A Feasibility Open Trial of Internet-Based Cognitive-Behavioral Therapy for Depression Among Homebound Older Adults

Background/purpose: 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. Access barriers to psychotherapy, an evidence-based depression treatment, are more pronounced in homebound older adults given their challenges attending sessions in the community. Internet-based cognitive-behavioral therapy (iCBT) is a promising approach to overcome some of these access barriers. The present study examined the feasibility of iCBT for depressed homebound older adults who are recipients of non-medical home care.

Methods: Participants were recruited from a local home care company, senior apartment buildings, and Meals-on-Wheels. 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. A feasibility open trial was conducted in the homes of homecare older adults (n=26). When possible, home care workers (HCWs) of older adults (n=13) were recruited to provide external support for iCBT usage. 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 (n=7) or receiving assistance from a research assistant (RA) (n=6). Primary outcomes included feasibility, acceptability, and depressive symptoms assessed using the Patient Health Questionnaire (PHQ-9). Secondary clinical outcomes included the GAD-7 for anxiety symptoms, the Montreal Cognitive Assessment (MoCA) for cognitive functioning, and the EQ-5D-5L for health-related quality of life.

Results: The mean therapy sessions completed was 4.7 out of 8 total sessions. The mean satisfaction rating was 7.7 (SD=2.9), and 86% would recommend the program to others with a depressed mood. There was a significant reduction in depressive symptoms (t = 4.56, p<.001, Cohen’s d =.98) and anxiety symptoms (t=4.2, p<.001, Cohen’s d =.89) and an increase on the EQ-5D-5L quality of life rating (t=2.19, p=.038, Cohen’s d =.26) at post-test. 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.

Conclusions and implications: iCBT is a feasible and acceptable treatment modality for homebound older adults with depressive symptoms and potentially effective. Data from the participant exit interviews suggest a need for refining the existing treatment platform to better meet the needs and capabilities of homebound older adults. Future studies are warranted to examine treatment effectiveness as a function of HCW support.