Despite the therapeutic needs of aging Holocaust survivors, no randomized controlled trial (RCT) of psychotherapy exists for this population, with very few on older adults in general. This RCT aimed to compare the efficacy of Life Review Therapy for Holocaust survivors (LRT-HS) relative to a supportive control group. Holocaust survivors with a probable diagnosis of full or subsyndromal posttraumatic stress disorder (PTSD) or depressive disorder were included. Exclusion criteria were probable dementia, acute psychotic disorder, and acute suicidality. The predefined primary endpoint was the course of PTSD symptom scores. In total, 49 of 79 consecutive individuals assessed for eligibility were randomized and included in the intent-to-treat analyses (LRT-HS: n = 24, control: n = 25; M age = 81.5 years, SD = 4.81, 77.6% female). Linear mixed models revealed no statistically significant superiority of LRT-HS for PTSD symptoms at posttreatment, with moderate effect sizes, Time x Condition interaction: t(75) = 1.46, p = .148, d within = 0.70, d between = 0.41, but analyses were significant at follow-up, with large effect sizes, t(79) = 2.89, p = .005, d within = 1.20, d between = 1.00. LRT-HS superiority for depression was observed at posttreatment, t(73) = 2.58, p = .012, but not follow-up, t(76) = 1.08, p = .282, with moderate effect sizes, d within = 0.46–0.60, d between = 0.53–0.70. The findings show that even in older age, PTSD and depression following exposure to multiple traumatic childhood events can be treated efficaciously using an age-appropriate treatment that includes structured life review and narrative exposure.