Six months since wife Margaret's death after 48 years of marriage. Not eating well, losing weight. Stopped going to his woodworking shop. Children live out of state, call weekly. GP prescribed sertraline — 'hasn't done much.' Says: 'I did everything I was supposed to do. I worked, I provided, I was faithful. And now I sit in this house alone.'
History
No prior psychiatric history. Korean War veteran (never discussed combat). Married at 26. Three children, seven grandchildren. Lifelong stoicism — 'men don't cry.' Grew up on a farm, worked at Boeing for 35 years. Church member but attendance has lapsed since Margaret died. No substance use. Mild cognitive concerns (word-finding difficulty) but MMSE normal.
Clinical note: Late-life depression is underdiagnosed and undertreated — older adults are less likely to endorse 'feeling sad' and more likely to present with somatic complaints, withdrawal, and cognitive concerns (Alexopoulos, 2005). Harold's mild word-finding difficulty warrants neuropsychological screening; comorbid cognitive decline changes the treatment picture significantly and may require structured, present-focused approaches rather than insight-oriented work. IPT has the strongest evidence for late-life depression (Reynolds et al., 1999; NICE CG90: recommended), with particular efficacy for grief-related presentations and role transitions. Life review therapy — structured reminiscence organized chronologically — has a solid evidence base for older adults (Pinquart & Forstmeier, 2012 meta-analysis: d = 0.57). Logotherapy and existential approaches are well-suited to the meaning questions that arise when life's structural roles (worker, spouse, provider) have ended. The Korean War service is a clinical detail worth exploring gently — many veterans of that era never processed combat experiences and present with late-onset PTSD symptoms after the death of a spouse, who functioned as the affective container (Davison et al., 2006). The sertraline is appropriate but insufficient alone — combined treatment (medication + psychotherapy) significantly outperforms either alone in older adults (Cuijpers et al., 2020). Harold's stoicism should be respected as a generational and cultural strength — not pathologized — while creating space for the grief it may be blocking. A clinician who demands emotional expression from a 74-year-old man raised on a farm in the 1950s is importing their own values, not practicing good therapy.
Where Approaches Genuinely Disagree
Is this depression or realistic grief about aging?
CBT
Even in late life, cognitive distortions maintain depression. 'I'm useless now' can be challenged.
vs.
Existential Psychotherapy
At 74, confronting mortality and diminishment is not a cognitive distortion — it is facing reality.