Cognitive behavioral therapy (CBT) is effective for treating late-life depression. However, office-based CBT is often inaccessible to older adults due to stigma, transportation, and other access barriers. As more older adults are digitally connected, internet-delivered CBT (iCBT) has emerged as a promising approach to address these barriers. Several systematic reviews and meta-analyses have showed that iCBT is as effective as face-to-face CBT for depression in mixed-age samples. However, the effectiveness of iCBT on older adults has not yet been synthesized. Age-based difference in response to and preferences of depression treatment modalities have been documented. A systematic review focused on older adults is therefore warranted to enable informed clinical decision making.
This study aimed to systematically review the literature on iCBT for older adults and to determine its effectiveness in treating late-life depression, and where possible, to perform a meta-analysis.
An experienced librarian and a trained research assistant performed searches using both MeSH terms and text word terms searching strategies from September to November 2017 using PubMed, PsychINFO, and Web of Science. Searches were re-run and articles extracted in January 2018. Two reviewers independently screened titles and abstracts for eligibility. Full texts of relevant articles were retrieved and reviewed. We included a variety of study designs to capture the full scope of the relevant literature, given that older adults were historically under-represented in iCBT trials. These study designs included randomized controlled trials (RCT), non-randomized controlled trials, and pre-post studies without a control group. We included studies in which all patients were 60 years or older or have a mean age of 60 or older. Studies using mixed-age samples were eligible only if the analyses were stratified by age groups so that an effect size specific to older adults could be calculated. The Cochrane Risk of Bias tool was used to appraise study quality. Effect size was calculated using Cohen’s d. Study heterogeneity was assessed using the I2 index, and meta-regression was used to examine potential moderators of effect sizes for all the included studies.
Systematic searches yielded 1415 results, 1296 of which were excluded after title/abstract reviewing. Ten out of the 119 articles retrieved for full-text review were included in the final review. Types of study design included RCTs (n=4), controlled trials without randomization (n=2), and uncontrolled trials (n=4).
Sample size ranged from 20 to 516 with a mean age of 66 years. The pooled effect size for all included studies was 1.13 (95% CI=0.88, 1.38). There was a large heterogeneity ((Q(9) = 41.06, p<.001, I2 = 78.1%). None of the patient-, treatment, and study-level characteristics were significant moderators of the effect sizes in meta-regression. Publication bias was not evident based on the Egger’s test and Begg’s test.
Conclusions and Implications
iCBT is a promising approach for treating late-life depression. However, older adults continue to be under-represented in iCBT trials and most studies involving older adults have low quality. Future studies using rigorous methods and designs are needed to further assess the effectiveness of iCBT for late-life depression.