Clinical and Cost-Effectiveness of Therapist-Guided Internet-Delivered Cognitive Behavior Therapy for Older Adults With Symptoms of Depression: A Randomized Controlled Trial

doi:10.1016/j.beth.2014.09.008

Behavior Therapy

Volume 46, Issue 2, March 2015, Pages 193-205

https://doi.org/10.1016/j.beth.2014.09.008 Get rights and content

Highlights

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Few older adults with symptoms of depression seek psychological treatment
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Internet-delivered cognitive behaviour therapy (iCBT) has potential for older adults
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This study examined the efficacy and cost-effectiveness of iCBT for older adults
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Large clinical improvements were found in symptoms of depression
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Evidence of the cost-effectiveness of iCBT was also found

Abstract

Depression is a common and significant health problem among older adults. Unfortunately, while effective psychological treatments exist, few older adults access treatment. The aim of the present randomized controlled trial (RCT) was to examine the efficacy, long-term outcomes, and cost-effectiveness of a therapist-guided internet-delivered cognitive behavior therapy (iCBT) intervention for Australian adults over 60 years of age with symptoms of depression. Participants were randomly allocated to either a treatment group (n = 29) or a delayed-treatment waitlist control group (n = 25). Twenty-seven treatment group participants started the iCBT treatment and 70% completed the treatment within the 8-week course, with 85% of participants providing data at posttreatment. Treatment comprised an online 5-lesson iCBT course with brief weekly contact with a clinical psychologist, delivered over 8 weeks. The primary outcome measure was the Patient Health Questionnaire-9 Item (PHQ-9), a measure of symptoms and severity of depression. Significantly lower scores on the PHQ-9 (Cohen’s d = 2.08; 95% CI: 1.38 – 2.72) and on a measure of anxiety (Generalized Anxiety Disorder-7 Item) (Cohen’s d = 1.22; 95% CI: 0.61 – 1.79) were observed in the treatment group compared to the control group at posttreatment. The treatment group maintained these lower scores at the 3-month and 12-month follow-up time points and the iCBT treatment was rated as acceptable by participants. The treatment group had slightly higher Quality-Adjusted Life-Years (QALYs) than the control group at posttreatment (estimate: 0.012; 95% CI: 0.004 to 0.020) and, while being a higher cost (estimate $52.9 l 95% CI: − 23.8 to 128.2), the intervention was cost-effective according to commonly used willingness-to-pay thresholds in Australia. The results support the potential efficacy and cost-effectiveness of therapist-guided iCBT as a treatment for older adults with symptoms of depression.

Trial Registration

Australian and New Zealand Clinical Trials Registry: ACTRN12611000927921; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=343384.

Section snippets

Participants

A total of 111 individuals applied to participate in the study via the eCentreClinic website (www.ecentreclinic.org) and 54 met the criteria for inclusion into the study. The inclusion criteria were as follows: (a) resident of Australia; (b) 60 years of age and over; (c) reported that they have been assessed by a general practitioner or medical specialist to rule out a reversible physical cause for their depression. An initial additional criterion that applicants had a total score ≥ 10 on the

Preliminary Tests

No differences were found between the treatment and control groups in demographic characteristics or in the proportions meeting diagnostic criteria (ps > .05). No differences were found between participants who did and did not complete posttreatment questionnaires (ps > .05). The numbers of treatment group participants meeting diagnostic criteria at pretreatment and at 3-month follow-up are shown in Table 2.

Symptom Outcomes for Overall Sample

Means and standard deviations for the PHQ-9 and the GAD-7 for the treatment and waitlist

Discussion

This RCT examined a new iCBT intervention, the Managing Your Mood Course, for older adults experiencing symptoms of depression. It was hypothesized that (a) the treatment group would report significantly reduced symptoms of depression at posttreatment compared with the waitlist control group, (b) symptom reductions of the treatment group would be sustained at 3-month and 12-month follow-up, and (c) the iCBT treatment would be cost-effective based on QALYs and commonly employed

Conflict of Interest Statement

N. Titov and B. Dear are authors and developers of the Managing Your Mood Course, but derive no personal or financial benefit from it. N. Titov, B. Dear, and B. Klein are funded by the Australian Government to develop and provide a free national internet and telephone-delivered treatment service, the MindSpot Clinic (www.mindspot.org.au), for people with anxiety and depression.

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Depression is prevalent among older adults, and internet-delivered psychological interventions (IDPIs) have emerged as a promising solution.
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25 relevant studies were identified. IDPIs were used for treatment, prevention, and assessment. Internet-based cognitive behavioral therapy was the most common psychotherapy. Seven strategies to provide tailored services include psychotherapy courses, professional involvement, mood and progress tracking, virtual community, timed reminders, additional learning resources, and gamification elements. Barriers contained cognitive impairment, low digital literacy, device inaccessibility, limited depression awareness, adherence issues, and acclimation time, while facilitators included prior treatment experience, real-life character stories, strong client-worker bonds, and integration into daily care routines.
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There is some evidence supporting the clinical benefits of low intensity psychological interventions for depressive and anxiety symptoms in older adults compared to passive controls. More research is needed to examine efficacy compared to active control conditions, and among those over 80 years.
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Although numerous studies have examined the effects of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety on quality of life, no meta-analysis has yet been conducted to integrate the results of these studies. We conducted systematic searches in PubMed, Cochrane, and PsycInfo, which included terms for treatment type, modality of delivery, condition, and main outcome. We included studies that met the following inclusion criteria: (a) randomized controlled trials, (b) patients allocated to some form of the control condition, (c) patients receiving some type of treatment of anxiety and/or depression involving Internet-delivered Cognitive Behavioral Therapy, (d) use of a validated outcome measure assessing the level of quality of life, (e) conducted with adult participants diagnosed with anxiety disorder and/or unipolar depression, (f) papers written in English. We analyzed 40 randomized controlled trials with a total of 4289 participants that met inclusion criteria. The pooled between-group effect size for the quality of life overall score was small (g = 0.35, 95 % CI: 0.26–0.44, p = .0001), favoring iCBT over the control conditions. Regarding the distinct quality of life domains measured by the World Health Organization Quality of Life Assessment, a statistically significant difference between iCBT and control conditions was found only for the physical health domain (g = 0.56, 95 % CI: 0.06–1.07, p = .029), in favor of iCBT. In both cases, heterogeneity was moderate. While the effect on the quality of life is small (the overall quality of life score) to moderate (the physical health domain score), we conclude that iCBT for depression and anxiety may be a promising approach for improving the quality of life of patients.
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^☆: The authors gratefully acknowledge the participants for their involvement and helpful comments. This research was enabled by a National Priority Driven Research Program Grant from beyondblue. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. BFD is supported by a National Health and Medical Research Council (NHMRC) Australian Public Health Fellowship. BFD, MDT, and SA had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Clinical and Cost-Effectiveness of Therapist-Guided Internet-Delivered Cognitive Behavior Therapy for Older Adults With Symptoms of Depression: A Randomized Controlled Trial☆

Highlights

Abstract

Trial Registration

Section snippets

Participants

Preliminary Tests

Symptom Outcomes for Overall Sample

Discussion

Conflict of Interest Statement

Behavior Therapy

Behaviour Research and Therapy

American Journal of Geriatric Psychiatry

Behavior Research and Therapy

Computers in Human Behaviour

Journal of Anxiety Disorders

General Hospital Psychiatry

Journal of Affective Disorders

Psychiatric Clinics of North America

The Journal of Affective Disorders

Internet-based and other computerized psychological treatments for adult depression: A meta-analysis

Cognitive Behaviour Therapy

Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis

PLoS One

Medicare benefits schedule book

Pharmaceutical benefits schedule

Evidence-based psychological treatments for late-life anxiety

Psychology and Aging

The natural history of late-life depression: A 6-year prospective study in the community

Archives of General Psychiatry

Measuring and valuing health benefits for economic evaluation

Anxiety, depression and disability across the lifespan

Aging and Mental Health

High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication

Archives of General Psychiatry

Is computerized cognitive-behavioural therapy a treatment option for depression in late-life? A systematic review

British Journal of Clinical Psychology

Internet-based treatment for older adults with depression and co-morbid cardiovascular disease: Protocol for a randomised, double-blind, placebo controlled trial

BMC Psychiatry

Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies

Psychological Medicine

Computer-aided psychotherapy for anxiety disorders: A meta-analytic review

Cognitive Behaviour Therapy

Psychometric comparison of the Generalized Anxiety Disorder Scale-7 and the Penn State Worry Questionnaire for measuring response during treatment of generalised anxiety disorder

Cognitive Behaviour Therapy

Internet-delivered cognitive behavioural therapy for depression: a feasibility open trial for older adults

Australian and New Zealand Journal of Psychiatry

CCi Digital Futures 2012: The Internet in Australia