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Psychology and Aging

2007, Vol. 22, No. 4, 657 665

Copyright 2007 by the American Psychological Association


0882-7974/07/$12.00 DOI: 10.1037/0882-7974.22.4.657

Improving Quality of Life in Diverse Rural Older Adults: A Randomized


Trial of a Psychological Treatment
Forrest Scogin, Martin Morthland, Allan Kaufman,
and Louis Burgio

William Chaplin and Grace Kong


St. Johns University

University of Alabama

The efficacy of home-delivered cognitive-behavioral therapy (CBT) in improving quality of life and
reducing psychological symptoms in older adults was examined in this study. One hundred thirty-four
participants, predominately African American and characterized as primarily rural, low resource, and
physically frail, were randomly assigned to either CBT or a minimal support control condition. Results
indicate that CBT participants evidenced significantly greater improvements in quality of life and
reductions in psychological symptoms. Mediation of treatment through cognitive and behavioral variables was not found despite the acceptable delivery of CBT by research therapists. These data suggest
that treatment can be effective with a disadvantaged sample of older adults and extend efficacy findings
to quality of life domains. Creating access to evidence-based treatments through nontraditional delivery
is an important continuing goal for geriatric health care.
Keywords: quality of life, rural, CBT, older adults

motivation (e.g., sense of purpose, energy, confidence, hope, and


compassion) to persevere and to perform well in stressful, boring,
or even affectively neutral situations (Frisch, 1998). According to
this definition, objective factors, such as physical health, functional ability, and life circumstances, are cognitively mediated
aspects of QOL. QOL has been found to be a significant predictor
of subsequent physical illness, psychological disorders, and healthcare costs (Moreland, Fowler, & Honaker, 1994; Schnurr, Hayes,
Lunney, McFall, & Uddo, 2006; Stewart, Ware, Sherbourne, &
Wells, 1992; Vitaliano, Dougherty, & Siegler, 1994; Ware, 1986).
The measurement and definition of QOL among older adults lacks
consensus, with some investigators more interested in healthrelated QOL (e.g., de Vreede et al., 2007) as measured by instruments, such as the Short Form Health Survey (Ware, 1986), and
other investigators more interested in global QOL or subjective
well-being (Diener, Suh, Lucas, & Smith, 1999). Our interest was
in the latter conception of QOL, and it served as an indicant of
positive outcome different than the psychological symptomreduction focus measured by our other outcome measure, the
Symptoms Checklist-90 (Derogatis, Rickels, & Rock, 1976).
There have been repeated calls to investigate strategies to improve
subjective well-being or QOL (e.g., Strupp, 1996), and there has
been an upsurge in investigations that make QOL the primary
intervention-outcome endpoint (e.g., Eng, Coles, Heimberg, &
Safren, 2001; Petry, Alessi, & Hanson, 2007).
Improving QOL for older adults is an important goal for the
reasons outlined above. One approach to improving QOL is to use
evidence-based interventions shown to improve several closely
related disorders. CBT has a strong evidentiary base in the treatment of geriatric anxiety (Ayers, Sorrell, Thorp, & Wetherell,
2007), geriatric depression (Scogin, Welsh, Hanson, Stump, &
Coates, 2005), caregiver distress (Gallagher-Thompson & Coon,
2007), and geriatric insomnia (McCurry, Logsdon, Teri, & Vitiello, 2007) and thus is a strong candidate as an intervention for

Access to healthcare services is problematic in rural areas,


particularly so for older adults. Basic mental health services are
even more difficult to access for rural dwellers, and specialized
geriatric mental health services are almost nonexistent. It is within
this context that we undertook an investigation of the efficacy of a
well-established psychological treatment, cognitive-behavioral
therapy (CBT), in improving quality of life (QOL) and reducing
psychological symptoms of a sample of rural older adults.
QOL evolved from the constructs of life satisfaction and subjective well-being, topics that have enjoyed a long and rich research focus in social gerontology (Lawton, 1975; Neugarten,
Havighurst, & Tobin, 1961). QOL as used in this study has been
defined as an individuals subjective interpretation of the extent to
which his or her most important needs, goals, and desires have
been satisfied (Frisch, 1998). It represents the persons overall
satisfaction or happiness in life and may reflect internal processes
that help maintain the persons daily life functioning by increasing

Editors Note.
article.RTZ

Bob G. Knight served as the action editor for this

Forrest Scogin and Martin Morthland, Department of Psychology, University of Alabama; Allan Kaufman, School of Social Work, University of
Alabama; Louis Burgio, Department of Psychology and the Center for
Mental Health and Aging, University of Alabama; William Chaplin and
Grace Kong, Department of Psychology, St. Johns University.
This research was supported by National Institute on Aging Grant
AG16311. We thank Peggye Dilworth-Anderson, Larry Beutler, and
Grover Wedgeworth of the Alabama Department of Public Health for their
contributions to this project.
Correspondence concerning this article should be addressed to Forrest
Scogin, Department of Psychology, University of Alabama, Tuscaloosa,
AL 35487-0348. E-mail: fscogin@as.ua.edu
657

SCOGIN ET AL.

658

improving QOL in older adults. CBT is based on the premise that


negative affect and emotional distress are related to maladaptive
information processing and lowered rates of engagement in rewarding activities. We reasoned that targeted intervention on these
mediating factors should bring about improvements in QOL in the
same way that it has been associated with improvements in anxiety
and depression in studies of clinically disordered older adults.
Moreover, difficulties experienced in domains of QOL, such as
self-regard, friendships, and relationships with children, have been
primary targets for CBT interventions designed to foster greater
acknowledgement of personal achievements, less harsh judgments,
and decreased rumination.
In this study, we were particularly interested in the effects CBT
would have on QOL and psychological symptoms in a low resource,
ethnically diverse, and medically frail sample of elders. These factors
have been emphasized as important gaps in the intervention literature
(V. Thompson, Bazile, & Akbar, 2004; U.S. Department of Health
and Human Services, 2001). Most studies of psychological interventions with older adults and CBT, specifically, have been with older
adults of above average socioeconomic status and little apparent
diminishment of cognitive ability. For example, studies by our research group (Floyd, Scogin, McKendree-Smith, Floyd, & Rokke,
2004) and others (L. W. Thompson, Coon, Gallagher-Thompson,
Sommer, & Koin, 2001) have recruited samples with a mean educational level of 14 years and mean Mini-Mental State Examination
(MMSE) scores of greater than 26 (Folstein, Folstein, & McHugh,
1975). To recruit our target population, we provided CBT in the
homes of participants thus enabling persons with physical and financial limitations to more readily receive services. We also concentrated
on recruiting persons residing in rural areas and those receiving
services from home health-care agencies and other community-based
service organizations. Because most studies of the efficacy of CBT
with older adults have included relatively few African American
participants, a goal of our study was to recruit enough African American elders to test for differential outcomes on the basis of race.
We predicted that participants receiving in-home CBT would show
significantly greater improvement in QOL and reductions in psychological symptoms than would participants randomly assigned to a
minimal support control condition. We chose this type of experimental design to control for the attention provided for by continuing
assessment and contact with the project. As this was an initial evaluation of the effects of CBT delivered in-home to a more disadvantaged sample, we did not employ a more rigorous placebo or comparative treatment design. Furthermore, we expected that no
statistically significant differences in treatment effects would be found
between African American and White participants because our study
procedures included the use of both African American and White
therapists, stratified random assignment to experimental conditions by
race, and attunement to ethnic differences with regard to the delivery
of the CBT intervention. Given the characteristics of our sample, these
findings would extend the efficacy of CBT to both a broader outcome
than depression or anxiety and to a more disadvantaged group of older
adults.

Method
Participants and Recruitment
Inclusion criteria for participation were as follows: (a) age of 65
years or older, (b) a T score of 55 or below on the Quality of Life

Inventory (QOLI; Frisch, 1992), (c) a T score of greater than 45 on


the Global Severity Index (GSI) of the Symptoms Checklist-90Revised (SCL-90-R; Derogatis et al., 1976) using norms for nonpatient adults, and (d) residence outside of the cities of Tuscaloosa
(AL) and Montgomery (AL). Fifteen participants residing in the
city limits of Tuscaloosa and Montgomery were randomized into
the study because they otherwise met inclusion criteria and were
recruited through existing referral mechanisms. Additionally, 4
participants with QOLI scores above 55 were randomized as were
2 participants 64 years of age. Though violating inclusion criteria,
we reasoned that we would remove these participants from the
sample when conducting analyses. However, we realized later that
to do so would violate the random assignment status of all participants who followed these allocations. We therefore decided to
include these participants in analyses rather than exclude them to
maintain the integrity of our random assignment (e.g., Friedman,
Furberg, & DeMets, 1998). All analyses were conducted twice,
with these participants included and then excluded, and there were
no meaningful differences. All results are therefore reported on the
full randomized sample.
Exclusion criteria were as follows: (a) self-reported history of
schizophrenia, bipolar disorder, or current substance abuse; (b)
receiving psychotherapy currently; or (c) significant cognitive
impairment as indicated by a score of 23 or less (16 or less for
those with less than a ninth-grade education) on the MMSE (Folstein et al., 1975).
We recruited participants using several different methods. Older
adults were recruited at public and private home health-care agencies, senior centers, church organizations, hospitals with associated
home health-care groups, and service providers, such as physicians
and pharmacists. In addition, advertisements and feature stories
were placed in local print media. These recruitment efforts emphasized that the study was designed to evaluate the effects of a
program to improve QOL among rural older adults. An acronym,
PEARL (Project to Enhance Aged Rural Living), was used to
encourage interest in the study.

Measures
Background information. Information was obtained on age,
gender, race, marital status, educational attainment, income, and
subjective financial burden.
Functional impairment. Functional impairment was measured
by a compilation of the 23-item Functional Assessment of Physical
Functioning (Ettinger et al., 1994) and seven items from the
Functional Independence Measure (Granger & Hamilton, 1987).
This 30-item scale measures activities of daily living and instrumental activities of daily living. Item responses range from Usually did with no difficulty to Unable to do with an option for an
unscored Never did. The average of all scored items is the
functional impairment index. Cronbachs alpha at Time 1 was .95.
Health status. Health status was evaluated through several
means. We used a self-reported one-item rating of general health
and asked participants about the presence of seven common comorbid medical conditions (Wisniewski et al., 2003). The general
health rating ranged from 1 poor to 6 excellent. The seven
comorbid medical conditions were arthritis, high blood pressure,
heart condition, chronic lung disease, diabetes, cancer, and stroke.

IMPROVING QUALITY OF LIFE IN OLDER ADULTS

Use of formal health care and services was assessed by a


modified version of the 21-item form developed for the Resources
for Enhancing Alzheimers Caregiver Health (REACH I) project
(Wisniewski et al., 2003). This form lists in-home, community,
physician, and hospital services that may have been used within
the past month. Each item has a follow-up question as to the
number of times the service was used. The measure of health-care
use was the sum of these items.
Outcome measures. The QOLI (Frisch, 1992) was used to
measure self-reported overall QOL. Sixteen domains are assessed
with the QOLI: health, self-regard, philosophy of life, standard of
living, work, recreation, learning, creativity, helping, love relationship, friendships, relationships with children, relationships with
relatives, home, neighborhood, and community. Each domain is
rated for importance on a 3-point Likert scale and for satisfaction
on a 6-point Likert scale. The cross-product is summed, and this
score is converted to T scores based on adult, community-dwelling
norms. Cronbachs alpha in the normative study was .79 (Frisch,
1992) and, in the present study, .65 at Time 1.
The SCL-90-R (Derogatis et al., 1976) was used as a measure of
overall psychological symptomatology. The 90 items of the SCL90-R comprise nine subscales: Anxiety, Depression, Psychoticism,
Paranoid Ideation, Phobic Anxiety, Somatization, Obsessive Compulsivity, Hostility, and Interpersonal Sensitivity. We used the GSI
as an indicant of overall symptom distress. Cronbachs alpha for
the 90 items at Time 1 assessment was .96.
Mediators. Two measures were used to assess possible mediation of effects associated with CBT. The Beck Hopelessness
Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974) is a
20-item measure that assesses negative attitudes and expectations
about the future. Example items are I look forward to the future
with hope and enthusiasm and I have enough time to accomplish
the things I want to do. Responses are true or false. Total
summed scores indicate degree of hopelessness. Cronbachs alpha
was .81 at Time 1 assessment. The BHS score was expected to
change as a result of the cognitive focus in CBT.
An abbreviated version of the Older Adult Pleasant Events
Schedule (OAPES; Teri & Lewinsohn, 1982) was used to test the
possible mediating role of changes in behavioral activation resultant to the behavior focus in CBT. The total score is the average of
the cross-products of frequency and enjoyability for each item.
Twenty items were selected from the original 66 to ease respondent burden. Cronbachs alpha at Time 1 was .81.

Procedure
Persons interested in participating were contacted by telephone
and given a brief overview of the project. For those with continued
interest, potential eligibility was ascertained by administering four
items from the QOLI and 10 items from the SCL-90-R. For those
with probable inclusive scores, an in-home Time 1 assessment was
scheduled. The Time 1 assessment included a detailed description
of study procedures and participant informed consent, followed by
gathering of sociodemographic information and counterbalanced
administration of the outcome and mediator measures.
Research assistants conducted standardized assessments in participants homes. Measures were read to participants to minimize
problems associated with low literacy and sensory limitations.
Response cards were used to aid participants. Participants received

659

a $25 gift card for the completion of each assessment. All assessments were audiotaped, and 20% were reviewed to ensure adherence to the assessment protocol.
Participants were randomized to CBT or the minimal support
condition (MSC) following baseline assessment. The randomization process involved stratifying participants on the basis of two
variables: site location (Tuscaloosa or Montgomery) and race
(African American or Caucasian). Among each of the four stratified groups, assignment to CBT or the MSC was decided on the
basis of a random number table. Research assistants were blind to
assignment at the time of baseline assessment.
Following randomization, participants in the CBT condition
were assessed on outcome and mediator variables at midtreatment
and immediately posttreatment (Time 2). The midtreatment assessment was undertaken to allow testing of temporal relations between mediator and outcome measures; this assessment also
served as an endpoint for those who received partial treatment.
Those assigned to the MSC were assessed a second time approximately 3 months following randomization. Thus, the controlled
comparison in this study was between the Time 1 and Time 2
assessments for the two conditions. Following Time 2 assessment,
MSC participants received CBT as outlined above. These data are
not included in the results presented here. All participants were
assessed a final time 6 months following the CBT intervention.
These data will be presented in a separate article.

Treatment
The therapists were five licensed Masters of Social Work
(MSW) clinical social workers (two African Americans and three
Caucasians) without prior CBT experience. We chose masterslevel therapists to accentuate external validity and translation of
the intervention as these are the persons who would most likely be
the personnel to administer the intervention in current service
agencies. Training of the therapists was conducted by the principal
investigators and consultants over four sessions that included 12 hr
of didactic instruction and 12 hr of experiential training. Feedback
was provided until competency was achieved on the basis of the
Cognitive Therapy Scale (CTS; Young & Beck, 1980). Weekly
group supervision was conducted with the therapists.
CBT. Treatment followed the manual developed by L. W.
Thompson, Gallagher-Thompson, and Dick (1995) for the delivery
of CBT to older adults. The standard course of treatment was 16
sessions with the opportunity to extend treatment to 20 sessions if
needed. Twice-weekly sessions were planned for the 1st month
with weekly sessions planned for the remainder of the treatment.
Major components of the treatment included activity scheduling,
identifying and changing unhelpful thoughts, relaxation, and assertiveness. The treatment protocol developed by L. W. Thompson
et al. included modifications of traditional CBT for use with older
adults, such as providing in-session cue cards as memory aids,
slowing down the pace of the intervention process, and simplification of homework assignments. We made a further modification
for use with our largely frail sample by encouraging the inclusion
of an intervention facilitator where available. Our rationale for the
facilitator was that we anticipated that many of our participants
would have difficulty in enacting treatment recommendations
without the aid of another because of physical and cognitive
limitations. We also believed that having an indigenous facilitator

660

SCOGIN ET AL.

would aid in the translation of intervention material in a culturally


sensitive manner. The average number of sessions attended by
CBT participants was 11.7. The average time to complete treatment was 5.3 months.
Participants were asked to identify a family member or friend
that could serve as a treatment facilitator. The only inclusion
criterion for facilitators was an MMSE score of 24 or higher (or 16
or higher for those with up to an eighth-grade education). Involvement of a facilitator was not a requirement for participation in the
study as many of the participants could not identify someone to
serve in this role but were otherwise eligible. Thirty-six percent of
the participants involved a facilitator who completed at least a
Time 1 assessment. For MSC participants, facilitators completed
assessments only. For CBT participants, facilitators engaged in a
combination of individual and conjoint sessions. Four individual
sessions with each facilitator were planned within the 1st month of
the participants treatment. The first two sessions were on ways in
which to facilitate the participants attainment of CBT goals, such
as reminding them to complete unhelpful thought diaries or identify pleasant events. Sessions 3 and 4 were devoted to teaching
facilitators general problem-solving skills that could be applied to
the facilitation role. Additionally, the facilitators attended four
conjoint sessions with the older adult participant in which he or she
was made familiar with the specific treatment goals. These sessions were spaced as evenly as possible across the course of
treatment. The average number of sessions attended by the 26
facilitators was 2.5 (range 0 8).
We compared the responses of participants who had a facilitator
and those who did not on the QOLI, SCL-90-R (GSI), BHS, and
OAPES and found no differences. We therefore did not consider
this in subsequent analyses.
MSC. Participants in this condition received brief weekly telephone calls from project staff. These supportive contacts were
made over the course of 3 months. These calls served both as a
means to monitor participants for deteriorating mental health and
as an incentive for continued participation in the project. CBT
techniques were not administered during these calls.
Treatment delivery. Treatment delivery was assessed through
reviews of audiotaped CBT sessions. An early (Sessions 2 8) and
late (Sessions 9 16) session was randomly selected and reviewed
by an independent team using the CTS (Young & Beck, 1980).
The CTS is an 11-item measure with two subscales. The General
Therapeutic Skills subscale assesses areas such as therapist understanding, interpersonal effectiveness, and pacing of the session.
The Specific Cognitive Therapy Skills subscale assesses areas
such as focus on key cognitions and behaviors, application of
cognitive-behavioral techniques, and quality of homework assigned. Each item is rated on a scale from 0 poor to 6
excellent, with 3 indicating satisfactory administration. The results
of these reviews suggested that the CBT was delivered competently. The mean scores across therapists on the General Therapeutic Skills subscale was 3.9, and the mean score on the Specific
Cognitive Therapy Skills subscale was 3.7. There were no significant differences among the therapists on the CTS.

less than .001. The characteristics of the experimental and control


conditions at Time 1 were compared to establish that randomization was successful. All continuous variables were compared simultaneously with a multivariate analysis of variance, and categorical variables were compared with chi-square techniques.
Mixed regression analyses (SAS PROC MIXED, Version 9.0)
were used to evaluate the effects of the intervention on QOL and
psychological symptoms. We conducted analyses to test for the
interaction of Time Experimental Condition on the QOLI and
the GSI using the intent-to-treat sample. Models including possible
treatment moderators were also tested. These moderators were
gender, race (African American/White), and MMSE score. Moderation would be suggested by the three-way interaction of Time
Experimental Condition Moderator.
Attrition was examined by dummy coding participants as completers (1) or dropouts (0) and assessing the associations between
this measure and the outcome and mediator variables. Additionally, this variable was included as a moderator in the primary
intent-to-treat analyses. The purpose of these analyses was to
determine whether degree of study completion was related to
trends in response. We tested a three-way interaction using completion status, time, and experimental condition. Significant interactions would suggest that findings were dependent on completion
status. There were no interactions of missing data patterns and the
primary variables.

Results
Participants
Figure 1 shows the flow of participants through the study. One
hundred thirty-four persons completed a baseline (Time 1) assessment and were randomized to the experimental conditions. Characteristics of the sample are presented in Table 1, and dependent
and mediational variable means and standard deviations by time
and condition are presented in Table 2. This sample is mostly
female (83%), predominately African American (57%), and somewhat older (M 75.4 years) than typically seen in community
intervention studies with older adults. The average MMSE score
(M 24.9) and educational levels (M 9.6 years) are also
relatively low, whereas the self-rated health status of the participants is relatively poor, consistent with our recruitment strategy.
Participants indicated they were experiencing on average three of
the seven comorbid chronic health conditions we assessed. The
participants reported moderate functional impairment as illustrated
by a mean score of 4.24 on the item Climbing several flights of
stairs and a mean score of 2.79 on the item Preparing your own
meals. There were no differences at Time 1 between the experimental conditions on any variables. African American and White
participants were also compared on Time 1 variables, and only
differences in years of education and MMSE scores were statistically different, with African American participants having lower
values.

Attrition
Statistical Analyses
All analyses used a critical alpha level of .05 for determining
statistical significance; exact levels are reported unless they are

Figure 1 provides information about attrition from the study.


Reasons for withdrawing from the study were varied, with most
related to becoming too medically frail to continue and/or moving

IMPROVING QUALITY OF LIFE IN OLDER ADULTS

661

259 Phone Screened

70 Not Interested
55 Ineligible
134 Randomized

Time 1 (Baseline)

7 Did Not
Begin CBT

70 CBT

64 MSC

14 Withdrew

12 Withdrew

Time 2

CBT
51 Assessed

MSC
50 Assessed

Figure 1. Flow of participants through study. Withdrew indicates participants discontinued for reasons
including (a) moved in with family, lost interest, no time/too busy, family reasons; (b) died, became too
medically frail, moved into an institutional setting; or (c) moved with no trace, lost contact. Time 2 for the
cognitive-behavioral therapy (CBT) condition is the endpoint assessment, either the midtreatment or posttreatment assessment. MSC minimal support condition.

in with family or into an institutional setting. The attrition rate


(25%) for the randomized sample is comparable to other similar
studies (e.g., Arean et al., 2005). There were no significant differences in attrition between the two conditions.

Outcomes
Examination of score distributions on the QOLI and GSI variables revealed several extreme values or outliers, and winsorizing
(Dixon & Tukey, 1968) transformations were used to minimize the
effects of these extreme scores on the analyses. Winsorizing has
been suggested as a data cleaning tool that maintains the size of the
sample and minimally affects the mean of a distribution while
reducing its variability. We used mixed regression analyses to test
the effect of treatment on the outcomes. For the QOLI, the model
parameters for the test of the interaction were 1.2 for time, indicating a general increase in the QOLI of 1.2 points between each
assessment time for both groups; 0.46 for treatment group, indicating a baseline difference of about half a point between the
groups; and, most critically, for the Time Treatment interaction,
the parameter estimate was 4.75 (z 4.25, p .001), indicating
an additional increase in the QOLI score of close to five points
between each assessment time for the CBT group compared to the
MSC group. For the GSI, the parameter estimates were 2.0 for
Time, indicating a general decrease in the GSI of two points
between each assessment time; 1.5 for Group, indicating a
1.5-point difference between the groups at baseline; and, most
critically, for the Time Treatment interaction the parameter
estimate was 1.91 (z 2.37, p .02), indicating an additional
decrease in the GSI at each assessment time for the CBT group
compared to the MSC group. The effect sizes associated with the
CBT versus MSC endpoint comparisons, expressed as d, are 0.62

for the QOLI and 0.46 for the GSI. These are considered to be of
moderate magnitude. Figures 2 and 3 show the estimated mean
values across time for the QOLI and GSI as a function of experimental assignment.
We were able to conduct analyses to determine whether the
treatment effects differed by ethnicity, as would be indicated by
Ethnicity Time Experimental Condition interactions, because
there were adequate numbers of both African American and White
participants in the sample. There was a significant three-way
interaction on the QOLI, with African American participants
showing a stronger response to treatment than the White participants. The parameter estimate for the three-way product was
4.59 (z 2.08, p .04) indicating that the increase in QOL
due to treatment was about 4.5 points lower for the White participants than for the African American participants. Subgroup analyses indicated that both African American and White participant
groups showed significant improvements in QOL. There was no
moderation by ethnicity on the GSI, nor did gender or mental
status moderate either of the outcome variables.

Mediators
CBT is theorized to produce beneficial effects through mechanisms that include increased engagement in pleasant events and
decreases in dysfunctional thinking. In the present study, we used
the OAPES and BHS to explore the role of these variables in the
treatment response. First, we were interested in whether there was
a significant change in OAPES and BHS scores as a function of
treatment. The Time Experimental Condition interactions were
not significant, indicating that the treatment did not impact these
mediators. There was no further testing of mediation given these
nonsignificant findings.

SCOGIN ET AL.

662
Table 1
Pretreatment Sample Characteristics

M SD or (N%)

Variable

75.4 7.1

Age
Gender
Women
Men
Race/ethnicity
African American/Black
Caucasian/White
Years of education
08
911
12
1316
1720
Income
$0$4,999
$5,000$9,999
$10,000$14,999
$15,000$19,999
$20,000$49,999
$50,000$70,000
Income adequacy
Not difficult
Not very difficult
Somewhat difficult
Very difficult
Marital status
Never married
Married
Widowed
Divorced
Separated
Self-reported level of health
Poor
Fair
Good
Very good
Excellent
Comorbidity
MMSE

111 (82.8)
23 (17.2)
77 (57.5)
57 (42.5)
49 (36.6)
33 (24.6)
29 (21.6)
20 (14.9)
3 (2.2)
3 (2.2)
59 (44.0)
25 (18.7)
9 (6.7)
11 (8.2)
3 (2.2)
14 (10.4)
17 (12.7)
50 (37.3)
49 (36.6)
8 (6.0)
27 (20.1)
78 (58.2)
12 (9.0)
8 (6.0)
46 (34.3)
60 (44.8)
18 (13.4)
6 (4.5)
2 (1.5)
3.05 (1.3)
24.9 3.5

Note. Includes 134 randomized participants who completed baseline.


Missing data for participants in the following categories are as follows:
income (24), income adequacy (4), marital status (1), self-reported level of
health (2), and comorbidity (7). Comorbidity is the number of reported
chronic health conditions from a list of seven. MMSE Mini-Mental State
Examination.

Health Status
We were also interested in the effects of CBT on health status.
For the Time Treatment interaction on the general health rating,
the parameter estimate was 0.29 (z 3.79, p .001), indicating
an additional increase in perceived health of 0.29 on the rating
scale between assessments. CBT participants reported improvement in their general health status, whereas MSC participants
basically were unchanged. The effect size on this variable was
0.76, considered of moderate magnitude. We did not find significant interactions on our measure of health-care use.

Discussion
The results of this study indicate that home-delivered CBT
improved QOL and reduced psychological symptoms for a sample

of medically frail, low resource, and primarily rural older adults.


These findings are important for several reasons. First, although
CBT has been shown to be effective in treating mental disorders in
older adults, the generalization of this efficacy to the improvement
of QOL suggests that CBT need not be restricted to those with a
diagnosable mental disorder. Mental disorders are associated with
lowered QOL, but there are many elders who experience diminished QOL although they evidence subsyndromal or minimal
psychopathology, especially in the presence of chronic health
conditions and functional disability. The results of this study
suggest that psychological intervention may aid these persons in
improving their mental health and life satisfaction. Second, these
findings extend the use of CBT to a more cognitively compromised (MMSE M 24.9) and less educated (education years M
9.6) sample than typically seen in community-based studies of
mental health interventions. Third, these data suggest that homedelivered CBT is a viable alternative to more traditional clinic or
office-based administration and may be particularly suited for use
by rural-based service agencies in communities that lack specialized geriatric mental health resources. For many of our participants, access to treatment would have been too difficult had they
been required to travel to receive the intervention. Medical frailty,
transportation difficulties, and stigma are among the factors that
have been identified as barriers that were to various degrees
surmounted with the present home-delivered approach. Finally,
these findings suggest that CBT can be effective with ethnically
diverse older adults. The majority of participants in this study were
African American, and improvement in QOL was actually significantly better for these participants than for White participants. The
reduction in psychological symptoms did not differ as a function of
ethnicity. These data thus begin to address the generality of psychotherapeutic benefit (in particular CBT) to older African Americans. This is one of the few studies to investigate the response of
older African Americans to CBT, and our findings are encouraging
with respect to efficacy.
The greater improvement in QOL by African American participants was unexpected. We explored baseline differences in the
two groups for possible explanations and found that only years of
education and MMSE scores differentiated the groups, with African American participants scoring significantly lower on both. If
anything, these differences might argue for a less robust response
for African American participants. Further research to replicate
and better understand this finding would be helpful.
With regards to health status, participation in CBT resulted in
significant improvement in self-rated general health but did not
produce statistically significant changes in the use of formal health
care and services. These findings suggest that improvements in
QOL and reductions in psychological symptoms may have produced concurrent improvements in subjectively experienced general health status.
In a more methodological vein, this is the first study with older
adults to exclusively use people with MSWs as research CBT
therapists. Their competent delivery of CBT in often challenging
circumstances suggests that CBT would be an appropriate
evidence-based treatment for mastery development by practitioners from this discipline. Those planning studies with CBT may
also find justification in the use of MSW therapists on the basis of
our experience.

IMPROVING QUALITY OF LIFE IN OLDER ADULTS

663

Table 2
Means (SDs) of Predictor and Outcome Variables by Time and Condition
Time 1
Measures
QOLI
SCL-90 (GSI)
BHS
OAPES
General health rating
Formal care & services
Functional impairment

Time 2

CBT

MSC

CBT

MSC

42.64 (9.22)
(n 70)
60.00 (7.05)
(n 70)
5.93 (4.15)
(n 70)
2.72 (0.63)
(n 69)
2.00 (0.95)
(n 70)
1.58 (1.09)
(n 69)
2.80 (0.85)
(n 69)

42.88 (8.83)
(n 64)
61.05 (7.91)
(n 64)
5.66 (3.31)
(n 64)
2.53 (0.62)
(n 64)
1.84 (0.83)
(n 62)
1.70 (1.12)
(n 63)
3.13 (0.95)
(n 64)

53.76 (13.94)
(n 51)
53.96 (8.12)
(n 50)
5.39 (4.29)
(n 51)
2.80 (0.64)
(n 51)
2.64 (0.98)
(n 42)
1.45 (1.18)
(n 40)
2.49 (0.84)
(n 42)

45.26 (13.42)
(n 50)
58.42 (10.88)
(n 50)
5.29 (3.88)
(n 48)
2.62 (0.59)
(n 48)
1.91 (0.95)
(n 47)
1.78 (1.31)
(n 49)
3.06 (1.03)
(n 48)

Note. CBT cognitive-behavioral therapy; MSC minimal support condition; QOLI Quality of Life
Inventory; SCL-90 (GSI) Symptoms Checklist-90 (Global Severity Index); BHS Beck Hopelessness Scale;
OAPES Older Adult Pleasant Events Schedule.

A recent study by Arean et al. (2005) found that combining CBT


with case management conferred some efficacy advantage over
CBT alone with respect to reducing depressive symptoms. In this
study, we explicitly instructed our MSW therapists to refrain from
case-management activities to ensure a more focused test of the
effects of CBT. It was evident that many of our participants
experienced significant case-management needs in health care,
housing, and finances, among others. It is likely that combining
case-management services with populations such as those served
in our study would also benefit from this form of multicomponent
intervention, and MSW therapists or psychologists would be wellequipped to provide this intervention.
Our focus on QOL as a primary outcome is also noteworthy.
Most studies of CBT or psychological treatments have targeted
mental disorders, such as depression. This study examined the
effects of this well-established treatment on improving overall life
satisfaction or QOL and found that improvements were seen in this

important outcome. Targeting QOL as a primary outcome may


prove useful in other studies with older adults.
Interestingly, changes on theory-relevant mediators of CBT
were not significant despite significant changes in QOL and psychological symptoms. Put differently, CBT did not produce
changes in hopelessness and pleasant events as would be expected.
This suggests that either the treatment is working through different
means, such as more general therapeutic factors, or the specific
measures used to assess mediation were weak. Studies isolating
therapeutic factors via dismantling or comparative designs may be
needed to address this issue. Scores on the BHS were rather low at
Time 1, and thus this floor effect may have attenuated opportunities to observe change and thus mediation on this variable. It is also
possible that hopelessness is a poor target for mediation in CBT,
and more traditional measures of dysfunctional thinking may
prove more fruitful. The lack of findings on pleasant events is also
difficult to understand and suggests that greater efforts need to be
undertaken to find the active ingredients at work in CBT with older
adults.

60
70

MSC
CBT

40

60
MSC
CBT

50

20

Time 1

Time 2

Figure 2. Adjusted Quality of Life Inventory means from mixed models.


MSC minimal support condition; CBT cognitive-behavioral therapy.

40

Time 1

Time 2

Figure 3. Adjusted Global Severity Index means from mixed models.


MSC minimal support condition; CBT cognitive-behavioral therapy.

664

SCOGIN ET AL.

Limitations
Several limitations to this study should be noted. First, the
design of the study does not allow us to unequivocally ascribe the
improvements made by the participants to the ingredients of CBT.
For example, the effects may have been due to the attention and
concern provided by the research therapists rather than the specific
focus of CBT on behavioral activation and cognitive processes.
These common factors are known to be important aspects of
psychotherapy change. The lack of significant change on the BHS
and OAPES is also consistent with this explanation. A more formal
test of the specificity of CBT would control for such factors.
Another limitation of the study was that some participants received
CBT with the assistance of facilitation, whereas other participants
did not have an available or willing facilitator. Although we found
no evidence in our analyses that the presence of the facilitator
impacted outcome, this was an uncontrolled factor and warrants
further investigation. Another limitation was that a relatively high
percentage of participants received only partial treatment rather
than the full course of CBT. However, we still found a significant
effect for treatment even with these participants included, on the
basis of intent-to-treat principles, in the primary analyses. Although the effect of treatment may have been stronger had participants received all sessions, our results suggest that a more abbreviated course of treatment may still be effective for populations
similar to those involved in this study. Indeed, many service
agencies may not have the resources to offer 16 20 sessions to
their consumers. Extracting the most essential aspects of the intervention would assist this process of translation from a research
study to the field, but efforts to shorten the protocol must be
sensitive to the extra time needed by some older adults to understand and act on treatment recommendations. As always, treatment
should be as brief as possible but not too brief.
Another limitation is the unknown durability of the effects
evidenced by participants. Analyses of follow-up data will be
forthcoming and reported in a subsequent article.

Summary
In summary, CBT was more effective, compared to those in the
MSC group, in improving the QOL and psychological symptoms
of this sample of older adults. This finding adds to a substantial
body of literature supporting the efficacy of this intervention with
anxiety (Ayers et al., 2007), depression (Scogin et al., 2005),
caregiver distress (Gallagher-Thompson & Coon, 2007), sleep
(McCurry et al., 2007), and several other disorders and problems
frequently experienced by older adults. The broad efficacy base for
CBT and similar psychological treatments corresponds well to a
growing recognition that many older adults report a preference for
such treatments (Gum et al., 2006; Rokke & Scogin, 1995). Attention to such patient preferences is a cornerstone of evidencebased practice according to the American Psychological Association (APA Presidential Task Force on Evidence-Based Practice,
2006). The other elements of evidence-based practice, such as use
of evidence-based treatments by skilled clinicians, comport well
with the results of this study and suggest that CBT delivered by
trained providers can improve the well-being of an often overlooked portion of the population. The particular way in which
treatment was delivered in this study will need translation to more

typical practice environments. For example, our providers traveled


many miles and spent considerable time reaching participants, and
this might not be practical outside a research context. Future
studies should examine the effectiveness of CBT or similar interventions when the intervention is delivered in-home but by more
indigenous providers with less monitoring of treatment delivery.
Such providers could be colocated in primary care settings or other
service entry points to promote case identification. In that much of
the CBT provided in this study emphasized more behavioral aspects of the intervention as therapists flexibly accommodated
lower literacy and cognitive impairment, a comparison of behavioral activation versus the full-package CBT seems indicated.
Studies with depressed middle-aged adults suggest that the ostensibly simpler behavioral activation may do as well or better than
CBT (Dimidjian et al., 2006; Jacobson et al., 1996). Coupling a
simpler yet effective treatment with case management might prove
even more effective in improving the QOL of disadvantaged older
adults. Providing access to such services remains a challenge for
those committed to the well-being of older adults.

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Received December 1, 2006


Revision received May 24, 2007
Accepted June 4, 2007

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