Cognitive behavioural therapy

Definition and model. CBT is an active, structured, time-limited, goal-directed psychotherapy that aims to change the thinking and behaviour that maintain a disorder. It rests on the cognitive model — a situation triggers an automatic thought, which drives emotion, physiological arousal and behaviour; these are underpinned by intermediate beliefs (rules and assumptions) and core beliefs (schemas). Changing the cognition changes the emotion and the behaviour.

Structure of treatment. Typically 8–20 weekly sessions of 45–60 minutes, individual or group, delivered with a collaborative, agenda-setting style and homework between sessions. Core techniques: psychoeducation, thought records and identification of cognitive distortions (catastrophising, all-or-nothing thinking, overgeneralisation, mind-reading), Socratic questioning and cognitive restructuring, behavioural activation and activity scheduling, graded exposure with response prevention, problem-solving, relaxation training, and relapse prevention.

Evidence base and indications in older adults. CBT for depression carries Level A evidence and is effective when compared with no treatment. Psychotherapy is as effective in older adults as in younger adults, and many older adults prefer counselling to psychopharmacological intervention. Indications: depression (especially mild to moderate), anxiety disorders and GAD, phobias including fear of falling, panic disorder, OCD (as exposure and response prevention), PTSD, insomnia (CBT-I, the first-line treatment for chronic insomnia at any age), chronic non-cancer pain, somatic symptom disorder, caregiver stress, and as psychological support during rational deprescribing.

Problem-solving therapy — the key geriatric variant. Individual CBT, particularly problem-solving therapy, is the recommended psychological intervention for late-life depression, and it is especially effective where executive dysfunction is present — the group least likely to respond to antidepressants. Its seven steps: define the problem → set a realistic goal → generate solutions → evaluate the options → choose and plan → implement → review the outcome.

Adaptations required in older adults. Psychotherapy may need to be modified to accommodate cognitive and sensory deficits. Practical adjustments: slower pace and shorter, more frequent sessions; written summaries, large print and audio recordings; hearing aids and spectacles in place, quiet well-lit room; repetition and memory aids for homework; involvement of family or carer; home visits or telephone/video delivery where mobility is limited. Content must be dynamic and sensitive to the existential issues of loss, dependency and change of status, yet fully aware of opportunities for growth and vigour, with the focus best directed at functional outcomes.

Limitations and related therapies. CBT requires some capacity for abstraction, insight and memory, so it is of limited use in moderate to severe dementia, delirium, and active psychosis, and needs motivation and regular attendance. Availability of trained therapists is a real constraint in India. Related and complementary approaches include interpersonal therapy, reminiscence and life review, behavioural activation, mindfulness-based interventions, dialectical behaviour therapy (personality disorders), and family therapy. Psychoeducation should be a routine part of treatment and, whenever feasible, should include family members — this prevents the unrealistic expectation of rapid, complete recovery that leads to premature termination.

Digital and remotely delivered CBT (2023–2025). Systematic reviews and randomised trials now show that internet-delivered and telephone/video CBT are effective in older adults for depression, anxiety and insomnia, with effect sizes approaching face-to-face therapy when therapist support is included — directly addressing the shortage of trained therapists and the mobility and transport barriers that limit uptake in this age group. Alongside this, mindfulness-based stress reduction was shown to be non-inferior to escitalopram for anxiety disorders (Hoge et al., JAMA Psychiatry 2023), and CBT-I remains the guideline-endorsed first-line treatment for chronic insomnia in older adults, in preference to any hypnotic.