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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 34-38

Improving depression and well-being in older adults using selection, optimization, and compensation model: A case series

1 Department of Clinical Psychology, Mental Health Institute, SCB Medical College, Cuttack, Odisha; Department of Clinical Psychology, School of Medical Science, Mizoram University (A Central University), Aizawl, Mizoram, India
2 Black Country Healthcare NHS Foundation Trust, Wolverhampton, UK

Date of Submission05-Feb-2021
Date of Decision04-May-2021
Date of Acceptance22-May-2021
Date of Web Publication05-Aug-2021

Correspondence Address:
Dr. Narendra Nath Samantaray
Department of Clinical Psychology, School of Medical Science, Mizoram University (A Central University), Aizawl, Mizoram
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_7_21

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Background: There is a need to study age-sensitive psychological management for improving the clinical and overall health outcome for elderly adults. Hence, we intended to evaluate the effects of selection, optimization, and compensation (SOC) model, usually studied in nonmental health settings predominantly, in managing depression and well-being of the elderly in a clinical mental health setting in an Indian context. Methods: A pre–postintervention with a 2-month-follow-up approach was adopted. We delivered six sessions over 4–5 months. An independent rater assessed participants using the Beck Depression Inventory-II and World Health Organization's Well-Being Index (WHO-5) at baseline, postintervention, and a 2-month follow-up. Results: There was a clinically significant improvement in depression severity and well-being of participants at the postintervention and 2-month follow-up. Conclusions: SOC-based intervention has potential therapeutic effects in improving depression severity and well-being of elderly individuals in clinical settings. We recommend the current protocol to be studied in a randomized design study with a larger sample size and a longer follow-up period.

Keywords: Aged, depression, geriatric, psychotherapy, quality of life, selection optimization and compensation

How to cite this article:
Samantaray NN, Kar N. Improving depression and well-being in older adults using selection, optimization, and compensation model: A case series. J Geriatr Ment Health 2021;8:34-8

How to cite this URL:
Samantaray NN, Kar N. Improving depression and well-being in older adults using selection, optimization, and compensation model: A case series. J Geriatr Ment Health [serial online] 2021 [cited 2022 Jan 27];8:34-8. Available from:

  Introduction Top

The prevalence rate of depression in India's elderly population is alarmingly high, ranging from 8.9% to 72%.[1] It is associated with lower quality of life, increased economic dependence, treatment cost, physical dependence for daily activities, self-neglect, and comorbid conditions that further exacerbate disability in older adults.[2],[3],[4] Besides individual hardships, depression is a public health challenge in developing countries.[4]

Nonetheless, the mental health care utilization rate is low in this population.[5] Moreover, it appears the elderly segment fails to receive due attention from policy-makers possibly because they contribute less comparatively.[6] In this context, management techniques focusing on improving the clinical symptoms and enhancing the productivity would be more beneficial.

In addition, when one of the treatment barriers of the elderly population is a financial constraint,[7] the existing general modules of cognitive-behavioral therapy,[8] which recommends 10 or more sessions, may not be pragmatic. Hence, a need exists to manage elderly depression through culturally age-sensitive intervention in fewer sessions. [6,9]

Selection, optimization, and compensation (SOC) is an age-sensitive life management intervention model that acknowledges individuals' challenges due to aging.[10] Selection refers to the individual preferences of choosing specific goals by reducing one's repertoire of existing priorities to a few. It may involve a reconstruction of one's goal hierarchy or the search for new ones. Optimization denotes the means adopted in achieving the selected goals, where compensation refers to methods adopted to counter the internal and external losses in pursuit of achieving goals. Compensation is utilizing available mental, technological aid or alternative means to those goals or ease optimization. However, it has been studied extensively in nonclinical settings or in other general medical conditions. [11,12]

Considering the above needs and marked paucity of research in elderly psychological management, we studied the feasibility and effectiveness of SOC intervention in managing depression and the well-being of the elderly in a clinical mental health setting in an Indian context.

  Methods Top


In a pre–postintervention with a 2-month-follow-up model four aged consecutive consenting patients attending the outpatient mental health services in a tertiary care in India, receiving the management based on SOC program for their diagnosis of depressive episode as per International Classification of Disease, tenth revision[13] were included in the study. All the included participants, aged over 60, were stabilized on selective serotonin reuptake inhibitor (n = 4) and benzodiazepine (n = 2) medications for at least 2 months before the study. None of them had a comorbid psychiatric diagnosis of psychosis, organic brain syndrome, or exposure to cognitive-behavioral intervention 1 year before the study. The written informed consent from all the participants was obtained. The participants' mean age was 63.5 years (range 62–66 years); the mean duration of depression 13 months (range = 6–18 months). All of the four participants had diabetes mellitus and hypertension for more than 10 years.


The clinical diagnosis of depression was confirmed using the Mini International Neuropsychiatry Interview.[14] The participants were assessed at the baseline, postintervention, and 2-month follow-up using participant-rated Beck Depression Inventory,[15] a 21-item well-validated measure, to rate the severity of depression.

Participants rated their well-being using the World Health Organization's Well-Being Index (WHO-5).[16] For suitability to calculate therapeutic change using Blanchard and Schwarz[17] formula, we assigned score “0” to “all of the time,” “1” to “most of the time,” “2” to “more than half of the time,” “3” to “less than half the time,” “4” to “some of the time” and “5” to “at no time;” hence, lower the score better the well-being.

To measure compliance toward SOC procedure, we asked participants to fill the Teshale and Lachman's[18] adapted brief version of the SOC questionnaire,[19] before the third and final session. The scores ranged from one to six on each item; to get a composite score, we averaged all four items. The higher the score, the greater is the compliance to the SOC application.

Intervention module

An experienced clinical psychologist (NNS) exposed the participants to the intervention model of SOC based on Baltes and Baltes[10] formulation for 6 sessions over 5–6 months. The structure of our intervention [Table 1] was adapted from Müller et al.,[20] module; with some addition and minor changes; such as the addition of mastery and pleasure rating for the selected tasks implementation and adaptation of action-plan from the second session onward instead from the third session as in Muller et al., module.
Table 1: Session wise selection, optimization, and compensation module

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In the first session, we discussed SOC intervention's rationale and facilitated the participants to construct specific, measurable, attainable, realistic, and time-based;[21] goals. However, we advised flexibility in adhering to the “time-based” protocol. Throughout, we emphasized the goal be based on the participant's values and activities that they consider meaningful. We assigned homework sessions on contemplating how the selected goals can be pursued given their resource and pragmatic aspects.

In the second session, we collaborated on a step-by-step action plan to optimally achieve the selected goal with review of assigned task. Here, we deliberated on goal-relevant means of practicing, re-learning activities, and resource allocation. Further, we analyzed the use of specific mental and technological strategies/aids or alternate methods to compensate for the age-based loss. We advised participants to document their efforts, progress, challenges, and mastery and pleasure ratings on each task daily.

From the third to the fifth session, we reviewed their progress and difficulties faced on the selected tasks. Furthermore, we discussed any further adaptation needed to continue the efforts for maintaining SOC. We discussed action plans focusing on using other available resources in the wake of impediments and the implementation of cognitive restructuring to counter negative thinking. In the final session, we reviewed the participants' progress, discussed the strategies to be used in case of future hurdles and SOC application in day-to-day life in the future.

Case Reports

Case A

A 66-year-old male retired college teacher reported a 6-month history of low mood, decreased appetite, and difficulty initiating sleep. Before that, he enjoyed reading books on social science and Vedic literature for 4–5 h a day. He had wish-listed many philosophical concepts to master but, 8 months prior, due to the complication of diabetic retinopathy, he had left reading/pursuing those. He even took others' assistance for traveling outside from home. He complained he could not find “a meaning to his life” anymore.

In the SOC program, on mutual discussion, the selected goals for him were to pursue and learn the wished concepts of Vedic literature, explaining the application of Vedanta in modern life and narrating its connection with contemporary science to his son, who is also a social-science scholar. To achieve these, he optimized his daily schedules by listening to Vedanta philosophies through online platforms from distinguished scholars, which helped him clarify many concepts like never before. He compensated by learning to use Google-voice assistance for accessing online content in phone and television sets. He believed one needs to understand Vedic philosophy to progress in personal and professional life; hence, he prepared to deliver lectures on these concepts in many community programs.

Case B

A 62-year-old housewife reported a 14-month history of irritable behaviors, low mood, and decreased interaction with family members. She had undergone a cataract surgery 8 months back. After her husband's death, 16-month back to a cardiac arrest, she moved from her village to the state's capital city to stay with her son (a government employee), daughter-in-law, and two granddaughters. She shared cordial relationships with her family members but accepted the lack of motivation in day-to-day life and reported herself as a huge burden to others. Previously she enjoyed cooking dishes and used to stitch new clothes for her entire family.

In the SOC program, the selected goals were learning new recipes, boutique-related work, and possibly doing a meager professional work related to stitching. She started spending time and effort on both these activities daily. With her daughter-in-law's collaboration, she practiced new recipes from available articles from local newspapers or magazines and television shows. She willfully took the responsibility of serving the learned recipes at lunch and dinner twice a week. She prepared evening snacks as well frequently. She became involved in stitching short dresses for her entire family. Gradually she started taking stitching orders from nearby ladies' tailor shops and in the company of them, learned new skills too.

Case C

A 64-year-old female retired schoolteacher complained of low mood, boredom, and irritability for 18 months. She was quite upset that 1 day she would die and would lose everyone. After her retirement, she and her husband stayed in a different city with their son's family consisting of a daughter-in-law and two grandchildren. She was born to a Hindu family, but after 6 years of her marriage, her in-law's family adopted Christianity as their faith, which she had adjusted to a long time back. In the assessment, she said she had a wish to gain adequate knowledge in the past about philosophies, teachings, and stories associated with the Christian religion as she had convincing information on the Hindu faith. Due to professional and other responsibilities, she could not focus on these earlier. When she was told the importance of behavioral activation and SOC, she set goals of (a) learning about Christian faith, stories, moral lessons associated with it (b) teaching the grandchildren about ethical values using learned stories from both faiths. In addition, in the latter part of the sessions, she revealed her acquired knowledge about the meeting points of two faiths and how the spiritual concepts have helped her overcome the fear of death.

Case D

A 62-year-old male retired bank employee reported a 14-month history of persistent low mood. He complained that he felt worthless as he was not contributing anything significant to his life. Eight months back, he opted for knee replacement surgery for his chronic rheumatoid arthritis problems. His only son was in service in a distant city, and the daughter settled in another city after marriage. He lost his wife 8 years back to tobacco-related cancer. He has thought of moving back to his village but was apprehensive of health care facilities. He was afraid that he might be less productive in a different city if he stayed with his son.

He had wished to contribute to society but could not find an appropriate way. After a few deliberations on SOC implementations, he chose to return to his village and give tuitions to needy village students free of cost or at a nominal price. He was felt assured that he could access a nearby tertiary-level hospital when needed. His specific interest was in teaching maths. He optimized his function by practicing and keeping updates with the recent syllabus for high-school children, implementing and learning different strategies to make his teachings more amenable. Later on, students from nearby villages also joined his coaching classes.

  Results Top

Therapeutic change

For analysis of clinically significant changes (50% and above) of four participants, we used Blanchard and Schwarz[17] formula. Results indicated a clinically significant improvement in depression severity depression (range = 54%–73%) and well-being (range = 56%–66%) of all participants at postintervention and the 2-month follow-up [Table 2].
Table 2: Baseline, post, and follow-up scores of Beck Depression Inventory-II and World Health Organization's Well-Being Index of four participants

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Selection, optimization, and compensation compliance

The maximum possible composite score of SOC use is 6 (24/4). The SOC composite score of the 4 participants (A, B, C, D) at the third session was 4.5, 5, 4.75, and 4.5, respectively. Similarly, at the final session, scores were 4.75, 5, 4.75, and 4.5; this indicates high usage and compliance of SOC techniques by the participants.

  Discussion Top

The observations in the case series indicated that the SOC-based psychotherapy had significant therapeutic effects in reducing depression severity and increasing the well-being of elderly individuals. These SOC efficacy findings are consistent with other studies and case reports. [22,23]

In similar studies elsewhere, older adults with lower happiness,[18] and limited resource,[24] enhanced their well-being and adaptation by using SOC. Interestingly Teshale and Lachman[18] found that individuals reporting lower happiness used higher SOC on the next day following session.

Another study[25] reported that SOC was mood-dependent and reduced by age; instead, it was best expressed as a precondition to successful aging. Similar to Teshale and Lachman's report, our findings support that with psychotherapy, the use of SOC can improve the mood of older adults; hence, SOC may not be necessarily mood-dependent.

In our study, all of the participants had other chronic medical conditions. Hence our findings are in line with recent findings from a review[11] that SOC enables older adults with multiple chronic conditions to live healthy and meaningful lives.

All the participants selected and optimized the goals which were high on personal value; hence the current findings might support the inference[26] that setting the personal values high is a determining factor in SOC. However, this might need further studies for robust conclusions, considering the methodological restriction of the current study.

Similarly, another avenue for future research related to the present findings is the importance of spirituality in improving older adults' mental and overall health. Two participants in our study enhanced their well-being and managed depression by working on their spiritual goals; this possibly supports the growing interest in studying the integration of spirituality in older adults' mental health interventions. [27,28]

  Conclusions Top

The age-sensitive SOC has potential therapeutic effects in reducing depression severity and increasing the well-being of elderly individuals in clinical settings. We recommend studying SOC efficacy with a larger sample size, randomized design, and a longer follow-up in future studies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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