 to 89, where the individual is in the stage of old age proper and is placed among older seniors in educational settings; and longevity—from 90 years and above [5]. Determining when a person becomes “older” is, however, highly relative. The terms senior/senior, senescent, geront, older person, person in the post-productive or post-retirement age, retiree, etc., are used in social sciences to denote the period of aging and old age. Reflecting on the most precise terminology, a dilemma arises as to which term to choose. We believe that the term senior is the most suitable and most direct designation for a person in older age [6]. Paľa argues that the issue of old age is always complex and has simultaneous biological, psychological, and social dimensions. The basic cause of biological changes in old age is wear and tear of individual organs, a slower metabolism, and reduced ability of biological adaptive mechanisms. In the aging process, qualitative shifts also occur in thinking, memory, motivation, and emotions. There is an overall slowing of mental functions, manifested especially in perception and responding. Perception of relationships, ability to form concepts, reasoning, and abstraction decline with age, while the use of analogy in solving new problems, based on prior experience, increases with age. The social character of aging is often linked to adaptability, but this is weakened by altered functional status and increased morbidity. Social aging also influences the older person’s ability to adapt to the changes brought by old age [7, 8].

Thus, old age is a life stage characterized by both external and internal changes. A person’s taste, lifestyle, standards, social contacts, and mental and physical disorders change. A large group of seniors’ illnesses consists of mental disorders, especially major and minor depressive episodes. We can state with confidence that discussions about the specifics of mental disorders in older age have been ongoing for a considerable time. It is true that some diagnoses have been defined by professionals as typical of old age. This includes, for example, endogenous depression in old age, which came to be called involutional depression [9]. Such a view, however, does not change the fact that untreated or undiagnosed depression clearly threatens quality of life and substantially shortens a senior’s life. A person with depression can benefit from appropriately chosen and implemented treatment at any age. Involutional depression in older adults is associated not only with involutional changes but also with adverse life situations that occur more frequently in later life than during productive life.

Depression is fundamentally a mood disorder. Core symptoms include pathological sadness, sadness, depressive, helpless, or dysphoric mood, hopelessness, helplessness, despair, often anxiety, tension, unjustified fear, or irritability, dysphoria, emotional lability, anhedonia, reduced energy, and increased fatigue [10]. Depression is currently among the most common psychiatric disorders. Its prevalence among women is about twice that among men, and it can occur at any age. An untreated depressive episode lasts 6–24 months, yet almost 12% of patients do not recover even five years after its end. In terms of severity, depression is classified as mild, moderate, or severe (major) [10, 11]. Depression is not ordinary irritability, short-lived dysphoria, low mood, or sadness. These so-called depressive states occur in bad weather, after tiring full-day work, after poor sleep, or heavy demands, and they can generally be overcome through increased activity, rest, sleep, food, or increased vitamin intake [10]. In differential diagnosis and comorbidity of depression, it is necessary to distinguish depression from lowered mood or grief after the loss of a loved one. Worsened mood, grief after loss of an important person or values are frequent mental expressions and part of ordinary human experience. In many cases, sadness or grief is not depression, and therefore confusing it with depressive disorder is inappropriate [11]. In the symptomatology of chronic grief, the self-directed cognitive features, along with persistent and irrational hopelessness, are absent, while this state is associated with suicidal thoughts and worthlessness [12]. In an individual with depressive disorder, at least 4 depressive symptoms are found on psychiatric examination that persist for at least 2 weeks, are intense and sustained, and impair functioning across life areas [10].

In diagnosing depression, attention is focused on psychological, social, and biological areas. In the biological domain, we assess sleep disturbances, eating patterns, and reduced energy. In the social domain, we examine sources of social support, but we also consider social relationships, financial security, and housing. In the psychological domain, we emphasize the patient’s self-image in relation to the environment and his or her self-comparison [13]. Praško and Možný [14] list among depressive symptoms particularly a general loss of interest, persistent suicidal thoughts, poor concentration, inability to experience joy, pessimism, worsened mood, guilt, hopelessness, and physical symptoms such as back pain, abdominal pain, headache, or weight fluctuations.

According to Anderson [15], depression currently affects 10–15% of people over 65. The prevalence of major depression in this age group is around 5.7%, and so-called subsyndromal depression (depression with 2–4 diagnostic signs and signs of social dysfunction) is present in about 15% of older adults [16]. In Slovakia, major (severe) depression was found in 14% of the general population aged 60 and above, while depressive symptoms were observed in 24.5% of older adults [17].

The most common accompanying symptom of depression in this age group is anxiety. Nearly half of patients over 60 with depression also experience psychological anxiety in addition to other depressive symptoms [18]. Depression in older adults is currently a major public health issue. This mental disorder has high prevalence, is often accompanied by other disease, negatively affects quality of life, and increases visits to healthcare facilities [19]. Many older adults, unfortunately, do not seek psychiatric treatment that could remove or at least alleviate their difficulties and help them return to their previous level of functioning and activity. This has the following consequences: 25% of older adults have symptoms of mental illness, yet many do not seek treatment; seniors make up only 2% of patients in private psychiatric clinics, and only 1.5% of direct costs for treating mental illness are spent on treatment for older adults [20]. Depression is the most common cause of emotional suffering in later life and is linked to substantial declines in quality of life and often occurs in the context of physical and cognitive dysfunction [21].

Causes of Depression in Old Age

Among the most common causes of depression in older adults are reduced neurotransmitter function, alcoholism, family history of depression, increased criticality and hostility from a partner, absence or lack of close relationships, insufficient social support, and low self-confidence [11]. As age increases, the importance of genetic predisposition in the development of depression decreases, while the importance of exogenous biological and psychosocial aspects increases [22, 23]. The biological aspects that contribute to the onset of depression are presented in Table 1.

Table 1 – Biological aspects predisposing to the development of depression in older adults

Warren [25] states that in older adults in whom depression appears, there are usually neurological abnormalities, including deficits in neuropsychological tests. In addition, physical illness is considered a significant biological predictor of depression in older adults. The relationship between depression and comorbid disease may be bidirectional. Health problems such as chronic pain can increase susceptibility to depression, and depression itself can worsen some illnesses.

Factors leading to late-onset depression likely involve complex interactions among genetic vulnerability, cognitive diatheses, age-related neurobiological changes, and certain age-associated stressful events occurring more often near the end of life. Co-occurring self-critical thinking may worsen and maintain a depressive state. With age, psychological vulnerability decreases, while protective factors include higher education, good socioeconomic status, good health, and good cognitive functions, as well as involvement in meaningful activities, including various religious engagements [22].

Factors contributing to depression in older adults, however, include psychosocial aspects to a large extent, such as adverse financial situations and loss of close persons, but also loneliness. According to Alexopoulos [26], up to 14% of older adults who lost a lifelong partner are directly at risk of developing major depression. Warren [25] lists psychosocial aspects within the framework of psychosocial stressors, where, similar to Alexopoulos, the loss of a close person is placed foremost as an event that can trigger a depressive episode.

Involutional depression is most often linked with physical illness or disability, and psychosocial aspects are not considered sufficiently. It is important, however, to recognize that a substantial share of depression’s causes is precisely these psychosocial aspects, including adverse life events as well as social isolation and resulting loneliness. Social isolation and loneliness in older adults appear to us as either a consequence or a direct impact of some negative life events. In this context, Anderson [15] goes on to argue that isolation and loneliness in older adults lead not only to depression but also to suicide. A negative determinant implicated in the onset of depression in older adults is therefore clearly serious life events. In the family history of older adults diagnosed with depression, such negative life events can be traced in 70–80%. These events occurred days or months before the onset of depression itself. Muhwezi et al. [27] include, among such life events, illness, family death, relocation, marital problems, strong attachment to home, social isolation, and also lack of friends. The family death is among the most significant stressors.

Cacioppo and Cacioppo [28] point out that research in social epidemiology on depression in a psychosocial risk framework suggests that lack of positive social relationships in older adults is a significant risk factor for broad morbidity and mortality. The authors continue that the nature of these social relations and mechanisms is important because the population is aging and healthcare costs related to chronic mental illness are rising. It is therefore necessary to determine the extent to which an older person feels socially isolated. Evidence suggests that loneliness increases emotional sensitivity to social threats and motivates the restoration of social contacts, but it can also impair executive functioning, sleep, and to a large extent mental wellbeing.

Regarding loneliness and subsequent depression, Savikko et al. [29] report a study with a sample of 6,786 adults older than 75, concluding that 39% of respondents experience loneliness and up to 5% describe it as frequent or regular. Poor health, poverty, sensory loss (hearing and vision), and low income are associated with this state. The most common subjective causes of loneliness in the sample were illness, death of a partner, and lack of friends. Loneliness therefore stems from social change in the life of an older person, as well as from natural life events and difficulties associated with aging.

The relationship between depressive symptoms and perceived loneliness was examined by Stek et al. [30] in a population sample of 85-year-old respondents in 2014. Depression was present in 23% of older adults and was associated with changes in marital status, institutionalization, and perceived loneliness. Respondents experiencing both depression and loneliness had a 2.1-fold higher risk of death. The data indicate that increased mortality risk may be attributed to depression, particularly in the context of perceived loneliness. According to Roberts et al. [31], social isolation is also a significant correlate of depression in later life, although low education, financial strain, and functional impairment are also considered additional causes.

Depression in older adults obviously cannot be linked only to psychosocial aspects. Causes in later life are also related to physical limitations, yet in this context physical limitation can be understood as a negative life event (e.g., stroke). This negative life event triggers subsequent social changes that the older person cannot cope with, which can lead to the onset of depression.

Results from a large study conducted in Japan indicate that suicides among older adults in the first five years after a stroke show a markedly increasing trend. The study’s author argues that this makes it necessary to provide increased social and psychological care to older patients after stroke, rather than focusing only on medical care. Stroke clearly increases the risk of both depression and subsequent suicide in older adults, primarily because of possible physical limitations. Older adults who have had a stroke and whose lives are marked by severe physical impairment need regular screening for depression and subsequent suicidal ideation [32, 33].

Many findings therefore suggest that physical limitations in older adults can lead to clinical depressive symptoms, which in turn means an increased risk of suicide. However, there is also evidence that suicidal behavior rises with various cognitive disorders [34]. In groups of older adults, depression most often affects those with chronic diseases and cognitive disorders, which naturally leads to psychological suffering. Aging-related processes, including the onset of atherosclerosis as well as inflammatory, endocrine, and immune changes, threaten human integrity and increase susceptibility to depression [35].

On the basis of the presented claims, we can conclude that physical limitations and cognitive disorders can reduce social contacts and the individual may become socially isolated due to limited mobility or limited capacity for thinking. Physical illnesses, therefore, together with cognitive disorders and negative life events determine social risk factors that can subsequently lead to a depressive episode, which may escalate to suicide.

According to Raja [36], causes of depression in older adults are multifactorial, and treatment should be comprehensive, including assessment of the individual’s life role, cognitive changes, medications used, and state of social support from the natural environment. The multifactorial determinant of depression in older adults can contribute to treatment being less successful than in other age groups, especially when all factors—including psychosocial factors directly related to depression—are not considered [26]. Psychosocial factors involved in the development of depression are shown in Scheme 1, where we also indicate possible links between biological and psychosocial factors.

Scheme 1 – Psychosocial factors in the development of depression in older adults

Symptoms of Depression in the Older Adult

Depression is likely the most common cause of emotional suffering in later life and significantly reduces the quality of life of older adults [37].

Depression in older adults differs from depression in younger groups both in course and in the distribution of clinical forms. Very rarely, the course is episodic with full remission, while 10–15% of depressions run chronically [38]. Adverse outcomes in depression in this age cohort are predicted by other determinants such as a family history of affective disorders, lower education, a slow or insidious onset of depression, delayed treatment onset, and in some cases low antidepressant doses [24]. Depression in older adults has a poor prognosis in primary care, because it is often a chronic illness that can be recurrent and frequently remains unresolved and untreated for long periods. In addition to symptoms such as worthlessness, psychomotor agitation, psychomotor retardation, mood disturbances, and thoughts of death, insomnia or difficulty falling asleep are also symptoms. Sleep disturbances appear to be a significant predictor of depression in older adults. According to Roberts et al. [31], sleep disturbances show strong co-occurrence patterns with other defining symptoms of severe depression. Sleep problems, especially chronic ones, are associated with later depression risk. In fact, many studies suggest that sleep disturbances may be prodromal for severe depression. There is also a meaningful interaction between age and depressive state in the context of performance functioning. Older adults diagnosed with depression have slower psychomotor tempo, reduced physical performance, and decreased problem-solving ability [39]. Heretik et al. [40] compared the frequency of positively scored items in BDI questionnaires across age groups and found that older adults with depressive disorders statistically significantly reported sadness and pessimism more often than younger age groups.

Commonly used pharmacological treatment regimes for depression, based on prescribing medication, are often effective but frequently dosed inappropriately, or, because of age and frailty with reduced health, are poorly tolerated in older adults. Evidence suggests that increased physical activity, including targeted exercise, is an effective alternative treatment for depression in older adults [41]. Geriatric (involutional) depression is more somatic and less cognitive compared with other age groups [19]. The treatment goal of depression in older adults is primarily to achieve remission, improve functional capacity and independence of the affected person, and support social reintegration [42]. Acute treatment is associated with prescribing various antidepressants, but expanded strategies are now gaining prominence, combining pharmacotherapy with psychotherapy [19].

Psychotherapy and Its Role in Managing Depression in the Older Adult

Psychotherapy is a treatment activity in which the psychotherapist uses personal expertise so that a client experiences desired change toward improved wellbeing, behavior in relationships, and social integration. Psychotherapy can be described as a special form of human encounter between the therapist and another person seeking help, while the therapist provides that help [43].

Great effort in psychotherapy research is currently directed toward identifying so-called active ingredients, that is, those elements of psychotherapy responsible for improvement in the patient’s condition. Many experts hope that studying these elements will further positively develop psychotherapeutic practice [44]. The list of the most important psychotherapeutic factors is presented in Table 2.

Table 2 – List of effective psychotherapeutic factors

The elements listed in the table are common across multiple psychotherapeutic orientations. They are ordered from a developmental perspective: at the beginning, the client develops trust, certainty, and safety. Along with these determinants, tension is reduced, with accompanying reduction of fear and anxiety symptoms. These so-called effective factors of psychotherapy apply not only to individual psychotherapy but also to group therapy. In group psychotherapy, we refer to them collectively as therapeutic factors [44]. Kivlighan and Holmes [45] conducted a meta-analysis of 15 psychotherapeutic groups aimed at identifying which therapeutic factors clients consider most important. They found that clients can be divided into four basic types, enabling the therapist to create a personal therapeutic style. The basic client groups and their characteristics are listed in Table 3.

Table 3 – Selection of therapeutic factors according to group member characteristics

Given the causes of depression in older adults (discussed in the previous section), we can expect that depressed seniors would, in group psychotherapy, prefer altruism and the provision of hope, with emphasis primarily on support and emotions in the context of honest sharing, catharsis, acceptance, and cohesion.

Mašát states that we understand group psychotherapy as an intervention strategy aimed at helping individuals with various mental health problems or social adaptation difficulties. It can be used for treating mood and thinking disorders, substance use, or relational dysfunction. Group psychotherapy may function as prevention, treatment, short-term crisis intervention, and also as part of rehabilitation [46]. The advantage of group psychotherapy over individual psychotherapy is that it helps members learn active participation in group life and thereby develop their own understanding of their current life situation; through group development, it contributes to individual growth and enriches members’ lives, while also supporting self-help and enriching individual personalities; it facilitates natural growth and development of social functioning in group members and prevents social dysfunction; and it provides help and support to individuals who need it because of their social situation [20].

Group psychotherapy has specific phases of development and group formation. Rieger [47] describes seven phases of psychotherapeutic group development: Decision-making, Orientation, Cohesion, Submission, Confrontation, Exploration, and Release. These phases are presented in Table 4.

Table 4 – Developmental phases of a psychotherapeutic group according to Rieger

Yalom and Leszcz [48] point out that group psychotherapy is, in certain cases where social support and interpersonal learning are important, more beneficial than individual therapy. However, individual psychotherapy and group psychotherapy can be complementary in some situations. According to Johansson and Werbart [49], among the disadvantages of group psychotherapy are lack of active participation by group members, limited space and time for self-expression, misunderstanding, rejection, insufficient space for personal activity, and an inappropriate therapeutic style.

Group psychotherapy with an older person can primarily be understood as planned and controlled treatment through immediate influence on the older person’s psyche [20]. In relation to depression in older adults, Blazer [37] reports interesting findings regarding the etiology of late-onset depression, where the above-mentioned group psychotherapy becomes effective. Group psychotherapy with older adults has specific characteristics, mainly stereotypes that serve as negative treatment factors in the context of viewing old age stereotypically as a substantial decline in mental, physical, and social capacities. The primary features of old age include certain disabilities, but old age also brings new challenges not only for the patient but also for society [50]. In treating depression within group psychotherapy, the primary focus is providing hope, support, understanding, and a proper bridge from social isolation to relationships. The therapist works with the depressed older person in the sense of creating a strong therapeutic relationship based on trust—not only in the therapist but also in other people—while trying to awaken in the older person a desire to live again. In a narrower context, this means an attitudinal change: creating distance from the pathological process, from feelings of guilt, and from self-critical reflections. Older adults should come to perceive depression as a severe life period that, however, does not determine life fatally. Psychotherapy not only helps the older person gain insight into his or her own way of experiencing life and relationships, but also teaches better social competence and provides information about depression, including recognition of early warning signs and how to respond appropriately [10]. Warren [25] argues that group psychotherapy is considered very effective in depression in later life, involving a short-term treatment phase with weekly meetings for 8–12 weeks. Some people may require longer treatment or less frequent meetings. According to Warren [25], evidence suggests that cognitive-behavioral therapy is the most effective; it focuses on identifying negative dysfunctional thoughts and increasing participation in pleasant social activities. Meta-analysis has shown that cognitive-behavioral approaches were significantly more effective in reducing depressive symptoms than depression treatment without psychotherapy. Cognitive-behavioral approaches aim to develop skills to improve one’s ability to cope with life problems. Thus, psychotherapy results in a substantial reduction in depressive symptoms, more so than usual pharmacological treatment alone.

The number of studies examining psychotherapeutic treatment of depression in older adults has increased considerably in recent years. For this reason, Cuijpers et al. [51] performed an updated meta-analysis in 2014. They concluded that psychotherapy is generally more effective in older age than in other age groups. It was found that the most effective treatment for depression in older individuals is the combination of psychotherapy and medication [21]. In relation to these findings, we present further results from a study conducted in 2014 by Encarnación. The aim was to indicate the possibility of increasing quality of life in older adults over 60 through group psychotherapy. The study involved 46 respondents aged 60–93. Results showed that participants assigned to the experimental group, where group psychotherapy was conducted, showed a significant decrease in anxiety and depression. This provides new evidence for the effectiveness of positive interventions in psychogerontology, suggesting that group psychotherapy helps increase subjective wellbeing and quality of life in older adults, with interventions aimed at strengthening personal and social resources in the context of the need to be happy [52].

Evidence is emerging supporting the use of group psychotherapy also to prevent depression in later life, including cognitive and behavioral approaches for bereaved older adults with chronic illnesses [22, 53]. Čerešník [54] argues that behavioral approaches are based on the work of Skinner, Bandura, and Wolpe. A basic premise of these approaches is that behavior is a product of learning. Gabura [55] states that proponents of this approach emphasize the importance that a person assigns to a stimulus rather than the stimulus itself; in general, this approach strives for direct changes in current behavior through learning and conditioning.

According to Čerešník [54], representatives of the cognitive-behavioral approach include Mahoney, Meichenbaum, Ellis, and Beck. The techniques used in this approach encompass a wide range, and within it we try to challenge irrational assumptions, change language, work with role-playing, and use different interpretations. In addition to these approaches, dynamic and experiential approaches are also relevant in group psychotherapy. In the dynamic approach, the therapist works with transference, allowing the client to re-experience unresolved situations from the past, thereby creating space for change in the person’s perspective on self, others, and the problem. Therapeutic work in this approach is understood as confrontation, clarification, interpretation, and processing of experience [38]. The therapist seeks to work with the client to create a mature and realistic alliance with the client’s “adult self” and encourages the client to become a partner in examining his or her difficulties [55]. The experiential approach views the person as an active being with potential for further growth. In this approach, pathology is seen as a mismatch between external and internal experience. The therapist often serves only as a catalyst, while the counselor-client relationship is an emotionally meaningful human relationship founded on one human being in alliance with another. This approach is based on humanistic psychology principles [38]. According to Gabura [55], acceptance, empathy, and congruence are characteristic of the experiential approach—that is, concepts rooted in humanistically oriented therapy or Rogers’ client-centered therapy.

Conclusion

As noted in the introduction, with advancing age new stressors, circumstances, and life events emerge, such as retirement, loss of a life partner, existential difficulties, conflicts with children, fear of death, and also unrest and subsequent anxiety. To these determinants are added physical illnesses, cognitive changes, and increasing negative feelings of loneliness and dependence. All these factors can contribute to the onset of depression in an older person, and this in turn can significantly affect the quality of life and perception of the world around them. Depression in older adults deserves special attention because this illness can have serious negative consequences for an older person’s life, including increased burden from physical illness and worsening functioning, and it is also linked to suicide risk. In addition to medication, group or individual psychotherapy can significantly contribute to treating depression. In this article, we focused more on the importance of group psychotherapy, whose benefit we see mainly in creating possibilities for social support, which is essential for seniors in old age. Negative psychosocial factors that underlie depression in older adults can be substantially reduced through purposefully designed group psychotherapy, thereby helping older adults live fully and with a positive sense of wellbeing. The choice of a specific psychotherapeutic approach for working with a depressed older person must be based on the individual situation, grounded in the pattern of symptoms present. The preference of the older person also plays a significant role, particularly regarding whether they seek improvement of negative symptoms or prefer broader psychosocial goals. It is clear that the selected approach is based on therapeutic goals and that in practice multiple psychotherapeutic methods are used in treating depression. The most frequently used are time-limited psychotherapeutic approaches aimed at reducing negative symptoms, especially cognitive, behavioral, and cognitive-behavioral approaches [56].

Viewing involutional depression as a natural part of aging is by no means justified. It is true that involutional depression has its specific features, but with an appropriate treatment program—including psychotherapy—it is possible to successfully manage and overcome it. Seniors, however, rarely seek treatment for their mental health problems and persistent depression, and it has been shown that the most effective treatment for depression in older individuals is the combination of psychotherapy and medication. In Slovakia, psychotherapy is regulated legally within the healthcare sector as a certified professional activity in the training system of healthcare workers. The key law underlying the education system in psychotherapy is Act No. 578/2004 Z. z., on providers of healthcare services..., as amended, particularly Part Four: Education of Healthcare Workers. Psychotherapy for an older adult with a healthcare indication and recommendation from a general practitioner or specialist is covered by health insurance. If a private psychiatrist or psychologist has a contract with a health insurer, it is highly likely that this contract also covers both individual and group psychotherapy. A major problem, however, is low reimbursement levels under insurers’ point-based payment systems. Patients are usually charged an additional fee ranging from 10–50 euros per hour. The issue of reimbursement for psychotherapy by health insurers needs to be addressed both through higher payments and through expanded healthcare indications because it is proven that psychotherapy is beneficial not only for the patient but also for the state, as it reduces work incapacity. Slovakia, however, is at the bottom within the EU in the number of psychotherapists per 100,000 inhabitants. We expect that in coming years psychotherapy will expand and psychotherapy services will become available to the wider public and therefore also to older adults. Accessibility can be improved through the creation of psychotherapeutic day units, possibly within existing social services as a supplement to provided forms of support, especially for the most vulnerable groups, including older adults. In practice, public awareness about possibilities for both group and individual psychotherapy should be increased. Waiting rooms of primary and specialist physicians currently lack informational leaflets that present psychotherapy as a concrete treatment option. At present, psychotherapy is primarily provided in specialized psychiatric or psychological practices. These services should be recommended to older adults on an ongoing basis by general or specialist physicians not only during crises when a person is already, for example, depressed, but psychotherapy should be a realistic component of prevention of psychosocial problems that threaten this age group. Mass media can be a driving force in psychotherapy outreach, potentially increasing public interest and thereby also older adults’ interest in mental health.

Mgr. Katarína Kotradyová, PhD. OZ Deti slnka, ul. Železničná 71, 053 61 Spišské Vlachy, Slovenská republika

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