Internet-Based Cognitive Behavioral Therapy for Depression: A Feasibility Study for Home Care Older Adults

Abstract

Purpose:

The present study examined the feasibility of internet-based cognitive behavioral therapy (iCBT) for home care older adults.

Method:

A feasibility open trial was conducted with 26 recipients of nonmedical home care with depressive symptoms. When possible, home care workers (HCWs) of older adults (n = 13) were recruited to provide external support for iCBT usage.

Results:

The mean therapy sessions completed was 4.7 out of 8, and 86% would recommend the program to others with depressed mood. Participants’ depressive symptoms and anxiety symptoms decreased, whereas their quality of life ratings improved.

Discussion:

iCBT is a feasible and acceptable treatment modality for home care older adults with depressive symptoms and is potentially effective. Future studies are warranted to refine the existing treatment platform to achieve a better fit between the demands of the program and the needs and capabilities of homebound older adults and to examine treatment effectiveness as a function of HCW support.

Keywords

homebound older adults computerized cognitive behavioral therapy cCBT direct care workers in-home care

Homebound older adults are among the most vulnerable groups to late-life depression, possibly due to the high rates of medical and cognitive comorbidities, social isolation, and other psychosocial stressors associated with being homebound (Musich et al., 2015). Up to half of homebound older adults experience clinically significant depressive symptoms, and 14% meet diagnostic criteria for current major depression (Xiang et al., 2018). When left untreated, depression can exacerbate physical problems, increase health care costs, lead to loss of independence, and reduce life expectancy (Qiu et al., 2010). Even mild depressive symptoms can cause functional impairment similar to that of heart disease or diabetes, and these symptoms are likely to persist without treatment (Lyness et al., 2009). Late-life depression can be successfully treated often with a combination of medication and psychotherapy, with some patients reaching full remission (Alexopoulos, 2005). However, older adults rarely use specialty mental health services due to stigma, provider shortage, cost, transportation, and other access barriers (Brenes et al., 2015). For homebound older adults, these barriers are compounded by substantial challenges associated with attending therapy sessions in the clinic. As a result, depression is often inadequately treated, and psychotherapy is rarely utilized among homebound older adults (Xiang et al., 2018). Developing strategies that deliver evidence-based treatment for late-life depression in easily accessible, nonstigmatizing settings that can reach a large number of homebound older adults becomes a priority for research and practice.

Newer models that embed psychotherapy in home-based settings, such as Meals-on-Wheels, show promise in overcoming important access barriers to mental health treatments (Bruce et al., 2015; Choi et al., 2014; Ciechanowski et al., 2004; Gitlin et al., 2013; Pepin et al., 2019; Quijano et al., 2007). However, these models often use trained professionals and involve substantial training burden for new providers; therefore, they have a limited impact on overcoming provider shortages in underserved communities. Moreover, few studies explored the feasibility of delivering mental health services in alternative settings such as nonmedical home care, which serves a large number of homebound older adults. Also, technology is underutilized with only a few exceptions (e.g., Choi et al., 2014; Pepin et al., 2019), although technology-assisted delivery of mental health services holds great potential to improve the accessibility and scalability of services (Kiosses, 2017).

Internet-based cognitive behavioral therapy (iCBT) for depression is a promising approach to address important access barriers to mental health treatments among homebound older adults. CBT is a popular therapeutic approach with strong evidence for efficacy (Hofmann et al., 2012). iCBT is automated psychotherapy based on CBT principles delivered via websites or apps. The iCBT patient is exposed to the same components as in conventional CBT, except that psychoeducational materials and instructions are provided through an internet-based treatment platform. Systematic reviews and meta-analyses have shown that iCBT is as effective as face-to-face CBT at treating depression in mixed-age samples (Andrews et al., 2018). Although iCBT has been less studied in older adults, emerging evidence from a recent systematic review and meta-analysis suggests that iCBT is acceptable to older adults and can be effective in reducing depressive symptoms in late life (Xiang et al., 2019).

Some studies have suggested that iCBT, when combined with human support, is more efficacious than self-guided iCBT (Baumeister et al., 2014). Supported iCBT provides more opportunities for technological troubleshooting and personalized feedback and may improve therapy adherence. Most person-supported iCBT programs, however, use highly trained mental health providers to motivate and assist users, which reduces intervention scalability due to cost and provider shortage (Tomasino et al., 2017). In recent years, studies have explored the feasibility and efficacy of iCBT supported by nonspecialists, such as peers, and produced promising results (Tomasino et al., 2017). These programs have the potential to alleviate further the problems of cost barriers to care and provider shortage.

Despite the promising potential of iCBT for late-life depression, older adults comprised only 3% of participants in all controlled and uncontrolled trials of iCBT between 2000 and 2010 (Crabb et al., 2012). Moreover, most iCBT trials involving older adults required computer and internet literacy and access (Xiang et al., 2019). High levels of dropout due to technological challenges and other barriers limit the ability to obtain maximum benefit from iCBT for people of all ages (Schueller et al., 2017). Issues related to technology may disproportionately affect older adults. The exclusion of older adults without internet access or computer experience raises the question of whether iCBT is an acceptable and effective treatment modality for this group. Lack of representation of older adults in previous studies also raises the question regarding the need for external support for those with lower computer literacy and mild cognitive impairment on iCBT use.

The present study attempts to address some of these knowledge gaps by exploring the feasibility of delivering iCBT, with optional human support from lay providers, in nonmedical home care. Nonmedical home care is a booming industry due to the rising aging population, consumer preferences for aging in place, and public policy favoring community-based alternatives to nursing homes (Kelly et al., 2013). Home care workers (HCWs) provide personal care and companionship to seniors needing assistance with daily activities, housekeeping, and transportation. These paraprofessionals make frequent home visits over an extended period, offering opportunities for prolonged engagement and symptom monitoring. Home care is provided full-time, part-time, or even around the clock to address a person’s long-term care needs. Home care is different from Medicare home health, which provides intermittent skilled nursing and rehabilitation care after an acute illness. We have extensively documented the burden of depression and inadequate treatments in the home care setting (Xiang et al., 2018), making it a nonspecialty setting where significant unmet need for mental health services exists. Distance to office-based treatments (transportation) and shortage of providers (workforce) are two major access barriers among homebound older adults. Using HCWs, lay providers without specialized mental health training, to assist the delivery of iCBT holds promise to overcome these barriers without involving a substantial training burden for new providers because the core therapeutic components are automated in iCBT. Despite its potential, iCBT, whether supported by HCWs or not, has not yet been tested among homebound older adults, who tend to be older, less familiar with technology, more cognitive and functionally impaired than their ambulatory peers, all of which are characteristics that may compromise their ability to benefit from an internet-based depression treatment.

The present study aims to explore the feasibility, acceptability, and preliminary effects of an iCBT program with optional HCW support for home care older adults with symptoms of depression. We conducted a feasibility open trial in the naturalistic setting of the homes of older adults receiving nonmedical home care. When possible, HCWs of older adult participants were recruited to provide external support for iCBT usage. We hypothesized that iCBT is an acceptable treatment modality to home care older adults, and it is feasible to augment the delivery of iCBT with HCW support.

Method

Participant Recruitment and Eligibility

Participants were recruited from a local home care company, senior apartment buildings, and Meals-on-Wheels in Southeast Michigan. Recruitment methods involved phone calls, in-person visits, referrals, distribution of recruitment flyers, and organized recruitment events in senior apartment buildings. Participants needed to (1) read and speak English, (2) be at least 60 years old, (3) have at least mild depressive symptoms at screening (≥5 on the Patient Health Questionnaire–9 [PHQ-9]), and (4) have received home care for 1 month or more at screening and expect continued care for at least 3 months. Participants were excluded if they met any of the following criteria: (1) were receiving psychotherapy, (2) were suicidal based on either the 9th item on the PHQ-9 or a diagnostic interview at the comprehensive baseline assessment, (3) met criteria for a psychotic disorder, (4) had three or more errors on a 6-item screener for cognitive impairment (Callahan et al., 2002), or (5) had a terminal illness. A trained clinical social worker conducted the Mini-International Neuropsychiatric Interview 7.0.0 Major Depressive Episode (MINI-MDE) and Generalized Anxiety Disorder (MINI-GAD) modules (Sheehan et al., 1998). A depressive disorder diagnosis based on the MINI was not required in order to improve the scalability of the treatment program in nonspecialized community settings. Participants were not required to have internet access or electronic devices to participate; they were provided with a tablet and internet access by the study team as needed.

Intervention

We conducted an extensive review of the relevant literature (Xiang et al., 2019) and considered several commercially available iCBT products for testing. We selected Beating the Blues (BTB) because it is commercially available in the United States, delivered in American English, and has a relatively robust literature supporting its efficacy. Randomized controlled trials of BTB have shown its effectiveness in treating both major and minor depression (Proudfoot et al., 2004; Rollman et al., 2018), and its efficacy was not affected by concurrent medication, the severity of depression, or treatment setting (Proudfoot et al., 2004). The BTB was one of several iCBT programs ever tested with older adults (McMurchie et al., 2013). Moreover, the BTB platform has a voice-over that reads the written content, a desirable feature for participants with vision problems. The BTB can be used as a stand-alone treatment with or without external support. BTB was not specifically designed for older adults but contained character stories that may be relevant to older people (e.g., loss and grief). The program has eight sessions, and each session is broken down into three to five modules. Each session contains a series of slides that include didactic text with voice-over, video clips of case examples, in-session exercises, and homework assignments to impart basic CBT techniques. Its core components include psychoeducation, cognitive restructuring, and behavioral activation.

Participants complete the PHQ-9 and the GAD-7 item at the start of Session 1 and again at the end of Sessions 3, 5, 7, and 8 to self-track symptoms. The program is accessible via computer, tablet, and mobile phone.

Based on the preliminary work of the study team, several modifications were applied to achieve a better fit between the demand of the iCBT program and the need and capabilities of homebound older adults. First, a client workbook was developed that contained a summary of each module, space for notes, and homework printouts. Although all homework assignments were available online, homework printouts were made available considering older adults’ preference for paper-based assignments. Using a paper workbook also acts as a reminder for the next task and a quick reference to previous sessions. Second, we recommended the tablet for participating in the program. Although BTB is compatible with multiple devices, tablets are easier for older adults to navigate than computers or PCs (Jin et al., 2007). Tablets are also more accessible than smartphones for older adults with vision impairments. Third, we added support from HCWs to assist with BTB initiation, engagement, and completion. The addition of HCW support was guided by the Efficiency Model of Support, a model for understanding the provision of human support in the context of behavioral intervention technologies (BITs; Schueller et al., 2017). A premise of this model is that BITs such as iCBT are used more often and are more effective when provided along with human support. The model considers failure points—why people might fail to benefit from a BIT—to guide the actions of supporters. These failure points involve usability (ease of use), engagement (motivation), fit (meeting user’s needs), knowledge (how to use a tool within a BIT), and implementation (how to apply the tool within a BIT into user’s life). Accordingly, we conceptualized the worker’s roles to include assisting program navigation (usability), troubleshooting technological difficulties (fit), giving reminders and encouraging up-take (engagement), aiding the completion of in-session exercises and homework projects (knowledge), and supporting the application of CBT techniques in client’s life (implementation).

Overview of Pilot Trial Design and Procedures

This study was approved by the Health Sciences and Behavioral Sciences Institutional Review Board of the University of Michigan (Ann Arbor, MI) and registered on ClinicalTrials.gov as NCT04267289. Single-group open trial design was employed comparing pretreatment to posttreatment outcomes. Figure 1 shows participant flow and allocation. Individuals who agreed to receive screening completed a brief screening interview either in person or over the phone. The screening interview assessed the participant’s depressive symptoms (PHQ-9), cognitive functioning (6-item screener by Callahan et al., 2002), and receipt of home care (e.g., length of care, frequency of visits). Participants who met the preliminary eligibility criteria after screening were invited to complete informed consent and a comprehensive baseline assessment at home. Those who remained eligible after the baseline assessment were invited to participate.

Figure 1.

Participant flowchart. Note. PHQ-9 = Patient Health Questionnaire–9.

When possible, participants were paired with one of their current HCWs who later received training to assist them with the iCBT program. HCWs were eligible if they were ≥21 years of age and willing to participate. Participating HCWs completed informed consent, a baseline survey, and an online training curriculum that consisted of psychoeducation, safety planning, information about the study, and worker’s roles in the iCBT program. The online training was asynchronous and took about 2 hr to complete. HCWs received a certificate of completion for completing the online training.

Information collected from the screening and comprehensive baseline assessment made us adapt the protocol to accommodate fewer home care visits (i.e., once every other week or once a month), worker refusal or ineligibility, or participant’s preference not to involve HCWs. In cases where consistent assistance from the same HCW was not feasible, participants were given the choice of working on the program on their own or receiving assistance from a research assistant (RA).

After the baseline interview, the study team conducted a home visit to dispatch a tablet (Galaxy Tab A 10.1 with 4G LTE) or install the program on their device (if using their device). A brief tutorial on how to use the program was also provided during the home visit. Enough tablets were purchased so that participants did not have to share a device. The program installation visit occurred within a week after the completion of the comprehensive baseline assessment for the RA-supported and self-guided participants. For HCW-supported participants, the program installation visit occurred within a week after the HCW completed the mandatory worker training. All participants received program access for 12 weeks following the program installation visit. At the end of the 12 weeks, participants were invited to complete a posttest assessment that consisted of questionnaires, a cognitive assessment, and an exit interview, all conducted at home. Older adult participants could earn up to US$120 for completing research assessments. HCWs could earn up to US$183 for completing the online training and research assessments. The study team did not provide extra compensation for HCWs to conduct routine home visits. Compensation was not dependent on treatment completion.

iCBT Support

All participants received a weekly informal check-in phone call from the research team, typically lasting 2–5 min each. For the HCW-supported group, HCWs were asked to assist their clients with the iCBT program during their routine visits with a set of recommended roles described previously. The RAs who assisted with the iCBT program were Master of Social Work students. RAs were instructed to schedule weekly home visits with the participants, each lasting no longer than 1 hr, to work on the iCBT program with their assigned participants. Other than general training on human subject protection and research ethics, RAs did not receive specialized training on CBT and were instructed to limit their roles to assisting participants with program navigation, technical troubleshooting, and homework planning.

Measurements

Primary outcomes included feasibility, acceptability, and depressive symptoms. Feasibility refers to the number of modules completed over the 12-week trial period. Assessments of acceptability and satisfaction were based on participants’ ratings of agreement with 12 questions adapted from the modified version of the Treatment Evaluation Inventory (Landreville & Guérette, 1998) and acceptability measures from previous studies (Sekhon et al., 2017). The primary clinical outcome was the PHQ-9 for depressive symptoms (Kroenke et al., 2001). Secondary clinical outcomes included the GAD-7 for anxiety symptoms, the Montreal Cognitive Assessment (MoCA) for cognitive functioning (Nasreddine et al., 2005), and the 5-level EQ-5D (EQ-5D-5 L) for health-related quality of life (The EuroQol Group, 1990). The MoCA BLIND (mocatest.org), which includes the same tasks as the MoCA full version except for the visual items, was administered to participants with severe vision impairment. Responses to the EQ-5D-5 L were converted into utility values using an algorithm for the U.S. population (Pickard et al., 2019), with a higher score corresponding to better health-related quality of life.

Statistical Analysis

Descriptive statistics were conducted to describe sample characteristics. Within-group differences between baseline and posttest outcomes were evaluated using paired sample t tests with two-tailed tests at α = .05. The within-group effect sizes were calculated using Cohen’s d (Cohen, 2013). Two previously used criteria for clinical significance were employed: (a) the proportion of participants who scored ≥10 on the PHQ-9 at pretreatment and subsequently <10 at posttreatment and (b) the proportion of participants with ≥50% reduction from their pretreatment PHQ-9 scores (Dear et al., 2013). We also examined the proportion of participants with substantial symptom deterioration. Between-group differences were explored through descriptive analysis of primary outcomes stratified by subgroups with varying levels of program completion and assistance. All analyses were intention-to-treat using the last observation carried forward and conducted using Stata Version 15 SE (StataCorp, College Station, TX).

Results

Participants

A total of 28 individuals were eligible, consented, and completed the baseline assessment, and 26 began their first BTB session (Figure 1). All participants who started the treatment were included in the analysis. Most participants (n = 19/26 or 73%) used tablets provided by the study team, and the remaining (n = 7/26 or 27%) used their own devices (one iPad, three Mac computers, one Chromebook, and two Windows PCs). As shown in Table 1, participant age ranged from 60 to 94 years, with an average of 76.4 years. Two legally blind participants completed the MoCA BLIND for cognitive testing, and the remaining (n = 24) completed the MoCA full version. The average MoCA score was 21.5, and half of the participants scored in the “normal range” based on a cutoff of ≥23 on the full version (Carson et al., 2018) and ≥18 on the MoCA BLIND (mocatest.org). Nearly three quarters had a history of major depression based on the MINI-MDE module. Slightly over one third of the sample reported having ever used a tablet, and less than two thirds reported having ever used a computer.

Table 1.

Sample Characteristics at Baseline.

Sample characteristics	N (%) or M (SD)
Age (years)	76.4 (9.2)
Age-group (%)
60–69	6 (23.1)
70–79	11 (42.3)
80–89	7 (26.9)
90+	2 (7.7)
Sex (%)
Female	18 (69.2)
Male	8 (30.8)
Race/ethnicity (%)
White or Caucasian, non-Hispanic	21 (80.8)
Black or African American, non-Hispanic	3 (11.5)
Hispanic or Latino	1 (3.9)
Mixed racial/ethnic, non-Hispanic	1 (3.9)
Education (%)
High school or less	4 (15.4)
Some college	8 (30.8)
Associate's Degree or Bachelor's Degree	6 (23.1)
Graduate	8 (30.8)
Household income (%)
$0–10,000	6 (24.0)
$10,001–20,000	10 (40.0)
$20,001–50,000	7 (28.0)
>$50,000	2 (8.0)
Marital status (%)
Married	4 (15.4)
Widowed	7 (26.9)
Divorced or separated	12 (46.2)
Never married	3 (11.5)
Lived alone (%)	20 (76.9)
Health, functioning, and health care utilization
Number of Elixhauser comorbidity index conditions ^a	4 (2)
MoCA score	21.5 (4.2)
≥23 on MoCA full version or ≥18 on MoCA BLIND (%)	13 (50.0)
Use of assistive device (%)
No device	6 (23.1)
Walker	14 (53.9)
Wheelchair	6 (23.1)
Help received from home care workers
Housekeeping (%)	20 (76.9)
Shopping (%)	15 (57.7)
Meal preparation (%)	13 (50.0)
Transportation (%)	11 (42.3)
Companionship (%)	9 (34.6)
Bathing or toileting (%)	6 (23.1)
History of major depression based on MINI-MDE (%)	19 (73.1)
History of generalized anxiety disorder based on MINI-GAD (%)	3 (11.5)
Ever received a diagnosis of depression (%)	18 (69.2)
Taking antidepressant medication (%)	18 (69.2)
Emergency room visit in the past 3 months (%)	13 (50.0)
An overnight hospital stay in the last 3 months (%)	7 (26.9)
Technology use and competency
Ever used a computer (%)	17 (65.4)
Ever used a tablet (%)	9 (34.6)
Self-rated skill on a tablet
Terrible	12 (46.2)
Not so great	4 (15.4)
Okay	7 (26.9)
Great	3 (11.5)
Had WIFI/internet at home (%)	19 (73.1)
Used own device to do iCBT (%)	7 (26.9)

Note. n = 26. iCBT = internet-based cognitive behavioral therapy; MoCA = Montreal Cognitive Assessment; MINI-MDE = Mini-International Neuropsychiatric Interview 7.0.0 Major Depressive Episode; MINI-GAD = Mini-International Neuropsychiatric Interview 7.0.0 Generalized Anxiety Disorder.

^a Participants were asked whether they ever had the following conditions: heart attack, heart trouble (such as angina, congestive heart failure, or coronary artery disease), stroke, diabetes without end-organ damage, diabetes with end-organ damage (retinopathy, neuropathy, nephropathy, or brittle diabetes), digestive problems or peptic ulcer disease (such as ulcer, colitis, or gallbladder disease), hemiplegia (hemiparesis, muscle weakness, or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), chronic pulmonary disease (asthma, emphysema, chronic bronchitis, or COPD), liver disease (without portal hypertension, includes chronic hepatitis), leukemia (acute or chronic), moderate or severe renal disease (such as ESRD), arthritis or rheumatism, cancer without metastasis, lymphoma, metastatic cancer, dementia, and AIDS.

Half of the participants (n = 13) were successfully paired with one of their current HCWs and started BTB with assistance from the HCW. The remaining half did not receive HCW assistance due to infrequent home care visits (i.e., once a month; n = 6), worker refusal or ineligibility (n = 2), or participant’s preference not to involve HCWs (n = 5). Seven of these participants worked on the program on their own, whereas six received assistance from the RAs.

Feasibility and Acceptability

Adherence and attrition

As shown in Figure 1, two participants formally withdrew shortly after starting BTB due to physical health problems and did not complete a posttest. Three remained in the study for the entire 12 weeks but were unable to complete a posttest, resulting in a follow-up rate of 80%. Just below a quarter of participants completed all eight sessions, and the average number of sessions completed was 4.7 (SD = 2.6) or 55% of all modules.

Acceptability and satisfaction

Of the participants who completed posttest assessment (n = 21), 18/21 (86%) stated that they would recommend this program to others who experience a depressed mood, and 15/21 (71%) found it an acceptable way of dealing with depressed mood. The average rating of overall satisfaction with the program was 7.7 (SD = 3) on a scale of 0 (not satisfied at all) to 10 (fully satisfied) among all participants who provided feedback. Among respondents who received assistance with BTB (n = 16), the average rating of satisfaction was 8.5 (SD = 2.4) for the assistance received. When asked how difficult it would have been if they were to do the program without assistance, three quarters (12/16) reported it would be “very difficult” or “extremely difficult” whereas one quarter (4/16) reported “somewhat difficult” (Table 2).

Table 2.

Acceptability and Satisfaction.

Acceptability and Satisfaction Items	N (%) Agree or Strongly Agree
I find the program requires a lot of effort.	11 (52.4)
I find this treatment an acceptable way of dealing with a depressed mood.	15 (71.4)
I like the procedures used in this program.	15 (71.4)
I believe this program is likely to be effective.	16 (76.2)
I feel confident in how I can perform the behavior required to participate in the program.	16 (76.2)
I feel that I understand the program and how it works.	20 (95.2)
I experienced discomfort during this treatment.	3 (28.6)
I believe this program is likely to result in permanent improvement.	13 (61.9)
Overall, I have a positive reaction to this treatment.	16 (76.2)
I would recommend this program to others who experience a depressed mood.	18 (85.7)
Rate your satisfaction with the program from 0 (not satisfied at all) to 10 (fully satisfied).	7.7 (2.9)
Rate your satisfaction with the help you received using the program from 0 to 10.	8.5 (2.4)
How difficult would it have been if you were to do the program on your own? ^a
Extremely difficult or very difficult	12 (75)
Somewhat difficult	4 (25)
Not difficult at all	0 (0)

Note. N = 21.

^a This item was asked to participants who received assistance with the online program (n = 16).

Clinical Outcomes

Depressive symptoms

Paired-sample t tests revealed an overall significant reduction in depressive symptoms from pretreatment to posttreatment (t = 4.56, p < .001, Cohen’s d = .98, see Table 3). Analysis of clinical significance showed that 10/16 (62.5%) scored ≥10 on the PHQ-9 at pretreatment and subsequently scored <10 at posttreatment, and 9/26 (35%) had a reduction of ≥50% of pretreatment PHQ-9 scores. Only two participants had symptom deterioration, with each participant scoring one point higher on the PHQ-9 at posttreatment.

Table 3.

Means, Standard Deviations and Effect Sizes for the Observed Means in the Entire Sample.

	n	Observed Means (SD)		Test Statistics	Within-Group Cohen’s d
Clinical Outcomes	n	Pre	Post	Test Statistics	Pre to Post
PHQ-9	26	10.65 (4.91)	6.42 (3.68)	t(25) = 4.56, p < .001	.98 (0.40, 1.55)
GAD-7	26	6.46 (4.46)	3.1 (2.92)	t(25) = 4.20, p < .001	.89 (0.31, 1.46)
MoCA	26	21.50 (4.19)	22.15 (3.74)	t(25) = 1.44, p = .162	.16 (−0.71, 0.38)
EQ-5D-5L	26	0.50 (0.25)	0.56 (0.24)	t(25) = 2.19, p = .038	.26 (−0.29, 0.80)

Note. PHQ-9 = Patient Health Questionnaire–9; GAD-7 = Generalized Anxiety Disorder–7; MoCA = Montreal Cognitive Assessment; EQ-5D-5L = 5-level EQ-5D.

Secondary clinical outcome measures

Paired-sample t tests revealed an overall significant reduction in anxiety symptoms from pretreatment to posttreatment (t = 4.2, p < .001, Cohen’s d = .89). The utility scores of EQ-5D-5 L increased significantly (t = 2.19, p = .038, Cohen’s d = .26). The MoCA score did not change significantly (see Table 3).

Between-Group Comparisons

By program completion

Given the relatively large variation in program completion rates, we conducted a supplementary analysis to compare outcomes by dividing participants into two subgroups based on whether they completed 50% of all eight sessions. As shown in Table 4, participants who completed ≤4 sessions (n = 13) tended to have lower acceptability and satisfaction ratings and a smaller change score on the PHQ-9. Results from the Wilcoxon–Mann–Whitney test showed a statistically significant between-group difference in satisfaction ratings (p = .01). The between-group differences in overall acceptability ratings and PHQ-9 change scores were not statistically significant at p < .05. However, these results should be interpreted with caution, given that this was a feasibility study and not powered to detect between-group differences.

Table 4.

Primary Outcome Measures by Program Completion.

Primary Outcomes	Completed ≤4 sessions (n = 13)	Completed ≥5 sessions (n = 13)
# of sessions completed	2.5 (1.2)	6.9 (1.3)
Treatment acceptability ratings	35.1 (8.9)	40.3 (3.4)
Satisfaction ratings	5.6 (3.4)	9 (1.7)
Pre- to postchange score on the PHQ-9 ^a	3.2 (5.2)	5.2 (4.2)

Note. The change score was coded such that a positive change score means a reduction in depressive symptoms or improvement in mental health. PHQ-9 = Patient Health Questionnaire–9. Mean (standard deviation) reported in the table.

^a Change score = pretest score–posttest score.

To gain further insights into the clinical effectiveness of the BTB, we examined changes on the PHQ-9 and GAD-7 for the six subjects who completed all eight BTB sessions. Visual examination of the single-subject graphs suggests a downward trend toward reduced depressive and anxiety symptoms as more sessions were completed (see Figure 2). The only exception was Subject 4, whose PHQ-9 score increased from a 2 at the end of Session 7 to an 11 by the end of Session 8, despite a steady decline from Session 1 to Session 7. A review of Subject 4’s records from the weekly check-in calls and the exit interview revealed that Subject 4 received an eviction notice and had to relocate toward the end of the 3-month period, which may explain the increased depressive symptoms toward the end of the program.

Figure 2.

Single-subject graphs for subjects who completed eight sessions of Beating The Blues. Panel (a) shows PHQ-9 scores at the start of Session 1 and at the end of Sessions 3, 5, 7, and 8 for the six subjects who completed eight sessions of the program. Panel (b) shows GAD-7 scores at the start of Session 1 and at the end of Sessions 3, 5, 7, and 8 for the six subjects who completed eight sessions of the program. Note. PHQ-9 = Patient Health Questionnaire–9; GAD-7 = Generalized Anxiety Disorder–7.

By levels of assistance

We explored potential differences in baseline characteristics and outcomes between the three groups with varying levels of assistance. Formal statistical testing indicated that the self-guided group had better self-reported technology competency than the two supported groups and revealed no other between-group differences. As shown in Table 5, the RA-supported group tended to have the best adherence, satisfaction, and reduction in depressive symptoms, followed closely by the HCW-supported group. The self-guided group had the lowest adherence, satisfaction, and symptom reduction. Formal statistical testing did not reveal any significant between-group differences in the primary outcomes. However, these results should be interpreted with caution, given that this was a feasibility study and not powered to detect differences among subgroups.

Table 5.

Primary Outcome Measures by Subgroups With Varying Levels of Assistance.

Primary Outcomes	HCW Supported (n = 13)	RA Supported (n = 6)	Self- Guided (n = 7)
# of sessions completed	5 (2.8)	5.8 (2.1)	3.1 (2.0)
Treatment acceptability ratings	37.4 (8.4)	39.6 (3.8)	39.2 (3.3)
Satisfaction ratings	7.5 (3.6)	8.6 (2.6)	7.2 (1.6)
Pre- to postchange score on the PHQ-9 ^a	4.1 (4.0)	5.8 (3.8)	3.1 (6.7)

Note. The change score was coded such that a positive change score means a reduction in depressive symptoms or improvement in mental health. HCW = home care worker; RA = research assistant; PHQ-9 = Patient Health Questionnaire–9; Mean (standard deviation) reported in the table.

^a Change score = pretest score–posttest score.

Discussion and Applications to Practice

This feasibility study suggests that iCBT is a feasible and acceptable treatment modality for homebound older adults with depressive symptoms and is potentially effective. Changes in depressive symptoms, anxiety symptoms, and quality of life ratings were all in the expected direction. The present study echoes report from previous studies that older adults will use and can benefit from iCBT with or without human support (Tomasino et al., 2017), and extends these findings to homebound older adults who tend to be older, more functionally and cognitively impaired, and less tech-savvy.

The relative reduction in depressive symptoms in our study was slightly larger than those from a nonrandomized control trial of BTB with older adults in the UK (McMurchie et al., 2013) but smaller than the pooled mean effect size from uncontrolled and controlled iCBT trials involving older adults (Xiang et al., 2019). We used a relatively low cutoff of ≥ 5 on the PHQ-9 for eligibility, whereas previous studies used higher cutoffs (8 or 10) (Dear et al., 2013; Tomasino et al., 2017). Over one third (38%) of our study sample scored below 10 on the PHQ-9 at baseline. Floor effects may have limited the range of change scores, resulting in slightly smaller effect size in the present study.

The overall program acceptability and satisfaction ratings were high and consistent with reports from iCBT trials with older adults (Dear et al., 2013). Ratings on several acceptability items warrant further discussion. Half of the participants reported that the program required much effort. When asked to elaborate, most participants talked about the sessions being too long, with some sessions taking as long as 2 hr. Three participants reported discomfort during the treatment, including one who was frustrated with the program navigation, and the other two felt distressed due to reflection on stressful life events during homework assignments.

The program adherence and usage statistics in the present study were poorer than those from iCBT trials involving older adults (Xiang et al., 2019) and BTB trials with mixed-age samples (Rollman et al., 2018). Specifically, less than a quarter of participants in the present study completed all sessions, and the mean sessions completed was 4.7. In comparison, the completion rate ranged from 55% to 92% from previous iCBT trials with older adults (Xiang et al., 2019). In an RCT of BTB in primary care patients (18–75 years), 36.7% completed all eight sessions, and the mean sessions completed was 5.4 (Rollman et al., 2018). Our sample was considerably older, more functionally and cognitive impaired, and less tech-savvy than the average participants in previous iCBT trials, which could explain the lower completion rates. For example, the mean age of our sample was 76 years compared to 66 years in prior iCBT trials involving older adults (Xiang et al., 2019). Over one third of our sample had no prior experiences using a computer or a tablet, whereas most previous studies required prior computer experience (Xiang et al., 2019). Moreover, half of our study sample scored below the “normal” range on the MoCA at baseline, indicating possible mild cognitive impairment among a large portion of participants. Besides, all participants in the present study had mobility limitations ranging from difficulty walking to using a wheelchair. At least eight participants (31%) reported interruptions to program usage caused by hospitalizations and age-related diseases. Another possible but idiosyncratic cause of lower adherence was that for all but three participants, the 12-week treatment period overlapped with major holidays (e.g., Thanksgiving, Christmas, and New Year), which may have limited their availability to complete all sessions.

The lower adherence rate, combined with feedback from participants from their exit interviews, points to various areas of potential improvement to the iCBT treatment platform that could fit the needs and capabilities of this group. First, web-based platforms in the future need to test well on different interfaces (e.g., tablet, PC, Mac) and pay attention to optimal button size and spacing to accommodate impaired manual dexterity in older adults (Jin et al., 2007). In our study, many participants grew confused and increasingly frustrated due to multiple accidental taps that made the slide on the screen go backward rather than forward. The navigation buttons on each slide were too small and close to each other, causing accidental taps. Second, all aspects of a given screen could include easily adjustable font size and voice-over narration to accommodate vision and hearing impairments. Third, lesson content should use plain language to accommodate low-literacy audiences. A few participants shared difficulty understanding certain words, which affected the comprehension of the lesson content and application of skills. Fourth, shorter modules and longer treatment duration may reduce user fatigue and improve adherence over time. Every participant who completed the exit interview wanted the modules to be shorter, and about half said they would finish the entire program if more time were allowed. Based on their feedback, a module completion length of approximately 15–20 min may be ideal. Estimation of the completion time for each module should consider the speed of movements typical of older adults. Although many modules in the BTB are relatively short and could be finished within 20 min by a younger person, participants in our study reported spending considerably more time on each module (around 30–40 min). Also, a more extended treatment period (e.g., from 3 to 4 months) can more easily accommodate the adverse health events (e.g., hospitalizations) that may be experienced by a frail older adult throughout treatment. Finally, although the current platform includes case examples of five characters with different backgrounds, the case examples are not particularly relevant for most older adults. Most participants chose to view a case example of an older lady who was grieving the loss of her husband over other examples that seemed to be less relatable. Inclusion of age-appropriate case stories, such as an older person coping with a late-onset disease or disability, maybe another strategy to improve adherence to iCBT among older adults with depression.

Feedback from the participants and results from descriptive statistics stratified by subgroups signaled potential group differences in treatment outcomes. The RA-supported group tended to have the best adherence, satisfaction, and reduction in depressive symptoms, followed closely by the HCW-supported group. The self-guided group had the lowest adherence, satisfaction, and symptom reduction. It is not entirely clear why the RA-supported group appeared to have the best outcomes. Having a consistent schedule, dedicated and uninterrupted time for program engagement, and increased feelings of accountability are possible explanations. All participants who received assistance endorsed that they would find it at least somewhat difficult if they were to complete the program on their own, including 75% who said it would be extremely or very difficult. Two legally blind participants, who both completed all eight sessions, reported that the assistance from their HCWs was indispensable for program completion. While these data suggest that human support may play a more critical role in iCBT engagement among functionally impaired older adults, whether HCW-supported iCBT is superior to self-guided iCBT warrants further investigation. Future studies that use in vivo observations will allow a more detailed analysis of HCWs’ roles in assisting clients with iCBT initiation, engagement, and completion.

This study has several limitations. This trial used a pre- and posttest design for the primary purpose of exploring feasibility rather than confirming effectiveness. The absence of a control group limited our ability to infer treatment effectiveness due to threats to internal validity intrinsic to single-group designs. For example, spontaneous remission from depression is not uncommon (Whiteford et al., 2013), which may explain away, in part, reductions in depressive symptoms. Moreover, this study was not powered to detect differences in outcomes by subgroups. Findings involving a comparison between subgroups should, therefore, be considered exploratory. It remains unclear to what extent the external assistance provided by the HCW and RAs had an impact on program adherence and clinical effectiveness and whether external assistance was required to achieve the desired outcomes. Finally, there were no long-term follow-up assessments after the treatment.

To our best knowledge, this was the first clinical trial of a fully automated iCBT program provided to home care older adults with depressive symptoms. Study findings demonstrated that it is feasible to recruit and retain homebound older adults in internet-based mental health treatment studies. Study findings indicate that iCBT is an acceptable and potentially effective treatment modality for depression in homebound older adults, who tend to be older, more functionally and cognitively impaired, and less tech-savvy than the average participants from previous iCBT trials. Data from the participant exit interviews, along with the relatively low adherence rate, suggest a need for refining the existing treatment platform to meet the needs and capabilities of homebound older adults. Another avenue for future research is to clarify the role of HCWs and to examine the impact of HCW-supported iCBT on the well-being of these workers through well-designed controlled studies.

Footnotes

Authors’ Note

The study has been registered on as NCT04267289.

Acknowledgments

The authors thank Home Watch Caregivers of Ann Arbor, Ypsilanti Meals on Wheels, managers, and social workers of senior apartment buildings in Ann Arbor and Ypsilanti, for the support provided during study recruitment, as well as older adults and home care workers who participated in the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the Blue Cross Blue Shield of Michigan Foundation; Michigan Department of Health and Human Services; and the National Institutes of Health, University of Michigan Older Americans Independence Center Research Education Core (grant number: AG024824).

ORCID iD

Xiaoling Xiang

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