Raising Our Spirits Together: Results of an Open Pilot Testing an Entertaining, Technology-Assisted, Group-Based Cognitive Behavioral Therapy for Depression Tailored for the Rural Context and Delivery By Clergy

Background: Rural adults experience depression at similar rates to urban peers; yet are significantly less likely to receive mental health treatment (e.g., Probst et al., 2006; Fortney et al., 2010). Rural communities face substantial barriers to care, including limited mental health professionals, access challenges related to cost/insurance and travel burden, and acceptability concerns due to stigma and lack of anonymity (e.g., HRSA, 2019; Proctor et al., 2016; Crumb et al., 2019). Innovative, community-engaged approaches, including building capacity among preferred, informal providers and leveraging technology, are essential for increasing access to needed depression treatment in the rural United States. Cognitive behavioral therapy, the gold-standard psychosocial treatment for depression, can be effectively delivered via technology-assisted approaches, by non-mental health providers, and in non-mental health community settings (e.g., Andrews et al., 2018; Himle et al., 2014; Zhang et al., 2019). This study utilized a community-engaged approach to tailor and test an entertaining, technology-assisted CBT (T-CBT) for depression, Raising Our Spirits Together (ROST), available via the Entertain Me Well platform, for delivery in the rural context by local clergy.

Methods: We recruited nine rural adults with depressive symptoms to participate in two pilot groups of the 8-session ROST intervention, facilitated by clergy. The first group completed three sessions in-person at a church before the COVID-19 pandemic necessitated stoppage of in-person activities. ROST moved to Zoom-based delivery, with clergy facilitating and sharing their screens to show technology-assisted content, for the remainder of the first group and entire second group. Participants completed assessments at baseline, post-treatment, and three-month follow-up to assess change in depressive symptoms (primary outcome) and anxiety (secondary outcome). Data analysis included descriptive statistics, paired sampled t-tests and repeated measures analysis of variance (ANOVA).

Results: The majority of participants identified as female (67%) and non-Hispanic white (89%). Two-thirds of participants reported annual household incomes less than $40,000. Participants’ average age was 65. Participants’ depressive symptoms, measured by the PHQ-9, significantly decreased, statistically and clinically, from an average baseline score of 14.4 to an average post-treatment score of 6.33 (t(8)=6.79; p<.001). This represents a large effect size of 2.03, based on small sample size corrected hedge’s g. Average anxiety symptoms based on the GAD-7 significantly decreased from baseline (M=7.89) to post-treatment (M=3.56; t(8)=2.41; p=.04). Repeated measures ANOVA showed a significant pattern of difference on depressive symptoms over time (F=17.7; p<.001), with a large effect size (partial eta squared=.689). A similar pattern was observed for anxiety (F=5.23; p=.018; partial eta squared=.395). Participants attended an average of 7.33 of 8 sessions.

Conclusions & Implications: ROST shows promise for improving depressive symptoms and anxiety among rural adults, and for engaging this population in treatment. Findings demonstrate the importance of treatment tailoring and add to growing literature of T-CBT’s effectiveness when supported by non-mental health providers. Results suggest potential acceptability and accessibility of T-CBT in this rural community, even among an older sample. This has important implications for delivering needed care during and after the COVID-19 pandemic which exacerbated depression prevalence without an increase in provider capacity.